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Yotebieng et al. International Breastfeeding Journal 2013, 8:1 1
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INTERNATIONAL BREASTFEEDING JOURNAL



RESEARCH Open Access



Infant feeding practices and determinants of poor
breastfeeding behavior in Kinshasa, Democratic
Republic of Congo: a descriptive study

Marcel Yotebieng 1,2 " Jean Lambert Chalachala 3 , Miriam Labbok 4 and Frieda Behets 1,5



Abstract

Background: Although breastfeeding is almost universally accepted in the Democratic Republic (DR) of Congo,
by the age of 2 to 3 months 65% of children are receiving something other than human milk. We sought to
describe the infant feeding practices and determinants of suboptimal breastfeeding behaviors in DR Congo.

Methods: Survey questionnaire administered to mothers of infants aged < 6 months and healthcare providers who
were recruited consecutively at six selected primary health care facilities in Kinshasa, the capital.

Results: All 66 mothers interviewed were breastfeeding. Before initiating breastfeeding, 23 gave their infants
something other than their milk, including: sugar water (16) or water (2). During the twenty-four hours prior to
interview, 26 (39%) infants were exclusively breastfed (EBF), whereas 18 (27%), 12 (18%), and 10 (15%) received
water, tea, formula, or porridge, respectively, in addition to human milk. The main reasons for water
supplementation included "heat" and cultural beliefs that water is needed for proper digestion of human milk. The
main reason for formula supplementation was the impression that the baby was not getting enough milk; and for
porridge supplementation, the belief that the child was old enough to start complementary food. Virtually all
mothers reported that breastfeeding was discussed during antenatal clinic visit and half reported receiving help
regarding breastfeeding from a health provider either after birth or during well-child clinic visit. Despite a median
of at least 14 years of experience in these facilities, healthcare workers surveyed had little to no formal training on
how to support breastfeeding and inadequate breastfeeding-related knowledge and skills. The facilities lacked any
written policy about breastfeeding.

Conclusion: Addressing cultural beliefs, training healthcare providers adequately on breastfeeding support skills,
and providing structured breastfeeding support after maternity discharge is needed to promote EBF in the DR
Congo.

Keywords: Breastfeeding, Exclusive breastfeeding, Infant feeding practices, Kinshasa, DR Congo



Background

Millennium Development Goal (MDG) 4 calls for a two-
third reduction in the under- five mortality rate by 2015.
Between 1990 and 2010, global deaths among children
under 5 years of age declined from over 12 million to 7.6
million [1], However, according to Countdown to 2015, an
organization that monitors progress towards reaching



* Correspondence: myotebieng@cph.osu.edu

College of Public Health, Division of Epidemiology, The Ohio State

University, Columbus, OH, USA

department of Epidemiology, The University of North Carolina at Chapel
Hill, Chapel Hill, NC, USA

Full list of author information is available at the end of the article



MDG 4, of 74 focus countries with available data for 2012
report, only 23 were on track to achieve the goal and 13
had made no progress. All but one (Haiti) of the countries
that had made no progress are in Sub-Saharan Africa [2],

The Democratic Republic (DR) of Congo is one of the
13 countries which has seen no progress towards MDG
4. It bears the third largest burden of child deaths world-
wide [3] and its under-five mortality rate has remained
high: from 180 for every 1000 live births in 1990 to 170
in 2010. Although these deaths are the result of a web of
complex determinants [4], there is enough evidence to
believe that breastfeeding practices play a major role in



o



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the extremely high infant mortality in the DR Congo.
First, results from the 2007 Demographic and Health
Survey (DHS) [5] show that of the 9.2% of infants who
die before their first birthday in DR Congo, 4.2% die
during the neonatal period and the remaining 5% be-
tween 1 and 12 months. Second, of the 116 out of 1000
babies born alive in 2010 in DR Congo who survived
through the first 28 days and subsequently died before
their fifth birthday, 20 died from diarrhea and 23 from
pneumonia, only malaria claim more under- 5 lives (28)
while AIDS accounts for only 2 [3]. More deaths in the
postnatal period and the predominant role of diarrhea,
pneumonia and malaria suggest that factors behind these
deaths are to be found among other sources in the feed-
ing practices. In fact, by the age of 6 months, more
than 10% of children in DRC are already stunted, vir-
tually 15% are underweight-for-age and approximately
the same percentage emaciated [5].

