Determinants of Non-Compliance with Exclusive Breastfeeding among Breastfeeding Women in the Mbandaka Health Zone in the DRC ()
1. Introduction
Breastfeeding presents itself as the first demonstration of a mother’s love for her child and this first relationship with the mother lays the foundations for all the child’s subsequent emotional and social relationships [1]. Breastfeeding involves feeding a newborn or infant with breast milk [2].
This is the optimal way to feed a healthy baby. The insufficient implementation of breastfeeding constitutes an important public health issue and its numerous benefits are widely recognized. Between aspirations and constraints: analyzes of the experience of breastfeeding among first-time mothers through the prism of social inequalities. Despite substantial evidence of benefits of breastfeeding for health and cognitive development, undeniable nutritional benefits and despite all the protections available to babies, most babies are not breastfed according to WHO recommendations, the rate of exclusive breastfeeding remains low [3]. We note that globally only 38% of babies are breastfed until the age of six months [4].
In Europe (in 2015), the percentage of babies exclusively breastfed for up to six months is below the standards recommended by the WHO, and this varies depending on the country: 13% in Denmark and 39% in the Netherlands which offer the best results, Switzerland 26%, while 95% of mothers are breastfeeding at the time of the baby’s birth. In 2020, the breastfeeding rate at birth in France was 74% [4].
According to the national perinatal survey (2022), France experienced a significant drop in the rate of exclusive breastfeeding at leaving the maternity ward and at two months, going from 74.2% to 39.4% [5]. In Belgium, out of 80% of mothers who breastfed after childbirth, only 30% continued to breastfeed after a month, the rest having switched to early food consumption. Exclusive breastfeeding is more often observed during childbirth among mothers with a higher socio-economic level than those with a low level [3]. The prevalence of exclusive breastfeeding in France is one of the lowest in European countries: 58% of children born in 2003 were only breastfed for ten weeks after leaving the hospital [6]. In England, the rate of exclusive breastfeeding is relatively low, with 60% of babies being bottle-fed just six weeks after birth [3].
In sub-Saharan Africa, exclusive breastfeeding for up to six months increased from 15% to 32% while in West and Central Africa it increased from 4% to 22% between 1990 and 2004. Despite this As a growing trend, exclusive breastfeeding at six months is exceptionally low and represents a public health priority in many countries around the world [7]. The consequences of low rates of exclusive breastfeeding for up to six months are numerous: for example, severe acute malnutrition linked to poor practices is one of the most important causes of infant mortality in developing countries. Some authors estimate that 3500 lives could be saved every day worldwide if all babies were exclusively breastfed for the first six months of their lives [3]. According to other authors, malnutrition is associated with nearly 40% of the 11 million deaths of children under five in developing countries, and it is estimated that 1.5 million of these deaths could be avoided by practice of immediate and exclusive breastfeeding during the neonatal period” [7].
In the DRC, UNICEF believes that breastfeeding is a common, natural and almost universal practice in the country. And out of 98% of births, only 37% of infants under six months are exclusively breastfed according to the results of the MICS 2010 survey. This indicates serious gaps in breastfeeding in the country [8].
According to the National Nutrition Program (PRONANUT acronym), the DRC has made exclusive breastfeeding one of the strategies to combat malnutrition in children aged 0 to 5 years [9]. However, the execution leaves a lot to be desired. Taking into account the development of the AME described above, the situation in the city of Mbandaka in general and in the ZS of Mbandaka, in particular, is no different from that recorded in the country as a whole. The report from the National Health Information System (SNIS) carried out in 2022 noted that 60% of children had developed episodes of serious diarrhea, more than half of whom had suffered from malnutrition [10].
Taking into account all these very striking data on the insufficiency of exclusive breastfeeding, and the absence of studies in our region of the city of Mbandaka, this study will fill this void by clarifying the determinants of non-compliance with exclusive breastfeeding among lactating women in the MBANDAKA health zone in the DRC.
2. Material and Method
2.1. Type of Study
This was a non-probabilistic, descriptive, cross-sectional study with an analytical aim.
2.2. Study Population
Our study population consists of breastfeeding women followed in Preschool Consultations in the 15 health areas of the Mbandaka ZS. They are the people best suited to provide information on the AME decision.
