2015

Postpartum Breastfeeding in Rural Niger : Demographic Analysis of a communication program for child health care

Naoko HORII

Thèse de Socio-démographie soutenue le 12 novembre 2015 par Naoko HORII sous la direction de Yves CHARBIT à l’université Paris Descartes.

Contact : Naoko.Horii chez gmail.com

Background

This research aims to evaluate the effects of a behavior change communication program promoting early initiation of breastfeeding within the first hour of birth among the most vulnerable mothers in rural Niger. The main objectives are to identify the social determinants of initial breastfeeding and to examine the typology of integrated communication strategies for the socio-economically vulnerable group of populations. Behavioral child health outcomes have become an important research subject in Demography. However, few studies have examined breastfeeding during the postpartum period in Sub-Saharan Africa (SSA). Very few demographic approaches were applied to evaluate neonatal care by looking into socio-economic inequity in SSA. This thesis quantifies predominantly qualitative information characterizing behavioral studies in breastfeeding among the most deprived population.

Methods

This is a secondary analysis of cross-sectional quantitative studies conducted in Niger at different points of time based on a literature review of previous studies conducted in Sub-Saharan Africa. The cross-sectional surveys include : the 2006 Niger Demographic Health Survey (DHS), the 2012 Niger DHS and the post-intervention survey (PIS) conducted in 2011 to evaluate a communication program promoting family and community based child health care in 4 regions of Niger. To constitute a study population for each dataset, the same exclusion criteria were applied to include women aged 15-49 years, having at least one child less than 24 months born with vaginal delivery. The PIS study population, drawn from the original survey with stratified random sampling, was divided into two strata, the intervention and control groups according to exposure to the communication program. Statistical analysis tools were the chi-square test and multivariate logistic regression. Independent variables include behavior change activities, socio-demographic and economic status of mothers, health seeking behavior and hygiene practices.

Results

Postpartum breastfeeding is impaired by income poverty in Niger. Regardless of socio-economic vulnerability, hygiene practice increases the chance of early initiation of breastfeeding. Multivariate analysis with the 2011 PIS shows that hand washing and use of a traditional latrine increases by 2.4 (95%CI : 76 ; 220) and by 2.3 (95%CI : 51 ; 248) respectively the odds of early initiation of breastfeeding. Government health workers, midwives, play a key role determining mothers’ postpartum breastfeeding. Antenatal care (ANC) provided by midwives increases the chance of early breastfeeding that increases by 52% (95%CI : 14, 103) compared to ANC provided by other health professionals among the most deprived group of populations. The PIS does not provide any information to evaluate the role of traditional birth attendants in neonatal care. An inter-sectorial approach addressing multiple dimensions of maternal and child health significantly increases by 6.9 odds (95%CI : 374, 900) early initiation of breastfeeding compared to those who are not reached by the whole integrated KFP promotion. Home visits by community volunteers are not significant (IC 95% : -10 ; 54). Involvement of mothers as a peer promoting exclusive breastfeeding significantly reduces the risk of delayed initiation of breastfeeding by 2.0 odds (IC 95% : 39 ; 189). However, the number of exposures to different types of communication strategies does not influence positively early breastfeeding.

Conclusions
The impact of community volunteers and health workers is limited with regard to early breastfeeding among the most deprived group of mothers. The model of behavior change communication with participatory peer promotion and a multi-sectorial approach combining optimal hygiene promotion suggests a response to socio-economic disparity.

