Effect of breastfeeding education and support intervention (BFESI) versus routine care on timely initiation and exclusive breastfeeding in Southwest Ethiopia: study protocol for a cluster randomized controlled trial

Effects of couple-based violence prevention education on male partners' knowledge, attitudes and controlling behavior related to intimate partner violence in rural Ethiopia: a cluster randomized controlled trial

Background

Supportive attitudes toward wife-beating and the experience of controlling behavior from husbands have been known to increase the risks of intimate partner violence (IPV). The aim of this study was to determine the effects of couple-based violence prevention education in addressing IPV-related knowledge, attitudes, and controlling behavior among male partners in rural Ethiopia.

Method

A cluster randomized controlled trial was conducted using a two-arm parallel group design. The 16 clusters were randomly allocated into 8 intervention groups and 8 control groups. A total of 432 couples (432 male partners and 432 pregnant wives) participated in the trial. Couple-based violence prevention education (CBVPE) was provided to the participants in the intervention group, while the control group received routine or standard care. Difference-in-difference analysis and the Generalized Estimating Equation (GEE) model were used to assess the effectiveness of the intervention.

Result

At the endline, 94.4% of male partners in the intervention group and 94.9% in the control group were available for the intention-to-treat analysis. Male partners in the intervention group were 3.7 times more likely to have good knowledge about IPV compared to male partners in the control group (AOR = 3.7; 95% CI 2.6-5.4). Male partners in the intervention group were 67.6% less likely to report supportive attitudes toward wife-beating compared to those in the control group (AOR = 0.324; 95% CI 0.229-0.459). Also, the proportion of controlling behavior exhibited by male partners in the intervention group was 56.4% less compared to the control group (AOR = 0.436; 95% CI 0.317-0.600).

Conclusion

The intervention proved effective in enhancing knowledge about IPV, reducing supportive attitudes toward wife-beating, and curbing controlling behaviors among male partners in the study setting. This approach holds promise for scaling up and adapting to similar contexts in Ethiopia.

Trial registration

The trial was registered on ClinicalTrials.gov with the identifier NCT05856214 on May 4, 2023.

Duration of Breastfeeding and Risk Reduction of Breast Cancer among Mothers Who Have Ever Breastfed: A Case-Control Study Conducted in Bahir Dar, Ethiopia

Introduction

Breast cancer is currently the most frequently detected cancer in women and the primary cause of cancer-related deaths globally. The incidence of breast cancer has significantly increased in countries across sub-Saharan Africa, counting Ethiopia. There are multiple determinants of breast cancer, a few of these can be changeable whereas others are not. Evidence suggests that breastfeeding, which is a changeable determinant, reduces breast cancer risk. However, there is a lack of evidence specifically linking the duration of breastfeeding to breast cancer risk. To date, no study has been conducted on the association between the duration of breastfeeding and the likelihood of breast cancer among Ethiopian women.

Objective

The aim of this study was to evaluate the relationship between breastfeeding duration and breast cancer risk in Ethiopian mothers who had breastfed, taking into account other significant determinants.

Methods

A hospital-based case-control study was carried out in Bahir Dar, Ethiopia, involving 203 women (70 cases and 133 controls). Face-to-face interviews were performed using a standardized, validated questionnaire that assessed various sociodemographic, reproductive, lifestyle, and dietary characteristics. Differences between cases and controls were evaluated using the chi-square test. The associations among factors were examined through bivariate and multivariable binary logistic regression, with results presented as odds ratios and 95% confidence intervals.

Results

The multivariable investigation revealed that an inverse relationship between breastfeeding duration and breast cancer risk. Mothers who breastfed for a longer period had a 93% lower risk of breast cancer (AOR = 0.07; 95% CI: 0.021-0.21) compared to those who breastfed for a shorter duration. Younger mothers had a 95% lower likelihood of developing breast cancer (AOR = 0.05; 95% CI: 0.003-0.91) than older mothers. Additionally, mothers with sedentary behaviour were 10.53 times more likely to develop breast cancer (AOR = 10.53; 95% CI: 5.21-21.36) than those who were moderately or highly active. Mothers who experienced chest therapy were 6.43 times more likely to develop breast cancer (AOR = 6.43; 95% CI: 3.20-13.90) compared to those who had not.