2.3. Sampling
To carry out this study we used purposive sampling which allowed us to choose the people who were best documented on the subject of study. It is a sampling method used in sample surveys, which is based on a reasoned (non-probabilistic) choice of the study sample.
Such a choice is reflected in the field by the application of certain rules for selecting the people interviewed. We endeavor to ensure that the distribution of the descriptive criteria of the sample selected is identical to that of the total population studied.
The sample size was 120 breastfeeding women who must meet the following inclusion criteria:
Be a breastfeeding woman;
Have a child aged 0 to 6 months;
Have attended the preschool consultation during our visit;
Voluntarily agree to participate in the study
People not meeting the criteria listed above were excluded from the study.
2.4. Collection of Data
To carry out this study, we used the questionnaire survey method and the questionnaire interview technique. Given the divergence of understandings between individuals on the theme, we required that the investigator alone complete the instrument to ensure concordance of responses and to elucidate confusing ideas, but with the free will of the participant.
2.5. Data Analysis Plan
Thus the data from the collection sites, recorded on the collection tools by the investigators, were compiled, cleaned then codified by creating new variables by the analyst. These data were entered using EXCEL 2010 software to create the database and then analyzed using SPSS version 20 software.
First, we made a description of the data by presenting the proportions in percentage and the average of certain variables. Second, we crossed the independent variables with the dependent variable using Pearson’s chi-square test to determine the relationship between them. The results of this study are estimated at a confidence interval (CI) of 95% with the alpha error risk set at 5% (p = 0.05).
2.6. Ethical Considerations
As any research that concerns humans, mainly in the field of health, brings ethical considerations into play from the start of the research, our approach is to first solicit the voluntary participation of subjects after having informed them of the nature, purpose, duration, and methods used during the research. The principles of confidentiality were required to respect the privacy and personality of the respondents. The survey questionnaires were kept in one place accessible only to the principal investigator. The investigator is committed to respecting the principles of confidentiality of the information provided to them and the anonymity of the subjects.
3. Results
Reading this Table 1 on marital status shows that only 20.8% of lactating women were married.
Regarding the age of the respondents, the result obtained indicates that 73.3% of breastfeeding women were over 25 years old. Regarding the level of study, the result obtained reveals that 66.7% of the women surveyed had a low level of study. As for profession, the same table shows that 81.7% of the women surveyed were unemployed. Table 2 shows that only 16.7% of the women surveyed had acceptable knowledge of the meaning of AME. Regarding knowledge of the benefits of breast milk for the baby, the result obtained indicates that 34.1% knew that breast milk gives good health to the baby. In terms of knowledge of the benefits of AME for the mother, the result reveals that only 10.9% of women knew that exclusive breastfeeding allows birth spacing for the mother. As for knowing the age of the child at the introduction of other liquids for the first time, Table 2 shows that 40% of women knew that it is at 6 months that a liquid other than breast milk must be introduced.
Table 3 shows that 60% of breastfeeding women had introduced water or other liquid into the child’s diet before the age of 6 months. Reading Table 4 indicates that the observation of low milk production from the breasts was cited as one of the main reasons justifying the introduction of water or other liquids into the child’s diet. Table 5 Indicates that the mother’s perception that the child is not satisfied RR = 2.43 [1.71 - 3.45], the baby’s refusal of breasts RR = 2.78 [1.96 - 3.94], the child cries a lot RR = 1.97 [1.50 - 2.58], the high heat RR = 2.01 [1.52 - 2.64] and the low milk production by the breasts RR = 3.06 [1.94 - 4.84] were statistically significantly associated (p < 0.000) with the introduction of liquids other than breast milk into the child’s diet before the age of 6 months. Table 6 indicates that maternal age RR = 1.46 [1.12 - 1.92], and level of education RR = 1.60 [1.22 - 2.09] were statistically associated significantly (p < 0.000) when introducing liquids other than breast milk into the child’s diet before the age of 6 months.
Table 1. Distribution of respondents according to socio-demographic characteristics.
No. |
Sociodemographic characteristics |
n=120 |
% |
1 |
Marital status |
|
|
|
Not married |
95 |
79.2 |
Married |
25 |
20.8 |
2 |
Age (in years) |
|
|
|
Under 25 |
32 |
26.7 |
More than 25 |
88 |
73.3 |
3 |
Level of study |
|
|
|
Low level |
80 |
66.7 |
High level |
40 |
33.3 |
4 |
Occupation |
|
|
|
No occupation |
98 |
81.7 |
With profession |
22 |
18.3 |
Table 2. Distribution of breastfeeding women according to knowledge of exclusive breastfeeding and its benefits.
