Scaling up breastfeeding in developing countries

Breastfeeding and female labor force participation: the probability of survival of children in Nepal under 3 years old

BACKGROUND

The number of breastfeeding mothers participating in a labor force to generate income has been increasing in Nepal. In this regard, the study aims to assess the survival of Under 3 children in Nepal from the mother based on their labor force participation and breastfeeding status.

METHODS

Data for the study were obtained from the Nepal Demographic and Health Survey 2016. The sample size of the study was 2,994 live births children, born in the last three years prior to the day of the interview. The robust hazard ratio and cox proportional hazard regression were conducted between dependent and independent variables with 95% confidence intervals (CIs) to conclude.

RESULTS

From a total of 2,994 live births, 85 children died within 36 months of birth. More than 80% of the non-working mothers were breastfeeding their children. The findings shows that the survival of children under-3 is positively associated with the interaction with the mother's work and breastfeeding status (Hazard Ratio 0.428, 95% CI 0.24, 0.75), family structure (Hazard Ratio 1.511; 95% CI 1.37, 1.655), relationship with the household head (Hazard Ratio 0.452; 95% CI 0.311, 0.65), wealth quintiles (Hazard Ratio 0.390; 95% CI 0.33, 0.46), caste (Hazard Ratio 0.652; 95% CI 0.60, 0.69), and religion (Hazard Ratio 2.015; 95% CI 1.09, 3.70) with model CI 95%, Log pseudo likelihood = -521.39236, prob. χ2 = 0.005 and time at risk = 52,748.

CONCLUSIONS

The highest rate of child survival was from the working mothers as well as continuing breastfeeding their children followed by mothers breastfeeding the child but not working, compared to mothers working but not breastfeeding the child, and mothers who were neither working nor breastfeeding their children respectively. This study provides clear evidence that breastfeeding is very important for the probability of survival of the child aged below 36 months and work of mother also have some positive impact on child survival. Employers should be encouraged to have a breastfeeding policy in the workplace through the establishment of a breastfeeding facility, and a flexible work schedule. At the same time government should also regulate the paid maternity leave and encourage societal support for the breastfeeding mothers.

Assessing sustainment of health worker outcomes beyond program end: Evaluation results from an infant and young child feeding intervention in Bangladesh

Introduction

Alive and Thrive (A&T) implemented infant and young child feeding (IYCF) interventions in Bangladesh. We examine the sustained impacts on health workers' IYCF knowledge, service delivery, job satisfaction, and job readiness three years after the program's conclusion.

Methods

We use data from a cluster-randomized controlled trial design, including repeated cross-sectional surveys with health workers in 2010 (baseline, n = 290), 2014 (endline, n = 511) and 2017 (post-endline, n = 600). Health workers in 10 sub-districts were trained and incentivized to deliver intensified IYCF counseling, and participated in social mobilization activities, while health workers in 10 comparison sub-districts delivered standard counseling activities. Accompanying mass media and policy change activities occurred at the national level. The primary outcome is quality of IYCF service delivery (number of IYCF messages reportedly communicated during counseling); intermediate outcomes are IYCF knowledge, job satisfaction, and job readiness. We also assess the role of hypothesized modifiers of program sustainment, i.e. activities of the program: comprehensiveness of refresher trainings and receipt of financial incentives. Multivariable difference-in-difference linear regression models, including worker characteristic covariates and adjusted for clustering at the survey sampling level, are used to compare differences between groups (intervention vs. comparison areas) and over time (baseline, endline, post-endline).

Results

At endline, health workers in intervention areas discussed significantly more IYCF topics than those in comparison areas (4.9 vs. 4.0 topics, p < 0.001), but levels decreased and the post-endline gap was no longer significant (4.0 vs. 3.3 topics, p = 0.067). Comprehensive refresher trainings were protective against deterioration in service delivery. Between baseline and endline, the intervention increased health workers' knowledge (3.5-point increase in knowledge scores in intervention areas, vs. 1.5-point increase in comparison areas, p < 0.0001); and this improvement persisted to post-endline, suggesting a sustained program effect on knowledge. Job satisfaction and readiness both saw improvements among workers in intervention areas during the project period (baseline to endline) but regressed to a similar level as comparison areas by post-endline.

