Received: 20 July 2020  |  Revised: 1 September 2020  |  Accepted: 11 October 2020
DOI: 10.1002/fsn3.1971  
O R I G I N A L  R E S E A R C H
Determining factors associated with breastfeeding and 
complementary feeding practices in rural Southern Benin
Fifali Sam Ulrich Bodjrènou1,2  |   Waliou Amoussa Hounkpatin2  |   Céline Termote3  | 
Geoffroy Dato1 |   Mathilde Savy4
1Alliance of Bioversity International and 
CIAT, Cotonou, Benin Abstract
2University of Abomey-Calavi, Faculty of This study aimed at characterizing breastfeeding and complementary feeding 
Agricultural Sciences, Abomey-Calavi, Benin practices in a food-insecure area of Benin and identifying factors associated with 
3Alliance of Bioversity International and 
CIAT, Nairobi, Kenya these practices. A cross-sectional study was conducted in the districts of Bopa and 
4NUTRIPASS-IRD, Cotonou, Benin Houéyogbé among n = 360 mother–child pairs. Children aged 0–17 months were con-
sidered. Socioeconomic characteristics among children and mothers, Breastfeeding on 
Correspondence
Fifali Sam Ulrich Bodjrènou, Alliance of demand, Breastfeeding frequency during children illness, and Positioning and Attachment 
Bioversity International and CIAT, Cotonou, of children while breastfeeding were assessed using semi-structured interviews and 
Benin; University of Abomey-Calavi, Faculty 
of Agricultural Sciences, Abomey-Calavi, observations. Qualitative 24-hr recalls were administered to mothers to compute 
Bénin. WHO recommended complementary feeding practices indicators namely minimum 
Email: bodjrenousam@gmail.com
dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable 
Funding information diet (MAD) among 6–17 months old children (n = 232). Associations between each 
the Ministry of Foreign Affairs of Finland; 
CGIAR. feeding practice and mothers' socioeconomic characteristics were tested using mul-
tivariate generalized linear models. Breastfeeding on demand and good positioning 
and attachment for breastfeeding rates were 59% and 66%, respectively. Only 26% 
of mothers used to increase breastfeeding frequency when their children were ill. 
The proportions of children who met MDD, MMF, and MAD were 51%, 75%, and 
44%, respectively. Children living in Houéyogbé were less likely to be breastfed on 
demand compared with those living in Bopa; however, they had better breastfeeding 
frequency during illness and meal frequency. Socioeconomic factors with significant 
association with breastfeeding practices were children age and sex and mothers’ ed-
ucation, ethnicity, and employment status. Complementary feeding practices were 
positively associated with children's age but not with other socioeconomic character-
istics. Breastfeeding and complementary feeding practices were almost suboptimal 
or medium and still need to be improved through well designed nutrition intervention 
program including nutrition education.
K E Y W O R D S
Benin, Breastfeeding practices, Complementary feeding practices, Determinants
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, 
provided the original work is properly cited.
© 2020 The Authors. Food Science & Nutrition published by Wiley Periodicals LLC
Food Sci Nutr. 2020;00:1–10.  www.foodscience-nutrition.com  |  1
2  |     BODJRENOU Et al.
1  | INTRODUC TION breastfeeding and complementary feeding practices in the interven-
tion area using indicators which addressed directly the limitations 
Benin is a West African country where child malnutrition is a among children feeding practices identified during the diagnostic 
public health problem. According to the latest Demographic and survey and (b) identifying factors that were associated with these 
Health Survey (DHS), about one-third of children under 5 years practices specifically in this intervention area. This could help to 
old were stunted in 2017-2018 (INSAE & ICF, 2019). A major con- identify factors other than those relative to the intervention which 
tributor to this situation is the inadequacy of breastfeeding and could also influence the effect of the intervention by affecting the 
complementary feeding practices. About one-half of newborns ability of the beneficiaries to adopt or reject recommended practices.