Knowledge of exclusive breastfeeding and its benefits |
n = 120 |
% |
1 Knowledge of the meaning of AME |
|
|
Response not compliant with the AME |
62 |
51.7 |
Breastfeeding the child only at the breast without combining it with other liquids for up to 6 months |
20 |
16.7 |
Do not know |
38 |
31.6 |
2 Knowledge of the benefits of AME for the baby |
|
|
Promotes growth |
18 |
15 |
Increases intelligence |
11 |
9.2 |
Milk contains nutrients |
10 |
8.3 |
Attachment to mother |
2 |
1.7 |
Gives good health |
41 |
34.1 |
I don’t know |
38 |
31.7 |
3 Knowledge of the benefits of AME for the mother |
|
|
Protects against breast cancer |
6 |
5 |
Allows birth spacing |
13 |
10.9 |
Protects against postpartum hemorrhage |
1 |
0.8 |
Mother-child attachment |
1 |
0.8 |
No idea |
99 |
82.5 |
4 Knowledge of the child’s age at the introduction of other liquids for the first time |
|
|
1 month |
6 |
5 |
2 months |
11 |
9.2 |
3 months |
17 |
14.1 |
4 months |
24 |
20 |
5 months |
14 |
11.7 |
6 months |
48 |
40 |
Table 3. Distribution of respondents according to the introduction of water or other liquids before the age of 6 months.
Having introduced water or other liquids before the age of 6 months |
n = 120 |
% |
Yes |
72 |
60 |
No |
48 |
40 |
Table 4. Distribution of respondents according to reasons for non-compliance with the AME up to six months.
No. |
Reasons for non-compliance with the AME |
n=120 |
% |
1 |
The child does not get enough from the breasts |
|
|
Yes |
59 |
49.2 |
No |
61 |
50.8 |
2 |
The child refuses breasts |
|
|
Yes |
54 |
45.0 |
No |
66 |
55.0 |
3 |
The child cries a lot |
|
|
Yes |
48 |
40.0 |
No |
72 |
60.0 |
4 |
Because it was hot |
|
|
Yes |
51 |
42.5 |
No |
69 |
57.5 |
5 |
I don't eat well myself |
|
|
Yes |
35 |
29.2 |
No |
85 |
70.8 |
6 |
Low milk production from the breasts |
|
|
Yes |
69 |
57.5 |
No |
51 |
42.5 |
7 |
Fear of death of child |
|
|
Yes |
35 |
29.2 |
No |
85 |
70.8 |
Table 5. Relationship between the introduction of water or other liquid into the child’s diet for reasons of non-compliance with the AME by the respondents.
Variables |
Having introduced water or other liquid |
x2 |
RR [95% CI] |
P value |
No (n = 72) |
Yes (n = 48) |
The child does not get enough |
|
|
32.12 |
2.43 [1.71 - 3.45] |
0.0000 |
Yes |
50 |
8 |
No |
22 |
40 |
The child refuses breasts |
|
|
43.46 |
2.78 [1.96 - 3.94] |
0.000 0 |
Yes |
5 0 |
4 |
No |
22 |
44 |
The child cries a lot |
|
|
23.94 |
1.97 [1.50 - 2.58] |
0.0000 |
Yes |
44 |
6 |
No |
34 |
42 |
High heat |
|
|
25.19 |
2.01 [1.52 - 2.64] |
0.00005 |
Yes |
45 |
6 |
No |
33 |
42 |
I don’t eat well myself |
|
|
13.61 |
1.74 [1.35 - 2.24] |
0.0000 |
Yes |
30 |
5 |
No |
42 |
43 |
Low milk production from the breasts |
|
|
39.15 |
3.06 [1.94 - 4.84] |
0.0000 |
Yes |
58 |
11 |
No |
14 |
37 |
Fear of death of child |
|
|
8.95 |
0.63 [0.45 - 0.87] |
0.0028 |
Yes |
25 |
30 |
No |
47 |
18 |
Table 6. Relationship between the introduction of water or other liquid into the child’s diet according to the sociodemographic characteristics of the respondents.