Mots-Clés

Breastfeeding, Determinants, Behavior change, Neonatal care, Vulnerability

Zone géographique

Afrique sub-saharienne, Niger

Publications relatives à la thèse


  • Horii Naoko (2014) « Promotion de l'allaitement optimal en Afrique sub-saharienne : le cas du Niger » (communication orale), présenté à Interdisciplinary approach from anthropology and demography on international migration and health, Osaka, Japon. http://www.minpaku.ac.jp/english/research/activity/news/rm/20140301-02.
    Résumé : La promotion de l’allaitement maternel est un des programmes de santé publique qui attire le moins d’investissement tant dans l’exécution des actions destinées au changement comportemental de la population que dans la réalisation de travaux scientifiques. Cette étude met en évidence l’importance de l’allaitement précoce et exclusif dont l’efficacité est reconnue pour réduire la mortalité des nouveau-nés, qui est en hausse en Afrique Sub-Saharienne. Cette étude se structure de trois parties : (1) Aperçu de la tendance de pratiques de l’allaitement précoce et exclusif dans la région de l’Afrique Sub-Saharienne, (2) Identification des déterminants de l’allaitement précoce sur la base des études précédentes et de l’analyse statistique de la base de donnée de l’Enquête Démographique et de Santé - Niger et (3) Evaluation de l’étude de cas au Niger sur la recherche action participative pour la promotion de soins de santé préventifs et curatifs, au nombre desquels l’allaitement optimal. Après avoir examiné les caractéristiques sociodémographiques et économiques, ainsi que les indicateurs comportementaux de recours aux soins par les mères au niveau familial et communautaire, quelques facteurs de risque qui déterminent les pratiques de l’allaitement ont été mis en évidence. Ils sont : types de personnels qui assistent l’accouchement, le lieu d’accouchement et statut économique du ménage. Les mères issues des couches sociales les plus pauvres ayant accouché à l’hôpital et ayant été assistées par les agents de santé, ont moins pratiqué l’allaitement dans l’heure qui suit l’accouchement. Une évaluation de l’impact du programme de communication au Niger, avec comparaison a posteriori, a été effectuée, afin d’examiner en particulier les influences de cette vulnérabilité socio-économique des mères sur le changement comportemental en terme d’allaitement précoce induit par les interventions de communication pour promouvoir les soins de santé de l’enfant.
    Mots-clés : Allaitement, communication, behaviour change.
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  • Horii Naoko (2019) Breastfeeding in Rural Niger: Lessons from Child Healthcare Promotion, Vol., 12, Cham : Springer International Publishing. (The Demographic Transformation and Socio-Economic Development book series (DTSD). ISBN : 978-3-030-22392-2 978-3-030-22393-9. http://link.springer.com/10.1007/978-3-030-22393-9.
    Résumé : This book investigates the most effective behavior change communication (BCC) strategies to reach socio-economically vulnerable mothers to promote early initiation of breastfeeding after birth in rural Niger. It thereby goes beyond conventional research frameworks by looking into multifaceted indicators including socio-economic and demographic status of mothers, environmental health, family and community based social network and typology of field activities. The book analyses demographic indicators by using field based pragmatic perspectives to scrutinise what the numbers tell in the local context. It also analyses a unique dataset of non-health related indicators such as income poverty to measure socio-economic vulnerability of mothers, involvement of and interactions with other family and community actors in child healthcare in addition to conventional socio-economic, demographic and health seeking behavioural indicators. The book draws policy and strategy recommendations based on the thorough analysis of each risk and protective factor for breastfeeding after birth to redirect technical and financial investment towards its most effective use for the optimal coverage of populations deprived from access to basic health and social services. As such this book is a very valuable read to researchers, public health and nutrition experts and decision makers in child health.
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  • Horii Naoko (2015) « Postpartum breastfeeding in rural Niger: demographic analysis of a communication program for health care », Thèse de Doctorat en démographie, Paris : Université Paris Descartes, 345 p.
    Résumé : This research aims to evaluate the effects of a behavior change communication program promoting early initiation of breastfeeding within the first hour of birth among the most vulnerable mothers in rural Niger. The main objectives are to identify the social determinants of initial breastfeeding and to examine the typology of integrated communication strategies for the socio-economically vulnerable group of populations. Behavioral child health outcomes have become an important research subject in Demography. However, few studies have examined breastfeeding during the postpartum period in Sub-Saharan Africa (SSA). Very few demographic approaches were applied to evaluate neonatal care by looking into socio-economic inequity in SSA. This thesis quantifies predominantly qualitative information characterizing behavioral studies in breastfeeding among the most deprived population. Methods:This is a secondary analysis of cross-sectional quantitative studies conducted in Niger at different points of time based on a literature review of previous studies conducted in Sub-Saharan Africa. The cross-sectional surveys include: the 2006 Niger Demographic Health Survey (DHS), the 2012 Niger DHS and the post-intervention survey (PIS) conducted in 2011 to evaluate a communication program promoting family and community based child health care in 4 regions of Niger. To constitute a study population for each dataset, the same exclusion criteria were applied to include women aged 15-49 years, having at least one child less than 24 months born with vaginal delivery. The PIS study population, drawn from the original survey with stratified random sampling, was divided into two groups, those exposed to the communication program and not exposed to such interventions. Statistical analysis tools were the chi-square test and multivariate logistic regression. Independent variables include behavior change activities, socio-demographic and economic status of mothers, health seeking behavior and hygiene practices. Results: Postpartum breastfeeding is impaired by income poverty in Niger. Regardless of socio-economic vulnerability, hygiene practice increases the chance of early initiation of breastfeeding. Multivariate analysis with the 2011 PIS shows that hand washing and use of a traditional latrine increases by 2.4 (95%CI: 76; 220) and by 2.3 (95%CI: 51; 248) respectively the odds of early initiation of breastfeeding. Government health workers, midwives, play a key role determining mothers’ postpartum breastfeeding. Antenatal care (ANC) provided by midwives increases the chance of early breastfeeding that increases by 52% (95%CI: 14, 103) compared to ANC provided by other health professionals among the most deprived group of populations. The PIS does not provide any information to evaluate the role of traditional birth attendants in neonatal care. An inter-sectorial approach addressing multiple dimensions of maternal and child health significantly increases by 6.9 odds (95%CI: 374, 900) early initiation of breastfeeding compared to those who are not reached by the whole integrated. Home visits by community volunteers are not significant (IC 95%: -10; 54). Involvement of mothers as a peer promoting exclusive breastfeeding significantly reduces the risk of delayed initiation of breastfeeding by 2.0 odds (IC 95%: 39; 189). However, the number of exposures to different types of communication strategies does not influence early breastfeeding. Conclusions: The impact of community volunteers and health workers is limited with regard to early breastfeeding among the most deprived group of mothers. The model of behavior change communication with participatory peer promotion and a multi-sectorial approach combining optimal hygiene promotion suggests a response to socio-economic disparity.
    Mots-clés : Behavior change, Breastfeeding, Determinants, Neonatal care, Vulnerability.
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  • Horii Naoko (2015) « Evaluation of a behavior change communication program for promoting early initiation of breastfeeding in rural Niger » (présenté à 12th European Nutrition Conference 2015), in Federations of European Nutrition Societies, Berlin : poster. http://www.karger.com/Article/Pdf/440895.

