Predictors of discontinuing exclusive breastfeeding before six months among mothers in Kinshasa: a prospective study

Much of a child’s future is determined by the quality of nutrition in the first 1,000 days, from conception to 24 months of age. When the child’s brain and body are developing rapidly, good nutrition is essential to lay the foundation for a healthy and productive future. The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for the first six months, followed by timely, adequate, safe and appropriate complementary feeding, while continuing breastfeeding for two years and beyond [1]. Breastfeeding has many benefits for infants, mothers and families. Breastfeeding ensures child’s growth, protects against common acute childhood infections [2, 3], decreases the rate of Sudden Infant Death Syndrome [4], promotes cognitive development and, prevents atopic diseases, obesity and diabetes mellitus [5]. For the mother, breastfeeding is economic and ensures maternal-child bonding, postpartum weight loss and birth spacing. Furthermore, breastfeeding is protective against breast and ovarian cancers [2].

The Lancet series on child survival estimated that, in low-income countries, 13 % of deaths among children under-five could be prevented if breastfeeding prevalence were increased to the optimal coverage of 90 % [6]. In 2010, among children younger than five years, suboptimal breastfeeding was responsible for 8 % of all deaths and 7.6 % of all childhood Disability Adjusted Life Years (DALYs) [7]. Large decreases in deaths and DALYs attributable to suboptimal breastfeeding were noted from 1990 to 2010. However, 5 % of developing countries, including the Democratic Republic of the Congo (DRC), had an increase in absolute number of DALYs attributable to suboptimal breastfeeding [7]. Half of all deaths of under-five children occur in just five countries: India, Nigeria, Pakistan, DRC and China [8]. In DRC, no significant progress has been noted towards reaching the Millennium Development Goal (MDG) related to the reduction of child mortality, MDG 4 [9]. Although breastfeeding is common, the proportion of women who exclusively breastfeed their babies up to six months remains low. During the Demographic and Health Survey (DHS) carried out in 2007, only 36 % of children younger than six months were exclusively breastfed [10]. To promote the practice of EBF, the country had implemented various strategies including the extension of the Baby Friendly Hospital Initiative (BFHI) in health facilities located in provinces, the establishment of Baby Friendly Communities and the implementation of the national code of the marketing of breast milk substitutes. In spite of those interventions, no significant change was noted in 2010. Indeed, the result from the 2010 Multiple Indicator Cluster Surveys (MICS) showed that nearly all mothers initiated breastfeeding, 37 % of children younger than six months were exclusively breastfed, 65 % of children from two to three months old were receiving complementary feeding and, only 5 % of children were exclusively breastfed at six months [11].

To set up successful breastfeeding promotion strategies, understanding the determinants of breastfeeding duration is necessary. A large number of studies carried out to evaluate socio-demographic factors associated with breastfeeding duration reported that women who are older, married, better educated and of higher income breastfeed longer [12–16]. Socio-demographic factors are almost non-modifiable by midwife interventions. To have an impact on breastfeeding duration and exclusivity, interventions should focus on modifiable factors. The modifiable factors that are positively associated with breastfeeding duration are the woman’s intention to breastfeed and breastfeeding self-efficacy, and the social support [12, 17]. Other factors associated with breastfeeding duration are hospital practices [18–20]. The reference for the improvement of breastfeeding practices in health facilities is the BFHI, summarized in the “Ten Steps to Successful Breastfeeding”: (1) Having a written breastfeeding policy that is routinely communicated to all health care staff, (2) training all health care staff in skills necessary to implement this policy, (3) informing all pregnant women about the benefits and management of breastfeeding, (4) helping mothers to initiate breastfeeding within a half-hour of birth, (5) showing mothers how to breastfeed and how to 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, (7) allowing mothers and infants to remain together 24 h 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 on discharge from the hospital or clinic. A health facility providing maternity services and care for newborn infants can be awarded the “Baby-Friendly” designation if it has implemented the Ten Steps and met the assessment criteria of the national Baby-Friendly authority.

