Early Initiation and Exclusivity of Breastfeeding in Rural Zimbabwe: Impact of a Breastfeeding Intervention Delivered by Village Health Workers

Mduduzi N N Mbuya, Cynthia R Matare, Naume V Tavengwa, Bernard Chasekwa, Robert Ntozini, Florence D Majo, Ancikaria Chigumira, Cynthia M Z Chasokela, Andrew J Prendergast, Lawrence H Moulton, Rebecca J Stoltzfus, Jean H Humphrey, SHINE Trial Team, Mduduzi N N Mbuya, Cynthia R Matare, Naume V Tavengwa, Bernard Chasekwa, Robert Ntozini, Florence D Majo, Ancikaria Chigumira, Cynthia M Z Chasokela, Andrew J Prendergast, Lawrence H Moulton, Rebecca J Stoltzfus, Jean H Humphrey, SHINE Trial Team

Abstract

Background: Suboptimal breastfeeding contributes to >800,000 global child deaths annually. Optimal breastfeeding includes early initiation (EI) and exclusive breastfeeding (EBF) for the first 6 mo.

Objectives: We tested the hypothesis that an intervention targeting context and infant age-specific barriers to EI and EBF will achieve a higher EI and EBF prevalence than those of women participating in the concurrently conducted 2015 Zimbabwe Demographic Health Survey (Z-DHS).

Methods: We designed an intervention to promote EI and EBF, and implemented it within the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe. Intervention modules were delivered at 4 perinatal time points by government-employed village health workers. We compared EI and EBF prevalence among SHINE women who provided outcomes at 1 mo (n = 2442) and 3 mo (n = 2728), with women in the 2015 Z-DHS.

Results: In cross-sectional analyses EI prevalence was 86.6% and 64.3% in the SHINE and Z-DHS samples, respectively; absolute difference (95% CI) = 22.4% (17.5%, 27.3%). EBF prevalence was similarly high (>80%) in both surveys during the first month of life; during 1 to <2 mo, 2 to <3 mo, 3 to <4 mo, 4 to <5 mo, and 5 to <6 mo, EBF prevalence was, respectively, 85%, 90%, 90%, 84%, and 75% in SHINE, and 71%, 65%, 35%, 26%, and 25% in Z-DHS; absolute difference (95% CI) = 50.2% (34.7%, 65.7%) at 5 to <6 mo. Cesarean delivery, mother's belief that intimate partner violence was sometimes justifiable, and having a male infant negatively modified the effects of the intervention.

Conclusions: The SHINE intervention achieved a high prevalence of EI and EBF. Concurrently addressing gender norms will be critical to make further progress. Formative studies to identify context- and infant age-specific barriers to EI and EBF may inform improvement of breastfeeding practices elsewhere. Important work remains to scale up this intervention beyond a research setting. SHINE was registered at www.clinicaltrials.gov as NCT01824940.

Keywords: Zimbabwe; breast milk; early breastfeeding initiation; exclusive breastfeeding; infants; village health workers.

Figures

FIGURE 1
FIGURE 1
Prevalence of early initiation of breastfeeding and exclusive breastfeeding according to months of age for mothers in SHINE compared with rural mothers participating in the 2010 and 2015 Zimbabwe Demographic Health Surveys. Sample sizes for 0 to

FIGURE 2

Illustrations of effect modification of…

FIGURE 2

Illustrations of effect modification of the benefit of the SHINE breastfeeding intervention on…

FIGURE 2
Illustrations of effect modification of the benefit of the SHINE breastfeeding intervention on breastfeeding outcomes. (A) Relative risk of late initiation of breastfeeding by cesarean delivery and receipt of Breastfeeding Module 1 in late pregnancy. Results were adjusted for place of delivery, mother's belief that intimate partner violence was sometimes justifiable, mother's HIV status, and infant sex. (B) Relative risk of early mixed feeding (1–2.5 mo) by belief that intimate partner violence was sometimes justifiable and receipt of Breastfeeding Module 2 in week 1 postpartum. Results were adjusted for mother's marital status and height, and infant's birth weight, age at survey, and sex. (C) Relative risk of late mixed feeding (2.5–5.9 mo) by infant sex and receipt of Breastfeeding Module 1 in late pregnancy. Results were adjusted for belief that intimate partner violence was sometimes justifiable, mother's age, education and HIV status, and infant's birth weight and age at survey. See Table 3 for a summary of all interactions observed. SHINE, Sanitation Hygiene Infant Nutrition Efficacy study.
FIGURE 2
FIGURE 2
Illustrations of effect modification of the benefit of the SHINE breastfeeding intervention on breastfeeding outcomes. (A) Relative risk of late initiation of breastfeeding by cesarean delivery and receipt of Breastfeeding Module 1 in late pregnancy. Results were adjusted for place of delivery, mother's belief that intimate partner violence was sometimes justifiable, mother's HIV status, and infant sex. (B) Relative risk of early mixed feeding (1–2.5 mo) by belief that intimate partner violence was sometimes justifiable and receipt of Breastfeeding Module 2 in week 1 postpartum. Results were adjusted for mother's marital status and height, and infant's birth weight, age at survey, and sex. (C) Relative risk of late mixed feeding (2.5–5.9 mo) by infant sex and receipt of Breastfeeding Module 1 in late pregnancy. Results were adjusted for belief that intimate partner violence was sometimes justifiable, mother's age, education and HIV status, and infant's birth weight and age at survey. See Table 3 for a summary of all interactions observed. SHINE, Sanitation Hygiene Infant Nutrition Efficacy study.

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