A total of 4172 interviews were conducted at KIBS1 (May 2014- March 2015) and 929 at KIBS2 (Jan- August 2017), among carers bringing an infant aged 13- <16 weeks to the clinic. Among participating carers at KIBS1, 3659 (87.8%) were mothers and 514 (12.3%) were non-maternal carers. Similarly, in the KIBS2 survey 788 (84.8%) infants attended with the mother and 141 (15.2%) with non-maternal carers. Most infants were currently living with the mother at both time points (3919/4172; 93.9% vs 875/929; 94.2%).
Characteristics of all carers, including both mothers and non-maternal carers, are shown in Table 1. Non maternal carers provided only basic information so the analysis that follows relates mainly to infants attending with the mother. At KIBS2, non-maternal carers were asked the reason for the mother’s absence, and most reported that this was because the mother was at work (64/141; 45.4 %) or at school (61/141; 43.3%), otherwise the mother was sick (1.4%) or there was another reason/data was missing (9.9%). There were significant differences between participating mothers at the two time points, mothers at KIBS2 had significantly higher levels of education, were more likely to live in a household where electricity was used for cooking, were more likely to be in a relationship with the child’s father and were less likely to be receiving a child support grant for any child (Table 1). The median age of mothers was 24 years (IQR 20-29) at KIBS1 and 26 years (IQR 21-31) at KIBS2, and of non-maternal carers was 32 years (IQR 24-45) and 33 years (IQR 26-44) at KIBS1 and KIBS2 respectively.
FEEDING PRACTICES FOR ALL INFANTS
There was some increase in the proportion of infants being exclusively breastfed among infants attending with both maternal and non-maternal carers over the three-year period between KIBS1 and KIBS2. However, this difference was larger among infants brought by the mother. The increase in EBF was largely due to a reduction in the proportion of all infants being mixed fed rather than an increase in the proportion of mothers breastfeeding. Overall, almost one-third of infants were not being breastfed at 14 weeks and this was similar at both time points. In addition, there was a large increase in non-breastfeeding among infants brought by non-maternal carers (Table 2).
FEEDING PRACTICES FOR INFANTS ATTENDING WITH THE MOTHER
Factors associated with EBF among participating mothers
The following analysis refers to mother-infant pairs. After controlling for the differences in participant characteristics between the two time points, the proportion of infants attending with the mother who were exclusively breastfed was higher at KIBS2 than KIBS1 (Table 3). Multi variable analysis shows that mothers who had returned to work or school and those living in a household where electricity is used for cooking were less likely to practice EBF, whereas those mothers in receipt of a child support grant were more likely to practice EBF (Table 3).
Duration of breastfeeding among mothers who stopped breastfeeding before 14 weeks.
At both time points a similar proportion of mothers had initiated breastfeeding but had already stopped breastfeeding at 14 weeks (17.1% vs 17.0%; p= 0.95). At both time points most of the mothers who stopped did so by the time the baby was four weeks old (69.4% KIBS1; 54.1% KIBS2), but at KIBS2 the duration of breastfeeding was longer among mothers who had stopped breastfeeding, as shown by the Kaplan Meier curve (p=0.0015) (Figure 1). Cox regression analysis further shows that the hazard ratio for stopping breastfeeding was significantly lower at KIBS2 vs KIBS1 (aHR; 95% CI 0.8 (0.6-0.9) but that no other factors were significantly associated with stopping breastfeeding (Supplementary Table 1).
Figure 1: Kaplan-Meier life table curve comparing KIBS1 and KIBS2 surveys, with respect to stopping breastfeeding
Reasons for not breastfeeding among mothers at 14 weeks
Among infants attending with their mother a similar proportion were not breastfed at 14 weeks (either never breastfed or stopped breastfeeding) at both time points (954/3659; 26.1% vs 192/788; 24.4% ; p= 0.30).
At KIBS2 those mothers who were no longer breastfeeding reported the primary reason for the decision to either not initiate breastfeeding and to stop breastfeeding. The commonest reason reported for stopping breastfeeding was that the mother had returned to work or school, and the commonest reason for never breastfeeding was concern about the mother’s health, including HIV. Among the 43 mothers who mentioned their own health as the main reason for stopping breastfeeding, 39 (90.7%) reported themselves HIV positive. Other common reasons for not breastfeeding were challenges related directly to breastfeeding; 54/192 (28.1%) mothers reported breastfeeding problems including problems related to the baby, to breast health and failure to establish breastfeeding (Table 4).