  • Horii Naoko (2014) « Optimal breastfeeding promotion in Sub-Saharan Africa » (communication orale), présenté à Interdisciplinary approach from anthropology and demography on international migration and health, Osaka, Japan. http://www.minpaku.ac.jp/english/research/activity/news/rm/20140301-02.
    Résumé : La promotion de l’allaitement maternel est un des programmes de santé publique qui attire le moins d’investissement tant dans l’exécution des actions destinées au changement comportemental de la population que dans la réalisation de travaux scientifiques. Cette étude met en évidence l’importance de l’allaitement précoce et exclusif dont l’efficacité est reconnue pour réduire la mortalité des nouveau-nés, qui est en hausse en Afrique Sub-Saharienne. Cette étude se structure de trois parties : (1) Aperçu de la tendance de pratiques de l’allaitement précoce et exclusif dans la région de l’Afrique Sub-Saharienne, (2) Identification des déterminants de l’allaitement précoce sur la base des études précédentes et de l’analyse statistique de la base de donnée de l’Enquête Démographique et de Santé - Niger et (3) Evaluation de l’étude de cas au Niger sur la recherche action participative pour la promotion de soins de santé préventifs et curatifs, au nombre desquels l’allaitement optimal. Après avoir examiné les caractéristiques sociodémographiques et économiques, ainsi que les indicateurs comportementaux de recours aux soins par les mères au niveau familial et communautaire, quelques facteurs de risque qui déterminent les pratiques de l’allaitement ont été mis en évidence. Ils sont : types de personnels qui assistent l’accouchement, le lieu d’accouchement et statut économique du ménage. Les mères issues des couches sociales les plus pauvres ayant accouché à l’hôpital et ayant été assistées par les agents de santé, ont moins pratiqué l’allaitement dans l’heure qui suit l’accouchement. Une évaluation de l’impact du programme de communication au Niger, avec comparaison a posteriori, a été effectuée, afin d’examiner en particulier les influences de cette vulnérabilité socio-économique des mères sur le changement comportemental en terme d’allaitement précoce induit par les interventions de communication pour promouvoir les soins de santé de l’enfant.
    Mots-clés : Allaitement, behaviour change, COMMUNICATION.
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  • Horii Naoko (2014) « Determinants of early initiation of breastfeeding and possible effects of communication program for behavior change in Niger » (communication orale), présenté à Colloque international Allaitement et pratiques de sevrage : approches pluridisciplinaires et diachroniques, Paris. http://www.ined.fr/fr/rendez_vous/seminaires_colloques/bdd/rendez_vous/856/.
    Résumé : Background. Optimal postpartum breastfeeding is uncommon in Niger, and its benefit is insufficiently exploited for reducing neonatal mortality risks. Less than half of mothers (48%) in Niger put their child to the breast within 1 hour of birth. UNICEF launched an integrated behaviour change communication program to promote key family practices, among others, early and exclusive breastfeeding. Objective. This study investigates risk factors hindering early initiation of breastfeeding in rural Niger. It analyzes the impact of a communication program promoting Key Family Practices. Methods. A secondary analysis was conducted based on a quantitative dataset of a retrospective comparative study conducted in four regions of Niger. The study population included 1,319 women aged 15-49 years having children less than 23 months. Multivariate logistic regression analysis examined the association between early initiation of breastfeeding and socio-demographic and economic status, and health seeking behaviours of mothers. Results. Mothers in polygynous unions were more likely to initiate early breastfeeding (66%, p=0.001) and be better-off (42%, p= 0.002) than those in monogamous unions. Program activities such as home visits by trained community workers tried to reach mothers in monogamous unions more (59%, p<0.001). In the intervention group, early breastfeeding increased for both groups: monogomous mothers showed progress as much as polygynous groups (90%, p<0.001, 87%, p<0.001 respectively). Conclusions and Implications. Further investigation is necessary to explore the role of socio-economic vulnerability on program responsiveness for improving postpartum breastfeeding.
