Abstract
BackgroundEarly 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.MethodsThis 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.ResultsPre-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.ConclusionsExpansion 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.
Highlights
Initiation of breastfeeding after birth and exclusive breastfeeding for the first six months improves child survival, nutrition and health outcomes
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
There were no significant differences in admissions for prematurity at pre-intervention compared to post-intervention (40.0% [n = 96/240] vs. 40.6% [n = 309/762], p = 0.88), maternal age (50.0% [n = 12/240] age 25–34 years vs. 43.7% [n = 332/759], p = 0.24) maternal gravidity (27.1% [n = 66/244] primigravida vs 31.5% [n = 238/755], p = 0.40), and age on admission (83.1% [n = 212/255] admitted on Day of life 0 (DOL0) vs. 85.4% [n = 677/793, p = 0.39)
Summary
Initiation of breastfeeding after birth and exclusive breastfeeding for the first six months improves child survival, nutrition and health outcomes. Initiation of breastfeeding within one hour after birth and exclusive breastfeeding for the first six months is recommended by the World Health Organization (WHO) [2]. Small and sick newborns requiring inpatient care after birth face unique challenges since the neonatal care unit environment is not always conducive for initiation of early and exclusive breastfeeding, including in settings such as Denmark, when an infant requires mechanical ventilation or is separated from the mother [7]. Small and sick newborns may experience difficulties breastfeeding, or are too immature or unstable to breastfeed immediately after birth, so mothers require specialized support to establish and maintain their milk supply [8, 9]. Despite the strong recommendation from WHO that maternity and newborn services have trained and competent staff who can provide successful breastfeeding support to lactating mothers [10], they have noted that early breastfeeding is compromised by inappropriate procedures, such as infantmother separation, performed by healthcare providers and outdated policies [6]
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