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Promotion of Exclusive Breastfeeding Is Not Likely to Be Cost Effective in West Africa

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Promotion of Exclusive Breastfeeding Is Not Likely to Be Cost Effective in West Africa Acta Pædiatrica ISSN 0803–5253 REGULAR ARTICLE Promotion of exclusive breastfeeding is not likely to be cost effective in West Africa. A randomized intervention study from Guinea-Bissau Marianne S. Jakobsen ([email protected]), Morten Sodemann, Sidu Biai, Jens Nielsen, Peter Aaby Bandim Health Project, Indepth Network, Danish Epidemiology Science Centre, Apartado 861, Bissau, Guinea-Bissau; and Statens Serum Institut, 2300 Copenhagen S, Denmark Keywords Abstract Anthropometry, Epidemiological study, Exclusive Aim: To evaluate the impact of promotion of exclusive breastfeeding on infant health in Guinea- breastfeeding, Guinea-Bissau, Infant mortality and morbidity, Randomized intervention study Bissau, West Africa, where mortality rates are high, breastfeeding is widely practiced but exclusive Correspondence breastfeeding is rare. Marianne Skytte Jakobsen, Bandim Health Project, Method: At the Bandim Health Project in Guinea Bissau, West Africa, a birth cohort of 1721 infants Danish Epidemiology Science Centre, Statens were randomized to receive health education: promotion of exclusive breastfeeding for the first Serum Institut 2300, Copenhagen S, Denmark. Email: [email protected] 4–6 months of life according to WHO recommendations at the time of the study. All children were followed from birth to 6 months of age. Received 2 April 2007; revised 2 June 2007; Results: Introduction of both water and weaning food was significantly delayed in the intervention accepted 23 August 2007 group. However we found no beneficial health effects of the intervention; there was no reduction in DOI:10.1111/j.1651-2227.2007.00532.x mortality in the intervention group compared with the control group (mortality rate ratio: 1.86 (0.79–4.39)), weight at 4–6 months of age was significantly lower in the intervention group (7.10 kg vs. 7.25 kg; Wilcoxon two-sample test: p = 0.03). There was no difference in diarrhoea morbidity and hospitalization rates. Conclusion: Although mothers were sensitive to follow new breastfeeding recommendations, it had no beneficial impact on infant health in this society with traditional, intensive breastfeeding. There seems to be little reason to discourage local practices as long as there are no strong data justifying such a change. In most low-income countries, health situation of infants INTRODUCTION is poor and there is a need for effective interventions that are There is no doubt that breastfeeding is the ideal food for in- carefully evaluated in order to achieve improvements in in- fants and it has been documented that an infant needs no fant health. Very few settings in low-income countries have supplement and does well easily on breast milk alone up to the possibility of evaluating the impact of health interven- the age of 6 months (1,2). Therefore exclusive breastfeeding tions on mortality. However, in Guinea Bissau, West Africa, is promoted worldwide by WHO to improve infant and child the Bandim Health Project maintains a demographic health health (3,4). However, evidence obtained from randomized surveillance system making longitudinal follow-up possible. studies showing that exclusive breastfeeding is beneficial to As in most Sub-Saharan countries the population in child health is limited. Only two randomized study, in which Guinea Bissau is characterized by high infant mortality and mothers were randomized to receive counselling about the high prevalence of infectious diseases. Almost 100% of the benefits of exclusive breastfeeding, have been conducted to mothers start breastfeeding but only few percent are breast- evaluate the direct effect of promotion of exclusive breast- feeding exclusively. Nonetheless, the tradition is prolonged feeding on infant morbidity and growth, one from Belarus breastfeeding with a median length of more than 22 months (5) and one from India (6). A study from Mexico examined, (9). The present randomized study with longitudinal follow- as a secondary outcome, the effect of exclusive breastfeeding up was designed to examine whether promotion of exclusive promotion on diarrhoea morbidity (7). breastfeeding is effective in reducing infant morbidity and The ultimate decision of how to feed an infant is taken mortality in Guinea-Bissau. by its mother or its family and is a product of culture and traditions as well as socioeconomic conditions and well- being of mother and child. It is therefore always a question SUBJECTS AND METHOD whether the observed impact of exclusive breastfeeding on Study area child health is due to reverse causality, selection bias, con- The Bandim health project founding or a causal effect. Several randomized studies have The study was conducted at the Bandim Health Project in demonstrated that the proportion of exclusive breastfeed- Guinea-Bissau, West Africa, one of the poorest countries in ing mothers and children can be increased by counselling the world (17). The infant mortality rate is 100/1000 (18) and (7–9). However the knowledge of the impact of exclusive the case fatality rate among children admitted to the only breastfeeding on child health is based mainly on observa- paediatric ward in the country is almost 15% for children tional studies (10–16). under 5 years of age (19). In the study area, suburban districts 68 C 2007 The Author(s)/Journal Compilation C 2007 Foundation Acta Pædiatrica/Acta Pædiatrica 2008 97, pp. 68–75 Jakobsen et al. Exclusive breastfeeding and infant health in the capital, people are living mainly in clay houses. Most and at the same intervals as in the intervention group. Only houses have no access to electricity, and water is collected during these visits no health education was given and only at public standpipes or wells. the information on introduction of water and weaning food Since 1978, the Bandim Health Project has maintained was obtained. These biweekly visits were conducted from a demographic health surveillance system, at the time of birth to 6 months of age or until the infant was reported to the study covering around 46 000 people in four suburban have started both water and weaning food. districts. All houses in the study area are visited monthly to record new pregnancies and new births. Children under Background information 3 years of age are followed with three-monthly home visits at Apart from the visits in which the intervention was deliv- which breastfeeding status, arm-circumference, vaccine sta- ered and information on feeding practices was obtained all tus, residence and survival are ascertained. Measurements of enrolled infants were followed with weekly morbidity inter- weight and height are collected by specific teams visiting ev- view and monthly monitoring of anthropometric data. All ery month for children less than 6 months of age. The project study children were further followed from birth to 6 months also registers all admissions at the paediatric ward of the na- of age, death, migration or weaning whichever came first tional hospital. The study was registered as a clinical trial through the routine registration system. Further the infor- and ethically approved by the Ministry of Health in Guinea mation included birth dates as well as background informa- Bissau and by the Danish Central Ethical Committee. tion such as residence, mother’s age, schooling, ethnic group and vaccination status. Information on hospitalization was Intervention design obtained from the Bandim Health Project’s routine registra- Study population. A cohort of infants born between 1 March tion system. HIV infection status was not available but the 2000 and 28 February 2001 were eligible for the study. In- prevalence of HIV-1 in the country was low at the time of the fants were enrolled in the study if the mother was recorded as study. All information from these different routines was col- living in the area during pregnancy and present when mother lected by field assistants unrelated to the intervention part and child were visited by the field assistant during the study of the study. period. Further in order to avoid birth-related deaths only Cluster versus individual randomization. With informa- children who were alive at 7 days of age were included; for tion interventions there is always a problem of communica- the majority of children dying within the first few hours of life tion between members of control and intervention groups we do not have any information on whether they were fed and therefore ‘contamination’ of the control group. To anything before dying. Exclusive breastfeeding for the first address the question of contamination of the intervention 4–6 months is the official policy in Guinean Bissau. Hence, message, we previously conducted a study in the same pop- we did not obtain informed consent at enrolment for the ulation randomizing mothers and children into clusters. In information campaign. that study we found that the variation in how intervention mothers changed feeding habits was the same within the Follow-up of enrolled infants clusters as between the clusters. We therefore concluded that Infants and mothers in both the intervention group and the contamination of that type of intervention message in the control group were visited every two weeks. During these population was not a major problem (9). In order to increase visits, health information was given to mothers in the inter- the power of the present study, we choose to randomize at vention group. The health information was provided indi- the individual level. vidually to the mother. As many mothers are illiterate it was Randomization procedure. All pregnancies detected by given orally in the local language Criolo by a local female the demographic surveillance system at Bandim Health health worker. We have previously performed focus group Project are allocated an ID number at the time the mother discussions with different groups of mothers. The local be- is recorded as pregnant. ID numbers are allocated sequen- liefs about why and when to introduce water and weaning tially within each subdistrict by an independent assistant food were used as basis for the intervention message, i.e.
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