Conclusions

Interventions such as breastfeeding counselling and promoting the recommended duration of breastfeeding are crucial in minimizing the risk of breast cancer. Enhancing physical activity should also be viewed as a vital approach for lowering breast cancer risk. Additionally, healthcare professionals need to limit exposure to chest radiation therapy to reduce the likelihood of breast cancer.

Magnus J, Assefa N, Wordofa MA. The protocol for a cluster randomized controlled trial to evaluate couple-based violence prevention education and its ability to reduce intimate partner violence during pregnancy in Southwest Ethiopia

BACKGROUND

A significant proportion of women in Ethiopia suffer from violence by their intimate partner during pregnancy, which has adverse maternal and newborn outcomes. Couple-focused interventions are effective in reducing and/or controlling violence between women and their intimate partners. However, interventions addressing intimate partners of the victims are not well studied, particularly in the Ethiopian setting. This study aims to assess the effect of couple-based violence prevention education on intimate partner violence during pregnancy.

METHODS

We will use a cluster randomized controlled trial to evaluate the effectiveness of couple-based violence prevention education compared to routine care in reducing intimate partner violence during pregnancy. Sixteen kebeles will be randomly assigned to 8 interventions and 8 control groups. In the trial, 432 couples whose wife is pregnant will participate. Health extension workers (HEWs) will provide health education. Data will be collected at baseline and endline. All the collected data will be analyzed using Stata version 16.0 or SPSS version 25.0. We will use the McNemar test to assess the differences in outcomes of interest in both intervention and control groups before and after the intervention for categorical data. A paired t-test will be used to compare continuous outcome of interest in the intervention and the control groups after and before the intervention. The GEE (Generalized Estimating Equation), will be used to test the independent effect of the intervention on the outcome of the interest. Data analysis will be performed with an intention-to-treat analysis approach. During the analysis, the effect size, confidence interval, and p-value will be calculated. All tests will be two-sided, and statistical significance will be declared at p < 0.05.

DISCUSSION

We expect that the study will generate findings that can illuminate violence prevention strategies and practices in Ethiopia.

TRIAL REGISTRATION

It has been registered on ClinicalTrials.gov as NCT05856214 on May 4, 2023.

Experiences of mothers with early weaning: a grounded theory

OBJECTIVE

To understand the experiences of mothers with early weaning.

METHOD

Qualitative research with a theoretical-methodological contribution from Grounded Theory (Straussian perspective), carried out in the context of primary health care in a medium-sized municipality in the northeast of Brazil. 19 collaborators participated by theoretical sampling. Data collection took place between April and September 2018, with in-depth interviews, and was analyzed in three stages: open and axial coding, and integration.

RESULTS

The central category "Women experiencing guilt and overload due to early weaning" was supported by three categories: a) conditions: "Showing the factors that limit breastfeeding"; b) actions/interactions: "Trying to balance motherhood and work during breastfeeding" and "Insufficient social support to keep exclusive breastfeeding"; and c) consequences: "Introducing formula and complementary foods before six months" and "Blaming oneself for the early weaning".

FINAL CONSIDERATIONS

The theoretical model can give support to managers and health professionals to advocate for longer maternity leaves and confront gender disparities and inequities, professional performance with conflicts of interest, and abusive marketing regarding the use of formula.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