These data have to be understood in the context of
relatively high utilization of primary health services and
high rates of breastfeeding initiation. Despite the chal-
lenges to accessing health care in DR Congo, DHS data
showed that 85% of pregnant women attend at least one
antenatal visit, 70% of live births occurred in a health
facility (97% in Kinshasa) and of children 12 to 23 months
of age, 71%, 59%, 45% received the first, second and third
doses of DPT immunization administered according to
the WHO immunization schedule (20) and the DRCs
Expanded Program of Immunization at 6, 10, and 14
weeks respectively, while 63% had been vaccinated against
measles (at 9 months). Moreover, breastfeeding is almost
universally accepted (9 out of 10 children are still being
breastfed at the age of one) in DR Congo. Yet, recent na-
tional surveys [5,6] showed that only 69% of 0 to 1 month
old are exclusively breastfed while 65% of 2 to 3 month
old are receiving something other than human milk in
an environment where, according to the recent WHO/
UNICEF progress report on sanitation and drinking-water
[7], only 23% of the urban population have access to im-
proved sanitation facilities and less than 50% to improved
drinking-water sources.

Optimal breastfeeding practices, including immedi-
ate postpartum initiation of skin to skin contact with
breastfeeding within one hour of birth, exclusive
breastfeeding (EBF) with no additional fluid or food
for 6 months [8], and continuation of breastfeeding
thereafter up to 24 months and beyond with age ap-
propriate complementary feeding, have great potential for
reducing under five mortality rate [9-11]. If at least 90% of
children were exclusively breastfed for the first six months
of life, the potential reduction in mortality would be
higher than from any other known effective intervention
[10]. In most sub-Saharan countries, particularly in those
with no or insufficient progress towards MDG 4, the



prevalence of EBF among infant 6 months old or younger
has not increased substantially and remains generally
below 40% [12].

Starting in 1990, global initiatives to improve
breastfeeding practices focused on maternity-level pol-
icies and practices known as the Ten Steps to Successful
Breastfeeding, which serve as the basis for the Baby-friendly
Hospital Initiative (BFHI) [13]. A maternity facility can
be designated 'baby-friendly' when it has implemented
the Ten Steps and has been reviewed using a national
assessment approach. These steps include the following:
(1) having a written breastfeeding policy that is routinely
communicated to all healthcare staff, (2) training all
healthcare staff in skills necessary to implement this pol-
icy, (3) informing all pregnant women about the benefits
and management of breastfeeding, (4) helping mothers
initiate breastfeeding within 30 minutes of birth, (5) show-
ing mothers how to breastfeed and maintain lactation,
even if they should be separated from their infants, (6) giv-
ing newborn infants no food or drink other than breast
milk, unless medically indicated and not accepting free or
low-cost breast milk substitutes, feeding bottles or teats,
(7) allowing mothers and infants to remain together
24 hours a day, (8) encouraging breastfeeding on demand,
(9) giving no artificial teats or pacifiers to breastfeeding in-
fants, and (10) fostering the establishment of breastfeeding
support groups and referring mothers to them upon dis-
charge from the hospital or clinic. Implementation of the
Ten Steps is associated with improvement in the rates of
EBF [14-16].

BFHI is not being implemented to any extent today in
DR Congo. The main attempt to implement BFHI steps
in the country was led by UNICEF in the early 2000s as
part of a national campaign of breastfeeding promotion,
Overall 25 health facilities including 13 in Kinshasa out of
more than 6,000 eligible facilities were certified through
this effort. The last hospital certified was in 2004 in
Katanga province when the funding stopped. Just two
years after the peace deal that ended the deadliest war
since World War II, which, in addition to decades of gross
mis-management, have left the country infrastructures in
shambles [17,18], the country was simply not ready to take
over the initial UNICEF efforts.

