CARRERA DE LAS ESTRELLAS-POTRILLOS-G

The WHO has defined eight core and seven optional infant and young child feeding indicators which are shown in full in Appendices 6.7-6.9 along with additional breastfeeding characteristics (World Health Organisation 2009). I thought it was plausible that the groups could have impacted on five of the WHO indicators (early initiation of breastfeeding, exclusive breastfeeding under six-months, bottle-feeding, timeliness of weaning and minimum meal frequency), and pre-lacteal feeding. The rationale and details for these models are presented in Table 6.3 and model results are presented in Table 6.4. The full final models including all predictor estimates, and the results of multiple imputation and sibling-adjusted models are located in Appendices 6.10-6.15.

Table 6.3 Rationale and details for self-reported breastfeeding and young child feeding models

Model Outcome Binary categorisation Sample Pathway to improved child growth

1 Early initiation of

breastfeeding

Baby put to breast within 1 hour of birth (yes/no) Full sample Child diarrhoea prevention/optimal growth. 178/244 groups requested Auxiliary Nurse Midwives to promote breastfeeding 2 Pre-lacteal

feeds

What was the child given first when born? Breast milk or other Full sample Child diarrhoea prevention/optimal growth 3 Exclusive breastfeeding for 6 months

Children only received breast milk the previous day (yes/no) Children 2.00-5.99 months Child diarrhoea prevention/optimal growth. 178/244 groups requested Auxiliary Nurse Midwives to promote breastfeeding; exclusive breastfeeding for 6 months advised in cycle 2 4 Bottle-feeding Ever fed anything from a

bottle (yes/no)

Full sample

Diarrhoea prevention: women advised to abstain from bottle feeding and use a cup and spoon instead 5 Timeliness of

weaning

Child received solid, semi-solid or soft food the previous day (yes/no)

6.00-8.99 months

Child nutrition/diet: age appropriate introduction of solid, semi-solid or soft food 6 Minimum

meal frequency

Child fed the appropriate number of times for their age, including breast milk, the previous day (yes/no)

6.00- 23.99 months

Child nutrition/diet: Guidance about feeding frequency from 6 months of age was given during women’s groups

147 There was no clear rationale for testing intervention associations with the following breastfeeding indicators, but I have briefly described them here. Self-reports of continued breastfeeding at one year were very high in both groups (>93%), as were rates of ‘ever breastfed’ children (>98%) and continued breastfeeding at two years (>82%). According to maternal report more than two-thirds of children received ‘age appropriate breastfeeding’ (exclusive breastfeeding <6 months and breast milk plus complementary food for ≥6 months) and this was similar between groups. ‘Predominant breastfeeding’ which allows a restricted range of other liquids for children <6 months was higher in the intervention areas (87.2%) than the control areas (75.6%). Median duration of breastfeeding went beyond 35.99 months in the intervention group and was 30.89 months in the control areas. Overall this highlights that self-reported breastfeeding behaviours were positive in both groups. The only measure of slight concern was colostrum discarding: this was reported by more than a fifth of women in the control areas and 5% in the intervention areas, although there is a lot of missing data in the intervention group due to a change in the surveillance questionnaire.

There was also no clear rationale to test for group differences for the following child feeding indicators, but I have briefly described them here to provide a contrast with the largely positive breastfeeding indicators. Minimum dietary diversity (maternal reports of consumption of ≥4 food groups in the previous 24 hours) was very low across groups at <10%. This is partially accounted for by the low proportion of children who had been introduced to other foods in the 6.00-8.99 month group and shows a positive relationship with child age. Minimum acceptable diet, derived from dietary diversity and minimum meal frequency, and depends on whether the child has been introduced to complementary foods, was lower amongst breastfed children in the intervention group than the control (62.0% versus 67.2%). Again this indicator was positively related to child age, with >83% achieving a minimally acceptable diet in the 18.00-23.99 age group. However, this indicator was strikingly low amongst non-breastfed children 6.00-23.99 months (0%-3.3%). Consumption of iron-rich foods appeared to be low across exposure groups, even in the oldest age group (<15%).

Model results

Self-reported early initiation and exclusive breastfeeding until 6 months were both higher in the intervention areas than the control areas (71.7% versus 64.2% and 71.2% versus 67.0% respectively). The introduction of soft, semi-solid and soft foods in children 6.00-8.99

148 months appeared low at ≤45%. Maternally reported minimum meal frequency for breastfed children was higher in the control group than the intervention (67.0% versus 61.4%). The same pattern was seen for non-breastfed children, although far fewer of these children in either exposure group met the criteria compared to breastfed counterparts. Reported bottle-feeding was higher in the intervention group than the control, consistently across age groups. Milk feeding frequency for non-breastfed children was low in both exposure groups (6.3%-7.2%). Self-reported pre-lacteal feeding was more common in the control areas than in the intervention areas (10.7% versus 7.7%) and most commonly included honey/honey water, goat’s/cow’s milk or sugar/sugar water. There were no significant associations of intervention exposure with any of these outcomes; this remained the case when the final models were re-run in the multiple imputed dataset and the sibling-adjusted dataset.

149 Table 6.4 The association between intervention exposure and maternally reported infant and young child feeding practices, adjusted for socio-demographic variables (0=control, 1=intervention)

Outcome Intervention % (n) Control % (n) Total % (n) Unadjusted OR (95%CI) Adjusted OR (95%CI) 1. Early initiation of breastfeeding1 71.7 (1295/1805) 64.2 (1430/2226) 67.6 (2725/4031) 1.413 (0.580-3.442) 1.410 (0.585-3.394) 2. Pre-lacteal feeding2 7.8 (140/1799) 10.8 (238/2200) 9.5 (378/3999) 0.696 (0.302-1.603) 0.665 (0.292-1.512) 3. Exclusive breastfeeding (children under six months) 3 71.2 (89/125) 67.0 (132/197) 68.6 (221/322) 1.217 (0.620-2.390) 1.246 (0.669-2.318) 4. Any bottle-feeding4 16.7 (301/1805) 11.3 (251/2226) 13.7 (552/4031) 1.575 (0.854-2.903) 1.463 (0.841-2.545) 5. Introduction of solid, semi-solid or soft foods (6.00-8.99

months)5

42.0 (170/390) 45.0 (94/209) 43.6 (170/390) 0.886 (0.504-1.557) 1.161 (0.638-2.112) 6. Minimum feeding frequency (6.00-23.99 months)6 61.4 (603/982) 67.0 (732/1092) 64.4 (1335/2074) 0.782 (0.490-1.250) 0.770 (0.483-1.229)

1_{Adjusted for: maternal education, relationship to household head, social group}

3_{Adjusted for: socio-economic status, social group}

3

Adjusted for: Income group

4

Adjusted for: socio-economic status, relationship to household head, maternal age, season of measurement

5

Adjusted for: socio-economic status

6

150