1. To describe types of breastfeeding support for healthy breastfeeding mothers with healthy term babies. 2. To examine the effectiveness of different types of breastfeeding support interventions in terms of whether they offered only breastfeeding support or breastfeeding support in combination with a wider maternal and child health intervention ('breastfeeding plus' support).  3. To examine the effectiveness of the following intervention characteristics on breastfeeding support:      a. type of support (e.g. face-to-face, telephone, digital technologies, group or individual support, proactive or reactive);      b. intensity of support (i.e. number of postnatal contacts);      c. person delivering the intervention (e.g. healthcare professional, lay person);     d. to examine whether the impact of support varied between high- and low-and middle-income countries.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes results of searches of CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP)) (11 May 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. Support could be provided face-to-face, over the phone or via digital technologies. All studies had to meet the trustworthiness criteria.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed risk of bias and study trustworthiness.  The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 116 trials of which 103 contribute data to the analyses. In total more than 98,816 mother-infant pairs were included.  Moderate-certainty evidence indicated that 'breastfeeding only' support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at six months (Risk Ratio (RR) 0.93, 95% Confidence Interval (CI) 0.89 to 0.97); stopping exclusive breastfeeding at six months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4-6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4-6 (RR 0.83 95% CI 0.76 to 0.90). Similar findings were reported for the secondary breastfeeding outcomes except for any breastfeeding at two months and 12 months when the evidence was uncertain if 'breastfeeding only' support helped reduce the number of women stopping breastfeeding.  The evidence for 'breastfeeding plus' was less consistent. For primary outcomes there was some evidence that 'breastfeeding plus' support probably reduced the number of women stopping any breastfeeding (RR 0.94, 95% CI 0.91 to 0.97, moderate-certainty evidence) or exclusive breastfeeding at six months (RR 0.79, 95% CI 0.70 to 0.90).  'Breastfeeding plus' interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4-6 weeks, but the evidence is very uncertain (RR 0.73, 95% CI 0.57 to 0.95). The evidence suggests that 'breastfeeding plus' support probably results in little to no difference in the number of women stopping any breastfeeding at 4-6 weeks (RR 0.94, 95% CI 0.82 to 1.08, moderate-certainty evidence). For the secondary outcomes, it was uncertain if 'breastfeeding plus' support helped reduce the number of women stopping any or exclusive breastfeeding at any time points.  There were no consistent findings emerging from the narrative synthesis of the non-breastfeeding outcomes (maternal satisfaction with care, maternal satisfaction with feeding method, infant morbidity, and maternal mental health), except for a possible reduction of diarrhoea in intervention infants.  We considered the overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions and as studies utilised self-report breastfeeding data, there is also a risk of bias in outcome assessment.   We conducted meta-regression to explore substantial heterogeneity for the primary outcomes using the following categories: person providing care; mode of delivery; intensity of support; and income status of country.  It is possible that moderate levels (defined as 4-8 visits) of 'breastfeeding only' support may be associated with a more beneficial effect on exclusive breastfeeding at 4-6 weeks and six months. 'Breastfeeding only' support may also be more effective in reducing women in low- and middle-income countries (LMICs) stopping exclusive breastfeeding at six months compared to women in high-income countries (HICs). However, no other differential effects were found and thus heterogeneity remains largely unexplained. The meta-regression suggested that there were no differential effects regarding person providing support or mode of delivery, however, power was limited.  AUTHORS' CONCLUSIONS: When 'breastfeeding only' support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points.  For 'breastfeeding plus' interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face-to-face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.

Predictors for the duration of breastfeeding among ethiopia women of childbearing age with babies; application of accelerate failure time and parametric shared frailty models

Introduction

Duration of breastfeeding is the length of the time that infants who were initially breastfed continue to receive breast milk until weaning. The duration of breastfeeding is important for a child's health, growth, and development. However, the duration of breastfeeding decreases from time to time and further leads children to be exposed to malnutrition (stunting, wasting, and weight loss). Children who did not get enough breastfeeding are also exposed to different diseases. Previous studies used a simple survival model and didn’t see the shared frailty model on the variable of interest. Therefore, the current study aimed to investigate the factors affecting the duration of breastfeeding among Ethiopian women of reproductive age with babies.

Methods

A cross-sectional study design was conducted on 15,400 women of childbearing age with babies in nine regional states and two city administrations. The data source for the analysis was the 2016 EDHS data. The Cox-proportional hazard model, AFT, and parametric shared frailty models were conducted for the current investigation. Weibull-gamma shared frailty model was in favor of others for current data analysis.