(54%) benefit from early initiation of breastfeeding (INSAE & 
ICF, 2019). The median duration of exclusive breastfeeding (EBF) 
was 2.4 months in rural areas and 1.3 months in urban areas, and 2  | MATERIAL S AND METHODS
the rate of EBF till six months of age barely reached 42% (INSAE 
& ICF, 2019). The diversity of complementary foods was low with 2.1 | Setting
only 28% of 6–23 months children who met the minimum dietary 
diversity (MDD) (INSAE & ICF, 2019). The study was conducted in the districts of Bopa and Houéyogbé 
A diagnostic study conducted in two districts of southern which present the highest rates of household food insecurity in the 
Benin (namely Bopa and Houéyogbé) located in a high food-inse- Mono department, respectively 40% and 34% (INSAE & PAM, 2014).
cure area reported that infants and young children feeding prac-
tices were suboptimal (Mitchodigni, et al., 2017a; Mitchodigni, 
et al., 2017b). Authors suggested that multisectoral interventions 2.2 | Sampling
should be implemented in this area to improve feeding practices 
for young children. Following this recommendation, a nutrition ed- The data presented in this paper were related to the baseline sur-
ucation program was planned in this region aiming at optimizing vey of the impact evaluation of the nutrition education intervention 
mothers’ knowledge on nutrition and subsequently, breastfeed- implemented in the districts of Bopa and Houéyogbé in Southern 
ing and complementary feeding practices. Nutrition education Benin (Bodjrenou et al., 2020). A total of eight villages were ran-
is meant to improve knowledge, skills, motivation, and behavior domly selected after stratification by district. In each village, 45 
of individuals or communities, leading potentially to subsequent mother–child pairs were randomly selected from an exhaustive list 
positive effects on nutritional status and health (FAO, 2005). In of 0 to 17-months-old children living in the villages using a random 
sub-Saharan Africa, nutrition education interventions showed number technique. We targeted this age-group firstly to focus on 
good contribution to improving breastfeeding practices (Aidam breastfeeding and complementary feeding practices. Secondly, 
et al., 2005; Tylleskär et al., 2011), complementary feeding prac- the intervention and its impact evaluation were meant to last for 
tices (Waswa et al., 2015) and also nutritional status of <2 years 6 months; hence, children would be 6–23 months old at endline. In 
children (Lassi et al., 2013). total, 360 mother–child pairs were surveyed.
In order to refine the messages' content and take into account 
the contextual factors as part of the intervention, an in-depth un-
derstanding of the situation toward breastfeeding, complementary 2.3 | Data collection
feeding practices, and associated factors in the area was necessary. 
Evidence from Benin and other African countries shows that multiple Mothers or primary caregivers of children were interviewed dur-
factors have the potential to affect positively or negatively breast- ing home visits by trained enumerators. Mothers' socioeconomic 
feeding and feeding practices among young children. These factors characteristics including age, ethnic group, employment status, 
include, but are not limited to, cultural beliefs and habits (Amoussa marital status, level of education, and participation in nutrition 
Hounkpatin et al., 2014; Aborigo et al., 2012; Aryeetey & Goh, 2013; education programs were collected. Breastfeeding on demand and 
Issaka et al., 2014; Otoo et al., 2009), households' socioeconomic attitudes toward breastfeeding frequency during child illness were 
status (Agho et al., 2011; Mitchodigni, et al., 2017b; Sokan-Adeaga recorded, while correct positioning and attachment of the child dur-
et al., 2019), agriculture practices within the households (Mitchodigni, ing breastfeeding was observed. We considered six parameters 
et al., 2017b), mothers' overall instruction (Olatona et al., 2017; Qureshi during the observations: breasts held by mother's hand, mother's 
et al., 2011; Sokan-Adeaga et al., 2019), mothers' occupation (Amoussa hand doing a "C-shape," child's chin attached to the breast, child's 
Hounkpatin et al, 2014; Mitchodigni, et al., 2017b; Nkrumah, 2017), as lip in eversion, child in straight position, and child's whole body 
well as knowledge and perceptions of appropriate practices (Aborigo facing the mother's chest (Unicef, 2012; Vinther & Helsing, 1997; 
et al., 2012; Agunbiade & Ogunleye, 2012; Aidam et al., 2005; Issaka WHO & UNICEF, 1993). Enumerators observed mothers breast-
et al., 2014; Otoo et al., 2009; Qureshi et al., 2011). feeding their children; each correct breastfeeding positioning and 
The present study, which was conducted before the implemen- attachment parameter adopted by mothers was marked “1,” and 
tation of the nutrition education program, aimed at (a) characterizing “0” otherwise.