Variables |
Having introduced water or other liquid |
x2 |
RR [95% CI] |
P value |
No (n = 72) |
Yes (n = 48) |
Age (in years) |
|
|
5.97 |
1.46 [1.12 - 1.92] |
0.015 |
Under 25 |
25 |
7 |
More than 25 |
47 |
41 |
Level of study |
|
|
10.00 |
1.60 [1.22 - 2.09] |
0.0016 |
Low level |
32 |
8 |
High level |
40 |
40 |
Marital status |
|
|
3.57 |
1.34 [0.97 - 1.85] |
0.058 |
Not married |
47 |
23 |
Married |
25 |
25 |
Mother’s occupation |
|
|
2.89 |
1.32 [0.32 - 1.84] |
0.088 |
No occupation |
50 |
26 |
With profession |
22 |
22 |
4. Discussion
The results related to marital status show that a significant number of respondents (79.2%) were unmarried. This situation is common in our city of Mbandaka in general and in the ZS of Mbandaka in particular where girls become pregnant before marriage while they are still with their parents and sometimes they allow themselves to go and live together. Furthermore, in the Congolese cultural value system, getting married is a great social consideration, which pushes young girls to live this life.
The results found in our study on married women or better still housewives show that only 20.8% of respondents were married. These results are far lower than those found (67.8%) by Sidibé Idrissa in Mali in 2021 and those of Diallo (88.4%) in 2019 [11] [12]. This high tendency of housewives observed in a sub-Saharan African country could be explained by the religious culture which wants women to be married.
In the study conducted in France by Hélène Cinelli (2022), we note that there is no intermediate category between marriage and singleness, married people are around 38.2%. This result is contrary to that found in our study where only 20.8% of respondents were married. This result could be explained by the difference in the study environment where France is a developed country while the DRC (Mbandaka health zone) happens to be a developing country where early sexuality, early motherhood, low level of education, poverty, irresponsibility of parents would be explanatory elements [5].
The most represented age group was that of 25 - 29 with 73.3%, this illustrates the image of the age category of breastfeeding mothers and reflects the productivity curve and the childbearing age in the Zone of Health of Mbandaka. Although the category of minors is less represented, it corresponds to that where the number of births is higher 55% according to WHO data (2023) [13]. The results of this study concerning the age of the respondents showed a predominance in the age group of 25 to 29 years (73.3%). These contrast with the results found by Diallo (2020) [2] where women aged 15 to 24 were more represented (38%). This disproportion could be explained by the fact that the Family Code of the Democratic Republic of Congo sets the legal age of marriage at 18 years of age for both spouses (2017). We also think that the study environment would also be a factor in the difference in the proportions observed. If Diallo in 2019 had carried out his study in Bamako in the capital of MALI, while our study was carried out in the Urban-Rural Health Zone of Mbandaka.
Regarding the level of studies, the results found show that the respondents in the majority of cases had a low level of studies: either primary (55.9%) and illiterate (10.8) which we have called in the context of this study “low level of study” with 66.7% were higher than those found by Diagne et al (27.3% in 2011) [14] and those found by Sidibé Idrissa (9.85% in 2021) [11].
As for the exercise of a profession, the results obtained indicate that 81.7% of the women surveyed were unemployed. This state of affairs can be explained by the fact that in the middle of her studies when a girl finishes primary school and/or becomes pregnant before obtaining her state diploma, she abandons her studies and devotes herself to running small businesses for survival and above all supporting the pregnancy. Currently, the rate of professional activity of women is lower than that of men. Indeed, according to a study conducted in 2019 by the Congolese Union of Media Women, we observe that the rate of active women was 32% compared to 68% for men.
However, it seems important to remember that the gaps in women’s access to the job market vary enormously within each country, particularly depending on the level of women’s education [15]. According to a study conducted by the Livelihood Resource Center (2024) [16], we note that in the DRC, many women abandon their studies too early with a very low level, which does not allow them to exercise any profession. But with the precariousness of social life, some of them get by carrying out small income-generating activities with a view to supplementing the family budget.