Results

Among the covariates, women living in urban area (Φ = 0.96; 95% CI; (0.94,0.97); p-value = 0.001), non-educated women(Φ = 1.03; 95% CI; (1.00,1.06); p-value = 0.039), primary educated women (Φ = 1.13; 95% CI; (1.11,1.15); p-value < 0.001), age of a child (Φ = 0.99; 95% CI; (0.76.0.99); p-value < 0.001) and non-smoker mothers (Φ = 1.60; 95% CI; (1.57, 1.63); p-value < 0.001),birth interval between 2–3 years(Φ = 1.02; 95% CI;(1.09, 1.25, p-value = 0.027), birth interval, > 3 years(Φ = 1.28; 95% CI; (1.06, 1.43); p-value < 0.01 significantly affected the duration of breastfeeding. The median survival time of breastfeeding of women of reproductive age with babies considered under study was 23.4 months. Clustering had a significant effect on the variable of interest.

Conclusion

Residence area, level of education, age of the child, smoking status of women, and birth interval of successive birth significantly affected the duration of breastfeeding in the current investigation. Hence, the health staff should conduct health-related education for young women, educated women, urban women, smoker women, and women with a shorter interval of birth to increase the women's attitude and awareness towards the use of long-duration of breastfeeding.

Effect of maternal nutrition education on early initiation and exclusive breast-feeding practices in south Ethiopia: a cluster randomised control trial

Introduction: Optimal breast-feeding practices make a major contribution to the promotion of healthy growth and development through much prevention of diarrheal and respiratory diseases which majorly cause morbidity and mortality in under-five children. However, breast-feeding practices remain suboptimality in Ethiopia. Objective: The study objective was to determine the effect of maternal nutrition education on early initiation and exclusive breast-feeding practice in the Hawela Tulla sub-city. Methods: A cluster randomised, parallel-group, single-blinded trial was used. About 310 pregnant women (155 for the intervention group and 155 for the control group) were included. Result: An early initiation of breast-feeding was significantly higher among women who received breast-feeding education than those who did not receive (104(72·7 %) v. 85(59·9 %), P = 0·022) and exclusive breast-feeding practice was also significantly higher among women who received breast-feeding education than those who did not receive (106(74·1 %) v. 86(60·6 %), P = 0·015). Breast-feeding education [AORs 1·55, 95 % CI (1·02, 2·36)], institutional delivery [AOR 2·29, 95 % CI (1·21, 4·35)], vaginal delivery [AOR 2·85, 95 % CI (1·61, 5·41)] and pre-lacteal feeding [AOR 0·47, 95 % CI (0·25, 0·85)] were predictors of early initiation of breast-feeding. Breast-feeding education [AOR 1·72, 95 % CI (1·12, 2·64)] and institutional delivery [AOR 2·36, 95 % CI (1·28, 4·33)] were also determinants of exclusive breast-feeding practices. Conclusion: Breast-feeding education improved early initiation of breast-feeding and exclusive breast-feeding practices. Providing sustained education to women regarding early initiation and exclusive breast-feeding practice should be strengthened.

Determinants of Knowledge and Attitude towards Breastfeeding in Rural Pregnant Women Using Validated Instruments in Ethiopia

Understanding the underlying determinants of maternal knowledge and attitude towards breastfeeding guides the development of context-specific interventions to improve breastfeeding practices. This study aimed to assess the level and determinants of breastfeeding knowledge and attitude using validated instruments in pregnant women in rural Ethiopia. In total, 468 pregnant women were interviewed using the Afan Oromo versions of the Breastfeeding Knowledge Questionnaire (BFKQ-AO) and the Iowa Infant Feeding Attitude Scale (IIFAS-AO). We standardized the breastfeeding knowledge and attitude scores and fitted multiple linear regression models to identify the determinants of knowledge and attitude. 52.4% of the women had adequate knowledge, while 60.9% of the women had a neutral attitude towards breastfeeding. In a multiple linear regression model, maternal occupation was the only predictor of the BFKQ-AO score (0.56SD; 95%CI, 1.28, 4.59SD; p = 0.009). Age (0.57SD; 95%CI, 0.24, 0.90SD; p = 0.001), parity (-0.24SD; 95%CI, -0.47, -0.02SD; p = 0.034), antenatal care visits (0.41SD; 95%CI, 0.07, 0.74SD; p = 0.017) and the BFKQ-AO score (0.08SD; 95% CI, 0.06, 0.09SD; p < 0.000) were predictors of the IIFAS-AO score. Nearly half of the respondents had inadequate knowledge and most women had a neutral attitude towards breastfeeding. Policymakers and managers could address these factors when planning educational interventions to improve breastfeeding practices.