Beside the fact that BFHI is not systematically implemented
in DR Congo, to our knowledge, there has been no pub-
lished report on breastfeeding practices and factors
that are behind the persistent high rate of early sup-
plementation. Data on West Africa as a whole indi-
cates that water supplementation was a major contributor
to the high rates of less than exclusive breastfeeding in the
early 1990s, with most neighboring countries reporting
more than 50% offering water in the first months of life.
In 2000, only about 35% of women in DR Congo were
still providing water to their infants in the first months of



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life [19,20], possibly accounting for the increase in EBF
rates noted above.

This study was carried out as part of a preliminary
phase of a cluster randomized trial designed to test
whether support for the implementation the Ten Steps,
coupled with provision of breastfeeding support in well-
child and immunization clinics as a unique approach to the
Step Ten (establishment of breastfeeding support groups in
community), would improve the rate of EBF at six months
in Kinshasa (NCT01428232). The main objective was
to describe breastfeeding practices and identify the main
determinants of the widespread early supplementation in
Kinshasa, DR Congo.

Methods

A cross-sectional survey was carried out in six selected
health facilities offering maternal and child health ser-
vices in Kinshasa, DR Congo. The six health facilities were
selected from a network of 44 maternity clinics that re-
ceive support from The University of North Carolina at
Chapel Hill in partnership with the Kinshasa School of
Public Health for implementation activities to prevent
transmission of HIV from mother-to-child. To inform
selection, study staff (two medical doctors) visited all
44 facilities between October and November 2011 and
collected information on factors that might affect the
quality of care provided in each facility. Health facilities
were then stratified by location (urban or periurban) and
type of management. Within each stratum, facilities were
sorted by the number of births and the proportion of
mothers returning for one week postpartum visit and
matched across strata for the average workload (number
of births/number of personnel). Six facilities with rela-
tively comparable workload across strata, the largest num-
ber of births per month, and the highest return for the
one week visits within each stratum were selected. This
selection scheme was adopted to ensure that health care
facilities at the periphery of the city, which might have
lower patient volumes with lower socio-economic status
than facilities in urban areas, were included in the final
sample while limiting the overall heterogeneity among the
selected facilities.

In each facility, all healthcare personnel of the mater-
nity and well-child clinics and a convenience sample of
mothers of healthy infants six months or younger present-
ing consecutively at the well-child clinic who agreed to
participate in the study, were recruited and interviewed.
Interviews were administered by two trained and bilingual
(French and Lingala, the main language used in Kinshasa)
interviewers using structured questionnaires developed and
adapted from Infant Feeding Practice Study Us [21] and
the Demographic and Health Surveys [22] questionnaires.
The mothers' questionnaire was available in French and
Lingala and contained questions on socio-demographic



characteristics, maternity experience, breastfeeding support
received, infant feeding practices (including a 24-hour re-
call), and other questions related to knowledge, beliefs and
attitudes regarding breastfeeding. Healthcare workers ques-
tionnaire was available only in French (the official working
language) and contained questions on professional experi-
ence, past training on breastfeeding, knowledge, attitude
and practice of breastfeeding support, and questions related
to the implementation of Ten Steps in their facility. Each
questionnaire contained both open and closed ended ques-
tions and took about 30 to 45 minutes to administer.

Information collected with questionnaires was double-
entered into an EPI-Info database. All responses to open
ended questions that were given in Lingala were imme-
diately translated into French prior to data entry by our
bilingual study staff. The data was summarized using
median and interquartile range (IQR) for continuous
variables and proportions for categorical variables. All
responses to open ended questions were reviewed for
themes, and similar responses were grouped together in
simple counts. All analyzes were conducted using SAS
9.2 (SAS Institute, Cary NC).

The study was approved by the Institutional Review
Board of the University North Carolina at Chapel Hill
(study # 11-1332) and the Ethical Committee of the
Kinshasa School of Public Health. All participants pro-
vided signed informed consent.

