Individual peer counselling for exclusive breastfeeding in Uganda

Introduction Breastfeeding remains a potent child survival strategy estimated to save up to 1.5 million infant deaths every year when optimally practiced. Despite breastfeeding being universal in most of sub-Saharan Africa, exclusive breastfeeding (EBF) is rarely practiced. Peer counselling for EBF, particularly in non-African settings, has been reported to lead to increased EBF levels. This thesis explores the experiences from the process of setting up a community-based individual peer counselling intervention for support of EBF in a trial in Eastern Uganda, and assesses its effect on mothers who opted to breastfeed. Methods This thesis is composed of three sub-studies done within a multi-centre cluster-randomized behavioural intervention trial (PROMISE-EBF) to assess the effect of individual peer counselling on EBF rates as one of its primary objectives. The trial took place in Burkina Faso, Uganda, Zambia and South Africa, but the focus of this thesis was on the process of setting up the peer counselling in the Ugandan urban and rural sites. The first sub-study assessed by qualitative methods the feasibility of training rural women as peer counsellors for EBF in the Iganga district in preparation for the main study. The next sub-study also used qualitative methods to explore the process of selection, training and follow-up of peer counsellors for the PROMISE-EBF trial in the Mbale district. The peer counsellors were given a pre- and post-test questionnaire to assess the effect of training and follow-up on their knowledge and attitudes towards EBF. Observations made during the study and field notes were used to understand this process. The last sub-study was cross-sectional following completion of the peer counselling visits which explored the perceptions and experiences of the supported women and how they felt about the peer counselling intervention. For this sub-study, we employed a mixed methods approach (qualitative and quantitative) and a semi-structured questionnaire for data capture. Results Training rural women with modest formal education to help their peers with breastfeeding proved feasible. Peer counselling for EBF was acceptable to the communities where it had been introduced by systematically involving community members and getting them, to participate in the selection process. The peer counsellors appreciated supervisory visits, which offered a venue for sharing their achievements and challenges. In the PROMISE-EBF study in Mbale, all the peer counsellors worked throughout the entire duration of the trial. Before training, the peer counsellors had some knowledge gaps and negative attitudes regarding EBF, but were positively influenced by the training and follow-up. The supported women were happy to have someone familiar from their community sit with them at home to help them with breastfeeding practices. The women receiving counselling were generally satisfied with its different aspects. Satisfaction was most prominent within the group that received 5 or more visits compared to the group that received <5 visits (80% versus 59%, p <0.001). The fathers and grandmothers influenced the infant feeding decisions adopted by the mothers. Conclusions Systematic planning and implementation of the peer counselling intervention for EBF was useful for making it acceptable to the community. Peers offered huge potential for breastfeeding support that was highly accepted among the supported mothers. In this rural Ugandan community where infant feeding decisions were made in consultation, involving other members of the family - especially the fathers and grandmothers - during the process of peer counselling appeared to improve the desired behaviour of practising EBF. In case of scale-up of this intervention, the main points to emphasise include: community involvement, proper training using appropriate culturally sensitive curricula and effective support supervision for the peer counsellors

Individual peer counselling for exclusive breastfeeding in Uganda

Introduction Breastfeeding remains a potent child survival strategy estimated to save up to 1.5 million infant deaths every year when optimally practiced. Despite breastfeeding being universal in most of sub-Saharan Africa, exclusive breastfeeding (EBF) is rarely practiced. Peer counselling for EBF, particularly in non-African settings, has been reported to lead to increased EBF levels. This thesis explores the experiences from the process of setting up a community-based individual peer counselling intervention for support of EBF in a trial in Eastern Uganda, and assesses its effect on mothers who opted to breastfeed. Methods This thesis is composed of three sub-studies done within a multi-centre cluster-randomized behavioural intervention trial (PROMISE-EBF) to assess the effect of individual peer counselling on EBF rates as one of its primary objectives. The trial took place in Burkina Faso, Uganda, Zambia and South Africa, but the focus of this thesis was on the process of setting up the peer counselling in the Ugandan urban and rural sites. The first sub-study assessed by qualitative methods the feasibility of training rural women as peer counsellors for EBF in the Iganga district in preparation for the main study. The next sub-study also used qualitative methods to explore the process of selection, training and follow-up of peer counsellors for the PROMISE-EBF trial in the Mbale district. The peer counsellors were given a pre- and post-test questionnaire to assess the effect of training and follow-up on their knowledge and attitudes towards EBF. Observations made during the study and field notes were used to understand this process. The last sub-study was cross-sectional following completion of the peer counselling visits which explored the perceptions and experiences of the supported women and how they felt about the peer counselling intervention. For this sub-study, we employed a mixed methods approach (qualitative and quantitative) and a semi-structured questionnaire for data capture. Results Training rural women with modest formal education to help their peers with breastfeeding proved feasible. Peer counselling for EBF was acceptable to the communities where it had been introduced by systematically involving community members and getting them, to participate in the selection process. The peer counsellors appreciated supervisory visits, which offered a venue for sharing their achievements and challenges. In the PROMISE-EBF study in Mbale, all the peer counsellors worked throughout the entire duration of the trial. Before training, the peer counsellors had some knowledge gaps and negative attitudes regarding EBF, but were positively influenced by the training and follow-up. The supported women were happy to have someone familiar from their community sit with them at home to help them with breastfeeding practices. The women receiving counselling were generally satisfied with its different aspects. Satisfaction was most prominent within the group that received 5 or more visits compared to the group that received <5 visits (80% versus 59%, p <0.001). The fathers and grandmothers influenced the infant feeding decisions adopted by the mothers. Conclusions Systematic planning and implementation of the peer counselling intervention for EBF was useful for making it acceptable to the community. Peers offered huge potential for breastfeeding support that was highly accepted among the supported mothers. In this rural Ugandan community where infant feeding decisions were made in consultation, involving other members of the family - especially the fathers and grandmothers - during the process of peer counselling appeared to improve the desired behaviour of practising EBF. In case of scale-up of this intervention, the main points to emphasise include: community involvement, proper training using appropriate culturally sensitive curricula and effective support supervision for the peer counsellors