Breastfeeding Education and Support to Improve Early Initiation and Exclusive Breastfeeding Practices and Infant Growth: A Cluster Randomized Controlled Trial from a Rural Ethiopian Setting

Although peer-led education and support may improve breastfeeding practices, there is a paucity of evidence on the effectiveness of such interventions in the Ethiopian context. We designed a cluster-randomized trial to evaluate the efficacy of a breastfeeding education and support intervention (BFESI) on infant growth, early initiation (EI), and exclusive breastfeeding (EBF) practices. We randomly assigned 36 clusters into either an intervention group (n = 249) receiving BFESI by trained Women's Development Army (WDA) leaders or a control group (n = 219) receiving routine care. The intervention was provided from the third trimester of pregnancy until five months postpartum. Primary study outcomes were EI, EBF, and infant growth; secondary outcomes included maternal breastfeeding knowledge and attitude, and child morbidity. The intervention effect was analysed using linear regression models for the continuous outcomes, and linear probability or logistic regression models for the categorical outcomes. Compared to the control, BFESI significantly increased EI by 25.9% (95% CI: 14.5, 37.3%; p = 0.001) and EBF by 14.6% (95% CI: 3.77, 25.5%; p = 0.010). Similarly, the intervention gave higher breastfeeding attitude scores (Effect size (ES): 0.85SD; 95% CI: 0.70, 0.99SD; p < 0.001), but not higher knowledge scores (ES: 0.15SD; 95% CI: -0.10, 0.41SD; p = 0.173). From the several growth and morbidity outcomes evaluated, the only outcomes with significant intervention effect were a higher mid-upper arm circumference (ES: 0.25cm; 95% CI: 0.01, 0.49cm; p = 0.041) and a lower prevalence of respiratory infection (ES: -6.90%; 95% CI: -13.3, -0.61%; p = 0.033). Training WDA leaders to provide BFESI substantially improves EI and EBF practices and attitude towards breastfeeding.

Adaptation and validation of the Iowa infant feeding attitude scale and the breastfeeding knowledge questionnaire for use in an Ethiopian setting

Background

Validated instruments to assess breastfeeding knowledge and attitude are non-existent in Africa including Ethiopia. We aimed to adapt and validate the Breastfeeding Knowledge Questionnaire (BFKQ) and the Iowa Infant Feeding Attitude Scale (IIFAS) for use in Afan Oromo (AO), the most widely spoken language in Ethiopia.

Methods

After forward-backward translation into Afan Oromo, the instruments were reviewed for content validity by a panel of a nutritionist and pediatricians, and pretested on a sample of 30 mothers. Then, a cross-sectional study involving 468 pregnant women in their second and third trimester was conducted between May and August 2017 in the Manna district, Southwest Ethiopia, using the final versions of the adapted questionnaires. We used exploratory and confirmatory factor analysis to assess the construct validity, receiver operating characteristic (ROC) curves to determine the predictive validity and Cronbach’s alpha coefficients to assess internal consistency.

Results

Using exploratory factor analysis (EFA), nine domains containing 34 items were extracted from the BFKQ-AO. A confirmatory factor analysis of the constructs from EFA confirmed construct validity of the instrument (χ2/df = 2.11, RMSEA = 0.049, CFI = 0.845, TLI = 0.823). In factor analysis of the IIFAS, the first factor explained 19.7% of the total variance and the factor loadings and scree plot test suggested unidimensionality of the tool. Cronbach’s alpha was 0.79 for the BFKQ-AO and 0.72 for IIFAS-AO suggesting an acceptable internal consistency of both instruments. For the sensitivity and specificity in predicting intention of breastfeeding for ≥24 months, the area under the curve (AUC) was 82% for IIFAS score and 79% for BFKQ score.

Conclusions

Here we present the first study that reported the use of the BFKQ and the IIFAS in Ethiopia. Our results showed that both BFKQ-AO and IIFAS-AO can be reliable and valid tools for measuring maternal breastfeeding knowledge and attitude in the study population, showing the potential for adapting these tools for application in a wider Ethiopian context.