Promotion of early and exclusive breastfeeding in neonatal care units in rural Rwanda: a pre- and post-intervention study

Background: Early initiation of breastfeeding after birth and exclusive breastfeeding for the first six months improves child survival, nutrition and health outcomes. However, only 42% of newborns worldwide are breastfed within the first hour of life. Small and sick newborns are at greater risk of not receiving breastmilk and often require additional support for feeding. This study compares breastfeeding practices in Rwandan neonatal care units (NCUs) before and after the implementation of a package of interventions aimed to improve breastfeeding. Methods: This pre-post intervention study was conducted at two district hospital NCUs in rural Rwanda from October–December 2017 (pre-intervention) and September 2018–March 2019 (post-intervention). Only newborns admitted before their second day of life (DOL) were included. Data were extracted from patient charts for clinical and demographic characteristics, feeding, and patient outcomes. Exclusive breastfeeding at discharge was based on last recorded infant feeding on the day of discharge. Logistic regression analysis was used to evaluate factors associated with exclusive breastfeeding at discharge. Results: Pre-intervention, 255 newborns were admitted in the NCUs and 793 were admitted in post-intervention. Exclusive breastfeeding on the day of birth (DOL0) increased from 5.4% (12/255) to 35.9% (249/793). At discharge, exclusive breastfeeding increased from 69.6% (149/214) to 87.0% (618/710). The mortality rate decreased from 16.1% (41/255) to 10.5% (83/793). Factors associated with greater odds of exclusive breastfeeding at discharge included admission during the post-intervention period (aOR 4.91; 95% CI 1.99, 12.11), and admission for infection (aOR 2.99; 95% CI 1.13, 7.93). Home deliveries (aOR 0.15; 95% CI 0.05, 0.47), preterm delivery (aOR 0.36; 95% CI 0.15, 0.87) and delayed first breastmilk feed (aOR 0.04 for DOL3 vs. DOL0; 95% CI 0.01, 0.35) reduced odds of exclusive breastfeeding at discharge. Conclusions: Expansion and adoption of evidenced-based guidelines, using innovative approaches, aimed at the unique needs of small and sick newborns may help to improve earlier initiation of breastfeeding, decrease mortality, and improve exclusive breastfeeding on discharge from hospital among small and sick newborns. These interventions should be replicated in similar settings to determine their effectiveness.

