Abstract
Background
Breastfeeding is the cornerstone of a newborn’s nutrition, containing crucial nutritional components. While a substantial body of research focuses on mothers, there is limited understanding regarding effective strategies to engage fathers in promoting breastfeeding practices. Therefore, this quasi-experimental study investigated a community-based intervention to improve breastfeeding exclusivity and initiation rates by targeting fathers in breastfeeding education.
Methods
This research was conducted in Dessie City in the Amhara region of Northeast Ethiopia from 5th October 2020 to 30th August 2021. Fathers and their wives were assigned individually to the intervention and control groups. Baseline data were gathered from selected Kebeles (Kebele: the lowest administrative level in Ethiopia) to identify couples seeking care through routine maternal and child health services. Fathers in the intervention area received breastfeeding education services at health facilities or home visits during antenatal, delivery, and postpartum periods. Trained midwives participated in giving breastfeeding education. In the control arm, they received routine counseling activities. Factors associated with early initiation and exclusive breastfeeding were analyzed using multivariable analysis among the two groups.
Results
The intervention involved 327 participants, 155 in the intervention arm and 172 in the control group. The multivariable analysis indicated that the community-based father health education intervention significantly influenced the early initiation of breastfeeding. Mothers in the intervention group were found to be nearly five times more likely to initiate breastfeeding within the first hour of their infants’ lives (AOR: 4.85, 95% CI: 1.36—17.32). A significant positive impact was also found for exclusive breastfeeding (EBF) of infants at the 1st, 4th, and 6th months (AOR: 3.95, 95% CI: 1.09—14.27), (AOR: 5.47, 95%CI: 2.18—13.70), and (AOR: 1.70, 95% CI: 1.02—2.85) respectively.
Conclusion
This study confirmed the positive effects of a community-based father education intervention on the rates of exclusive breastfeeding during the first, fourth, and sixth months, as well as the early initiation of breastfeeding. The government and healthcare workers should implement policies supporting father-inclusive breastfeeding initiatives such as creating awareness and the critical role fathers’ play.
Keywords: Breastfeeding, Community-based intervention, Fathers, Quasi-experimental study
Introduction
Breastfeeding is a feeding practice of mothers for their infants & young children through breast [1]. Breast milk is naturally tailored to meet their specific nutritional needs [2] and contains all nutrients that a healthy child requires [3]. The World Health Organization (WHO) infant-feeding guidelines recommend that all infants be breastfed within one hour of birth and exclusively breastfed until six months of life [4]. As of 2023, the global rate of exclusive breastfeeding in the first six months of life is 48%, close to the World Health Assembly’s target of 50% by 2025 [5].
Globally, because of inadequate breastfeeding in combination with high levels of diseases, more than 10 million children under five years die each year. Of this figure, 41% occur in Sub-Saharan Africa and 34% in the South Asian region [6]. A cohort study in Ghana revealed that 22% of neonatal deaths could be prevented if all infants were breastfed within the first hour of birth, and 16% of deaths could be prevented if all infants were exclusively breastfed for six months [7]. Annually, in developing countries, raising rates of exclusive breastfeeding to optimal levels is projected to prevent 13% of all deaths among children below 5 years of age [8].
The practice of exclusive breastfeeding for six months among developing countries ranges from 10.1% in Lebanon to 77% in Jordan [9]. According to the 2016 Ethiopian Demographic and Health Survey (EDHS), the prevalence of exclusive breastfeeding is 58% [10]. Based on particular research findings, the rate of exclusive breastfeeding ranges from the lowest (18%) in Dabat, Amhara regional state [11] to the highest (71.3%) in Guba, Oromia Regional state [12]. Though lack of breastfeeding has a significant impact, none of the studies emphasize the importance of engaging fathers in breastfeeding practice. Fathers’ involvement in breastfeeding practices is crucial as it fosters a supportive environment that enhances the mother’s confidence and commitment to breastfeeding. When fathers actively engage, mothers can strengthen their connection with the baby and improve the family’s well-being [13].