    Mots-clés : Behavior Mechanism, Breastfeeding, COMMUNICATION, Marital status.
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  • Horii Naoko (2014) « La promotion de l’allaitement optimal au Niger », in Questions de migrations et de santé en Afrique sub-saharienne, Harmattan, Paris : Yves CHARBIT, Teiko MISHIMA, p. 149-174. (Populations). ISBN : 978-2-343-04674-7. http://www.editions-harmattan.fr/index.asp?navig=catalogue&obj=livre&no=45106.
    Résumé : La promotion de l’allaitement maternel est un des programmes de santé publique qui attire le moins d’investissement tant dans l’exécution des actions destinées au changement comportemental de la population que dans la réalisation de travaux scientifiques. Cette étude met en évidence l’importance de l’allaitement précoce et exclusif dont l’efficacité est reconnue pour réduire la mortalité des nouveau-nés, qui est en hausse en Afrique Sub-Saharienne. Cette étude se structure de trois parties : (1) Aperçu de la tendance de pratiques de l’allaitement précoce et exclusif dans la région de l’Afrique Sub-Saharienne, (2) Identification des déterminants de l’allaitement précoce sur la base des études précédentes et de l’analyse statistique de la base de donnée de l’Enquête Démographique et de Santé - Niger et (3) Evaluation de l’étude de cas au Niger sur la recherche action participative pour la promotion de soins de santé préventifs et curatifs, au nombre desquels l’allaitement optimal. Apres avoir examiné les caractéristiques sociodémographiques et économiques, ainsi que les indicateurs comportementaux de recours aux soins par les mères au niveau familial et communautaire, quelques facteurs de risque qui déterminent les pratiques de l’allaitement ont été mis en évidence. Ils sont : types de personnels qui assistent l’accouchement, le lieu d’accouchement et statut économique du ménage. Les mères issues des couches sociales les plus pauvres ayant accouché à l’hôpital et ayant été assistées par les agents de santé, ont moins pratiqué l’allaitement dans l’heure qui suit l’accouchement. Une évaluation de l’impact du programme de communication au Niger, avec comparaison a posteriori, a été effectuée, afin d’examiner en particulier les influences de cette vulnérabilité socio-économique des mères sur le changement comportemental en terme d’allaitement précoce induit par les interventions de communication pour promouvoir les soins de santé de l’enfant. 母乳保育推進は、公衆衛生分野のなかで、人びとの行動変革を目指す実践的な運動においても、また学術研究においても、最も関心の浅いプログラムのひとつである。本研究では、サブサハラ・アフリカ地域で今なお増え続ける新生児死亡率の削減に有益な効果をもたらすと考えられている産後母乳保育の早期開始と完全母乳保育の重要性を明らかにする。 本研究は、主に次の３部によって構成される。 （１）サブサハラ地域における産後母乳保育の早期開始、および完全母乳保育の実践状況についての概観 （２）過去の文献調査およびニジェール国人口保健調査（Demographic Health Survey）データベースの統計分析に基づいた、産後母乳保育の確定要因の抽出 （３）ニジェール国における予防と治療のためのヘルスケア、とりわけ完全母乳保育を推進するための参加型アクションリサーチの事例研究についての評価 社会人口的および経済学的特質を検討するとともに、家族やコミュニティー・レベルでの母親による子供の健康ケアのためのサービスへのアクセスを積極的に求める行動に関わる要因を詳細に分析する。それによって、母乳保育の実践の有無に関わるいくつかの危険因子が明らかとなる。代表例としては、出産に立ち会う人間の資格、出産場所、世帯の経済状況などが挙げられる。たとえば最も貧困な社会層に属し、ヘルスワーカー（病院の医師および助産婦）の立ち会いのもとに病院で出産した母親は、産後母乳保育の早期開始の定義による出産後一時間以内に母乳保育の実践をしない傾向にあることなどの点が本研究で明らかとなった。 最後に、ニジェール国におけるコミュニケーション・プログラムの事例研究を取り上げ、事後（アポステリオリ）比較分析手法を用いた評価を行う。乳児の保健医療を推進する本プログラムにおける早期母乳保育について、母親の社会・経済的な脆弱性が、母親の行動の変化にどのような影響を与えるかという点について検討したい。
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  • Horii Naoko (2015) « Evaluation du programme de la communication pour le changement comportemental sur l’allaitement précoce au Niger » (présenté à Conference of Société Francaise de Santé Publique), in Determinants sociaux de la santé: des connaissances a l’action, Tours : poster. http://www.sfsp.fr/manifestations/congres2015/donnees/articles_aut/fs_aut500_session30_art05.htm.