Reasons for not breastfeeding: returning to work or school
At KIBS1 and KIBS2 it was common for mothers to have returned to work or school by the time the baby reached 14weeks (542/3659; 14.8% vs 103/788; 13.1%; p=0.36). At KIBS2 returning to work or school was the commonest reason reported by mothers for early cessation of breastfeeding (Table 4). Multi-variable analysis showed that after controlling for participants differences between the time points (education level; relationship with child’s father; use of electricity for cooking; receiving a child support grant) mothers who had returned to work or school were significantly more likely not to be breastfeeding at 14weeks (AOR 3.8; 95% CI 3.1-4.6).
At KIBS1 mothers who had returned to work or school were less likely to have initiated breastfeeding than non-working or schooling mothers (19.4% vs 8.6%), but this difference was not present at KIBS2 (6.8% vs 7.3%). However, in both surveys mothers who had returned to work or school were less likely to be breastfeeding exclusively compared to non-working/schooling mothers.
Table 5 shows that the significant improvements in EBF rates achieved among non-working/schooling mothers between KIBS1 and KIBS2, are not shown among mothers who had returned to work or school. However, there are small improvements in all indicators for working/ schooling mothers. Controlling for baseline characteristics did not alter the overall findings for mothers returning to work or school.
Further, the analysis shown in Table 5 excludes infants brought by a non-maternal caregiver, whose mothers were most often absent because of being at work or school.
Reasons for not breastfeeding: HIV positive
Among participating mothers, 1274/2567 (32.3%wgt) reported themselves HIV positive at KIBS1 and 303/788 (38.7%) at KIBS2. Multi variable analysis showed that after controlling for differences between the time points (education level; relationship with child’s father; use of electricity for cooking; receiving a child support grant) mothers who reported themselves HIV positive were significantly less likely to be breastfeeding at 14weeks (AOR 2.1; 95% CI 1.7-2.6). At both time points, HIV positive mothers were significantly more likely than HIV negative mothers to report never breastfeeding and to have stopped breastfeeding at 14weeks (Table 6).
Table 6 shows that breastfeeding practices improved among HIV positive mothers between KIBS1 and KIBS2, and this improvement was in line with improvements shown among HIV negative mothers. However, the proportion of HIV positive mothers not breastfeeding at 14 weeks remained similar at both time points (435/1274; 34.1%; 40.2%wgt vs 107/303; 35.3%, p= 0.27). For each of the feeding practices shown in Table 6, differences remained when controlling for differences between participant characteristics between KIBS1 and KIBS2.
FEEDING ADVICE PROVIDED TO MOTHERS
The proportion of mothers who reported receiving feeding advice in the antenatal clinic was similar at both time points (3049/3659; 83.3% vs 662/788; 84.3%, p=0.74). Comparing KIBS2 with KIBS1 more mothers reported receiving both advice and help with breastfeeding (1809/3659; 49.4% vs 532/788; 66.4%, p<0.001), and fewer mothers received neither help nor advice with feeding after delivery (624/3659; 17.1% vs 97/788; 12.3%, p=0.009). Few mothers reported receiving feeding advice during a household visit from a CHW in the postnatal period at both time points (378/3659; 10.3% vs 70/788; 8.9%, p=0.47).
After controlling for differences in participants characteristics, mothers who received feeding advice in the ANC were less likely to have stopped breastfeeding at 14 weeks compared to mothers who received no advice (AOR 0.71; 95% CI 0.6-0.9). Similarly mothers who received feeding advice from a CHW were less likely to have stopped breastfeeding at 14 weeks (AOR 0.75 95% CI 0.6 -1.0). In contrast, mothers who received advice at the time of delivery were more likely to have stopped breastfeeding at 14 weeks compared to mothers who received no advice (AOR 1.33; 95% CI 1.1=1.6). However, those mothers who received both advice and help at the time of delivery were less likely to have stopped breastfeeding (AOR 0.83; 95% CI 0.7- 1.0).