The Knowledge-Practice Gap in Exclusive Breastfeeding and Milk Expression Among Healthcare Providers: A Hospital-Based Cross-sectional Study in Kigali, Rwanda

Technical Summary: The Knowledge-Practice Gap in Exclusive Breastfeeding Among Healthcare Providers in Kigali, Rwanda

Problem Statement
Despite being primary advocates for exclusive breastfeeding (EBF), healthcare providers (HCPs) in Rwanda face a significant "knowledge-practice gap." While Rwanda boasts high national EBF rates (approx. 81%) and progressive national policies, including extended maternity leave, HCPs in hospital settings struggle to practice EBF themselves. This study addresses the paradox where medical professionals, who counsel patients on the life-saving benefits of EBF, encounter workplace conditions that prevent them from adhering to these same recommendations. The research seeks to quantify this gap, assess the specific barriers within hospital environments, and determine the extent to which institutional support systems fail to align with national policy.

Methodology

• Design: A descriptive cross-sectional study utilizing quantitative methods.
• Setting: Three public hospitals in Kigali, Rwanda: Centre Hospitalier Universitaire de Kigali (CHUK), Muhima Hospital, and Kacyiru Hospital.
• Participants: A pragmatic sample of 60 healthcare provider mothers (nurses, midwives, doctors, and allied health professionals) with infants aged six months or older. The study targeted the accessible population of eligible HCPs during a one-month recruitment window (November 2024).
• Data Collection: A structured, self-administered questionnaire adapted from a validated tool by Ishak et al. The instrument covered sociodemographics, EBF knowledge and practices, milk expression frequency, workplace barriers, and perceived support.
• Analysis: Data were analyzed using Stata version 17.0. Descriptive statistics summarized demographics and practices. Bivariable analysis using Fisher's exact test (chosen due to small cell frequencies in the EBF group) examined associations between EBF status and various factors.
• Limitations: The study acknowledges a small sample size (n=60), reliance on self-reported data (potential recall and social desirability bias), and a cross-sectional design that precludes causal inference.

Key Results

• Knowledge vs. Practice: There is a stark disparity between knowledge and action. While 98–100% of participants recognized the benefits of EBF (growth, immunity, infection reduction), only 11.7% (7/60) achieved EBF for the full six months. Conversely, 85% practiced mixed feeding.
• Milk Expression: A majority (63.3%) were unable to express breast milk during work hours. Among those who did not practice EBF, the primary reasons were perceived insufficient milk production (41.5%) and the time-intensive nature of expression (37.7%).
• Barriers: The most frequently cited barrier was lack of time (55%), followed by inadequate colleague support (21.7%) and perceived insufficient milk production.
• Institutional Support: 65% of respondents reported their hospitals lacked policies supportive of EBF. While 46.7% identified flexible work hours as the most needed support, only 35% perceived their employer as supportive of breastfeeding needs.
• Statistical Associations: Bivariable analysis revealed that EBF status was significantly associated with:
  • Age: Participants aged 35–44 were more likely to practice EBF than those aged 25–34 (P=0.011).
  • Education: Those with a Bachelor's degree or higher were more likely to practice EBF (P=0.040).
  • Occupation: Midwives and doctors had higher EBF rates compared to nurses (P=0.006).
  • Parity: Participants with three or more children were more likely to practice EBF (P=0.003).
  • Commute: A commute time exceeding one hour was significantly associated with EBF practice (P=0.003).
  • Support: Inadequate colleague support and a neutral (rather than supportive) employer stance were significantly associated with EBF status. Notably, maternity leave duration and the presence of formal hospital policies did not show a statistically significant association with EBF outcomes in this sample.

Key Contributions

• Contextual Evidence: This study provides rare, facility-level data from an urban Rwandan setting, highlighting that high national EBF rates do not necessarily translate to supportive environments for healthcare staff.
• Identification of Structural Barriers: The research shifts the focus from individual knowledge deficits (which were minimal) to structural and organizational determinants, specifically time constraints, lack of facilities, and workplace culture.
• Policy-Practice Discrepancy: It documents a critical implementation gap where national policies (e.g., 14-week maternity leave) are not effectively operationalized at the hospital level to support breastfeeding staff.

Significance and Claims
The paper claims that the primary barrier to EBF among HCPs in Kigali is not a lack of knowledge, but rather workplace constraints and a lack of structural support. The authors argue that medical expertise is often insufficient to overcome a workplace environment that does not allow mothers the time or space to breastfeed.

The study concludes that addressing this gap requires a shift from individual-level education to facility-level interventions. Specifically, the authors advocate for:

1. Formal lactation policies that are actively enforced.
2. Designated, private spaces for milk expression.
3. Flexible scheduling and protected time for expression.
4. Cultivating a supportive workplace culture that normalizes breastfeeding breaks.

The authors modestly note that while formal policies are necessary, they are insufficient without consistent collegial support and a culture that actively accommodates breastfeeding mothers. The findings suggest that without these systemic changes, the "knowledge-practice gap" will persist, potentially undermining the credibility of EBF counseling provided by these healthcare professionals.