Previous research explored different factors for exclusive breastfeeding for six months. The salient factors associated with exclusive breastfeeding are maternal age, maternal level of education, maternal employment status, maternal knowledge, place of delivery, residence, culture, and household wealth status [11, 14–17].
Fathers influence breastfeeding initiation and exclusivity [17]. They are considered social supporters of their wife’s breastfeeding [18, 19] and a source of resources for childcare and breastfeeding in the family [20, 21]. The role of fathers in supporting Exclusive Breastfeeding (EBF) has been included in the global strategy for breastfeeding promotion issued by the World Health Organization [22]. However, it was not included in the original Ten Steps to Successful Breastfeeding [23] and was not addressed explicitly in the Ten Steps revised version [24]. Paternal breastfeeding education is aimed at strengthening breastfeeding knowledge, positive attitudes, and their involvement in physical and emotional support to the mothers, ultimately improving the breastfeeding practices of the mothers [25, 26]. Prior studies often focus solely on mothers, overlooking the critical role fathers can play in supporting breastfeeding practices. There is a cultural belief that fathers are assumed to be inferior if someone else sees them while supporting their wives [27]. Therefore, this interventional study highlights the impact of breastfeeding education on fathers’ involvement in breastfeeding, demonstrating how educating fathers can enhance breastfeeding practices and outcomes. This, in turn, contributes to improved children and maternal well-being, the development of informed policies, and the establishment of evidence-based practices.
Methods and materials
Study area and period
A quasi-experimental study was conducted in six Kebeles of Dessie city from September 3 to October 2, 2020. Kebeles that did not have a common boundary were selected purposively. According to the reports from the city’s administrative health office, Dessie has ten urban and eight rural Kebeles, with an estimated population of 218,471 residents. Four community health centers, two private hospitals, and various clinics are found in the study area.
Study population
The study subjects were expectant fathers of the current pregnancy and their pregnant wives whose gestational age was 12 to 32 weeks on September 01, 2020. Fathers were included if they had lived with their wives at home. Participants were included individually in the study if they communicated regularly with their wives. If the women were wrongly identified as pregnant or experienced a pregnancy loss (miscarriage, stillbirth, neonatal death) during the follow‐up period, or mothers who were seriously ill and unable to answer questions, or they were divorced or separated or emigrated from the study area during the intervention and assessment periods, they were excluded from the survey during follow-up. Similarly, couples who met the inclusion criteria but were temporary residents without ID cards in the study area were excluded from the study. Eligible pregnant women were identified using lists maintained by health extension workers in the catchment area. The study covered all couples who lived in the specified Kebeles and met the inclusion criteria. However, if a couple left the study area or their address was unknown, they were excluded from the study during the intervention period. The couples were reintroduced into the study if they returned to the study area and their addresses were obtained. Ultimately, 155 couples in the intervention arm and 172 in the control arm participated in the study.
Operational definition
Exclusive breastfeeding
Infant was fed only breast milk (with the exception of ordered medicines and vitamins by health professionals) for six months.
Early initiation of breastfeeding
Initiation of breastfeeding within the first hour following birth.
Intervention group
Fathers who got breastfeeding education in the intervention setting.
Control group
Fathers who did not get breastfeeding education and live in the control area.
Intervention
The investigators conducted a community-based intervention that spanned both antenatal and postnatal periods. The intervention was conducted from October 5, 2020, to August 30, 2021. The intervention was designed in accordance with the national breastfeeding guidelines and the World Health Organization (WHO) breastfeeding intervention strategy targeting fathers [28]. Ten midwives and eight health extension workers took a two-day training before the intervention to enhance their understanding of the benefits of breastfeeding, early initiation, and exclusive breastfeeding. The training includes lectures, group discussions, role-playing, and field practice with fathers. It involved 25 fathers residing in Kebeles who were not part of the intervention. Throughout the training, the trainees received feedback from the fathers to improve their health education-delivery skills.