Results

Characteristics of participants
Mothers

Ten mothers were interviewed in each of the 4 selected fa-
cilities, 15 and 11, respectively, from the two remaining fa-
cilities, for a total of 66 mothers. The median age of the
mothers was 25 years (IQR 20 to 29) and that of their in-
fant was 3 months (IQR 2 to 4). Over 80% were married
or living with a partner (Table 1). Most mothers (86%)
reported having completed more than the primary
level of education. Only four mothers had a salaried
(formal sector) job, while 73% worked as informal traders
at home, in their neighborhood or at the market. The me-
dian number of children reported to be alive for each
mother was 2 (IQR 1 to 3). Thirty-seven mothers (56%)
reported having someone at home who helped to care for
their infants. This help consisted of 14 in-laws, 2 maids,
and 20 mothers, grandmothers, or other family relatives.

Healthcare workers and hospital environment

Forty-eight healthcare providers were also interviewed.
They were predominantly female (42), nurses (35), mid-
wives (11) and doctors (2). They had being working in
their respective health facilities for an average of 14.2 years
(range: 1-37 years). Nonetheless, only 8 reported having
ever received any formal training on how to provide



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Table 1 Characteristics of study participants from a
survey of mothers attending 6 well-child clinics in
Kinshasa





Number


Percent


Age in years: median (IQR)




25 (20. 3)


Marital status






Single


12


18.2


Married


24


36.4


Live-in boyfriend


30


45.5


Education






Primary


9


13.6


Secondary


49


74.2


University


8


12.1


Occupation






Home/neighborhood small trade


37


56.1


Market small trade


11


16.7


Salaried (paid job)


4


6.1


Sewing


4


6.1


Hairdresser


7


10.6


Student


2


3.0


Farm work


1


1.5


Number of surviving children:




2(1,3)


1


25


37.9


2


18


27.3


3


14


21.2


4+


9


13.7


Previous child loss






Yes


3


4.5


No


63


95.5


Child age in months: median (IQR)




3 (2,4)


1


9


13.6


2


17


25.8


3


16


24.2


4


13


19.7


5


10


15.2


6


1


1.5



Abbreviation: IQR Interquartile range.



breastfeeding support to mothers. The training received
was mainly as part of training on prevention of mother-
to-child transmission of HIV (PMTCT); none of the train-
ings included a supervised practice section. No written
breastfeeding policy was observed in the six facilities (or
any of the 44 surveyed). However, all held regular health
promotion classes during antenatal clinic visits in which
breastfeeding was discussed. However, the information
discussed was not recorded on antenatal clinic visit card
or anywhere else. After a normal delivery, children and



mothers were kept in the immediate postpartum observa-
tion room for few hours during which skin-to-skin contact
was practiced. During the immediate postpartum period,
infants and mothers were kept together in the same bed
in the postpartum room for 2 to 3 days before they were
discharged. Commercial infant food, artificial teats, and
pacifiers were not observed in the delivery room or post-
partum rooms. No advertisement for breast milk substi-
tute was observed. Sugar water supplementation when
given was with a spoon (usually) or syringe (drop in the
mouth). For formula, families have to buy everything in-
cluding bottles from the market.

Breastfeeding practices

All 66 mothers were breastfeeding on the day of the
interview. Twenty mothers (30%) reported initiating
breastfeeding within the first hour after birth; 20
(31%) reported initially feeding their infants something
else before breastfeeding initiation (Table 2). The early
supplementation, prior to breastfeeding initiation, was
mainly with sugar water for 16 (80%) infants, plain water
for two, and formula for the last two others. A 24-hour re-
call of infant feeding showed that 26 (39%) infants were
being exclusively breastfed. Of the exclusively breastfed
infants, 19 (73%) were 3 months of age or younger.
Supplements used in the last 24 hours included: water
(15 infants), sugar water (1 infant), tea (2 infants), for-
mula (12 infants), and porridge (10 infants). Liquid sup-
plementation, such as sugar water, water or tea, dropped
from 67% among one month olds to 25% among 3 month
olds and 10% among 5 months old infants. All formula
supplementation was among infants 4 months or younger,
while 7 of the 10 infants supplemented with porridge were
4 months or older.

