Millennium Development Goal (MDG) 4 calls for a two-third reduction in the under-five mortality rate by 2015. Between 1990 and 2010, global deaths among children under 5 years of age declined from over 12 million to 7.6 million [1]. However, according to Countdown to 2015, an organization that monitors progress towards reaching MDG 4, of 74 focus countries with available data for 2012 report, only 23 were on track to achieve the goal and 13 had made no progress. All but one (Haiti) of the countries that had made no progress are in Sub-Saharan Africa [2].
The Democratic Republic (DR) of Congo is one of the 13 countries which has seen no progress towards MDG 4. It bears the third largest burden of child deaths worldwide [3] and its under-five mortality rate has remained high: from 180 for every 1000 live births in 1990 to 170 in 2010. Although these deaths are the result of a web of complex determinants [4], there is enough evidence to believe that breastfeeding practices play a major role in the extremely high infant mortality in the DR Congo. First, results from the 2007 Demographic and Health Survey (DHS) [5] show that of the 9.2% of infants who die before their first birthday in DR Congo, 4.2% die during the neonatal period and the remaining 5% between 1 and 12 months. Second, of the 116 out of 1000 babies born alive in 2010 in DR Congo who survived through the first 28 days and subsequently died before their fifth birthday, 20 died from diarrhea and 23 from pneumonia, only malaria claim more under-5 lives (28) while AIDS accounts for only 2 [3]. More deaths in the postnatal period and the predominant role of diarrhea, pneumonia and malaria suggest that factors behind these deaths are to be found among other sources in the feeding practices. In fact, by the age of 6 months, more than 10% of children in DRC are already stunted, virtually 15% are underweight-for-age and approximately the same percentage emaciated [5].
These data have to be understood in the context of relatively high utilization of primary health services and high rates of breastfeeding initiation. Despite the challenges to accessing health care in DR Congo, DHS data showed that 85% of pregnant women attend at least one antenatal visit, 70% of live births occurred in a health facility (97% in Kinshasa) and of children 12 to 23 months of age, 71%, 59%, 45% received the first, second and third doses of DPT immunization administered according to the WHO immunization schedule (20) and the DRC’s Expanded Program of Immunization at 6, 10, and 14 weeks respectively, while 63% had been vaccinated against measles (at 9 months). Moreover, breastfeeding is almost universally accepted (9 out of 10 children are still being breastfed at the age of one) in DR Congo. Yet, recent national surveys [5, 6] showed that only 69% of 0 to 1 month old are exclusively breastfed while 65% of 2 to 3 month old are receiving something other than human milk in an environment where, according to the recent WHO/UNICEF progress report on sanitation and drinking-water [7], only 23% of the urban population have access to improved sanitation facilities and less than 50% to improved drinking-water sources.
Optimal breastfeeding practices, including immediate postpartum initiation of skin to skin contact with breastfeeding within one hour of birth, exclusive breastfeeding (EBF) with no additional fluid or food for 6 months [8], and continuation of breastfeeding thereafter up to 24 months and beyond with age appropriate complementary feeding, have great potential for reducing under five mortality rate [9–11]. If at least 90% of children were exclusively breastfed for the first six months of life, the potential reduction in mortality would be higher than from any other known effective intervention [10]. In most sub-Saharan countries, particularly in those with no or insufficient progress towards MDG 4, the prevalence of EBF among infant 6 months old or younger has not increased substantially and remains generally below 40% [12].
Starting in 1990, global initiatives to improve breastfeeding practices focused on maternity-level policies and practices known as the Ten Steps to Successful Breastfeeding, which serve as the basis for the Baby-friendly Hospital Initiative (BFHI) [13]. A maternity facility can be designated 'baby-friendly' when it has implemented the Ten Steps and has been reviewed using a national assessment approach. These steps include the following: (1) having a written breastfeeding policy that is routinely communicated to all healthcare staff, (2) training all healthcare staff in skills necessary to implement this policy, (3) informing all pregnant women about the benefits and management of breastfeeding, (4) helping mothers initiate breastfeeding within 30 minutes of birth, (5) showing mothers how to breastfeed and maintain lactation, even if they should be separated from their infants, (6) giving newborn infants no food or drink other than breast milk, unless medically indicated and not accepting free or low-cost breast milk substitutes, feeding bottles or teats, (7) allowing mothers and infants to remain together 24 hours a day, (8) encouraging breastfeeding on demand, (9) giving no artificial teats or pacifiers to breastfeeding infants, and (10) fostering the establishment of breastfeeding support groups and referring mothers to them upon discharge from the hospital or clinic. Implementation of the Ten Steps is associated with improvement in the rates of EBF [14–16].
BFHI is not being implemented to any extent today in DR Congo. The main attempt to implement BFHI steps in the country was led by UNICEF in the early 2000s as part of a national campaign of breastfeeding promotion, Overall 25 health facilities including 13 in Kinshasa out of more than 6,000 eligible facilities were certified through this effort. The last hospital certified was in 2004 in Katanga province when the funding stopped. Just two years after the peace deal that ended the deadliest war since World War II, which, in addition to decades of gross mis-management, have left the country infrastructures in shambles [17, 18], the country was simply not ready to take over the initial UNICEF efforts.
Beside the fact that BFHI is not systematically implemented in DR Congo, to our knowledge, there has been no published report on breastfeeding practices and factors that are behind the persistent high rate of early supplementation. Data on West Africa as a whole indicates that water supplementation was a major contributor to the high rates of less than exclusive breastfeeding in the early 1990s, with most neighboring countries reporting more than 50% offering water in the first months of life. In 2000, only about 35% of women in DR Congo were still providing water to their infants in the first months of life [19, 20], possibly accounting for the increase in EBF rates noted above.
This study was carried out as part of a preliminary phase of a cluster randomized trial designed to test whether support for the implementation the Ten Steps, coupled with provision of breastfeeding support in well-child and immunization clinics as a unique approach to the Step Ten (establishment of breastfeeding support groups in community), would improve the rate of EBF at six months in Kinshasa (NCT01428232). The main objective was to describe breastfeeding practices and identify the main determinants of the widespread early supplementation in Kinshasa, DR Congo.