The breastfeeding intervention consisted of several components: 1) individual health education sessions during their antenatal care follow-up and at the time of delivery, 2) minimum of two and maximum of six telephone calls, 3) monthly base group breastfeeding education session, and 4) one home-based breastfeeding education session during postnatal period delivered by trained health personnel. Individual-based SMS messages promoting breastfeeding highlighted the importance of early initiation, exclusive breastfeeding, and ways fathers could support their wives. Each father received about 20 breastfeeding SMS messages and five printed leaflets containing the key interventional notes. The materials help fathers gain a better understanding of and motivation for recommended breastfeeding practices. Fathers received them when they initially consented to take part in the study. The intervention was given to the couples in the intervention group, while the usual routine breastfeeding counselling was given to the mothers in the control group. Monthly group breastfeeding education sessions lasting 20 to 30 min were conducted. The health extension workers organized the groups at the intervention site. The fathers’ grouping was made considering their nearest residency setting to each other. On the day following delivery, individual health education sessions were conducted at health centers and during home visits. Fathers received information about the benefits of breastfeeding and the ways they could support their wives during the postpartum period. The overall breastfeeding education was given by trained BSc midwives. Following delivery, three follow-up visits were made at the end of the first, fourth, and sixth months by community health extension workers.
A monthly meeting was planned by the paternal leader after consultation with other fathers concerning the time, place, and topic of the meeting and in discussion with each father. However, this plan was cancelled due to Corona Virus Disease-19 (COVID-19) risk. Then, discussion groups were formed involving 10 to 15 fathers. For fathers’ experiences about the benefits of breastfeeding, leaflets containing individual experiences were shared for those fathers who had less breastfeeding practice. Similarly, photo sharing through telegram was facilitated. In addition, unexpected fathers’ experience sharing was done during community-based health development army meetings, comprised of five members led by health extension workers. Printed certification of fathers whose infants initiated breastfeeding early and exclusively breastfed was made to increase their compliance and to motivate other fathers whose infants not have early initiation EBF.
In the control group, routine health services were provided similar to those at the intervention site. Mothers who delivered at health institutions received counselling on new-born care, nutrition, vaccination, and other primary health care services during antenatal and postnatal care. The overall participant selection process of the intervention is illustrated in Fig. 1. This interventional study had two specific objectives, describing the breastfeeding practice in the intervention and control arms and explaining the effect of fathers’ breastfeeding intervention on early initiation and exclusive breastfeeding. The study hypothesized that if fathers are educated about breastfeeding and their involvement in breastfeeding is crucial, the messages on the educational materials were designed to guide fathers.
Fig. 1.
Participant selection and analysis flow chart of father education for breastfeeding improvement
Data collection
The socio-demographic characteristics of the couples were collected at baseline through interviewer-administered questionnaires. These indicators included parental age, education, residency, occupation, family size, and average monthly income of the household. Similarly, within an hour of birth, health extension workers measured the weight of infants born at home. Data were collected by external data collectors who were unaware of the study’s hypothesis. Intervention outcomes were assessed by visiting all selected mothers at one, four, and six months postpartum. During the first visit, the interviewer used structured questionnaires to ask mothers about their infants’ characteristics, including gender, birth weight as recorded, type of delivery, and timely initiation of breastfeeding. The questionnaire was adapted after reviewing a previous intervention measuring breastfeeding practices [29]. The definition of exclusive breastfeeding and early breastfeeding initiation were based on the WHO standard guidelines [26]. Exclusive breastfeeding and timely initiation of breastfeeding were identified from the mothers’ recall.
Statistical methods
Data were entered into Epi-Data and analyzed using SPSS version 26. The overall effect of the intervention was assessed using the Number Needed to Treat (NNT) analysis at the individual level. The differences in baseline characteristics between the two groups were evaluated using the Chi-square test. Multivariable logistic regression was computed to calculate the odds ratio used to detect the strength of the association between father education intervention and early initiation and EBF. A P-value of less than 0.05 was used to determine a statistically significant association between the variables.