BODJRENOU Et al.      |  3
The enumerators stayed in the study villages for about 2 weeks. for categorical variables and mean ± SD for continuous variables. 
This gave them several opportunities to observe mothers' prac- Comparisons among the two districts were also performed using 
tices. If an enumerator did not have the opportunity to observe a chi-square tests for categorical variables and Mann–Whitney test or 
breastfeeding episode when interviewing a mother, she/he did not Student's t tests for continuous variables. Associations between so-
ask the mother to breastfeed her child, as this might disturb the cioeconomic characteristics of mothers and breastfeeding and feed-
habits. Enumerators had taken advantage of their stay in the village ing practices outcomes were analysed through a two-step approach. 
and would come back to make the observation as soon as he would Bivariate analyses (chi-square, Mann–Whitney, and Student's t tests) 
have the opportunity to see the child at the breast. There is no spe- were first performed to identify factors with significant association 
cific duration of a breastfeeding episode. We have observed that with each practice. Variables that were significant at 20% (Mickey & 
youngest children breastfed longer and more frequently than older Greenland, 1989; Trekpa et al., 2005) were kept for the next step. 
ones. Enumerators recorded different parameters of breastfeeding Secondly, we used generalized linear model (GLM) with binomial 
positioning and attachment as soon as mother positioned child and distribution probability and logit link function to build models pre-
started breastfeeding. senting the contribution of the variables (those that were significant 
The children aged 6–17 months feeding practices were also as- in bivariate analysis) to each outcome. All independent variables 
sessed using a qualitative 24 hr recall  (WHO et al., 2008). All foods were entered together into each model in one step. Data presented 
and drinks that had been used to feed the child the previous day included odd-ratios, confidence interval associated, z-value, and 
and their constitutive ingredients were listed by the mother or the p-value.
primary caregiver. The relevance of regression models was assessed by displaying 
the goodness of fit parameters (X-squared and p-value) associated 
with Hosmer–Lemeshow test (p-value should be higher than 5%) and 
2.4 | Data management and statistical analysis the error rate (quality of model's predictions) derived from the con-
fusion matrix (error rate should be <0.5). Where Hosmer–Lemeshow 
The following binary variables were computed and analysed: (a) test was not significant, we performed Pearson's residuals test (p-
Breastfeeding on demand (yes/no) (b) Breastfeeding frequency when value should be <5%).
the children were ill (increased versus unchanged or decreased). For Descriptive analyses and bivariate analyses were carried out 
each mother, a breastfeeding positioning and attachment score was using SPSS 23.0 (IBM-SPSS, 2014) while GLM and relative tests were 
computed by summing up the mark attributed to each of the six po- conducted using R (Zuur et al., 2013). All analyses took into account 
sitioning parameters that were considered during the observations. the study design.
The score, which theoretically ranged from 0 to 6 points, was re-
coded as a binary variable using the median score as a threshold: 
(a) mothers with a score less than the median and (b) mothers with 3  | RESULTS
a score equal or higher than the median (hence considered as “good 
positioning”). 3.1 | Socioeconomic characteristics of the sample
From the 24 hr recall data, foods were categorized into seven 
food groups as recommended namely: (a) grains, roots, and tubers; The average ages were 8.4 ± 4.9 months for children and 
(b) legumes and nuts; (c) dairy products; (d) flesh foods; (e) eggs; 27.5 ± 5.9 years for mothers. Boys represented 53.1% of children 
(f) vitamin-A rich products; (g) fruits and vegetables different from in the sample. Most of mothers were from the Sahouè ethnic group, 
those rich in vitamin-A (Kennedy et al., 2010; WHO et al., 2008). had no schooling, and lived with their husbands (Table 1). Children's 
The minimum dietary diversity (MDD), minimum meal frequency characteristics (gender and age) were similar across districts. 
