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Product Code: 00006490

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Objective: Lack of exclusive breastfeeding for infants withi the age of 0 and 6 months and no breastfeeding for children aged 6 to 24 months is linked to increased odds of death before the second birthday. Infant mortality in these age groups is due to bot infectious and non-infectious causes. We examine the existing evidence for impact of proper breast- feeding on all-cause mortality in children aged 0 to 24 months in Africa.

Methods: We carried out a systematic search of the literature to examine the influence of other breastfeeding practices versus EBF on mortality rates in the initial 180 days post birth and the effect of no breastfeeding versus any breastfeeding type on mortal- ity rates between 6 and 24 months post birth. We Performed our search in the PubMed and Cochrane Library databases. Data obtained was analyzed used the Generic Inverse Variance Method using the R Software, and heterogeneity was assessed using forest plots.

Results: The pooled effect size (Odds Ratios) for the difference in mortality between infants who were predominantly breastfed vs those that were fed on breast-milk alone was found to be 1.15, 95% CI [1.05; 1.27]. This implies that predominantly breastfed children were 15% more likely to die between the months of 0-6 compared to children who were fed on breast-milk alone. Compared to infants who were fed solely on breast-milk, infants that were not breastfed were 9.64 times more likely to die (OR = 9.64 95% CI [8.01; 11.62], Three studies). Compared to infants between the ages of 6-23 months who got any form of breastfeeding, infants who never received any breast-milk were 3.19 times more likely to die (OR = 3.19 95% CI [1.42; 7.15] Five studies).

Conclusion: The findings from our study are consistent with previous research on the protective ability of proper breastfeeding habits on infant and child mortality. They sup- port the WHO recommended practices of EBF for the half an year and continued/partial breastfeeding up to the second birthday as key interventions in reducing infant and child deaths in these age groups.


Table of Contents
Abstract ii
Declaration and Approval iv
Figures and Tables ix
List of Abbreviations x
Acknowledgments xi

Chapter 1: Introduction
1.1 Background 1
1.2 Objectives 3
1.2.1 Overall objective 3
1.2.2 Specific objectives 3
1.3 Justification of Study 3

Chapter 2: Literature Review
2.1 Introduction 5
2.1.1 Breastfeeding Practices and Infant Mortality from Infectious Diseases 5
2.1.2 Breastfeeding and Infant Mortality from Non-infectious Causes 10

Chapter 3: Methods
3.1 Types of studies 13
3.2 Study participants 13
3.3 Study interventions/exposures 13
3.4 Search strategy used for identifying studies 14
3.5 Data extraction 16
3.6 Statistical methods used for data analysis 16
3.6.1 Odds Ratios and Relative Risk 16
3.6.2 Generic Inverse Variance Method 19
3.6.3 Forest plots 19
3.6.4 Test of heterogeneity among the studies 19
3.6.5 Theory of Fixed Effects and Random Effects Model 21

Chapter 4: Results
4.1 PRISMA Diagram 23
4.1.1 Inclusion Criteria 23
4.1.2 Exclusion Criteria 23
4.2 Final articles for meta-analysis 25
4.3 Pooled Effect Sizes 26
4.3.1 Forest plot for pooled effect of breast feeding practices on mortality rates for children aged 0-6 months - Predominant VS Exclusive breast feeding 26
4.3.2 Forest plot for pooled effect of breast feeding practices on mortality rates for children aged 0-6 months - Partial VS Exclusive breast feeding 26
4.3.3 Forest plot for pooled effect of breast feeding practices on mortality rates for children aged 0-6 months - No Breast feeding VS Exclusive breast feeding 28
4.3.4 Forest plot for pooled effect of breast feeding practices on mortality rates for children aged 6 to 23 months - No Breast feeding Vs Any type of breastfeeding 29

Chapter 5: Discussion
5.0.1 Strengths and Limitations 31
6 Conclusion 32
Bibliography 33

Figures and Tables

Figure 1. Prisma Diagram 24
Figure 2. Comparing Predominant VS Exclusive breast feeding between 0-6 months) 26
Figure 3. Comparing Partial VS Exclusive breast feeding between 0-6 Months 27
Figure 4. Comparing No Breast feeding VS Exclusive breast feeding between 0-6 Months 28
Figure 5. Comparing No Breast feeding vs Any type of breastfeeding between 6-23 Months 29

Table 1. Sample table to explain Odds Ratios and Relative Risk 16
Table 2. Final articles for meta-analysis 25

List of Abbreviations

ACI’s Acute Respiratory Infections
DHS Demographic and Health Surveys
EBF Exclusive Breastfeeding
HR Hazard Ratio
IMCR Infant and Child Mortality Rate
OR Odds Ratio
PBF Partial Breastfeeding
RCT Randomized Controlled Trials
RR Relative Risk
RSV Respiratory Syncytial Virus
SIDS Sudden Infant Death Syndrome
SRMA Systematic Review and Meta-analysis
U2M Under-2-Mortality
UNICEF United Nation Children’s Fund
WHO World Health Organization

Chapter 1

1.1 Background

Infant mortality remains a critical area of concern as far as children health and survival is concerned in Africa. The death of babies before their second birthday continues to be a challenge not only in Kenya but in other developing and under developed nations in Africa. According to UNICEF’s latest child mortality report published in September 2020, an estimated 2.6 million children whose age is below 5 years died in 2019 in the African region. Additionally, it is important to note infant deaths account for approximately 70% of the total under-5-mortality (UNICEF, 2021). The Sub-Saharan Region, made up of 44 nations located south of the Sahara Desert, accounted for over 90% of all the total deaths in Africa in 2019 (UNICEF, 2021). Statistics released by the World Bank further revealed that the mortality rate in Africa was 76 deaths per 1000 live births and the highest as compared to other regions in the world (World Bank, 2021). Other regions had much lower rates with Europe and Central Asia at 8 and North America at 6 while North Africa and Middle East was at 22 per 1000 births.