Results
Basic characteristics of the parents
The result is presented in adherence to the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) guidelines for nonrandomized/quasi-experimental study designs [30]. Three hundred and twenty-seven (155 intervention and 172 control groups) fathers participated in this research project. All couples living in the study area were assigned to one of the two groups. Their allocation was based on their living conditions, ensuring groups did not share common boundaries. During the assignment stage, 159 couples were enrolled in the intervention group, while 182 couples joined the control group. However, by the end of the sixth month, 155 couples in the intervention group and 172 in the control group remained to assess the impact of breastfeeding education on early initiation and exclusive breastfeeding. Sixty-seven (43.2%) of fathers in the intervention arm and 88(51.2%) in the comparison group were above the age of 34 years. Similarly, more than three-fourths of fathers in the intervention, 133(85.8%) and 135(78.5%) of fathers in the control arms were urban residents. Using the Chi-square test, paternal education and maternal occupation differed significantly at baseline (Table 1).
Table 1.
Baseline characteristics of the study participants
| Characteristics | Study population groups | P-value | |
|---|---|---|---|
| Intervention N (%) | Control N (%) | ||
| Paternal Age | |||
| ≤ 34 | 88(56.8) | 84(48.8) | 0.150 |
| 35 and above | 67(43.2) | 88(51.2) | |
| Maternal age | |||
| ≤ 34 | 125(80.6) | 141(82.0) | 0.763 |
| 35 and above | 30(19.4) | 31(18.0) | |
| Residence | |||
| Rural | 22(14.2) | 37(21.5) | 0.086 |
| Urban | 133(85.8) | 135(78.5) | |
| Paternal education | |||
| Unable to read & write | 9(5.8) | 16(9.3) | 0.016 |
| Able to read & write | 11(7.1) | 17(9.9) | |
| Grade up to 12 | 85(54.8) | 64(37.2) | |
| Diploma & above | 50(32.3) | 75(43.6) | |
| Maternal education | |||
| Unable to read & write | 20(19.9) | 20(11.6) | 0.875 |
| Able to read & write | 12(7.7) | 14(8.1) | |
| Grade up to 12 | 89(57.4) | 94(54.7) | |
| Diploma & above | 34(21.9) | 44(25.6) | |
| Maternal occupation | |||
| House wife | 103(66.5) | 109(63.4) | 0.029 |
| Private | 12(7.7) | 28(16.3) | |
| Employee | 22(14.2) | 26(15.1) | |
| Others | 18(11.6) | 9(5.2) | |
| Paternal occupation | |||
| Farmer | 14(9.0) | 30(17.4) | 0.091 |
| Private | 44(28.4) | 52(30.2) | |
| Employee | 49(31.6) | 80(46.5) | |
| Others | 48(31.0) | 10(5.8) | |
| Number of alive children | |||
| Three and below | 142(91.6) | 155(90.1) | 0.640 |
| Above three | 13(8.4) | 17(9.9) | |
| HH monthly income | |||
| Lowest to the median | 88(56.8) | 87(50.6) | 0.262 |
| Above the median | 67(43.2) | 85(49.4) | |
Others includes daily labors, currently no jobs, and merchants
Basic characteristics of the newborns
The intervention and control groups showed significant differences in delivery type, infant birth weight, and place of delivery. The rate of child delivery through caesarean sections was almost twice as high in the control group (34 or 20.6%) than in the intervention group (17 or 11.2%). One hundred forty-three (94.1%) of births in the intervention arm and 142(85.5%) of infants in the comparison group were delivered at the health institution (Table 2).
Table 2.
Infant related characteristics
| Characteristics | Intervention arm N (%) | Comparison arm N (%) | P-value |
|---|---|---|---|
| Delivery type | |||
| Cesarean | 17(11.2) | 34(20.6) | 0.023 |
| Spontaneous | 135(88.8) | 131(79.4) | |
| Place of delivery | |||
| Health institution | 143(94.1) | 142(85.5) | 0.013 |
| Home | 9(5.9) | 24(14.5) | |
| Infant sex | |||
| Female | 85(54.8) | 90(52.3) | 0.649 |
| Male | 70(45.2) | 82(47.7) | |
| Infant birth weight | |||
| Low Birth Weight | 31(20.0) | 52(30.2) | 0.034 |
| Normal Birth Weight | 124(80.0) | 120(69.8) | |
LBW Low Birth Weight, NBW Normal Birth Weight
Over-all effect of the intervention
The number needed to treat (NNT) analysis is as follows:
This implies that five couples need to have breastfeeding education intervention to have one additional woman breastfeed exclusively.
