This study assessed the association of Infant and young child feeding (IYCF) practices with childhood illnesses and the possible determinants of IYCF practices in Rwanda using the Rwanda Demographic and health survey 2020. Among children below 6 months, 80.9% of them were exclusively breastfed. This prevalence is higher compared to the overall worldwide 48% prevalence of exclusive breastfeeding among children 0–5 months reported by UNICEF [4] and the collective target for the global rate by 2030 of 70% [37]. The prevalence of EBF in Rwanda is still higher compared to the whole of sub-Saharan Africa (32%) [38]. The prevalence of EBF in countries like Uganda (42.8%) and Tanzania (59%) is lower compared to that of Rwanda in this study[3]. Findings from previous studies concur with those from a study in sub-Saharan Africa which found the overall prevalence of EBF at 36% [38, 39]. The difference in the findings may be explained by the variations in the national level breastfeeding policies, attitudes, and perceptions regarding breastfeeding, as well as sociodemographic dynamics such as the level of education of women, their wealth index, exposure to media, mode of delivery, number of antenatal visits attended and place of delivery [21, 39].
According to this study, despite the high levels of complementary feeding of the children aged 6–23 months, some mothers (2.1%) delayed complementary feeding. These findings align with previous studies in Rwanda. For example, Umugwaneza et al. found out that women had a belief that children should be first fed on fluids before starting semi-solid food which deprived most of the children the essential nutrients for growth [19]. The misconceptions and negative beliefs about child feeding among women in Rwanda could thus explain the observed trend in delayed complementary feeding. Moreover, a previous study in Rwanda, found that despite the high and stagnated prevalence of complementary feeding, there were high levels of stunting among children attributable to low nutrient intake from complementary feeds [40]. The global alliance for improved nutrition attributed such trends to the high costs of buying nutritious complementary feeds in Rwanda [41].
There was a higher incidence of diarrhea, cough, and fever among children below 24 months of complementary breastfeeding in this study as compared to those on EBF. In other words, EBF had an overall protective advantage against common childhood illnesses considered in this study, regardless of the age group (below 6 months vs 6–23 months). These results concur with those from many other studies that have also shown EBF to be inversely associated with the occurrence of childhood illnesses like fever, cough and diarrhea, and infective gastroenteritis [42–45]. The observed higher odds of childhood illness among children on complementary feeding may be attributed to improper hand-washing practices, and providing half-cooked or uncooked food as complementary feeds which increases exposure to pathogens [44]. As compared to complementary feeding, EBF limits exposure to environmental pathogens that may be introduced through feeds and fluids and breast milk also has bioactive constituents that may function alone to enhance an infant's immune system [46]. In addition, complementary feeds might be either too early or too late, are hard to measure, and may therefore end up delivering an inappropriate quantity of nutrients to support the energy needs of a child for a healthy life in addition to microbial contamination, hence causing illnesses [47].
In this study, 5.5% of the females were not breastfeeding at all. Although small, it has public health relevance since the effects of compromised nutrition in such a critical stage of child development may be irreversible. Our findings are supported by a UNICEF report that highlighted that some (about 3.3%) women do not breastfeed their children in low- and middle-income countries [4]. Some factors that may influence women’s decision to not breastfeed their children at all include a need to return to work and tight work schedules, lack of support from the spouse, insufficient breast milk, financial barriers like pump assistance, personal issues like body image, stigma and lack of confidence which can cause a negative attitude towards breastfeeding [48]. Medical reasons like suffering from HIV/AIDS, and ill health for both the child and the mother are some of the other factors that could influence decisions against breastfeeding even when the mothers know about its benefits [49–51]. These same reasons might explain why some women in Rwanda do not breastfeed at all.