(MMF), and minimum acceptable diet (MAD) were computed fol- Mothers' age, marital status, and ethnic group were also similar 
lowing WHO and UNICEF guidelines (Kennedy et al., 2010; WHO across districts. However, the proportion of mothers with no school-
et al., 2008). Children aged 6–23 months were considered having ing was significantly lower in the district of Houéyogbé than Bopa, 
met MDD if they had consumed foods from at least four different with 45.0% and 77.2% respectively (p-value <.001).
food groups out of the seven recommended over the day prior to Only 13.9% of mothers had no income generating activity. 
the survey. Children who received solid, semi-solid, or soft foods Mothers living in Bopa were mainly involved in agriculture (48.3%), 
(including milk feeds for nonbreastfed children) the minimum num- trading (39.4%), and food processing (26.7%) while those living in 
ber of times or more the day prior to the survey were considered Houéyogbé were involved in agriculture (27.2%), trading (23.9%), 
having met MMF. A child who met both MDD and MMF was con- foods selling (24.4%), food processing (23.3%), and handicraft 
sidered having met MAD (WHO et al., 2008). We, then, determined (20.6%) (Table 1).
the proportions of children having met MDD, MMF, and MAD. Less than 6% of mothers had benefitted from a nutrition educa-
Characteristics of mothers and feeding practices indicators were tion program in the past with a difference between districts (Bopa: 
described and presented using descriptive statistics: percentages 2.2%; Houéyogbé: 9.4%; p-value =.003) (Table 1).
4  |     BODJRENOU Et al.
TA B L E  1   Socioeconomic characteristics of children and mothers (n = 360)
Parameters n All Bopa Houéyogbé p-value
Children characteristics
Age (months) 360 8.4 (4.9) 8.5 (4.8) 8.2 (5.0) .578S
Gender
Male 191 53.1 50.6 55.6 .342C
Female 169 46.9 49.4 44.4
Mothers characteristics
Age (years) 358* 27.5 (5.9) 28.1 (5.9) 26.9 (5.8) .054S
Marital status
Living alone 73 20.3 16.7 23.9 .088C
Living with husband 287 79.7 83.3 76.1
Formal education level
No schooling 220 61.1 77.2 45.0 <.001C
Literate or primary school 95 26.4 21.1 31.7
Secondary school and more 45 12.5 1.7 23.3
Ethnic group
Sahoué 295 81.9 82.2 81.7 .891C
Other 65 18.1 17.8 18.3
Employment status
No activity 50 13.9 11.1 16.7 .128C
Food processing 90 25.0 26.7 23.3 .465C
Agriculture 136 37.8 48.3 27.2 <.001C
Animal breeding 29 8.1 7.8 8.3 .846C
Trading 114 31.7 39.4 23.9 .002C
Foods selling 64 17.8 11.1 24.4 .001C
Handicraft 45 12.5 4.4 20.6 <.001C
Number of activities 1.4 (1.0) 1.5 (0.9) 1.3 (1.0) .178M
Attended nutrition education programs in the past
At least once 21 5.8 2.2 9.4 .003C
Never 339 94.2 97.8 90.6
Note: Values presented are percentage for categorical variables and Mean (Standard Deviation) for continuous variables. p-values presented are 
probabilities relative to chi-square test (C) for categorical variables, Student's t test for Ages (S) and Mann–Whitney test (M) for Number of activities.
*Two mothers did not know and could not estimate their exact age; therefore, we missed this information. 
3.2 | Feeding practices 3.3 | Factors associated with 
breastfeeding practices
All children in our sample were breastfed. Percentage of moth-
ers who used to breastfeed on demand their children were 58.7% Mothers who lived in Houéyogbé were less likely to breastfeed on 
(Figure 1); this proportion was slightly higher in Bopa than Houéyogbé demand (OR = 0.59, CI 95% = [0.36; 0.98], p = .04) than mothers 
(63.9% and 53.4%, respectively; p-value = 0.043). The proportion who lived in the district of Bopa (Table 2). Mothers who had higher 
of mothers who had met good positioning and attachment for breast- school level (at least secondary school) were 3.08 more likely to 
feeding was 66.1% with no significant difference across districts breastfeed on demand than mothers with no schooling (OR = 3.08, 
(Figure 1). Only one-quarter of mothers declared increasing breast- CI 95% = [1.40; 6.79], p = .005). Likewise, mothers who practiced 
feeding frequency when their children were ill. trading and those who were not from the Sahouè ethnic group had 
The percentages of children meeting the requirements of MDD, higher odds to breastfeed on demand than others (Table 2).