In Kinshasa, capital of DRC, only seven health facilities had been designed “Baby-Friendly”. Yotebieng had reported mother’s reasons for starting supplementation with liquid, formula and porridge before six months in this setting [21]. However, to our knowledge, no study has been published on predictors of EBF duration, including baby-friendly practices. Due to socio-cultural differences, the factors identified elsewhere may or may not be the same in Kinshasa. This study aimed to identify predictors of discontinuing EBF before six months among mothers in Kinshasa.

A total of 422 mother-child pairs were recruited for the study and, 405 (96.0 %) were followed for the full six months. Attrition was due to the migration of the family (16/17) or to the child’s death (1/17). All 422 recruited mothers were included in the statistical analyses. Flow of participants from recruitment to statistical analysis is presented in Fig. 1.

All 422 mothers initiated breastfeeding, 233 (55.2 %) did it within an hour of birth and 73 (17.3 %) within thirty minutes. During the maternity stay, 369 (87.5 %) children were exclusively breastfed. At six months, only 12 (2.8 %) infants were exclusively breastfed. The highest rates of EBF discontinuation were noticed during the first and fourth months. Twenty-five percent of mothers stopped EBF during the first month, 17 % during the second month, 18 % during the third month and 22 % during the fourth month. The median duration of exclusive breastfeeding was 10.9 weeks (IQR 4.3 to 14.9).

Regarding each baby-friendly hospital practice individually, mothers who had exclusively breastfed during the stay in the maternity (CHR = 1.59; 95 % CI 2.14, 1.18), those who had been helped to breastfeed correctly (CHR = 1.55; 95 % CI 1.25, 1.92)] and those who were informed about the benefits of breastfeeding (CHR = 1.32; 95 % CI 1.08, 1.62), had higher hazard of EBF at six months. Initiating breastfeeding within 30 min after birth was not significantly associated with the discontinuation of EBF (CHR = 1.28 (95 % CI 0.99, 1.66).

The study power was estimated at 1.00 using Stata 12 with the following parameters: sample size: 422, probability of failure observed: 0.9597 (1–17/422), and default values of Hazard ratio (HR), standard deviation (SD) and type of test.

This study aimed to identify predictors of discontinuing EBF before six months among mothers in Kinshasa. The results showed a low rate of exclusive breastfeeding at six months (2.8 %), and the main predictors of discontinuing EBF before six months were the lack of confidence in the ability to breastfeed and having no plan about the duration of EBF.

Rate of EBF at six months during this study is almost similar to the rate reported in Kenya (2 %) [16]. These findings suggest that very few women breastfeed exclusively up to six months in Africa, although in this part of the world, almost all mothers initiate breastfeeding. Interventions have to be set up to increase the rate of children exclusively breastfed up to six months.

In this study, the highest rates of EBF discontinuation were noticed during the first and fourth months. Breastfeeding problems encountered during the first days after childbirth could explain the high rate of EBF discontinuation during the first month of life. The high number of mothers who stopped exclusive breastfeeding during the fourth month was probably due to the resumption of income-generating activities. In DRC and in particular in Kinshasa, when a woman gives birth, she stays at home for around three months in order to take care of the baby and ensure her recovery. Then, she resumes her routine activities.

In this cohort, less than two thirds of mothers (55.2 %) initiated breastfeeding within an hour of birth, similar findings were reported in Kenya [16]. Regarding the exclusivity of breastfeeding, the majority (87.5 %) of children were exclusively breastfed at the maternity discharge. This rate decreased to 75 %, 50 % and 25 % at four, eleven and fifteen weeks of life respectively. These findings suggest that, the antenatal support received by mothers is not sufficient in itself to increase the duration of EBF. Therefore, it should be followed by a postnatal breastfeeding support to help mothers to overcome breastfeeding challenges.

