Open Access Research article

Growth effects of exclusive breastfeeding promotion by peer counsellors in sub-Saharan Africa: the cluster-randomised PROMISE EBF trial

Ingunn Marie Stadskleiv Engebretsen1*, Debra Jackson2, Lars Thore Fadnes13, Victoria Nankabirwa45, Abdoulaye Hama Diallo6, Tanya Doherty27, Carl Lombard8, Sonja Swanvelder8, Jolly Nankunda9, Vundli Ramokolo17, David Sanders2, Henry Wamani5, Nicolas Meda6, James K Tumwine9, Eva-Charlotte Ekström10, Philippe Van de Perre111213, Chipepo Kankasa14, Halvor Sommerfelt115, Thorkild Tylleskär1 and on behalf of the PROMISE EBF-study group

Author Affiliations

1 Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, PO Box 7804, 5020 Bergen, Norway

2 School of Public Health, University of Western Cape, P Bag X17, Bellville 7535, South Africa

3 Department of Clinical Dentistry, University of Bergen, PO Box 7804, 5020 Bergen, Norway

4 Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY 10032, USA

5 School of Public Health, Makerere University, Kampala, Uganda

6 Centre MURAZ, Ministry of Health, PO Box 390, Bobo-Dioulasso, Burkina Faso

7 Health Systems Research Unit, Medical Research Council, 7505 Cape Town, South Africa

8 Biostatistics Unit, Medical Research Council, 7505 Cape Town, South Africa

9 Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda

10 Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden

11 INSERM U1058, Montpellier, France

12 Université de Montpellier I, Montpellier, France

13 Centre Hospitalier Universitaire Montpellier, Département de Bactériologie-Virologie, Montpellier, France

14 Department of Paediatrics and Child Health, School of Medicine, University of Zambia, Lusaka, Zambia

15 Department of International Public Health, Norwegian Institute of Public Health, N-0403 Oslo, Norway

For all author emails, please log on.

BMC Public Health 2014, 14:633  doi:10.1186/1471-2458-14-633

Published: 21 June 2014



In this multi-country cluster-randomized behavioural intervention trial promoting exclusive breastfeeding (EBF) in Africa, we compared growth of infants up to 6 months of age living in communities where peer counsellors promoted EBF with growth in those infants living in control communities.


A total of 82 clusters in Burkina Faso, Uganda and South Africa were randomised to either the intervention or the control arm. Feeding data and anthropometric measurements were collected at visits scheduled 3, 6, 12 and 24 weeks post-partum. We calculated weight-for-length (WLZ), length-for-age (LAZ) and weight-for-age (WAZ) z-scores. Country specific adjusted Least Squares Means with 95% confidence intervals (CI) based on a longitudinal analysis are reported. Prevalence ratios (PR) for the association between peer counselling for EBF and wasting (WLZ < −2), stunting (LAZ < −2) and underweight (WAZ < −2) were calculated at each data collection point.


The study included a total of 2,579 children. Adjusting for socio-economic status, the mean WLZ at 24 weeks were in Burkina Faso −0.20 (95% CI −0.39 to −0.01) and in Uganda −0.23 (95% CI −0.43 to −0.03) lower in the intervention than in the control arm. In South Africa the mean WLZ at 24 weeks was 0.23 (95% CI 0.03 to 0.43) greater in the intervention than in the control arm. Differences in LAZ between the study arms were small and not statistically significant. In Uganda, infants in the intervention arm were more likely to be wasted compared to those in the control arm at 24 weeks (PR 2.36; 95% CI 1.11 to 5.00). Differences in wasting in South Africa and Burkina Faso and stunting and underweight in all three countries were small and not significantly different.


There were small differences in mean anthropometric indicators between the intervention and control arms in the study, but in Uganda and Burkina Faso, a tendency to slightly lower ponderal growth (weight-for-length z-scores) was found in the intervention arms.

Trial registration number NCT00397150

Exclusive breastfeeding promotion; Peer counselling; Child growth; Anthropometry; Stunting; Wasting; Underweight; Undernutrition; Community randomised trial