Magnitude and factors associated with delayed initiation of breastfeeding among mothers who deliver in Mulago hospital, Uganda.

Background: Breastfeeding as a determinant of infant health and nutrition saves up to 1.5 million infant lives annually. Though breastfeeding is mostly universal in sub-Saharan Africa, early initiation of breastfeeding is rarely practiced.Objective: To determine magnitude and factors associated with delayed initiation of breastfeeding among mother-infant pairs who deliver in Mulago hospital.Methods: We carried out a descriptive cross sectional study, where 665 mother-infant pairs were interviewed within 24 hours following delivery; with additional qualitative data collected using focus group discussions to understand reasons for delaying initiation. The data was analysed by identification and coding of themes.Results: In this study, 31.4% mothers delayed initiation of breastfeeding. This was associated with maternal HIV positive status (AOR 2.3; 95% CI 1.3-4.2), inadequate prenatal guidance, (AOR 3.6; 95% CI 1.9-6.8), inadequate professional assistance to initiate breastfeeding (AOR 1.8; 95% CI 1.2-2.8) and caesarean section delivery (AOR 8.6; 95% CI 4.7-16.0). Other reasons were perceived lack of breast milk, need of rest for both mother and baby after labor, and negative cultural beliefs.Conclusion: In Mulago Hospital 1:3 mothers delayed initiation of breastfeeding. The reasons for delayed initiation include; inadequate information during ANC, HIV positive serostatus, caesarian section delivery and negative cultural ideas.Keywords: Breastfeeding, initiation, delayed, HI

"She would sit with me": mothers' experiences of individual peer support for exclusive breastfeeding in Uganda

Background: Different strategies have been used to improve the initiation and duration of breastfeeding. Peer counsellors are reported to improve exclusive breastfeeding levels, but few studies have assessed the satisfaction of women with the support given, especially in Africa. In this paper we describe women’s experiences of peer counselling for exclusive breastfeeding in an East African setting. Methods: In the Ugandan site of PROMISE-EBF, a multi-centre community randomised trial to evaluate the effect of peer counselling for exclusive breastfeeding on infant health, 370 women in the intervention arm participated in a study exit interview. Individual peer counselling was offered to women in 12 of the 24 study clusters, scheduled as five visits: before childbirth and during weeks 1, 4, 7 and 10 after childbirth. During the visits, the women were given information and skills to help them breastfeed exclusively. After the 10-week visit, they were interviewed about their feelings and experiences related to the peer counselling. Results: Overall, more than 95% of the women expressed satisfaction with the various aspects of peer counselling offered. Those who had received five or more visits were more likely to give positive responses about their experience with peer counselling than those who had received fewer visits. They explained their satisfaction with time spent with the peer counsellor in terms of how much she discussed with them. Most women felt their knowledge needs about breastfeeding were covered by the peer counsellors, while others expressed a desire to learn about complementary feeding and family planning. Attributes of the peer counsellors included their friendliness, being women and giving support in a familiar and relaxed way. Women were positive about the acquisition of knowledge and the benefit to their babies from the peer counselling. They preferred a peer counsellor to a health worker for support of exclusive breastfeeding because of their friendly approach. Conclusions: Individual peer counselling to support exclusive breastfeeding was positively received by the women

Magnitude and factors associated with delayed initiation of breastfeeding among mothers who deliver in Mulago hospital, Uganda.

