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On Complementary Feeding in Koibatek, Kenya: a Randomized Control Study Mildred Maingi1*, Judith Kimiywe2 and Sharon Iron-Segev1

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On Complementary Feeding in Koibatek, Kenya: a Randomized Control Study Mildred Maingi1*, Judith Kimiywe2 and Sharon Iron-Segev1 Maingi et al. BMC Public Health (2018) 18:600 https://doi.org/10.1186/s12889-018-5519-1 RESEARCHARTICLE Open Access Effectiveness of Baby Friendly Community Initiative (BFCI) on complementary feeding in Koibatek, Kenya: a randomized control study Mildred Maingi1*, Judith Kimiywe2 and Sharon Iron-Segev1 Abstract Background: Appropriate infant and young child nutrition is critical for proper growth and development. In order to promote optimal nutrition at an early age, the World Health Organization (WHO) and UNICEF have developed the Baby Friendly Hospital Initiative (BFHI) to address poor breastfeeding practices in maternity wards. However, impact is limited in less developed countries like Kenya, where more than half of all births are home deliveries. Therefore, Kenya has explored the adoption of Baby Friendly Community Initiative (BFCI) in its rural settings. In contrast to the BFHI, the BFCI supports breastfeeding and optimal infant feeding in community. BFCI has been implemented in Koibatek, in rural Kenya. This study aimed at assessing the effectiveness of BFCI on complementary feeding practices of children aged 6–23 months, by comparing intervention and control groups. Methods: This was a randomized control study design that included 270 mother-infant pairs enrolled in the Baby Friendly Community Initiative (BFCI) project in Koibatek. Evaluation was carried out using structured questionnaires. Results: A statistically significantly higher proportion of children in the intervention group compared to the control group attained minimum dietary diversity (77% vs. 58%; p = 0.001), minimum meal frequency (96% vs. 89%; p =0.046) and minimum acceptable diet (77% vs. 61%; p = 0.005). The odds of attaining minimum dietary diversity, minimum meal frequency and minimum acceptable diet were statistically significantly higher for the intervention group compared to control group (OR: 4.95; 95%CI 2.44–10.03, p = < 0.001; OR: 14.84; 95%CI 2.75–79.9, p = 0.002; OR: 4.61; 95%CI 2.17–9.78, p = < 0.001 respectively). Conclusion: The BFCI intervention was successful in improving complementary feeding practices. Strengthening and prioritizing BFCI interventions could have a significant impact on child health outcomes in rural Kenya. Trial registration: ISRCTN03467700. Registration 24 September 2014. Retrospectively registered. Keywords: Baby Friendly Community Initiative, Complementary feeding Background Organization (WHO) recommends exclusive breastfeeding Appropriate infant and young child nutrition (IYCN) is of infants for the first 6 months of life, with continued critical for optimal growth and development [1]. Poor breastfeeding together with proper complementary feeding nutrition in childhood is associated with negative outcomes for up to 2 years of age [4]. In Kenya, poor IYCN is still a on cognitive development, morbidity in later life and over- major challenge. According to the Kenya Demographic all economic productivity [2, 3]. The World Health Health Survey (KDHS) 2014, stunting levels were 26%, while severe stunting was observed in 12% of children aged 18 to 23 months. Additionally, data from KDHS 2014 indi- * Correspondence: [email protected] 1School of Nutritional Sciences, The Hebrew University of Jerusalem and The cated that only 22% of children in Kenya were fed accord- International School of Agricultural Sciences, P.O Box 12-761001, Rehovot, ing to the WHO recommended feeding practices [5]. Rural Israel Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Maingi et al. BMC Public Health (2018) 18:600 Page 2 of 11 settings of Kenya have high rates of acute malnutri- available foods and improve sanitation and hygiene [14]. tion, which is primarily attributed to poor child feed- The 6th step of BFCI centers on ensuring that breast- ing practices, poor health-seeking behavior and poor feeding beyond 6 months until 2 years or more is sus- sanitation and hygiene [6]. tained and that timely, appropriate, adequate and safe In order to address poor IYCN practices, improve complementary feeding is maintained [12]. Activities health and reduce mortality in Kenya, the child survival such as the establishment of mother to mother support and development strategy aims at accelerating and scale groups, cooking demonstrations, home visitations, inclu- up of