Discussion

Our study showed sustained impact of IYCF interventions on health workers' knowledge, but not job satisfaction or job readiness-and, critically, no sustained program effect on service delivery. Programs of limited duration may seek to assess the status of and invest in protective factors identified in this study (e.g., refresher trainings) to encourage sustained impact of improved service delivery. Studies should also prioritize collecting post-endline data to empirically test and refine concepts of sustainment.

Prevalence of exclusive breastfeeding among mothers in the informal sector, Kampala Uganda

Exclusive breastfeeding (EBF) for the first six months of life is effective in preventing infant morbidity and mortality. However, 36% of Ugandan children below 6 months are not breastfed exclusively despite its active promotion. This study determined the prevalence and factors associated with exclusive breastfeeding among mothers working in the informal sector in Kampala district. A community based cross-sectional study targeting 428 interviews with mothers with children aged 0–5 months was conducted. Analysis was done using modified Poisson regression in Stata version 14. The prevalence of exclusive breastfeeding was 42.8%. The factors associated with exclusive breastfeeding included: attending antenatal care at least 4 times (APR = 1.24; 95% CI: 1.01–1.51), intention to exclusively breastfeed for 6 months (APR = 1.26; 95% CI: 1.01–1.57) or longer (APR = 1.38; 95% CI: 1.06–1.76), proper breastfeeding practices (APR = 4.12; 95% CI: 2.88–5.90), age of the infant (APR = 0.78; 95% CI: 0.65–0.94) and (APR = 0.48; 95% CI: 0.39–0.60) for children aged 2–3 and 4–5 months respectively and working in a lower position (APR = 0.68; 95% CI: 0.55–0.83). Mothers should be encouraged to attend antenatal care where they learn about the benefits of exclusive breastfeeding to children below 6 months hence enabling them to make informed decisions about exclusive breastfeeding. The government of Uganda should ensure maternity leave benefits of the employment act are enforced in the informal sector to allow women to practice EBF.

Can complex programs be sustained? A mixed methods sustainability evaluation of a national infant and young child feeding program in Bangladesh and Vietnam

Background

Poor early-life nutrition is a major barrier to good health and cognitive development, and is a global health priority. Alive & Thrive (A&T) was a multi-pronged initiative to improve infant and young child feeding behaviors. It aimed to achieve at-scale child health and nutrition improvements via a comprehensive approach that included nutrition counseling by health workers, policy change, social mobilization and mass media activities. This study evaluated the sustainability of activities introduced during A&T implementation (2009–2014) in Bangladesh and Vietnam.

Methods

This was a mixed methods study that used a quasi-experimental design. Quantitative data (surveys with 668 health workers, and 269 service observations) were collected in 2017; and analysis compared outcomes (primarily dose and fidelity of activities, and capacity) in former A&T intervention areas versus areas that did not receive the full A&T intervention. Additionally, we conducted interviews and focus groups with 218 stakeholders to explore their impressions about the determinants of sustainability, based on a multi-level conceptual framework.

Results

After program conclusion, stakeholders perceive declines in mass media campaigns, policy and advocacy activities, and social mobilization activities – but counseling activities were institutionalized and continued in both countries. Quantitative data show a persisting modest intervention effect: health workers in intervention areas had significantly higher child feeding knowledge, and in Bangladesh greater self-efficacy and job satisfaction, compared to their counterparts who did not receive the full package of A&T activities. While elements of the program were integrated into routine services, stakeholders noted dilution of the program focus due to competing priorities. Qualitative data suggest that some elements, such as training, monitoring, and evaluation, which were seen as essential to A&T’s success, have declined in frequency, quality, coverage, or were eliminated altogether.