Mothers' reasons for supplementing

Mothers who reported any supplementation were asked
to state the reasons why they decided to give the par-
ticular supplement to their babies. The most common
reasons for "liquid only" supplementation was hot wea-
ther and cultural beliefs that water is required for proper
digestion of breast milk (Table 3): "It was very hot" - 18
year old mother of a three months old infant; "I have al-
ways heard that breast milk is hot" - 27 year old
mother of a one month old infant; "breast milk is hot
and water must be added for proper digestion" - 23
year old mother of a six month old infant; "Water is
life! A child has to drink water" - 20 year old mother
of a four month infant. Water was also given as treat-
ment for hiccups. For formula supplementation, the
most frequent reasons given were that the baby was cry-
ing all the time (9/12), beliefs that the baby was not get-
ting enough milk (5/12), or the infant was sucking all
the time (4/12). One mother reported that it was



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Table 2 Reported breastfeeding practices

Number Percent

Early initiation of breastfeeding**

Yes 20 30.3

No 46 70.8

Supplementation prior to breastfeeding
initiation

Yes 20 31.3

No 44 68.8

Supplements given prior to breastfeeding
initiation

Sugar water 16 80.0

Water 2 9.5

formula 2 9.5
Exclusive breastfeeding

Yes 26 39.4

No 40 62.1
Supplements

Liquid (water, sugar water, tea)* 18 45.0

Formula 12 30.0

Porridge 1 10 25.0

^Initiation of breastfeeding within 1 hour of birth.

*Liquid supplementation only; ^either with other liquid or alone.



because she wanted to go back to work/school Porridge
was mainly given as supplemental food when the mother
or someone else thought it was the proper age: "my
stepmother asked me to start giving him porridge at 4
months' - 20 year old mother of a five month old in-
fant; "my baby wasn't getting full" - 27 year old mother
of five month old.

Knowledge, attitudes and beliefs
Mothers

Mothers' questionnaire contained eight statements re-
garding breastfeeding benefits, establishment and main-
tenance of milk supply, and breast milk supplementation.
These statements were read to mothers and they were
asked to state for each whether it was "true", "false", or if
they "don't know". In general, mothers appeared to have
some knowledge of the benefits of breastfeeding for
both themselves and their babies (Table 4). Over half
(54%) of them agreed that "supplemental feeding is
detrimental to the establishment and maintenance of
good milk supply 1 ; 45% agreed that "a baby who is
breastfed still needs to drink water like everyone else".
Mothers were also asked to state what they believed was
the recommended duration of exclusive breastfeeding.
Only 36 (55%) mothers correctly stated six months while
29 (44%) stated a recommended duration between 1 and 5
months.



Table 3 Mothers' reasons for starting the reported
supplementation

Type of supplement and main reasons* Frequency

Liquid (water, sugar water, tea) alone 1 7

Hot Weather: "it was very hot"; "his lips were dry after 6
feeding"

Cultural beliefs: "breast milk is hot and it's a meal! Water 6
must be added"; "breast milk is hot! Water must be added
for proper digestion"; "Water is life! the child must take
water"; "He was having hiccups"

I thought I did not have enough milk 5

Formula 12

/ thought I did not have enough milk 5

My baby was crying all the time 9

My baby was sucking all the time and it was difficult 4

The baby's father wanted it added to human milk 2

The grandmother of the baby wanted it added to human 2
milk

Other 3
Porridge

/ thought I did not have enough milk 1

My baby was crying all the time 5

My baby was sucking all the time and it was difficult 2

The baby's father wanted it added to human milk 0

The grandmother of the baby wanted it added to human 2
milk

Other 3

Responses were elicited with the following question: Why did you decide to
add (name the addition) to breast milk? Response options were provided and
selection of more than one reason was allowed. Option other was provided
for participant to specify reason that were not provided in the options.