evidence-based high impact interventions [7]. sion of spouses and grandmothers in support groups The Ministry of Health in Kenya has implemented the and the introduction of income generating projects such Baby Friendly Hospital Initiative (BFHI), developed by as kitchen gardens are all components of this initiative the WHO and United Nations Children’sFund [15, 16]. Knowledge of appropriate exclusive and contin- (UNICEF) in 1990 in order to address poor breastfeed- ued breastfeeding duration, amount of food to feed a ing practices in maternity wards [8, 9]. This initiative child based on their age, recommended food groups and emphasizes implementation at the hospital level and feeding during illness have been used as indicators to de- promotion breastfeeding in hospitals. However, the im- velop messages for counseling mothers. Evaluation of pact of BFHI is limited in less developed countries like the effectiveness of BFCI on complementary feeding is a Kenya, where more than half the women, especially the very important aspect that has not been well addressed. poor still deliver at home [10, 11]. Therefore, to extend This study therefore aimed at assessing complementary the benefits of BFHI to all mothers in the community, feeding practices after BFCI implementation in Koibatek, Kenya has explored adoption of the Baby Friendly a rural setting in Kenya. Community Initiative (BFCI) [12]. BFCI is a community-based initiative that was devel- Methods oped to expand on the 10th step of BFHI which focuses Study design on supporting breastfeeding mothers after they have left This study was part of a large cluster randomized con- the health facility. The Government of Kenya through trolled trial that included a total of 812 mother-infant the Ministry of Health is considering the adoption of pairs, half of whom were in the intervention group [12]. BFCI which entails eight steps of BFCI in achieving the This sample size was derived by considering the cluster goal of supporting breastfeeding mothers when they go randomized design [17]. By using a precision level of 5% back to their homes [13]. The eight steps are as pre- (two sided t-test), a power of 80% and adjusting for ex- sented in Table 1 below. pected design effect (3.15) based on correlation coeffi- The overall aim of BFCI is to promote breastfeeding, cient of 0.035 and a cluster size of 62.5, a sample size of complementary feeding, maternal nutrition using locally 738 was derived. Adding 10% to cater for loss to follow up, it was estimated that a sample size of 812 would be Table 1 Eight Steps of Baby-Friendly Community Initiative sufficient to determine the effect of the intervention on 1. Have a written Maternal Infant and Young Child Nutrition (MIYCN) infant feeding practices in the community. policy summary statement consistently communicated to health Evaluation of the trial was carried out in a subset of care providers, community health workers and community members; the cohort at 20 months. 2. Train health care providers and community health volunteers on The intervention group received the BFCI intervention MIYCN policy, in order to equip them with necessary skills to which was composed of a) home visitations to offer per- implement the policy; 3. Promote and support optimal maternal nutrition among women sonalized counseling and support on infant feeding; b) es- and their families; tablishment of mother support groups; c) provision of 4. Educate all pregnant women and lactating women and their infant feeding education materials and d) income generat- families on benefits of breastfeeding to all parties and risks associated with artificial feeding; ing activities, while the control group received standard 5. Help mothers to initiate breastfeeding their children soon after care which comprised of usual services offered in health delivery; within 1 h of birth and support them to maintain exclusive facilities such as standard counseling on immunization, breastfeeding for 6 months. Address any problems related to breastfeeding; general nutrition, ante-natal, post-delivery and hygiene. 6. Encourage mothers to continue breastfeeding their children up to Nutrition education/counseling conducted in the inter- 2 years or beyond, in conjunction with the appropriate, adequate vention group covered; immediate skin to skin contact of and safe complementary feeding while providing holistic care and stimulation of the child; a mother and her baby after birth, initiation of breastfeed- 7. Provide a friendly environment, supportive of breastfeeding ing, exclusive breastfeeding, mothers’ nutrition, introduc- families; tion
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