The study also found various sociodemographic factors associated with child-feeding practices. Regarding exclusive breastfeeding, women with no health insurance had higher odds of practicing exclusive breastfeeding than those with health insurance. These results are contrary to those from other studies where health insurance was found to increase, by 21%, the chances of EBF since it provided means to cover for costs of lactation support services and breastfeeding equipment [47, 52]. This can be explained by the fact that health insurance in low- and middle-income countries rarely covers breastfeeding equipment and lactation support services. Alternatively, mothers who afford insurance are in higher economic classes and have stable but highly demanding jobs/ employment which limits their time to breastfeed. Such mothers find it convenient to buy formula and other feeds for their babies instead of compromising their working time to breastfeed.
Women who had no media access had higher odds of EBF compared to those with media access. This concurs with results from a study that reported women with mobile phones to have 75% lower odds of EBF which was attributed to the distractive effect of mobile phones on breastfeeding women [53]. In addition, a study found that mothers who viewed more adverts about infant formula in media had lower odds of breastfeeding than their counterparts who viewed less or no adverts, as the latter perceived infant formula as the most convenient option for child feeding [54]. This is supported by the fact that the tendency to exclusively breastfeed mainly depends on the specificity of the content shared on media. Information focusing on the negative implications of breastfeeding like breast deformation could discourage women from breastfeeding [55].
Our results also show that women living in the Western and Southern regions, which are rural areas of Rwanda, had higher odds of EBF than those in Kigali, an urbanized region. This corroborates the findings of previous studies that also report women staying in urbanized regions having lower odds of EBF compared to those in rural areas [56]. A study done in Lao People's Democratic Republic, south-East Asia also found that mothers in urban areas had significantly lower odds of exclusive breastfeeding and complementary feeding [57]. This was explained by the fact that most urban households were in a higher wealth quartile, and can easily afford infant formula [57]. Another study in Ethiopia found that mothers in urban areas were 67% less likely to breastfeed exclusively [58]. This could be because women in urban areas are also more likely to be in formal employment, with limited maternity leave and a shorter time to dedicate to EBF compared to the women in the rural areas of the country.
Regarding complementary feeding among children aged 6–23 months, mothers who had attained at least primary education had higher odds of practicing complementary breastfeeding as compared to those with no formal education. In the same regard, a study in Pakistan found that children of uneducated mothers were highly malnourished [59]. This could be because educated mothers have attained knowledge about proper feeding practices and their benefits for their children.
In this study, older maternal age (45-49years) was associated with higher odds of complementary feeding, and this aligns with results from a systematic review that found mothers with advanced maternal age to have prior experience with proper child feeding practices [60]. Studies in Bangkok and Zimbabwe also reported a similar trend, with mothers below 25 years having lower odds of appropriate child practices due to lack of experience [61, 62]. Moreover, mothers of younger age have been reported to have less concern about their children’s hunger compared to those of advanced age [63].
Study findings also indicate that women in the poorest wealth quintile had less odds of complementary feeding compared to those in the richest wealth quintile. These results are consistent with other studies, for example, in Bangladesh where women with a higher wealth index were in the position to initiate appropriate complementary feeding for their children [62]. Studies from Zimbabwe and Mongolia reported that economic independence increased the odds of appropriate complementary feeding [61, 64]. This is because such women are more likely to meet the minimum meal frequency for their children [65]. Also, the wealth index is directly proportional to the household food security; thus the higher the wealth index, the higher the likelihood of affording appropriate complementary feeding [66].
Strengths and limitations
In this study, we used the most recent data from the 2020 Rwanda Demographic and Health survey, with a large sample size hence making our results generalizable to all women with children below 24 months in Rwanda. Additionally, worldwide, the DHS is known to have high response rates, with a big sample size and quality standardized data collection procedures, thus, our findings can be compared with other studies of the same design elsewhere.
However, the study has some limitations. The study used a cross-sectional design, and this does not allow causal inference but rather associations only. There is also a risk of recall and information bias since most of the data was self-reported. Since this is a secondary data analysis, there was also a lack of data on some key aspects of IYCF such as meal frequency, method of preparation, and hygienic environment, among others. Despite the limitations, the study provides useful insights into the relationship between IYCF practices and childhood illnesses in Rwanda.