A large literature on socio-demographic factors associated with breastfeeding duration and exclusivity widely acknowledge that women who are younger, less educated, single, of lower income, unemployed and first-time mother, breastfeed shorter [13–16, 27]. Similar to other studies [28, 29], the current study did not find association between EBF up to six months and the following mother’s socio-demographic characteristics: age, level of education, marital status, family income, occupation, and parity. Given that the study had sufficient power (1.00), this finding can be explained by the fact that the association between these factors and breastfeeding practice is influenced by others factors. The effect of the marital status on breastfeeding duration, for instance, may be influenced by the father’s attitude toward breastfeeding. A woman whose partner has a negative attitude toward breastfeeding may breastfeed for shorter time periods. Regarding the family income, in low-income countries, women with low economic status may have less access to complementary foods and breast-milk substitutes. Thus, EBF may be the only option available to them. Finally, the effect of the mother’s employment on breastfeeding depends on the job flexibility. Full-time employees stop earlier breastfeeding than unemployed mothers. However, self-employed mothers did not differ significantly from unemployed mothers regarding their breastfeeding practice [30].

Psychosocial factors seems to be the most important modifiable predictors of breastfeeding duration [12, 31]. In this study, the strongest predictor of discontinuing EBF before six months was the lack of confidence in the ability to breastfeed. The second predictor in importance was being undecided on the expected duration of EBF. These two predictors are highly correlated; the breastfeeding self-efficacy predicts the intention to breastfeed [31]. Interventions to promote EBF should focus on the improvement of the mother’s breastfeeding self-efficacy. This improvement could be achieved by watching other mothers breastfeeding, by the mothers’ own successful breastfeeding experiences, by her perception of being supported by people in her social network (including health professionals, friends and, the child’s father and grandmother), and by a healthy physical and mental status [32].

According to this study, mothers who had a low level of knowledge on breastfeeding had lower hazard of EBF at six months. The same observation was made by other authors in Sub-Saharan Africa countries [13, 33]. There was no significant relationship between cessation of EBF before six months and the mother’s attitude toward breastfeeding. This result, in contradiction with the literature [27], can be explained by the fact that the lowa Infant Feeding Attitude Scale assess the mother’s attitude toward breastfeeding in opposition to formula. Another instrument should be developed and validated for the assessment of the attitude toward EBF.

Mothers who encountered breastfeeding problems during the first week were more likely to stop EBF before six months. The mother’s confidence in her ability to breastfeed, even though high during the antenatal period, can suddenly decrease early in the postpartum period, if she encounters any difficulty to breastfeed. On the other hand, a mother who encountered problems and who overcome them develops greater breastfeeding self-efficacy. During breastfeeding education sessions, role-play activities on solving breastfeeding problems may be a useful strategy to increase the mother’s breastfeeding self-efficacy.

In this study, the more the mother experienced BFHI practices, the longer she exclusively breastfed. The BFHI is the global initiative of WHO and UNICEF that gives to every baby the best start in life by creating a health care environment that protects, promotes and supports breastfeeding. Internationally, impact studies have demonstrated that, if well integrated, the initiative is an effective intervention to increase breastfeeding initiation, duration, and exclusivity [19, 20, 34]. Findings of this study reinforce this evidence and may suggest the extension of the BFHI to all Kinshasa maternity facilities. Contrary to the literature [12], the timing of breastfeeding initiation was not associated with EBF duration. This contradiction could be due to the fact that, this variable, measured retrospectively, might be incorrectly estimated by the mother.

This study can be interpreted in light of its strengths and limitations. One of the strengths of this study is that the low reliability of EBF duration determined retrospectively was avoided. The prospective approach was chosen to better understand the breastfeeding practice over time. In addition, the study had sufficient power and less than 5 % of lost to follow-up were noted. With regard to the limitations, the recall bias was not completely avoided. Indeed, the day when foods or drinks other than breast milk were introduced was determined retrospectively. Therefore, mothers could or could not remember precisely that moment.

In this study, very few mothers exclusively breastfed up to six months, regardless of age, education, occupation, marital status, family income and parity. The main determinants of EBF duration include confidence in the ability to breastfeed and the intention to exclusively breastfeed. BFHI practices were also found to have an impact on EBF up to six months; the more a mother experienced BFHI practices the longer she was exclusively breastfeeding. To promote successful EBF among mothers in Kinshasa, interventions should focus on the improvement of the mother’s confidence in her ability to breastfeed and on the extension of the BFHI to all maternity facilities.