Maternal and Child Health Journal

, Volume 22, Issue 5, pp 762–771 | Cite as

Implementation of Steps 1–9 to Successful Breastfeeding Reduces the Frequency of Mild and Severe Episodes of Diarrhea and Respiratory Tract Infection Among 0–6 Month Infants in Democratic Republic of Congo

  • Paul ZivichEmail author
  • Bruno Lapika
  • Frieda Behets
  • Marcel Yotebieng



Global initiatives to improve breastfeeding practices have focused on the Ten Steps to Successful Breastfeeding. The aim of this study was to assess the effect of implementing Baby-Friendly Hospital Initiative (BFHI) steps 1–9 and BFHI steps 1–10 on incidence of diarrhea and respiratory illnesses in the first 6 months of life.


We reanalyzed a cluster randomized trial in which health-care clinics in Kinshasa, Democratic Republic of Congo, were randomly assigned to standard care (control group), BFHI steps 1–9, or BFHI steps 1–10. Outcomes included episodes of diarrhea and respiratory illness. Piecewise Poisson regression with generalized estimation equations to account for clustering by clinic was used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI).


Steps 1–9 was associated with a decreased incidence of reported diarrhea (IRR 0.72, 95% CI 0.53, 0.99) and respiratory illness (IRR 0.48, 95% CI 0.37, 0.63), health facility visits due to diarrhea (IRR 0.60, 95% CI 0.42, 0.85) and respiratory illness (IRR 0.47, 95% CI 0.36, 0.63), and hospitalizations due to diarrhea (IRR 0.42, 95% CI 0.17, 1.06) and respiratory illness (IRR 0.33, 95% CI 0.11, 0.98). Addition of Step 10 attenuated this effect: episodes of reported diarrhea (IRR 1.24, 95% CI 0.93, 1.68) and respiratory illness (IRR 0.77, 95% CI 0.60, 0.99), health facility visits due to diarrhea (IRR 0.76, 95% CI 0.54, 1.08) and respiratory illness (IRR 0.75 95% CI 0.57, 0.97), and hospitalizations due to respiratory illness (IRR 0.48 95% CI 0.16, 1.40); but strengthened the effect against hospitalizations due to diarrhea (IRR 0.14, 95% CI 0.03, 0.60).


Implementation of steps 1–9 significantly reduced incidence of mild and severe episodes of diarrhea and respiratory infection in the first 6 months of life, addition of step 10 appeared to lessen this effect.

Trial Registration



Diarrhea Respiratory illness Infants Breastfeeding Baby-Friendly Hospital Initiative (BFHI). 



We are grateful for the participation and time of the mothers and infants who participated in the study; the time and efforts of the personnel at the participating clinics (Esengo, Kikenda, Kitega, Libikisi, Lukunga, and Luyindu); the technical support of Drs. Aimee Lulebo, Dinah Kayembe, Landry Kiketa, Jean Lambert S. Chalachala, Mrs. Kathryn Salisbury, and Deidre Thompson; the data collection and data entry contributions of Clever Akili, Dyna Anambatu, Valerie B. Chalachala, Marie Dauly, Dydy Kayembe, Mamie Lulebo, Fanny Matadi, Myriam Mbonze, Espérance Mindia, Sarah Mushiya, Gisèle Mvumbi, Dodo Mwela, Jolly Ntirume, Ros Samba; and the administrative support of the UNC, KSPH, and Alive & Thrive administrative teams.


The original trial was supported by a grant from the Bill & Melinda Gates Foundation to FHI 360, through the Alive & Thrive Small Grants Program managed by UC Davis via a sub-award to the University of North Carolina at Chapel Hill. MY is partially supported by the NIAID U01AI096299-01 and the NICHD R01HD087993. The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit the paper for publication.