Healthcare providers

A modified version of the 8 statements was also used to
evaluate the knowledge of healthcare workers. Overall,
the healthcare workers appeared to have some know-
ledge of breastfeeding benefits. However, while all of
them responded that it was false that "a newborn who is
being breastfed still needs to drink water like anyone
else" or that it was true that "children who are exclusively
breastfed ten to have fewer episode of diarrhea" 36
(75%) of them wrongly stated it was true that "in the first
1 or 2 days after birth the quantity of milk produced is
too small to meet all the needs of a baby" and 35 (73%)
that "mothers who think that their breast milk is insuffi-
cient for their baby should top up each breastfeeding with
a bottle of formula or porridge, juice etc. . (Table 4).

Breastfeeding support
in hospital

Only two mothers reported not attending any ante-
natal clinic (ANC) visit during their pregnancy. Of
those who attended at least one ANC, 56 (86%) recalled



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Table 4 Beliefs, attitudes, about breastfeeding and breastfeeding practices among mothers and health care workers

Knowledge about breastfeeding* True (%) False (%) Don't know (%)

Mothers



A woman who is exclusively breastfeeding is less likely to become pregnant three months after delivery than a
woman who is formula feeding


39 (60)


9 (14)


1 7 (26)


Supplemental feeding is detrimental to the establishment of a good milk supply


36 (55)


13 (20)


17(26)


It is usually advisable for babies to receive liquid (water, sugar, juice, etc.. . .) before the first breastfeeding


8(12)


47 (71)


11 (17)


It is usually advisable for mothers not to give their babies the first milk that comes out after delivery


6(9)


50 (76)


10(15)


If a child who is breastfed has not regained his birth weight by two weeks, the mother should be encouraged to
start supplement breast milk with the bottle.


13 (20)


43 (65)


10(15)


A 1 j-£ J' < / / £ / ./ . / . •// • ££• , 1 II 1 , • i '.J / ..I • J

A breastfeeding mother who feels that breast milk is insufficient should supplement it with a bottle or porridge
after each feeding.


33 (50)


28 (42)


5 (8)


A baby who is breastfeed still needs to drink water like everyone else


30 (45)


30 (45)


6 (9)


If a baby cries at night, it is recommended to give him a bottle before putting him/her to sleep.


7 (11)


55 (83)


4 (6)


Health care workers








In the first 7 or 2 days after birth the quantity of milk produced is too small to meet all the needs of a baby


36 (75)


10 (25)


0


Colostrum acts as a purgative and is important to clear the meconium and helps prevent jaundice


42 (88)


3(6)


3(6)


A newborn who is being breastfed still needs to drink water like everyone else




48 (100)




Children who are exclusively breastfed tend to have fewer episodes of diarrhea


48 (100)






Children who are exclusively breastfed are more likely to develop an ear infection or pneumonia




47 (98)


1 (2)


Regular and frequent breastfeeding can help reduce the risk of uterine bleeding and help the uterus return to
its previous size


44 (92)


3(6)


1 (2)


Frequent, on demand, and prolonged breastfeeding can help reduce the risk of breast or ovarian cancer


32 (67)


6(12)


10 (21)


Mothers who think their breast milk is insufficient for their baby should top up each breastfeeding with a
bottle of formula or porridge, juice etc.. . .


35 (73)


2(4)


1 1 (23)



^Statements were read to participants and they were asked to state for each whether it was "true", "false", or if they "don't know."



that breastfeeding was discussed. However, only 33 (50%)
mothers recalled a healthcare provider helping them with
breastfeeding following the birth of their infants. The
same number of mothers also recalled receiving some help
during a well-child clinic visit while 20 (30%) reported re-
ceiving help from a health provider both in the maternity
after birth and during well-child clinic visit. Mothers who
reported receiving help from healthcare staff were asked
in a follow-up question, what the staff did to show them
how to breastfeed. Healthcare workers mainly showed
them things about positioning, attachment, or nipple care.
Not a single mother mentioned discussion of EBF or water
supplementation. On a scale of "0" to "5" with "0" mean-
ing "Not at all useful" and "5" meaning "Very useful", all
mothers scored the help they received "3" or above; with
22 (67%) given the maximum score - "5". However, only
three of the 48 healthcare workers interviewed reported
that there was an actual plan in their facility to help
mothers to breastfeed their infants.