Concerning the introduction of water and/or other liquids than breast milk, the results reveal that 40% of the women surveyed had respected the recommendation of PRONANUT (2013) in terms of IYCF (Food and Nutrition of Young Children For this purpose, two profiles can be identified: the first profile brings together subjects who have voluntarily accepted AME for its benefits for the child and the mother in the first six months of life after birth and the second. relating to a large number of subjects who have questioned, for various reasons, the prescriptions of IYCF. This retraces to a certain extent the experience that each subject has had over time with regard to two products: water and other fluids given for the first time before 6 months of age [9].
The results on the determinants of non-compliance with the AME show that the mother’s perception that the child is not satisfied, the baby’s refusal of breasts, the child cries a lot, high heat and low production of milk from the breasts were statistically significantly associated with the introduction of liquids other than breast milk into the child’s diet before the age of 6 months.
Reading these results leads us to think that this state of affairs could come from the fact that the new birth is often considered a happy event where each member of the family and adjoining neighbors, for their part, provides certain advice and instills in the mother the inappropriate practices. This explains the influence that these people have in family life and the care of the woman after childbirth, especially since in the city of Mbandaka, childbirth represents a very powerful moment and event. Here, it should be noted that women tend to believe that crying means that breast milk is not enough to cover their needs and/or that the child is thirsty or not satisfied. Hence the need to add other liquids or even complementary foods to compensate for breast milk. Some women even think that when it is hot, breast milk also becomes warm, they do not know that milk adapts to any climate.
We also note that these results can also be understood in the sense that many women in the city of Mbandaka abandon their studies too early with a very low level, which does not allow them to exercise a paid profession. Given the precariousness of social life, some of them get by carrying out small income-generating activities with a view to supplementing the family budget. This low economic level is more perceptible by the large number of young people wandering on the roads and around drinking establishments, the most frequented, selling a few food products, sometimes at late hours in order to ensure the survival of their families. A situation that seems to force them to adopt debauched behavior in order to gain money. This results in a high number of single mothers. This situation is common in the city of Mbandaka in general and in the ZS of Mbandaka in particular where girls become pregnant before marriage while they are still with their parents and sometimes they allow themselves to go and live together for free with the father of pregnancy, question of their care. Plunging willingly or by force into this marital situation, the unmarried mother too quickly introduces complementary food and tramples underfoot the IYCF recommendations regarding the nutrition of young children. This risky behavior unwittingly leads to an increase in infant morbidity and mortality due to pathologies that can be avoided by simply respecting Exclusive Breastfeeding (AME). To this end, the report from the National Health Information System (SNIS) shows that 60% of children had developed episodes of serious diarrhea, more than half of whom had suffered from malnutrition. We believe, however, that we can considerably reverse the prevalence of malnutrition in our environment by correctly practicing the recommendations on AME.
The analysis focused on 120 breastfeeding women among whom (60%) had diversified their child’s diet before six months while continuing to breastfeed. This way of doing things does not respect the requirements of the national nutrition policy, while (40%) of women had breastfed exclusively for up to six months and then they had diversified their diet [9].
From these results, we note that we found a rate of exclusive breastfeeding which was higher than that found in the MICS 2010 survey with a rate of 37% for the whole country and that of 31.1% found by Veyry in 2022. This leads us to think that the fact of having a high exclusive breastfeeding rate would be due to the work done recently by midwives in healthcare establishments, on communication for behavior change carried out on the benefits of exclusive breastfeeding for the mother and her baby [17].
However, our rate remains lower than that of 66% found by Diagne et al in Senegal in 2021. This difference observed could be explained by the study population. Indeed, the study population of Diagne et al consisted of women attending the IPS (Intervention in Prevention and Support for breast-feeding) one of whose main vocations would be the education of breast-feeding mothers on hygiene. of the child, care for mothers and their children.
5. Conclusion
In the context of this study, the AME rate at six months was 40%, this rate is lower than the WHO/UNICEF recommendations (2023). The reasons given here to justify stopping AME at six months are none other than beliefs or social representations concerning the child’s crying, the hot climate, and the low milk production by the mother herself. etc. This is a challenge for health professionals who must adapt and strengthen the SBCC (Communication for Social and Behavioral Change) strategy and support for AME in order to ensure adequate nutrition for babies and thus prevent malnutrition. The results found confirm our hypothesis according to which: Socio-cultural and socio-economic factors would influence non-compliance with the AME.
Conflicts of Interest
The authors declare no conflicts of interest.