MMF, and MAD were respectively 50.9%, 75.4%, and 43.5% (Figure 2). In Regarding good positioning and attachment for breastfeeding, 
Houéyogbé, 82.5% of children met the MMF while they were only 68.6% only the children's age was associated with this indicator. Mothers of 
in Bopa (p-value =.015). The other indicators did not differ across districts. older children tended to have lower odds of having good positioning 
BODJRENOU Et al.      |  5
F I G U R E  1   Breastfeeding practices in 
the sample and by district: Percentage 0.043 0.504 0.612 
100
of children achieving Breastfeeding on 90
Demand, Good Positioning and attachment 
for breastfeeding and Increased 80
63.9 66.1 67.8
Breastfeeding Frequency during illness. 70 64.4
58.7
(% = Percentage; p-values presented are 60 53.4
probabilities relative to chi-square test 50
comparing the two districts) 40
25.7 29.6
30 22.0
20
10
0
Breaseeding On demand Posioning for Increased breaseeding
breaseeding frequency during illness
All Bopa Houéyogbé
0.789 0.015 0.247
100
90 82.5
80 75.4
68.6
70
60 50.9 50.0 51.8
47.4
50 43.5 39.9
40
30
F I G U R E  2   Complementary feeding 20
practices in the whole sample and by 
district: Percentage of children achieving 10
recommended complementary feeding 0
practices. (% = Percentage; p-values Minimum Dietary Diversity Minimum Meal Frequency Minimum Acceptable Diet
presented are probabilities relative to chi-
square test comparing the two districts) All Bopa Houéyogbé
and attachment for breastfeeding compared with others (OR = 0.94, CI 95% = [1.04; 1.23], p = .006) and the MAD (OR = 1.09, CI 
CI 95% = [0.90; 0.99], p = .01) (Table 2). 95% = [1.01; 1.19], p = .04). Children who lived in Houéyogbé were 
Several factors were associated with the frequency of breast- more likely to meet the MMF compared to children who lived in 
feeding during illness episodes. Increased breastfeeding was more Bopa (OR = 2.47, CI 95% = [1.24; 4.93], p = .01). However, the 
likely to happen among mothers who lived in Houéyogbé com- district was not associated with the MMD or the MAD. The vari-
pared with those living in Bopa (OR = 2.16, CI 95% = [1.12; 4.18], ables related to the mothers' education and employment were 
p = .02), when children were older (OR = 1.10, CI 95% = [1.02; not associated with any of the complementary feeding practices 
1.19], p = .02), and when they were boys (OR = 0.51, CI 95% = indicators.
[0.27; 0.96], p = .04). Unexpectedly higher the education level of 
mothers was, lesser was the likelihood to increase the frequency 
of breastfeeding illness episodes (OR = 0.19, CI 95% = [0.08; 0.48], 4  | DISCUSSION
p = .0004) (Table 2).
Results from our study showed that children feeding practices were 
suboptimal or medium and this situation requires actions for im-
3.4 | Factors associated with complementary provement. The definition of adequate interventions requires first 
feeding practices to have a good knowledge of the situation and associated factors. 
Thus, we observed that age and sex of children, district of residence, 
Very few factors were associated with the three indicators on ethnic group, education level, and employment status of mothers 
complementary feeding practices (Table 3). Only the age of were associated with breastfeeding practices, with some variations 
children was positively associated with the MDD (OR = 1.13, depending on the indicators used. Mothers' education was positively 
%
6  |     BODJRENOU Et al.