In communities

Mothers were also asked if someone else showed them
how to breastfeed after delivery beside hospital personnel.
Of the 22 (34%) mothers who responded yes, 12 reported



getting the help from their own mother or grandmother,
five from their mother in-laws and the remaining from
their sister (1), neighbor (1) or a nurse in the neighbor-
hood (2). As with healthcare providers, the help reportedly
focused mainly on child positioning and nipple care. Only
one mother mentioned that she was informed by the per-
son not to give any water or anything else to her baby.

Healthcare workers were asked if there was a breastfeeding
support group to which they referred mothers at their dis-
charge from the maternity clinic, all 48 healthcare pro-
viders responded no.

Discussion

The goal of this study was to describe breastfeeding
practices and identify potential determinants of the per-
sistent low rate of EBF in Kinshasa. Using the Social
Ecological framework [23], a conceptual model that
addresses the importance of interventions directed at
changing intrapersonal, interpersonal, organizational,
community, and public policy factors which support
and maintain unhealthy behaviors, our results suggest
that the most important determinants of unnecessary
liquid supplementation and early introduction of com-
plementary food are mainly to be found in the first



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three levels of the framework: 1) the individual level
characteristics such as knowledge, attitudes, beliefs,
and skills; 2) the interpersonal factors, particularly the
support from family, friends and healthcare providers; and
3) community factors such as community support groups
or breastfeeding friendly hospital policy. The need for
comprehensive support was also reflected in a recent re-
view of community-based support for breastfeeding that
concluded that interventions appear to have the greatest
impact when they are part of multi-level, comprehensive
interventions [24].

At the core of the widespread use of supplemental
feedings is the limited knowledge among healthcare
providers and mothers about human milk production,
composition, and its adequacy for infants' needs. This
combined with the fact that over 73% of healthcare pro-
viders interviewed believed that the quantity of milk
produced in the first 24 to 48 hours after birth is not
sufficient for an infants needs with their expressed
concern about low blood sugar, it is easy to understand
why such a high number of infants are supplemented
(in particular with sugar water) even before initiation of
breastfeeding. Although concern about low blood sugar in
newborns is justifiable, as it can cause brain injury [25],
the best way to prevent low blood sugar in newborns is
early initiation of breastfeeding with frequent feedings
[26-28] . Moreover, recommendation or provision of sugar
water to infants by healthcare workers contradicts the
message on EBF and reinforces the cultural misbeliefs that
"an infant needs to drink water". In addition, of mothers
who reported having received some breastfeeding support
after birth or during well-child visits, the only somewhat
consistent advice was on positioning, and nipple care. But
it is unclear what nipple care might include that would
not be potentially damaging.

Furthermore, it is of interest that despite the relatively
high level of education among this group of urban mothers,
up to 45% of them did not know the recommended dur-
ation of EBF. The fact that most mothers who gave solid
food to their infants did so because of their belief that
the child had reached the age to start complementary
food, suggests that social desirability bias may be as-
sociated with either of the two responses. However,
whether mothers knowingly gave a wrong recommended
duration of EBF as a way of justifying their own introduc-
tion of complementary food early or because they did not
know the recommended duration of EBF, may suggest that
the knowledge and subsequent behaviors are modifiable
with proper education and support.

Most mothers reported having someone at home who
helps them take care of their infants and that this person
has consider influence on how the infant is fed. Inter-
ventions aiming at changing some of the less than opti-
mal breastfeeding behaviors should include an effort to



reach and educate family members about EBF and its
recommended duration. Half of the participating mothers
reported receiving some breastfeeding support during
well-child clinic visits suggesting well-child clinics could
be used as potential alternative or supplement to commu-
nity support for breastfeeding mother after discharge from
maternity unit. But the effectiveness of well-child clinics
as a unique approach for Step 10 merits further study.