Background: Breastfeeding as a determinant of infant health and nutrition saves up to 1.5 million infant lives annually. Though breastfeeding is mostly universal in sub-Saharan Africa, early initiation of breastfeeding is rarely practiced. Objective: To determine magnitude and factors associated with delayed initiation of breastfeeding among mother-infant pairs who deliver in Mulago hospital. Methods: We carried out a descriptive cross sectional study, where 665 mother-infant pairs were interviewed within 24 hours following delivery; with additional qualitative data collected using focus group discussions to understand reasons for delaying initiation. The data was analysed by identification and coding of themes. Results: In this study, 31.4% mothers delayed initiation of breastfeeding. This was associated with maternal HIV positive status (AOR 2.3; 95% CI 1.3-4.2), inadequate prenatal guidance, (AOR 3.6; 95% CI 1.9-6.8), inadequate professional assistance to initiate breastfeeding (AOR 1.8; 95% CI 1.2-2.8) and caesarean section delivery (AOR 8.6; 95% CI 4.7-16.0). Other reasons were perceived lack of breast milk, need of rest for both mother and baby after labor, and negative cultural beliefs. Conclusion: In Mulago Hospital 1:3 mothers delayed initiation of breastfeeding. The reasons for delayed initiation include; inadequate information during ANC, HIV positive serostatus, caesarian section delivery and negative cultural ideas

Community based peer counsellors for support of exclusive breastfeeding: experiences from rural Uganda

BACKGROUND: Universal exclusive breastfeeding for the first six months could reduce infant mortality by 13%. Although 99% women initiate breastfeeding in Uganda, exclusive breastfeeding rates remain low. Although peer counsellors for support of breastfeeding mothers have been found useful in other countries, they have not been used in Uganda. The aim of this pilot study was to assess the feasibility of training community based peer counsellors to support exclusive breastfeeding in a rural district in Uganda. METHODS: With assistance of the investigators, the local communities selected fifteen women aged 25 to 30 years. These women were trained for five days on breastfeeding counselling using the La Leche League curriculum. After training they returned to their communities and started supporting breastfeeding peers. They were followed up and supported in their work for three months. The programme was evaluated through focus group discussions with the peer counsellors, fathers and mothers. RESULTS: The trainees appreciated the knowledge gained and discussed cultural beliefs which affect breastfeeding. They offered breastfeeding support to 15 mothers each within the first two months. They found time to visit and help their breastfeeding peers despite busy schedules. They identified common breastfeeding problems as "insufficient breast milk", sore nipples, breast engorgement, mastitis and poor positioning at the breast. They further observed that most of these problems were eased by correct positioning of the baby at the breast. The peer counsellors were easily accepted by their communities. The mothers were happy to have someone within their community helping them with their breastfeeding problems. Although the peer counsellors were initially selected as volunteers, soon they demanded remuneration. CONCLUSION: The training and follow up of peer counsellors to support exclusive breastfeeding in this rural district is feasible. The peer counsellors were accepted by their communities

Malaria Parasitaemia among Infants and Its Association with Breastfeeding Peer Counselling and Vitamin A Supplementation: A Secondary Analysis of a Cluster Randomized Trial

Background: Malaria is the second highest contributor to the disease burden in Africa and there is a need to identify low cost prevention strategies. The objectives of this study were to estimate the prevalence of malaria parasitaemia among infants and to measure the association between peer counselling for exclusive breastfeeding (EBF), vitamin A supplementation, anthropometric status (weight and length) and malaria parasitaemia. Methods: A cluster randomized intervention trial was conducted between 2006 and 2008 where 12 of 24 clusters, each comprising one or two villages, in Eastern Uganda were allocated to receive peer counselling for EBF. Women in their third trimester of pregnancy (based on the last normal menstrual period) were recruited in all 24 clusters and followed up until their children’s first birthday. Blood was drawn from 483 infants between 3 and 12 months of age, to test for malaria parasitaemia. Results: The prevalence of malaria parasitaemia was 11% in the intervention areas and 10% in the control areas. The intervention did not seem to decrease the prevalence of malaria (PR 1.7; 95% CI: 0.9, 3.3). After controlling for potential confounders, infants not supplemented with Vitamin A had a higher prevalence for malaria compared to those who had been supplemented (PR 6.1; 95% CI: 2.1, 17.6). Among children supplemented with vitamin A, every unit increase in lengthfor- age Z (LAZ) scores was associated with a reduced prevalence in malaria (PR 0.5; 95% CI:0.4, 0.6). There was no association between LAZ scores and malaria among children that had not been supplemented. Conclusion: Peer counselling for exclusive breastfeeding did not decrease the prevalence of malaria parasitaemia. Children that had not received Vitamin A supplementation had a higher prevalence of malaria compared to children that had been supplemented