TA B L E  2   Results from the GLM on breastfeeding practices
Confidence interval associated to OR
Parameters OR 2.50% 97.50% Z-value p-value
Breastfeeding on demand (n = 356; Hosmer and Lemeshow goodness of fit: X-squared = 11.03, df = 8, p-value = .1999; Error rate = 38.48)
(Intercept) 0.62 0.33 1.19 −1.42 .15471
District_Houéyogbé (Ref = Bopa) 0.59 0.36 0.98 −2.04 .04104
Gender_Female (Ref = Male) 0.96 0.61 1.50 −0.19 .84630
Education_Literate or Primary school 1.44 0.84 2.45 1.34 .18083
(Ref = No schooling)
Education_Secondary school 3.08 1.40 6.79 2.79 .00526
(Ref = No schooling)
Ethnic group_Others (Ref = Sahouè) 1.93 1.04 3.57 2.10 .03583
Agriculture_Yes (Ref = No) 1.72 0.90 3.28 1.63 .10271
Trading_Yes (Ref = No) 1.89 1.07 3.35 2.20 .02817
Children's age (months) 1.05 1.00 1.10 1.91 .05591
Number of activities 1.00 0.70 1.42 −0.01 .99260
Good positioning and attachment for breastfeeding (n = 358; Hosmer and Lemeshow goodness of fit: X-squared = 4.81, df = 8, p-value = .7775; 
Error rate = 32.68)
(Intercept) 3.48 1.77 6.84 3.62 .00030
District_Houéyogbé (Ref = Bopa) 0.87 0.55 1.39 −0.57 .56751
Gender_Female (Ref = Male) 1.20 0.76 1.90 0.77 .44025
Ethnic group_Others (Ref = Sahouè) 1.53 0.82 2.85 1.33 .18406
Animal breeding_Yes (Ref = No) 0.47 0.18 1.23 −1.54 .12467
Trading_Yes (Ref = No) 0.61 0.36 1.05 −1.79 .07306
Children age 0.94 0.90 0.99 −2.47 .01369
Number of activities 1.14 0.84 1.55 0.86 .38758
Food selling_Yes (Ref = No) 0.54 0.29 1.00 −1.97 .04859
Increasing breastfeeding frequency during illness (n = 256; Hosmer and Lemeshow goodness of fit: X-squared = 9.68, df = 8, p-value = .2881; 
Error rate = 26.17)
(Intercept) 0.07 0.01 0.48 −2.71 .00674
District_Houéyogbé (Ref = Bopa) 2.16 1.12 4.18 2.29 .02179
Gender_Female (Ref = Male) 0.51 0.27 0.96 −2.10 .03585
Marital status_Living With husband 1.88 0.78 4.54 1.40 .16268
(Ref = Living Alone)
Education_Literate or Primary school 0.19 0.08 0.48 −3.53 .00042
(Ref = No schooling)
Education_Secondary school 0.54 0.19 1.57 −1.13 .25849
(Ref = No schooling)
Food processing_Yes (Ref = No) 1.38 0.70 2.74 0.92 .35523
Animal breeding_Yes (Ref = No) 1.32 0.49 3.51 0.55 .58170
Children age 1.10 1.02 1.19 2.33 .01985
Mother age 1.01 0.95 1.07 0.29 .76961
Abbreviations: OR, odd-ratio; Ref, modality of reference.
associated with breastfeeding on demand but was negatively asso- and they may have less time to apply good practices compared to 
ciated with breastfeeding frequency during illness. Educated moth- mothers with informal jobs or no job at all. Employed mothers may 
ers are likely to have a better knowledge of the importance of good also be stressed and tired, resulting in little time or energy at the 
breastfeeding practices (Al Ketbi et al., 2018), and we would expect end of the day to nurse their babies properly (Netshandama, 2002). 
better practices among them. On the other hand, educated mothers Moreover, home-based activities like agriculture or small trading 
are also more likely to be employed in public or private companies offer to mothers the opportunity to stay at home or nearby. Other 
BODJRENOU Et al.      |  7
TA B L E  3   Results from the GLM on 
complementary feeding practices Confidence interval 
associated to OR
Parameters OR 2.50% 97.50% Z-value p-value
Minimum dietary diversity MDD (n = 230; Hosmer and Lemeshow goodness of fit: 
X-squared = 5.91, df = 8, p-value = .6573; Error rate 41.30)
(Intercept) 0.37 0.12 1.14 −1.73 .08421
District_Houéyogbé (Ref = Bopa) 0.95 0.55 1.64 −0.17 .86438
Gender_Female (Ref = Male) 1.04 0.60 1.79 0.14 .89179
Nutrition education_Yes (Ref = No) 2.37 0.67 8.42 1.34 .18186
Food processing_Yes (Ref = No) 0.69 0.35 1.36 −1.06 .29011
Children age (months) 1.13 1.04 1.23 2.75 .00589
Number activities 0.82 0.59 1.14 −1.17 .24133
Minimum meal frequency MMF (n = 230; Hosmer and Lemeshow goodness of fit: 
X-squared = 10.76, df = 8, p-value = .2157; Error rate = 24.35
(Intercept) 1.64 0.51 5.32 0.83 .40960
District_Houéyogbé (Ref = Bopa) 2.47 1.24 4.93 2.57 .01020
Gender_Female (Ref = Male) 1.33 0.71 2.50 0.90 .37000
Education_Literate or Primary 1.34 0.60 2.99 0.72 .47360
school (Ref = No schooling)
Education_Secondary school 0.63 0.22 1.78 −0.88 .38110
(Ref = No schooling)
Children age 1.01 0.92 1.11 0.20 .84050
Minimum acceptable diet MAD (n = 230; Hosmer and Lemeshow goodness of fit: 