Supplementary material

10995_2018_2446_MOESM1_ESM.docx (15 kb)
Supplementary material 1 (DOCX 15 KB)


  1. Bhutta, Z. A., Das, J. K., Walker, N., Rizvi, A., Campbell, H., Rudan, I., & Black, R. E. (2013). Interventions to address deaths from childhood pneumonia and diarrhoea equitably: What works and at what cost? Lancet, 381(9875), 1417–1429. Scholar
  2. Das, J. K., Salam, R. A., & Bhutta, Z. A. (2014). Global burden of childhood diarrhea and interventions. Current Opinion in Infectious Diseases, 27(5), 451–458. Scholar
  3. Hoddinott, P. (2016). Step 10: the breastfeeding support paradox. The Lancet Global Health, 4(1), e19. Scholar
  4. Hoddinott, P., Craig, L., Maclennan, G., Boyers, D., & Vale, L. (2012). The FEeding Support Team (FEST) randomised, controlled feasibility trial of proactive and reactive telephone support for breastfeeding women living in disadvantaged areas. British Medical Journal Open, 2, e000652. Scholar
  5. Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., et al. (2007). Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment (Full Report), 153, 1–186.Google Scholar
  6. Kramer, M. S., & Kakuma, R. (2012). Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic Reviews, 8, CD003517. Scholar
  7. Liu, L., Johnson, H. L., Cousens, S., Perin, J., Scott, S., Lawn, J. E., et al. (2012). Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. The Lancet, 379(9832), 2151–2161.CrossRefGoogle Scholar
  8. Ministere du Plan, Institut National de la Statistique, & UNICEF. (2010). Enquete par grappes a indicateurs multiples—RDC 2010: Resultat Preliminaires.
  9. Simmer, K., & Patole, S. (2015). Implementation of the Ten Steps to Successful Breastfeeding programme in DR Congo. The Lancet Global Health, 3(9), e506–e507. Scholar
  10. UNICEF. (2005, January 12). The Baby-Friendly Hospital Initiative.
  11. Victora, C. G., Bahl, R., Barros, A. J. D., França, G. V. A., Horton, S., Krasevec, J., et al. (2016). Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017), 475–490. Scholar
  12. Wagner, E. A., Chantry, C. J., Dewey, K. G., & Nommsen-Rivers, L. A. (2013). Breastfeeding concerns at 3 and 7 days postpartum and feeding status at 2 months. Pediatrics. Scholar
  13. Walker, C. L., Rudan, I., Liu, L., Nair, H., Theodoratou, E., Bhutta, Z. A., et al. (2013). Global burden of childhood pneumonia and diarrhoea. The Lancet, 381(9875), 1405–1416. Scholar
  14. Wang, H., Bhutta, Z. A., Coates, M. M., Coggeshall, M., Dandona, L., Diallo, K., et al. (2015). Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015. The Lancet, 388(10053), 1725–1774. Scholar
  15. WHO/UNICEF. (2009). Baby-friendly hospital initiative: Revised, updated and expanded for integrated care.
  16. WHO/UNICEF. (1989). Protecting, promoting and supporting breast-feeding: The special role of maternity services—A joint WHO/UNICEF statement. Geneva, Switzerland: WHO/UNICEF.
  17. Yotebieng, M., & Behets, F. (2016). Step 10: The breastfeeding support paradox—Authors’ reply. The Lancet Global Health, 4(1), e20. Scholar
  18. Yotebieng, M., Chalachala, J. L., Labbok, M., & Behets, F. (2013). Infant feeding practices and determinants of poor breastfeeding behavior in Kinshasa, Democratic Republic of Congo: A descriptive study. International Breastfeeding Journal, 8(1), 11. Scholar
  19. Yotebieng, M., Labbok, M., Soeters, H. M., Chalachala, J. L., Lapika, B., Vitta, B. S., & Behets, F. (2015). Ten Steps to Successful Breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: A cluster-randomised controlled trial. The Lancet Global Health, 3(9), e546-555. Scholar
  20. You, D., Hug, L., Ejdemyr, S., Idele, P., Hogan, D., Mathers, C., et al. (2015). Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation. The Lancet, 386(10010), 2275–2286. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Paul Zivich
    • 1
    • 5
    Email author
  • Bruno Lapika
    • 2
  • Frieda Behets
    • 3
    • 4
  • Marcel Yotebieng
    • 1
  1. 1.Division of Epidemiology, College of Public HealthThe Ohio State UniversityColumbusUSA
  2. 2.Department of AnthropologyThe University of KinshasaKinshasaDemocratic Republic of the Congo
  3. 3.Department of EpidemiologyThe University of North Carolina at Chapel HillChapel HillUSA
  4. 4.School of MedicineThe University of North Carolina at Chapel HillChapel HillUSA
  5. 5.Chapel HillUSA

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