Effectiveness of couple counselling versus maternal counselling in promoting exclusive breast feeding: a randomised controlled trial in Nyando District, Kenya
Ogada, Irene Awuor
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The World Health Organisation and United Nations’ Children’s Fund recommend exclusive breastfeeding (EBF) for 6 months. The prevalence of EBF among children below 6 months is 32% and 35% in Kenya and Nyanza province respectively. Despite fathers being identified as stakeholders in infant feeding, few interventions target them in activities to promote EBF. There is limited information on the effectiveness of breastfeeding interventions targeting fathers, particularly in sub-Saharan Africa. The purpose of this study was to compare the effectiveness of ‘Couple Counselling’ to ‘Maternal Counselling’ in promoting EBF practice, knowledge and attitudes among mothers and fathers, in Nyando District, Kenya. This was a community-based cluster-randomised trial in which study participants were assigned to three study groups- two experimental (maternal counselling and couple counselling) and one control, based on a ratio of 1:1:1. The final sample size for the study groups were as follows: 101 couples for the control group, 88 couples for maternal counselling and 91 couples for couple counselling. Breastfeeding counselling was conducted with mothers only in the maternal counselling group and with both mothers and fathers in the couple counselling group. Couples in the control group received no counselling from the research team. Participants in each of the experimental groups received a minimum of eight counselling sessions; 1 prenatally and 7 post-natally, on a monthly basis. To determine infant feeding practices, data was collected from mothers on a monthly basis in all study groups, through researcher-administered questionnaires. Focus group discussions and key informant interviews were conducted to collect qualitative data. Breastfeeding practices were determined based on 24- hour dietary recalls. Data was analysed using SAS version 9.2 software. From Kaplan Meier survival analysis, 12% of the infants in the control, 33% in the maternal and 44% in the couple counselling were exclusively breastfed continuously (without change) for 6 months. Significantly fewer infants in the maternal counselling group (Adjusted Hazard Ratio [AHR]: 0.63; CI: 0.50-0.80; p=0.001) and couple counselling group (AHR: 0.53; CI: 0.30-0.93; p=0.028) than in the control group were discontinued from EBF before the age of 6 months. Exclusive breastfeeding was not significantly different between the two experimental groups at 6 months (AHR: 0.81; CI 0.46-1.43; p=0.465). Maternal counselling resulted in significantly higher improvement in maternal breastfeeding knowledge (Difference in difference [DID] of -1.780, p=0.001), while couple counselling resulted in significantly higher improvements in maternal attitudes towards breastfeeding (DID of 3.381, p=0.001). Among the fathers, couple counselling led to significantly higher improvements in knowledge (DID of 2.600, p=0.001), and no significant differences in the change of attitudes among the experimental groups (DID of 0.637, p=0.299). Couple counselling was acceptable to 99.2% of the mothers and 87.6% of the fathers. Factors negatively influencing paternal involvement in breastfeeding issues were: time constraints (89.6%), gender roles (72.7%), limited information and unintentional exclusion of fathers by mothers from the breastfeeding process. The predictors of EBF were: being a female infant (AHR: 1.39; CI: 1.15-1.66; p<0.001), being a housewife (AHR: 0.65; CI: 0.5-0.84; p=0.001) and being of lower socio-economic status (AHR: 1.55; CI: 1.13-2.14; p=0.006). Younger mothers also tended to be more likely to exclusively breastfeed compared to older ones (AHR: 1.03; CI: 1.00-1.05; p=0.022). The findings of this study may be useful to the Ministry of Health and organisations concerned with children’s health to strengthen or re-design current EBF programmes and strategies to include the fathers.