X-squared = 31.33, df = 8. p-value = .0001229; Pearson's Residuals: 0.3878219; Error 
rate = 38.26)
(Intercept) 0.31 0.10 0.97 −2.01 .04430
District_Houéyogbé (Ref = Bopa) 1.20 0.69 2.09 0.64 .52060
Gender_Female (Ref = Male) 1.22 0.71 2.10 0.71 .47850
Food processing_Yes (Ref = No) 0.79 0.39 1.60 −0.65 .51370
Children age 1.09 1.01 1.19 2.07 .03810
Number of activities 0.79 0.56 1.11 −1.38 .16860
Food selling_Yes (Ref = No) 1.88 0.92 3.85 1.73 .08300
Abbreviations: OR, odd-ratio; Ref, modality of reference.
activities such as food selling require to leave home, and this may af- practices, especially breastfeeding on demand or EBF, were better 
fect time spent with children and breastfeeding practices (Amoussa in rural than urban areas. On the other hand, level of urbanization 
Hounkpatin et al, 2014; Nkrumah, 2017). Mother's marital status could be positively associated with other practices. For example, 
was not associated with breastfeeding practices in our study. Yet, when a child is sick, Beninese mothers living in rural areas would 
a study in Ghana revealed better breastfeeding practices among preferentially treat their children with medicinal herbs in the form of 
women who lived with their husband (Rose, 2007). Indeed, when tisanes (Allabi et al., 2011; Towns et al., 2014); the intakes of these 
husbands have good financial situation, women could benefit from tisanes could reduce breastmilk consumption. This echoed with our 
these resources and devote more time to nursing roles and less to finding: mothers living in Houéyogbé were more likely to increase 
income generating activities. breastfeeding frequency when children were ill than mothers living 
We also found that mothers living in Bopa, who were mostly in- in Bopa.
volved in home-based activities, were more likely to breastfeed on Breastfeeding on demand varied according to mothers’ ethnic 
demand than those living in Houéyogbé. The fact that Houéyogbé groups. Children from the Sahouè ethnic group were less likely to 
is more urbanized than Bopa may explain these results (Mitchodigni, benefit from breastfeeding on demand than others. As shown in other 
et al., 2017b). These results are in line with national DHS (INSAE sub-Saharan contexts (Asare et al., 2018; Jacdonmi et al., 2016; 
& ICF, 2019; INSAE, 2015) and other studies from low- and Tawiah-Agyemang et al., 2008; Wanjohi et al., 2017), social and cul-
middle-income countries (Hitachi et al., 2019; Iffa & Serbesa, 2018; tural beliefs were determinant for breastfeeding practices. Finally, 
Kumar et al., 2017) which reported that most of breastfeeding children's age was negatively associated with the likelihood to adhere 
8  |     BODJRENOU Et al.
to the recommended positions for breastfeeding. Mothers explained approaches allow a detailed description of participants' feel-
during informal discussions that as children were growing up, they be- ings, opinions, experiences, and interpretations of their actions 
came stronger and more agitated; consequently, it was more difficult (Rahman, 2017). However, they have some limitations. Results can-
to control them during breastfeeding. not be generalized to the entire research population with the same 
Regarding complementary feeding, as expected, we observed that degree of certainty as quantitative measures. Sample size used in 
children's age was positively associated with the MDD and MAD. qualitative research is often smaller than that used in quantitative 
Generally, mothers used to replace breast milk with porridge and then research methods (Dworkin, 2012). Qualitative research results are 
family foods progressively as children are growing up. Traditional por- not tested to determine whether they are statistically significant or 
ridges that are first given to young children consist of a cereal mixed due to chance (Atieno, 2009). Therefore, we decided to use quanti-
with water and sometimes sugar, which provide low dietary diversity. tative method to ensure measurability and comparability (statistical) 
The family meals that are eaten by older children offer higher dietary of indicators since we aim to collect data related to the same indica-
diversity. Thus, as children are growing up and start eating family meals, tors at the end of the intervention.
their dietary diversity increases (Amoussa Hounkpatin et al, 2014).
