| Summary: | Background. Starting in 2001, the World Health Organization (WHO) began to
recommend exclusive breastfeeding (EBF) in the first 6 months of life and
continued breastfeeding until 2 years or older. Breastfeeding promotion needs to be
conducted to increase the duration of EBF. We conducted an experimental trial of
multilevel promotion of EBF, including several suspected determinants. This was
an ecological, comprehensive, and integrated interventional approach using local
resources.
Objectives. To examine the effectiveness of multilevel promotion of EBF on the
duration of EBF and child growth. Moreover, this study sought to learn whether
maternal knowledge could improve EBF duration and whether EBF could predict
breastfeeding duration.
Methods. A quasi experiment with a pretest posttest control group design was
assigned in 2 public health centers in the Demak District. The sample size was
determined using the sample size calculations for comparative studies of survival
analysis. A total of 163 mothers were enrolled, as well as fathers and grandmothers.
Intervention of multilevel promotion of EBF was conducted at the organizational,
community, family, and individual levels. This was a complex intervention that
modified breastfeeding determinants, integrated multidisciplinary partnerships, and
involved community leaders (i.e., voluntary health workers, traditional birth
attendants, Muslim scholars, and heads of villages). The strategies applied were
advocacy, training, media, and home visit counseling. The outcomes measured were
EBF duration and its determinants, breastfeeding duration, and nutritional status.
We employed (a) survival analyses to depict the pattern of EBF and breastfeeding
duration, (b) Cox proportional-hazard with hazard ratio (HR) to examine the effect
of intervention on EBF duration and its determinants, (c) logistic regression with
odds ratio (OR) to test whether EBF affected breastfeeding duration, and (d)
linear/logistic regression and mixed effect linear/logistic regression (with OR and
coefficient beta) to measure the effect of the intervention on nutritional status.
Results. The duration of EBF increased after the multilevel promotion of EBF. The
median post-intervention duration in the intervention group was 18 weeks compared
with 0.1 weeks in the control group (p < 0.001). Mothers in the control group were
three times more likely to stop EBF per unit time than mothers in the intervention
group (adjusted hazard ratio aHR 3.01, 95% CI: 1.96, 4.63). Mothers with a high
level of knowledge had the greatest chance of improving EBF duration. Mothers
who had a knowledge score >80 had a 79.1% (aHR 0.21 95% CI 0.11, 0.38) greater
chance of continuing to breastfeed exclusively compared to mothers who had a
knowledge score <60. In addition, mothers who received the grandmother's support
to feed, received free samples of milk formula at discharge, and experienced breast
engorgement, respectively, had a 2.04 (95% CI 1.32,3.15), 1.99 (95% CI 1.25,3.18),
and 1.97 (95% CI 1.32,2.95) fold risk of shortening duration of EBF. The mean
duration of breastfeeding was 22.8 months. EBF was not a significant factor in
prolonging the duration of breastfeeding. Breastfeeding duration was affected by
the mother's breastfeeding plan and age, the child's nutritional status, and EBF
promotion. Mothers who planned to breastfeed less than 24 months had a 13.8(95% CI 2.96,64.2) fold risk of shortening breastfeeding duration than mothers who
planned to breastfeed until 24 months. Younger mothers had a 3.43(95% CI
1.20,9.77) fold risk of shortening the duration of breastfeeding than older mothers
(age > 30 years). Children who were underweight had an 84% (0.16 95% CI
0.035,0.77) risk of being breastfed longer than children with a normal weight. On
the contrary, the mothers who did not receive EBF promotion had an 88% (HR 0.12
95% CI 0.043,0.36) risk of prolonging the duration of breastfeeding than mothers
who received EBF promotion. The multilevel promotion of EBF could improve the
nutritional status. At the age of 4 to 6 months, there was a weight gain in the
intervention group 0.09 kg (95% CI 0,01
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