Effect of father education intervention
According to the multivariable analysis, community-based father education intervention positively affected early initiation of breastfeeding, EBF, and infants’ birth weight. Mothers from the intervention group had nearly 5 times higher odds of initiating breastfeeding early. Similarly, mothers in the intervention group had nearly 4, 51/2, and 3 times higher odds of exclusively breastfed their infants at 1, 4, and 6 months, respectively, compared to infants in the control group (Table 3).
Table 3.
Relation with father education intervention and breastfeeding
| Early initiation of BF | Yes (%) | No (%) | Un-adjusted OR (95%CI) | Adjusted OR (95%CI) |
|---|---|---|---|---|
| Intervention (N = 152) | 121(79.6) | 31(20.4) | 2.58(1.569–4.273) | 4.85(1.36,17.32) |
| Control (N = 168) | 101(60.1) | 67(30.9) | 1 | 1 |
| EBF at 1st month | Yes | No | ||
| Intervention (N = 152) | 149(98.0) | 3(2.0) | 4.90(1.390–17.279) | 3.95(1.09, 14.27) |
| Control (N = 167) | 152(91.0) | 15(9.0) | 1 | 1 |
| EBF at 4th month | Yes | No | ||
| Intervention (N = 151) | 145(96.0) | 6(4.0) | 5.54(2.245–13.718) | 5.47(2.18, 13.70) |
| Control (n = 166) | 135(81.3) | 31(18.7) | 1 | 1 |
| EBF at 6th month | Yes | No | ||
| Intervention (n = 149) | 125(83.9) | 24(16.1) | 3.35(1.960–5.732) | 2.96(1.67, 5.23) |
| Control (n = 166) | 101(60.8) | 65(39.2) | 1 | 1 |
| Infants birth weight | LBW | NBW | ||
| Intervention (n = 155) | 124(80.0) | 31(20.0) | 1.73(1.040–2.888) | 1.70(1.02–2.85) |
| Control (n = 172) | 120(69.8) | 52(30.2) | 1 | 1 |
Discussion
This research project proposed a hypothesis regarding the impact of community-based father education on enhancing breastfeeding practices. The study further contributes to the existing body of evidence by demonstrating that a community-based intervention targeting fathers can significantly improve the early initiation and exclusivity of breastfeeding practices following childbirth.
Based on the adjusted findings from a multivariable logistic regression model, it was observed that mothers living in the intervention area, where their husbands actively participated in the breastfeeding promotion program, reported initiating breastfeeding at an earlier stage. Additionally, these mothers exhibited higher rates of exclusive breastfeeding (EBF) in the first, fourth, and sixth months compared to counterparts in the control group. This encouraging effect of the intervention on early breastfeeding initiation provides further evidence that agrees with earlier controlled trials [31, 32] and quasi-experimental studies with similar intervention strategies [28, 33].
The current study’s results indicate the most significant difference between the intervention and control groups regarding exclusive breastfeeding (EBF) rates in the fourth month. This discrepancy is due to the behavioral changes exhibited by fathers in the intervention group. Previous research on breastfeeding processes supports this finding, as it reveals that fathers in the intervention group actively supported their partners by caring for the infant, undertaking household chores, and providing emotional assistance [34]. A randomized controlled study conducted in Brazil also supports this finding, highlighting the positive correlation between father’s support for breastfeeding and mothers’ breastfeeding practices at four months post-partum in the intervention group. Conversely, in the comparison group, there was a notable decline in father’s support for breastfeeding, with no improvement observed in mothers’ breastfeeding practices after the same duration [35]. These findings suggest that incorporating fathers in antenatal and postnatal care has a beneficial effect on promoting exclusive breastfeeding. Furthermore, the results align with a controlled study conducted in Italy, which revealed the correlation between father involvement and exclusive breastfeeding rates at six months [36]. Likewise, a quasi-experimental research finding in China [34] supports the current, highlighting the positive impact of father involvement in childcare. This study confirmed that father health education can improve the early initiation of breastfeeding and exclusive breastfeeding. The study increased the fathers’ knowledge and skills to support the breastfeeding decision-making process and how to support their wives, resulting in increased rates of early initiation and exclusive breastfeeding practice. The intervention may alter the fathers’ perception that the woman solely must take care of her children. A qualitative phenomenological study is congruent with this finding that improving the fathers’ knowledge about breastfeeding increases their participation [37]. Therefore, health planners and policymakers should consider engaging fathers in antenatal and postnatal care services. Healthcare providers should also contemplate fathers during the antenatal, delivery, and postnatal services.