Living in Houéyogbé also seemed to be more favorable to higher 
meal frequency among children than living in Bopa; probably be- 5  | CONCLUSION
cause of the difference of urbanization (Mitchodigni, et al., 2017b). 
No other factors were found to be associated with the complemen- Breastfeeding and complementary feeding practices were not op-
tary feeding indicators we investigated. timal in the districts of Bopa and Houéyogbé, department of Mono, 
We observed that some intercepts were significant (Increasing Southern Benin. These results supported the importance of a nutri-
Breastfeeding Frequency during Illness, Good Positioning, and tion education program at the community level in order to improve 
Attachment for Breastfeeding, minimum acceptable diet). Thus, there mothers’ and community members’ knowledge and attitudes toward 
were possibly other factors influencing feeding practices, but these children feeding practices. Moreover, socioeconomic, cultural, and de-
factors were not collected in the present study. mographic factors such as age and sex of children, district of residence, 
Mitchodigni, et al. (2017b) showed also that agriculture, espe- ethnic group, education level, and employment status identified in the 
cially the diversity of food groups grown by households, increased present paper as influencing infants and children feeding practices will 
the likelihood of meeting the MDD among 6–23 months old children. be taken into account when designing the community-based nutrition 
Moreover, we expected that participating in a nutrition education education program. According to these factors, different categories of 
program in the past would have been associated with present feed- people within our target population will be defined. Thus, key mes-
ing practices. Indeed, many studies had shown that nutrition educa- sages will be adapted to address each of these categories considering 
tion interventions targeting breastfeeding or dietary habits had good their specific backgrounds in terms of knowledge, occupation, food 
contribution to improving breastfeeding and complementary feeding habits, culture, and beliefs.
practices in low- and middle-income countries especially in Africa 
(Aidam et al., 2005; Lassi et al., 2013; Tylleskär et al., 2011; Waswa ACKNOWLEDG MENTS
et al., 2015). In other cases, nutrition education helped to increase Research activities were funded by the Ministry of Foreign Affairs of 
knowledge and attitudes but not practices (Mojisola et al., 2019; Finland and CGIAR; The corresponding authors received also a PhD 
Ruzita et al., 2007). However, in the present study few mothers (<6%) allowance from IRD.
participated this program and this could not allow good analysis or 
conclusions. Moreover, participating a nutrition program does not nec- CONFLIC T OF INTERE S T
essary lead to behavior change and achieving the adequate knowledge "No conflicts of interest."
does not guarantee the adoption of good practices. Some other factors 
such as limited access to nutritious foods (Dang et al., 2005), financial E THIC AL APPROVAL
constraints (Aborigo et al., 2012; Otoo et al., 2009), and pressures The study was conducted in accordance with the Declaration of 
or support from families including food taboos (Kakute et al., 2005; Helsinki. Ethical clearance was obtained from the Benin National 
Amoussa Hounkpatin et al, 2014; Issaka et al., 2015) play an import- Ethics Committee for Scientific Research (N°45/MS/DC/SGM/DFR/
ant role. In the other hand, nutrition education programs have to be CNERS/SA). Administrative authorities of the two districts were in-
well planned and delivered (Chapman-Novakofski, 2014) and intensive formed and approved the study. Written informed consent of par-
(Bukusuba, 2005; Roy et al., 2005) to ensure their efficiency . ticipants was obtained after receiving complete information about 
the study in the local language.
4.1 | Limitation ORCID
Fifali Sam Ulrich Bodjrènou  https://orcid.org/0000-0002-5619-3409 
We could have used qualitative method in the present study to Waliou Amoussa Hounkpatin  https://orcid.
have in-depth understanding of the situation. Qualitative research org/0000-0002-2902-8248 
BODJRENOU Et al.      |  9
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