Under-2-Mortality in Africa is fueled by various causes among them transmiNable and non-transmiNable diseases. According to WHO, the major causes of infant and child mortality in Africa are Pneumonia, Malaria, Diarrhea and Pre-term birth complications. Data obtained from the WHO website shows that Pneumonia accounted for 16% of the total deaths in 2016 while Diarrhea and Malaria accounted for 20% of total deaths in children whose age is below two years of age. It is important to note that 45% of all U2M in Africa is aNributed to malnutrition as an underlying factor as revealed in a study conducted in South Africa (Itaka & Omole, 2020). The neonatal period which is a critical phase that determines survival rate has also in the past had a high mortality rate of 28 deaths per 1000 live births and main cause been Neonatal Sepsis and birth complications. These facts point to the conclusion that majority of deaths in children under the age of 2 are caused by Infectious diseases which are preventable.
The WHO has in the past and continually put great emphasis on the need for all nations in the WHO African region to cooperate in lowering the high ICMR in Africa. The health watchdog recommends many interventions that if properly practiced can significantly reduce U2M. One of such interventions is optimal infant feeding practices as well as adherence to laid out vaccination schedules. WHO continually gives and updates guide- lines on the optimal breastfeeding habits for babies under the age of 2 years. The different breastfeeding categories are defined as below:

1. Exclusive Breastfeeding- The baby is fed on breast milk only from the nursing mother or from a wet nurse. This category allows vaccines and other medicines as the only other fluids that can be offered to the baby before 6 months (Organization et al., 2008).
2. Predominant Breastfeeding- Under this practice, the infant is fed on breast-milk as the main source of nutrients (Organization et al., 2008). However, the child can be offered water and other water-based fluids like fruit juices.
3. Partial/Complimentary Breastfeeding- Babies on this feeding program are fed on breast-milk as well as other solid foods and infant formula (Organization et al., 2008).

Additionally, the WHO recommends optimal breastfeeding practices that can boost im- munity among infants and children under 2. These practices are initiation to breastfeed- ing before the lapse of the initial 60 minutes post birth and feeding on breast milk alone until the baby turns 6 months old (WHO, 2009). Further, mothers are advised to prac- tice complementary feeding and continued breastfeeding up to the age of 2 years for maximum immunity against childhood diseases (WHO, 2009).

The recommendations on optimal infant feeding habits by WHO are based on scien- tific research conducted in Africa and other continents linking proper breastfeeding and reduced infant mortality rates. Numerous studies have pointed to the importance of breastfeeding in boosting infant’s immunity and thus bringing down the ICMR .Timely initiation to breastfeeding has been found to increase the odds of survival for babies un- der the age of 2 according to findings from a study by Neovita Group (Group et al., 2016). Further findings have revealed that optimal breastfeeding has a protective ability against Diarrhea which is among the top causes of U2M in Africa (Ogbo et al., 2017).
Three more studies based in Africa have determined that the WHO breastfeeding prac- tices have protective effects against ARIs including pneumonia and Bronchiolitis (Shi et al., 2015; Ahmed et al., 2020; Troeger et al., 2017). These, amongst many other studies, highlight the significance of breastfeeding in reducing infant deaths among many other key factors.

The present study will pool results from all eligible studies and come up with more robust effect estimates that can be confidently relied upon in implementing the WHO recom- mended infant feeding practices.

1.2 Objectives

1.2.1 Overall objective

To assess the evidence for the effect of breastfeeding practices on infant mortality from all causes

1.2.2 Specific objectives
i. To conduct a systematic review to identify relevant papers that studied the effect of breast feeding practices on infant and child mortality in Africa.

ii. To determine the effect Non-breastfeeding, predominant or partial infant wet nursing in the first six months of life compared to exclusive breastfeed- ing on infant mortality.

iii. To determine the effect of lack of breastfeeding between 6 and 24 months of age compared to any form of breastfeeding on child mortality.

1.3 Justification of Study

The link between breastfeeding and child mortality has been widely researched in Africa. This fact implies that there are many individual researches that have investigated and reported the impact of optimal breastfeeding practices and the risk of death under infants and children aged 2 years and below. Each of these studies employs a unique study design to generate results, unique sample size and different age groups are assessed for each study. For instance, Zhao et al. (2020) uses secondary data from DHS and a sample size of 215,000 participants in assessing the impact breastfeeding has on IMR within the within the initial 180 days of life (Zhao et al., 2020). A different research carried out in Ethiopia in 2020 used a prosperity matching concept and a sample size of 4,000 participants to assess the impact of breastfeeding practices on ICMR from ARIs and Di- arrhea Ahmed et al. (2020). Several other reviews and analyses investigated the effect of best breast-feeding practices on mortality from Malaria, obesity and malnutrition related complications across Africa.

The already existing research on this subject is wide yet diverse with regards to methods, cause of mortality, sample sizes and breastfeeding categories assessed. In order to be able to draw more robust conclusions on the subject, our present study pools results from the different studies that meet our eligibility criteria. Some of the main advantages of a SRMA is increased precision as the pooled result is obtained from more studies and provide more convincing evidence (Deeks et al., 2019). Further, our SRMA will provide a solid base upon which recommendations based on the results can be relied upon. According to Wao et al in their detailed book chapter on the rationale and methods of conducting SRMA, the health sector requires recommendations based on precision and high level reliability which is achieved through SRMA (Wao et al., 2017). The other reason why this study is important is because despite having many SRMAs on the subject, none has focused solely on studies performed within the African Continent.

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