Formula supplementation was observed mostly in the
first three to four months of life. The primary reason
given by mothers for formula supplementation was the
impression that the baby was not getting enough milk. It
is well documented that most mothers who stop exclu-
sively breastfeeding do so because of the perception that
their infant is not getting enough or is not satisfied with
breast milk alone [29]. However, it is recognized that
this 'reason' is often a proxy for other problems and
constraints in the mothers life [30]. The lack of readily
available source of breastfeeding information and sup-
port following hospital discharge may explain, in part,
the high frequency of formula supplementation [31,32].
Moreover, in addition to the non-implementation of the
10 steps to successful breastfeeding, the lack of training
of health workers combined with the absence of a writ-
ten policy on breastfeeding in health facilities, limits the
impact of the observed efforts to implement other steps
of the BFHI.

Finally, it is of interest in this setting, where nearly all
women breastfeed initially, that there was strong emphasis
on positioning rather that patterns of breastfeeding. This
may be due to the fact that this is the emphasis in many
training materials developed in the industrialized coun-
tries, where few women have the opportunity to observe
breastfeeding or have help from their family or friends
who are successful breastfeeders. It may be important to
adjust the content of breastfeeding training for health pro-
fessionals in these settings to be less about latch on and
more about patterns over time.

Despite the systematic approach used to describe
breastfeeding behaviors and determinants, this study has
limitations. Our data came from a small convenience
sample of mothers and healthcare providers from a very
limited number of health facilities in Kinshasa, DR
Congo. Educated mothers who exclusively breastfeed
their infants for the recommended duration may cluster
in certain health facilities that might be seen as offering
better quality of services. Even with the careful consider-
ations that went into the selection of facilities that
served as study sites, the small number of facilities (six)
selected may not represent the average health facility in
Kinshasa. Moreover, the small sample size of healthcare
workers and mothers interviewed does not allow statis-
tical testing, In addition, information on breastfeeding
practices and reasons for supplementation were all



Yotebieng et al. International Breastfeeding Journal 2013, 8:1 1
http://www.internationalbreastfeedingjournal.eom/content/8/1/1 1



Page 8 of 9



collected through face-to-face interviews and are suscep-
tible to recall or social desirability bias. However, the fact
that the rate of EBF in our sample is comparable to the
one reported in national representative samples [5,6]
suggests a limited impact of these potential biases and
offers some confidence for applicability beyond the study
sample.

Conclusion

This work supports the understanding that comprehen-
sive approaches, especially including Step 2, training of
health workers, and Step 10 Community support, may
lead to changes in poor hospital practices that reinforce
negative cultural beliefs and sub-optimal practices among
mothers. This, coupled with the lack of community sup-
port groups, may account for much of the persistent low
rate of EBF in Kinshasa, DR Congo.

Competing interests

The authors declare they have no conflicts of interests.
Authors' contributions

MY, ML, and FB conceived and designed the study. MY and JLC were
responsible for data collection and quality. MY analyzed the data, and wrote
the first draft of the manuscript. All authors contributed to final review and
editing, including interpretation of results, and read and approved the text
as submitted.

Acknowledgments

This work was supported by a grant from the Bill & Melinda Gates
Foundation to FHI 360, through the Alive & Thrive Small Grants Program
managed by UC Davis. The sponsors of the study had no role in study
design, data collection, data analysis, data interpretation, writing of the
report, or the decision to submit the paper for publication. We are grateful
for the participants' time and data collection and data entry contributions of
Drs. Landry Kiketa and Dinah Kayembe.

Author details

College of Public Health, Division of Epidemiology, The Ohio State
University, Columbus, OH, USA. department of Epidemiology, The University
of North Carolina at Chapel Hill, Chapel Hill, NC, USA. 3 School of Public
Health, The University of Kinshasa, Kinshasa, DR, Congo. 4 Carolina Global
Breastfeeding Institute, Department of Maternal and Child Health, The
University of North Carolina at Chapel Hill, Chapel Hill NC, USA. 5 School of
Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC,
USA.

Received: 21 January 2013 Accepted: 28 September 2013
Published: 1 October 2013

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