Our reanalysis of the Endline Survey data of the JP revealed that 63% of mothers breastfed their newborns within an hour after birth which is below the 90% DOH target. There is also evidence that membership in breastfeeding support groups and visit by peer counselors only had marginal effects on promoting EIBF after confounding variables were controlled in the analysis. However, we did not find any interaction between peer counselor visit and membership in breastfeeding support groups in promoting EIBF. In other words, the two variables affected EIBF independently of each other, that is, peer counselor visits plus mothers’ membership in breastfeeding support groups did not significantly lead to more mothers initiating breastfeeding early after their delivery.
A home visit by a peer counselor during the mothers’ pregnancy is to encourage them to get adequate prenatal care and to educate them this early on the positive effects of EIBF. The mothers were also coached by these peer counselors to continue breastfeeding their newborns exclusively up to six months after birth and to introduce quality complementary food only after six months but continuing breastfeeding even beyond two years after the child’s birthday. Breastfeeding support groups, on the other hand, were organized in the communities to promote proper IYCF practices among the mothers with infants and children less than two years old. These groups also encouraged and supported mothers so they can initiate breastfeeding early, continue to breastfeed their infants exclusively until the baby is six months old. Together with proper complementary feeding, members of the support groups motivated each other to continue breastfeeding up to two years and beyond, if possible, to maximize the positive effects of mothers’ milk on young children.
From an implementation standpoint, one of the possible reasons for the lack of association between membership in breastfeeding support groups and EIBF and/or peer counselor visit during pregnancy and EIBF was the inconsistency on how the peer counselors and the breastfeeding support groups engaged with the mothers. This could be due to poor and/or inadequate training, and/or lack of clear guidelines on how to engage mothers. While some support groups and peer counselors had been active in the intervention sites, some could have failed to engage or interact with the mothers meaningfully for the latter to initiate breastfeeding within an hour after delivery.
The importance of family- or community-based interventions to improve neonatal and child health cannot be overemphasized. Community-based interventions were shown to reduce all-cause neonatal mortality by 10–50% (25). However, a Cochrane review reported no strong evidence to conclude that non-healthcare professional-led interventions have an effect in promoting early initiation of breastfeeding (26), which is similar to the findings of this study. The findings of both the Cochrane review and this study suggest that promoting EIBF could benefit from other ways of integrating non-healthcare professionals, such as peer counselors and breastfeeding support groups, within the system. This problem is not new; a 2005 review posited the following gaps in operations research for community-based interventions to promote child health: [1] how health workers, including non-healthcare professionals, could most effectively deliver the needed services for newborns and children at the community; [2] scope of service of community health workers; [3] ways to link community health workers with referral facilities to provide care for mothers and children; and [4] how can community-based interventions be managed sustainably (27).
Among the main exposures of the study, it may be argued that the effect of membership in breastfeeding support groups is of borderline significance, and the non-significant association could be due to low statistical power of the study. However, this is unlikely as the study had enough number of respondents considering that there was a sufficient number of respondents with the outcome of interest, according to the ‘rule-of-10’ (28). This is further evidenced by the narrow confidence intervals of the adjusted ORs of the main associations of interest. However, the same cannot be said for tests for statistical interaction, which are notorious for having low statistical power (29). This partly explains the absence of a statistically significant effect of the hypothesized interaction between visit by a peer counselor and membership in breastfeeding support groups and EIBF.
In measuring the effectiveness of community interventions, such as the effect of being visited by a peer counselor or membership in breastfeeding support groups on EIBF, a cluster randomized trial would be a better design to use (30). However, as the main objective of the JP wasa to decrease the prevalence of undernutrition and improve the prevalence of optimal breastfeeding practices, and not to assess effectiveness of interventions, a before-and-after evaluation design using a series of two cross-sectional studies was used. As a result, reverse causality may adversely affect the internal validity of this analysis, which is inherent in cross-sectional study designs (31). While this is not a problem for the main exposure variables and for most of the variables under consideration, this can be a problem for some confounders which may change with time, such as maternal knowledge scores.
Selection bias is also a threat to the internal validity of this study. At the design stage, we excluded some 44 barangays in Zamboanga City due to the unsafe peace and order situation. If there are systematic differences in the mother-newborn dyads in these areas relative to the mother-infant pairs included in the study, there could be a selection bias. We also excluded 154 observations due to missing data; however, considering that only about 5% of the respondents had missing data, its effect on the outcome could be minimal. Nevertheless, this analysis utilized self-reported data, the findings of the study are only as good as the reports of the mothers who took part in the study.
Another limitation of this study is residual confounding. The Endline Survey did not have any data on the educational status of the mother and opinion of other family members, which were shown to be important determinants of EIBF (20). We also failed to collect data on the number of visits of peer counselors, as well as the number of sessions held by the breastfeeding support groups, which prevented us from studying possible dose-response relationships between the exposure variables and EIBF. Despite this, we controlled for the effect of other important confounders like mode of delivery. In the cross-tabulations, the two exposures of interest were initially strongly associated with EIBF but later were found to be weakly associated with the outcome after adjusting for confounding. Other variables, such as place of residence, were important determinants of EIBF in the literature (20), and from the results of the cross-tabulations, they were observed to confound the associations of interest. In the final model, however, their confounding effects on the outcome were already controlled. This implies that there could be context-specific determinants of EIBF, which our data failed to capture (12,32).
Recommendations
The roles of peer counselors and breastfeeding support groups in promoting EIBF remain unclear. Despite this, we believe that they could still have a role in promoting EIBF. We recommend that peer counselors and breastfeeding support groups should have clear messages to deliver to target mothers - that is, to encourage pregnant mothers to see trained healthcare professionals like midwives and nurses, who were reported to be more effective in promoting EIBF (26). In doing so, they are also encouraging the mother to have more antenatal care visits, which would result to better outcomes for both the mother and the child (33).
The suggestion to integrate non-healthcare professionals in efforts to promote EIBF could be tested further in future studies. Operations research can address various information gaps on child health which could be addressed by doing community trials (34). This has been emphasized by the Cochrane review which concluded that current evidence on the effectiveness of non-healthcare professional-led interventions on EIBF are few and of very poor quality (26). Thus, methodologically-sound studies to assess the effectiveness of peer counselors and/or support groups in promoting EIBF are still needed. The need for more research on this topic to influence policies and programs is demonstrated by the low EIBF rates worldwide, including the Philippines (6).