We conducted this study in the Rwinkwavu District Hospital (RDH) and Kirehe District Hospital (KDH) NCUs. RDH and KDH are Rwandan Ministry of Health public hospitals located in Kayonza and Kirehe Districts in the eastern province of Rwanda. Both RDH and KDH have been supported by PIH/IMB, an international non-governmental organization, since 2005 and 2007, respectively. RDH supervises eight health centers in its catchment area with a population of 215,555 and KDH supervises 16 health centers in its catchment area with a population of 384,776 [17], in addition to two health centers and over 60,000 people in a refugee camp in the catchment area [18]. The NCUs provide care for small and sick newborns and are equipped with incubators, radiant warmers, syringe pumps, phototherapy, oxygen and continuous positive airway pressure machines for the management of common neonatal conditions. They are staffed by nurses, with an average nurse to patient ratio of 1 to 8.5 [19], and general practitioners, with mentorship by a pediatrician and midwife. Typically, there is one general practitioner who conducts rounds on patients on the neonatal unit each day. The education level of the nurses vary, and include, either a general nurse with a two-year diploma (A1 level) or a general nurse with a Bachelor’s degree (A0 level). Several inputs were introduced into the hospital neonatal care units to promote exclusive breastfeeding, including porridge for mothers and water filters to provide a high calorie, high protein supplement and ensure adequate hydration; pillows for more comfortable breastfeeding positioning; screens for mothers to breastfeed or express breastmilk privately; refrigerator and materials for storage of expressed breastmilk, and educational posters promoting exclusive breastfeeding and Kangaroo Mother Care (KMC). In addition to these inputs, a training was conducted in February 2018 called Working with Infants with Feeding Difficulties delivered by two Speech and Language Therapists who are experts in infant feeding. A description of that training package and a case study from its implementation in Rwanda has been described elsewhere [20]. As a result of the training and in an effort to ensure sustainability of the skills learned during the training, each hospital hired two Expert Mothers to serve as peer counsellors to support mothers in assessing breastfeeding readiness, improve positioning and attachment, and create a breastfeeding-friendly, caring environment for mothers with a focus on one-to-one as well as group counselling. The Expert Mothers were chosen based on criteria including previously having an infant in the neonatal unit and commitment to sharing her experience with other mothers. The Expert Mothers are trained on the Working with Infants with Feeding Difficulties package, provided with a job aid and tablet loaded with Global Health Media videos for counselling of mothers. We conducted a pre-post study. We included all newborns admitted to the RDH and KDH neonatology units in two periods including pre-intervention from October 2017 to December 2017 and post-intervention from September 2018 to March 2019 who were admitted before their second day of life. The manuscript was prepared following the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Guidelines [21]. Data from nationally standardized neonatology patient charts is routinely collected by trained data collectors on a structured paper, two-page form and then entered in a Microsoft Access database. Data completeness and accuracy were checked through routine data quality assessment activities that are conducted by monitoring and evaluation staff. Types of data collected about the infant include the infant’s reason for admission, day of life on admission, relevant perinatal history, length of stay, and discharge outcomes. Data collected about the mother includes maternal history, such as age, gravida, and para, and type of delivery. A very detailed feeding and weight gain history is recorded on the paper form, including the nutrition method through which the infant was receiving nutritional support (via the breast, via a naso-gastric tube, via a cup, or nil per os [NPO, nothing by mouth].) and the nutrition type (breastmilk only, breastmilk and artificial milk, artificial milk only, or intravenous fluids). Our primary outcome was exclusive intake of breast milk at the time of discharge among infants discharged alive. Data on the infant’s feeding history which was last recorded in the patient chart on the day of discharge was used to assess exclusive breastfeeding at the time of discharge. Day of life 0 (DOL0) referred to the child’s day of birth. Newborns exclusively fed breastmilk were defined as the feeding type recorded in the patient’s chart as ‘only breast milk’, regardless of the method of feeding (i.e., via breast, via naso-gastric tube, etc.). Fed on breast was defined as the method of feeding recorded in the patient’s chart as ‘only on the mother’s breast’ (i.e., not via cup, not via naso-gastric tube, etc.). Low birthweight (LBW) was defined as any birth below 2,500 g and premature births are births before 37 weeks gestation. Home delivery was defined as a birth that takes place in the community outside of the care of a skilled healthcare provider, regardless of whether the home delivery was planned delivery or a precipitous delivery. We described sociodemographic characteristics of infants and their mothers, and clinical and feeding characteristics of infants using frequencies and percentages for categorical data and median and interquartile ranges for continuous data. We conducted bivariate analysis using Chi-square test to compare the pre- and post-intervention periods for all categorical sociodemographic, clinical and feeding characteristics described for infants with data recorded unless a cell contained a value of less than five, in which case Fisher’s exact test was used. Wilcoxon Ranksum test was used for bivariate analysis of continuous variables for infants with data recorded. We assessed change in mortality from pre- to post-intervention using multivariable logistic regression controlling for the child’s condition, birthweight in grams, and child’s sex. Then, we used multivariable logistic regression models to identify predictors associated with the outcome ‘exclusive breastfeeding on discharge’, built using backward stepwise procedures for all variables significant at α = 0.20 in bivariate analyses. All factors significant at the α = 0.05 significance level were retained in the final model. The data were analyzed using Stata v.15.1 (Stata Corp, College Station, TX, USA). The study received ethical approval from the Rwanda National Ethics Committee (No. 105/RNEC/20). Data was captured through review of routine records and so additional informed consent specific to this study was not required.

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