  • Horii Naoko (2014) « Impact Assessment of a Behavior Change Communication Program in Niger » (communication orale), présenté à Annual Conference (Society for Nutrition Education and Behavior), Milwaukee. http://download.journals.elsevierhealth.com/pdfs/journals/1499-4046/PIIS1499404614002012.pdf.
    Résumé : Objectives: This study assesses the impact of behavior change communication on early initiation of breastfeeding in Niger. Study Design: A secondary analysis of a post intervention survey conducted in Niger in 2011. The study population includes 2,091 women aged 15-49 years with children less than 23 months. They are categorized into an intervention group exposed to the communication program and control groups not exposed to the intervention. Outcome, Measures and Analysis: The outcome vari- able is early initiation of breastfeeding, which is defined as putting a child to breast within 1 hour of birth. Independent variables include different types of communication program activities. Other variables include socio-demographic, economic, environmental and health seeking behavior related in- dicators. Chi-square tests identify the determinants of early initiation of breastfeeding based on the entire population of the study sample. Stratified bivariate analysis and multivar- iate logistic regression examine the influence of the communication program on initiation of breastfeeding. Results: Based on the entire population, home visits by trained community volunteers to mothers showed slight but positive influence on improved initiation of breastfeeding which increased by 15% compared to mothers who have not received home visits (95% CI: -11, 34). Regardless of socio-economic vulnerability, mothers' involvement in breastfeeding promotion increased by 99% their early initiation of breastfeeding compared to those not involved in any health promotion activities (95% CI: 39, 185). Conclusions: The study suggests that a community based participatory approach could be an equity-focused model for behavior change in early initiation of breastfeeding.
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  • Horii Naoko, Allman James, Martin-Prével Yves et Waltisperger Dominique (2017) « Determinants of early initiation of breastfeeding in rural Niger: cross-sectional study of community based child healthcare promotion », International Breastfeeding Journal, 12 (1). DOI : 10.1186/s13006-017-0134-9. http://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-017-0134-9.


