Elsevier

The Lancet

Volume 361, Issue 9367, 26 April 2003, Pages 1418-1423
The Lancet

Articles
Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomised controlled trial

https://doi.org/10.1016/S0140-6736(03)13134-0Get rights and content

Summary

Background

Exclusive breastfeeding is recommended until age 6 months. We assessed the feasibility, effectiveness, and safety of an educational intervention to promote exclusive breastfeeding for this length of time in India.

Methods

We developed the intervention through formative research, pair-matched eight communities on their baseline characteristics, and randomised one of each pair to receive the intervention and the other to no specific intervention. We trained health and nutrition workers in the intervention communities to counsel mothers for exclusive breastfeeding at multiple opportunities. We enrolled 1115 infants born in the 9 months after training—552 in the intervention and 473 in the control communities. Feeding at age 3 months, and anthropometry and of diarrhoea prevalence at age 3 months and 6 months were assessed. All analyses were by intention to treat.

Findings

We assessed 483 and 412 individuals at 3 months in the intervention and control groups, respectively, and 468 and 412 at 6 months. At 3 months, exclusive breastfeeding rates were 79% (381) in the intervention and 48% (197) in the control communities (odds ratio 4·02, 95% CI 3·01–5·38, p<0·0001). The 7-day diarrhoea prevalence was lower in the intervention than in the control communities at 3 months (0·64, 0·44–0·95, p=0·028) and 6 months (0·85, 0·72–0·99, p=0·04). The mean weights and lengths, and the proportion with weight-for-height or height-for-age Z scores of 2 or less, at age 3 months and 6 months did not differ much between groups. Intervention effect on exclusive breastfeeding, diarrhoeal morbidity, and anthropometry at age 6 months in the low-birthweight subgroup was similar to that for all births.

Interpretation

Promotion of exclusive breastfeeding until age 6 months in a developing country through existing primary health-care services is feasible, reduces the risk of diarrhoea, and does not lead to growth faltering.

Introduction

The results of two randomised controlled trials1, 2 and some observational studies3, 4, 5, 6, 7, 8, 9, 10 have shown a protective effect of breastfeeding against diarrhoea compared with other forms of feeding. In developing countries, breastfeeding is common but exclusive breastfeeding is not.1, 11, 12 No large-scale trial has assessed promotion of exclusive breastfeeding in a population with high breastfeeding rates. In a fairly small trial,1 which was designed to assess this possibility, diarrhoea was reduced in the first 3 months of life in a secondary analysis. To justify large-scale interventions, a reduction in diarrhoea and other illnesses through promotion of exclusive breastfeeding in developing countries during the first 6 months of life needs to be shown.

WHO, in its guidelines,13 recommends exclusive breastfeeding for the first 6 months rather than the first 4–6 months. There are concerns that exclusive breastfeeding for this long might be difficult, however, particularly where maternal malnutrition is common.13 Also, few data exist on physical growth that provide reassurance that exclusive breastfeeding for 6 months does not lead to growth faltering, particularly in low-birthweight infants.14

Two strategies have been successful in the promotion of exclusive breastfeeding: the Baby Friendly Hospital Initiative, which increased the likelihood of exclusive breastfeeding in Belarus, where most births take place in health facilities, 2 and the use of peer counsellors in settings where most babies are delivered at home.1, 12 The second approach, based on recruitment of workers dedicated to a single intervention, is unlikely to be sustainable in health systems with few resources.

Our aim was to assess the success, and effects on prevalence of diarrhoea and physical growth, of a community based intervention to promote exclusive breastfeeding until age 6 months and complementary feeding thereafter. Our findings on effects on complementary feeding will be reported separately.

Section snippets

Participants

Between Jan 1, 1998, and March 31, 2002, we did a cluster randomised controlled trial in the state of Haryana, India, in communities located 3–5 km from the main highway.

Before we selected the study sites we sought collaboration from the local health system, who ultimately became a partner in the study. We also sought oral permission from community leaders to include their area in the study, and obtained written informed consent from all parents of infants. The study was approved by the ethics

Results

In Haryana, the literacy rates are low; 50% of women and 15% of men have never been to school.11 The common occupations for men are agriculture and employment in factories. Water supply is through community hand pumps. Families normally defecate in the fields. Maternal undernutrition rates are high; 26% of married women have a body-mass index of less than 18·5 kg/m2.11 Health care is provided through primary-health centres, each of which serves a population of about 30 000 through two or three

Discussion

Our findings indicate that promotion of exclusive breastfeeding until age 6 months in a developing country setting through existing primary-health-care services is feasible, does not lead to growth faltering, and reduces the risk of diarrhoea. Additionally, educational intervention greatly improved the rates of exclusive breastfeeding, as previously indicated by the results of two community-based trials, which assessed the use of peer counsellors, and several hospital and clinic based

References (24)

  • P Howie et al.

    Protective effects of breastfeeding against infection

    BMJ

    (1990)
  • WH Oddy

    Breastfeeding protects against illness and infection in infants and children: a review of the evidence

    Breastfeed Rev

    (2001)
  • Cited by (0)

    Members listed at end of paper

    View full text