Our study showed that a multi-level intervention, aimed at improving rates of exclusive breastfeeding in a hospital neonatology unit in rural Rwanda, increased early and exclusive breastmilk feeding, and also reduced length of stay and decreased mortality among small and sick newborns.
We found that from the pre- to post-intervention period, significantly more infants were fed exclusively on the breast and were exclusively fed breastmilk. We also observed earlier initiation of breastfeeding in the post-intervention and this earlier initiation increased the odds that an infant was discharged exclusively feeding on breastmilk. This is consistent with other studies as it is well known that if milk removal does not occur either by infant suckling or expression by hand or pump, milk secretion will start to decline around day 3 postpartum[21, 22]. A study comparing milk expression within 1 hour after delivery to within 1–6 hours after delivery showed that the earlier expression group had earlier lactogenesis stage II (transition from colostrum to copious breast milk production) and resulted in higher milk volume[23]. Another study showed that milk volume on postpartum day 4 is predictive of having an adequate milk supply at 6 weeks[24]. These studies demonstrate the critical need for early expression of breast milk after delivery, whether the infant is able to breastfeed on the breast or if the mother expresses breastmilk and the infant receives breastmilk through other enteral feeding routes (i.e., cup, naso-gastric tube).
Mortality among newborns decreased from the pre- to post-intervention period, particularly among infants born LBW. The association between decreased mortality and exclusive breastfeeding has been well established in the literature and is often promoted as strong support for initiation of early and exclusive breastfeeding[1, 3–6, 25].
Overall length of stay showed a significant reduction from the pre- to post-intervention period. While hospital neonatology units are meant to be an environment for infants to improve from various illnesses or conditions, long length of stay in hospitals also increases an infant’s chance of contracting hospital acquired infections[26]. Therefore, the ability to reduce the length of stay for newborns may have an impact on the overall morbidity of the infant. While we did not measure morbidity in this study, early initiation of breastfeeding has been shown to reduce morbidity in newborns[3], which likely has a positive impact on the total length of hospitalization. Reducing the time families, particularly mothers, spend in hospitals can also have a significant impact on the mother’s stress, and the family’s economic situation[27, 28]. Reduced length of stay was likely a secondary outcome of improved breastfeeding rates in the post-intervention period. The overall larger number of admissions with a birthweight greater than 1,500 grams and gestational age over 32 weeks in the post-intervention period may have also contributed to lower mortality and shorter length of stay.
We found that the location of where the infant is born was associated with whether they are discharged from the hospital exclusively breastfeeding or not. Infants born at health centers or in the home were less likely to be discharged exclusively breastfeeding, compared to those born in the hospital which has also been seen in other studies[29, 30]. There may be many reasons for this. Infants born at home need to first be transferred to the health center, and subsequently to the hospital which may delay the introduction of breastmilk for those infants, and subsequently impact whether the infant is discharged exclusively breastfeeding. The clinical staff at health centers may also be less experienced in caring for high-risk newborns, and may not follow essential newborn care practices and delay introduction of breastmilk since the infant needs to be clinically stabilized and then transferred to the hospital.
Infants born preterm were less likely to be discharged exclusively breastfeeding compared to infants born at term. Infants born preterm have unique feeding needs that require specialized interventions and management, and other studies have demonstrated similar findings of reduced exclusive breastfeeding rates even among moderate to late preterm newborns compared to term newborns[31]. Similarly, infants admitted for infection risk or neonatal infection in our study had much higher odds of exclusive breastfeeding. These findings are not surprising, as these infants are often term and feed easily. But notably, even when considering all of these factors in multivariate analysis, admission during the post-intervention period was the strongest predictor of exclusive breastfeeding at the time of discharge with nearly double the odds of exclusive breastfeeding compared to the pre-intervention period. Other factors in the neonatal care unit environment may also interfere with early and exclusive breastfeeding, including delayed initiation of KMC, or skin-to-skin contact, especially for sick newborns[32]. We were unable to measure timing or duration of KMC but this is an area that warrants further attention to reduce breastfeeding barriers.
Our study has some limitations. First, we used routinely collected data for the study, which results in some missing data and reliance on clinician skills in completion of medical files. In addition, precise measurement of gestational age is a challenge in Rwanda like in other low- and middle-income countries where availability of ultrasound dating is limited. Due to the use of routine data, it was not possible to reliably discriminate between newborns with infection or those with risk of infection and so we included all of these newborns in our sample. We also had a small sample size of patients born with HIE and those born with extremely low birth weight, which prevented measurement of the impact of interventions on these subsets.