Strengths and limitations
According to the supervision report, all fathers received individual health education at the time of delivery and during postnatal care. Although some mothers gave birth in hospitals outside the intervention area, we contacted them through phone calls and SMS messages to ensure their inclusion in the final data collection. One challenge faced by the intervention was pregnant women admitted to hospitals during nighttime and weekends, which hindered the provision of intended health education for early initiation of breastfeeding in the first hour of birth. The investigators should explore certain limitations that have implications for the scientific community. Firstly, the analysis conducted in the current study did not incorporate multilevel analysis. Kebeles and resident settings (urban, rural) might influence the father’s involvement in breastfeeding. In addition, the outcome was measured based on the mother’s recollection, resulting in recall bias.
Furthermore, the intervention model lacked collaboration between governmental and non-governmental bodies. Consequently, the study suggests that advanced improvements could be achieved if future studies are conducted in cooperation with the government and non-governmental bodies. The study was done during the COVID-19 pandemic season, which interfered with the effective delivery of the health education intervention. Lastly, the investigators would like to recommend a future study involving cluster randomized controlled trials and multilevel analysis to yield more valid measures of fathers’ involvement, as well as the inclusion of fathers in childcare practices.
Conclusion and recommendation
Although there are limitations associated with quasi-experimental designs, this interventional study positively influenced the early initiation of breastfeeding and the rates of exclusive breastfeeding (EBF) at the first, fourth, and sixth months. Therefore, it is advisable to replicate this intervention in different settings, taking into careful consideration the role of fathers in childcare. Fathers can be actively involved in district hospitals, commune health centers, and within their own homes to ensure their continuous engagement in childcare practices. Additionally, the father’s involvement could be explicitly addressed and potentially incorporated as an additional component of the Ten Steps recommended by the World Health Organization (WHO) for promoting breastfeeding. Based on the findings of this study, we recommend that responsible government agencies, such as the Ministry of Health, national and regional Public Health Institutions, and dedicated non-governmental organizations (NGOs) like UNICEF and WHO, consider integrating breastfeeding counseling for fathers into existing maternal and child health services at all levels of healthcare institutions.
Acknowledgements
First, we would like to thank the midwives who delivered the breastfeeding education intervention, the health extension workers who collected the data, and the couples who participated in the intervention. Second, we have to thank Wollo University for funding this study.
Authors’ contributions
Conceptualization: WMA, TBT, AMM Formal analysis: WMA, TBT Investigation: WMA, TBT, AMM Methodology: WMA, TBT, AMM Project administration: WMA, AMM Manscript writing and edition: WMA, TBT, AMM.
Funding
Wollo University provided the fund as an annual staff research funding program for the staff members in 2020/21.
Data availability
All the data supporting the findings are within the manuscript. Additional detailed information and datasets are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval was obtained from the ethical review committee at Wollo University, College of Medicine and Health Sciences. A letter of permission to conduct the study was obtained from the administrative office of each Kebele. A written informed consent was obtained from the father/mother before data collection. They were told that participating in the study was voluntary. Participants were assured their right to withdraw from the study during the intervention and interview. No personal identifiers were included in the data collection. The data was securely stored, accessible only to the principal investigator, and maintained confidentially and anonymously. All the procedures of this study were conducted according to the Helsinki Declaration of ethical approval and consent to participate.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All the data supporting the findings are within the manuscript. Additional detailed information and datasets are available from the corresponding author upon reasonable request.