  • Horii Naoko, Guyon Agnes et Quinn Victoria (2011) « Determinants of delayed initiation of breastfeeding in rural Ethiopia: programmatic implications. », Food Nutr Bull, 32 (2) (juin), p. 94-102. DOI : 10.1177/156482651103200203. http://www.ncbi.nlm.nih.gov/pubmed/22164971.
    Résumé : BACKGROUND: A number of studies have examined the possible adverse impact of services offered by health workers and community members on postpartum infant feeding practices. The present analysis utilized extant data collected previously through the baseline surveys of two related child health and nutrition projects implemented in rural Ethiopia and explored key risk factors associated with delayed initiation of breastfeeding for more than 1 hour after birth. OBJECTIVE: To investigate the most important determinants of delayed initiation of breastfeeding. METHODS: Multivariate logistic regression was performed to analyze data from baseline cross-sectional surveys carried out in 2003 and 2004 in selected districts across three regions in Ethiopia. RESULTS: Attendance at delivery by a health worker was found to be an important risk factor for the delayed initiation of breastfeeding, whereas attendance by traditional birth attendants or family and/or friends represented a protective factor for early initiation of breastfeeding. Additional analysis suggests that targeting of behavior change interventions on optimal infant feeding to these health workers could reverse the risk relationship and lead to improvements in the rate of early initiation of breastfeeding. CONCLUSIONS: Provision of inadequate breastfeeding information in the health system and attendance at delivery by health workers are associated with a delay in the initiation of breastfeeding. Births attended by trained traditional birth attendants and family members are associated with better practices. Targeting health workers, community members, families, and women to promote optimal infant feeding practices is likely to hold much potential to increase the adoption of early initiation of breastfeeding.
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  • Horii Naoko, Habi Oumarou, Dangana Alio, Maina Abdou, Alzouma Souleymane et Charbit Yves (2016) « Community-based behavior change promoting child health care: a response to socio-economic disparity », Journal of Health, Population and Nutrition, 35 (12) (décembre). DOI : 10.1186/s41043-016-0048-y. http://jhpn.biomedcentral.com/articles/10.1186/s41043-016-0048-y.
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