Cost of individual peer counselling for the promotion of exclusive breastfeeding in Uganda

<p>Abstract</p> <p>Background</p> <p>Exclusive breastfeeding (EBF) for 6 months is the recommended form of infant feeding. Support of mothers through individual peer counselling has been proved to be effective in increasing exclusive breastfeeding prevalence. We present a costing study of an individual peer support intervention in Uganda, whose objective was to raise exclusive breastfeeding rates at 3 months of age.</p> <p>Methods</p> <p>We costed the peer support intervention, which was offered to 406 breastfeeding mothers in Uganda. The average number of counselling visits was about 6 per woman. Annual financial and economic costs were collected in 2005-2008. Estimates were made of total project costs, average costs per mother counselled and average costs per peer counselling visit. Alternative intervention packages were explored in the sensitivity analysis. We also estimated the resources required to fund the scale up to district level, of a breastfeeding intervention programme within a public health sector model.</p> <p>Results</p> <p>Annual project costs were estimated to be US$56,308. The largest cost component was peer supporter supervision, which accounted for over 50$139 and the cost per visit was US$26. The cost per week of EBF was estimated to be US$15 at 12 weeks post partum. We estimated that implementing an alternative package modelled on routine public health sector programmes can potentially reduce costs by over 60%. Based on the calculated average costs and annual births, scaling up modelled costs to district level would cost the public sector an additional US$1,813,000.</p> <p>Conclusion</p> <p>Exclusive breastfeeding promotion in sub-Saharan Africa is feasible and can be implemented at a sustainable cost. The results of this study can be incorporated in cost effectiveness analyses of exclusive breastfeeding promotion programmes in sub-Saharan Africa.</p

Outcome of infants with 10 min Apgar scores of 0-1 in a low-resource setting

Background In high-resource settings, postponing the interruption of cardiopulmonary resuscitation from 10 to 20 min after birth has been recently suggested, but data from low-resource settings are lacking. We investigated the outcome of newborns with Apgar scores of 0–1 at 10 min of resuscitative efforts in a low-resource setting. Methods This observational substudy from the NeoSupra trial included all 49 late preterm/full-term newborns with Apgar scores of 0–1 at 10 min of resuscitation. The study was carried out at Mulago National Referral Hospital (Kampala, Uganda) between May 2018 and August 2019. Outcome measures were mortality and hypoxic-ischaemic encephalopathy in the first week of life. All resuscitations were video recorded and daily reviewed by trial researchers. Results Median duration of resuscitation was 32 min (IQR 17–37). Advanced resuscitation was provided to 21/49 neonates (43%). Overall, 48 neonates (98%) died within 2 days of life (44 in the delivery room, three on the first day and one on the second day) and one survived at 1 week with severe hypoxic-ischaemic encephalopathy. Conclusion Our study adds information from a low-resource setting to the recent evidence from high-resource settings about prolonging the resuscitation in infants with Apgar scores of 0–1 at 10 min. The vast majority died in the delivery room despite prolonged resuscitative efforts. We confirm that duration of resuscitation should be tailored to the setting, while the focus in low-resource settings should be improving the quality of antenatal and immediately after birth care.acceptedVersio

Is facility based neonatal care in low resource setting keeping pace? A glance at Uganda\u2019s National Referral Hospital.

Objectives: To identify reasons for neonatal admission and death with the aim of determining areas needing improvement. Method: A retrospective chart review was conducted on records for neonates admitted to Mulago National Referral Hospital Special Care Baby Unit (SCBU) from 1st November 2013 to 31st January 2014. Final diagnosis was generated after analyzing sequence of clinical course by 2 paediatricians. Results: A total of 1192 neonates were admitted. Majority 83.3% were in-born. Main reasons for admissions were prematurity (37.7%) and low APGAR (27.9%).Overall mortality was 22.1% (Out-born 33.6%; in born 19.8%). Half (52%) of these deaths occurred in the first 24 hours of admission. Major contributors to mortality were prematurity with hypothermia and respiratory distress (33.7%) followed by birth asphyxia with HIE grade III (24.6%) and presumed sepsis (8.7%). Majority of stable at risk neonates 318/330 (i.e. low APGAR or prematurity without comorbidity) survived. Factors independently associated with death included gestational age &lt;30 weeks (p 0.002), birth weight &lt;1500g (p 0.007) and a 5 minute APGAR score of &lt; 7 (p 0.001). Neither place of birth nor delayed and after hour admissions were independently associated with mortality. Conclusion and recommendations: Mortality rate in SCBU is high. Prematurity and its complications were major contributors to mortality. The management of hypothermia and respiratory distress needs scaling up. A step down unit for monitoring stable at risk neonates is needed in order to decongest SCBU