Breastfeeding Interpersonal Communication, Mobile Phone Support, and Mass Media Messaging Increase Exclusive Breastfeeding at 6 and 24 Weeks Among Clients of Private Health Facilities in Lagos, Nigeria

"[T]his study demonstrates that training health-care providers in private health facilities..., providing breastfeeding counseling, and offering mobile phone support for breastfeeding increases exclusive breastfeeding among their clients."

A variety of factors are known to influence breastfeeding practices, including: the sociocultural context; information and support from the health system, family, and community; and individual-level determinants. To address these factors and the barriers they may pose to optimal breastfeeding practices, the Alive & Thrive (A&T) initiative in Nigeria undertook a breastfeeding promotion intervention in Lagos State in collaboration with Equitable Health Access Initiative from May 2019 to April 2020. This study measures the impacts of the intervention on early initiation of breastfeeding and exclusive breastfeeding, also exploring secondary outcomes such as effects on mothers' breastfeeding knowledge and intentions.

The research described here is a quasi-experimental longitudinal cohort study of women interviewed in their third trimester of pregnancy and at 6 and 24 weeks postpartum to measure breastfeeding intentions and practices. It was conducted in 20 private health facilities (10 intervention and 10 comparison facilities) in Lagos State, Nigeria.

The intervention consisted of several components: 6 hours of initial and 2 hours of quarterly refresher training for facility managers and staff on implementation of the World Health Organization (WHO)/United Nations Children's Fund (UNICEF)'s e Baby-Friendly Hospital Initiative (BFHI) and breastfeeding counseling skills; provision of interpersonal communication and counseling in person and on WhatsApp by health facility staff; distribution of behaviour change communication (BCC) materials, including posters and counseling cards; delivery of mobile phone messages; and mass media television spots on breastfeeding that were played on LED screens at the intervention facilities.

In addition to the specific intervention components delivered in intervention facilities during this study, A&T's overall infant and young child feeding (IYCF) programme was ongoing in Lagos State. Grounded in principles of behavioural science, systems strengthening, and social marketing, A&T's BCC strategy included strategic use of data, interpersonal communication, social mobilisation, mass media, and policy advocacy. For example, in the areas where the intervention facilities were located, A&T supported IYCF community mobilisation activities, which included sensitisation and training of traditional and religious leaders on IYCF to improve awareness of optimal IYCF practices in their communities. Also in these areas, selected doctors, nurses, midwives, community health extension workers, and traditional birth attendants in public and private health facilities were trained to provide IYCF counseling to pregnant and breastfeeding mothers.

A&T did not provide support for breastfeeding promotion activities in comparison facilities during this study. Facilities in the comparison areas continued with their usual breastfeeding activities, such as individual breastfeeding counseling offered during provider visits, if at all, with no implementation of BFHI. However, A&T's IYCF programme's television and radio spots were publicly broadcast throughout the state, which explains why the researchers could not randomly assign facilities to study arms.

The researchers used logistic regression models adjusted for clustering to measure intervention impact in a cohort of women (n = 1,200: 600 in each arm). Main findings:

• The intervention significantly increased the percentage of infants who were exclusively breastfed at 6 weeks (83% intervention; 76% comparison; P = 0.02) and 24 weeks (66% intervention; 52% comparison; P < 0.001).
• However, it had no impact on early initiation of breastfeeding (35% intervention; 33% comparison; P = 0.65).
• Among infants who were exclusively breastfed at 6 weeks, the odds of continued exclusive breastfeeding at 24 weeks were higher in the intervention arm than in the comparison arm (odds ratio (OR) 1.6; 95% confidence interval (CI): 1.2-2.1).
• Infants had increased odds of being exclusively breastfed at 6 weeks if their mothers discussed breastfeeding with a private health provider (OR, 2.3; 95% CI: 1.5-3.4), received text or WhatsApp messages about breastfeeding (OR, 1.7; 95% CI: 1.0-2.7), or heard breastfeeding radio spots (OR, 4.2; 95% CI: 1.2-14.7).
• Infants had increased odds of exclusive breastfeeding at 24 weeks if their mothers participated in a WhatsApp breastfeeding support group (OR, 1.5; 95% CI: 1.0-2.2).

The researchers note that in-person interpersonal communication by private health providers was the most common exposure throughout the intervention. Exposure to mobile phone and mass media intervention components was low during pregnancy and ramped up throughout the intervention, but remained below 50% coverage for most of these types of exposures at 24 weeks. Women reported that very few of their husbands or mothers/mothers-in-law received text messages about breastfeeding.

In the researchers' estimation, the size of the intervention effect on exclusive breastfeeding was large enough to make the intervention worth expanding to other private facilities in Lagos and in other cities in Nigeria. However, they suggest that further analysis of the data collected during the study is needed to adapt the intervention to ensure better uptake of early initiation of breastfeeding and more involvement of influential family members. The intervention could also be tested in other low- and middle-income countries (LMICs) to determine whether it is equally effective and whether other modifications are necessary.

In conclusion, the findings of this study support the recognition that a functioning health-facility-based strategy for delivering breastfeeding counseling and support to women is essential for breastfeeding promotion in LMICs. Because health providers have been shown to be trusted sources of breastfeeding information and support during pregnancy and the postpartum period, they can play an important role in counseling women and supporting their breastfeeding decisions, thereby facilitating the continuation of exclusive breastfeeding.