Conclusions

The inclusion of multiple activities in A&T and efforts to integrate the program into existing institutions were seen as crucial to its success but also made it difficult to sustain, particularly given unstable financial support and human resource constraints. Future complex programs should carefully plan for institutionalization in advance of the program by cultivating champions across the health system, and designing unique and complementary roles for all stakeholders including donors.

The effect of the Alive & Thrive initiative on exclusive breastfeeding in rural Burkina Faso: a repeated cross-sectional cluster randomised controlled trial

BACKGROUND

The benefits of exclusive breastfeeding on mortality, health, and development of children have been well documented. In Burkina Faso, the Alive & Thrive initiative combined interpersonal communication and community mobilisation activities with the aim of improving knowledge, beliefs, skills, and, ultimately, breastfeeding outcomes. The objective of this study was to determine the effect of the Alive & Thrive initiative on exclusive breastfeeding in Boucle du Mouhoun, Burkina Faso.

METHODS

We did a cluster-randomised trial with data collected with two independent, population-representative, cross-sectional surveys: a baseline survey done before the start of the initiative implementation and an endline survey done 2 years later. Rural villages in Boucle du Mouhoun, Burkina Faso, were randomly allocated by use of computer generated pseudo-random numbers, and women were eligible for participation if they had a livebirth in the 12 months preceding the survey and resided in a village selected for the study. The primary outcome was exclusive breastfeeding among infants younger than 6 months. Masking was not possible for the intervention implementation. All women who participated in the trial were included in the analysis population. The trial is registered with ClinicalTrials.gov, number NCT02435524.

FINDINGS

Between June 2 and July 28, 2015, 2288 mothers participated in the baseline survey and between June 12 and July 25, 2017, 2253 mothers participated in the endline survey. At endline, there was a risk difference of 38·9% (95% CI 32·2-45·6, p<0·001) between the reported prevalence of exclusive breastfeeding in the intervention group and that of the control group.

INTERPRETATION

A multidimensional intervention deliverable at scale in a low-income setting resulted in substantial increases in mothers' optimal breastfeeding knowledge and beliefs and in reported exclusive breastfeeding practices. However, it is possible that the findings might have been influenced by social desirability bias.

FUNDING

Bill & Melinda Gates Foundation, London School of Hygiene & Tropical Medicine.

Maternal work and exclusive breastfeeding in Mansoura, Egypt

BACKGROUND

Working mothers face unique barriers to breastfeeding, despite the compelling evidence of its benefits. The aim of this study was to describe exclusive breastfeeding (EBF) rate of working mothers and associated factors.

METHODS

Cross-sectional study was carried out in Mansoura District, Egypt from 1 July to 31 December 2017 among working mothers attending health care facilities for vaccinating their infants aged 6 months. Data were collected using a questionnaire covering sociodemographic and occupational data; breastfeeding supportive workplace facilities; antenatal and natal care; infant's data; and EBF practice.

RESULTS

EBF rate was 14.1%. Independent predictors were being still on work leave, return to work 4 months after childbirth, working as farmer/manual worker and in trades and business, and being self/family employed.

CONCLUSIONS

EBF rate is low among working mothers. There is a need to extend maternity leave and provide promoting workplace facilities.

Large-Scale Social and Behavior Change Communication Interventions Have Sustained Impacts on Infant and Young Child Feeding Knowledge and Practices: Results of a 2-Year Follow-Up Study in Bangladesh

Background

Sustained improvements in infant and young child feeding (IYCF) require continued implementation of effective interventions. From 2010-2014, Alive & Thrive (A&T) provided intensive interpersonal counseling (IPC), community mobilization (CM), and mass media (MM) in Bangladesh, demonstrating impact on IYCF practices. Since 2014, implementation has been continued and scaled up by national partners with support from other donors and with modifications such as added focus on maternal nutrition and reduced program intensity.

Objective

We assessed changes in intervention exposure and IYCF knowledge and practices in the intensive (IPC + CM + MM) compared with nonintensive areas (standard nutrition counseling + less intensive CM and MM) 2 y after termination of initial external donor support.

Methods

We used a cluster-randomized design with repeated cross-sectional surveys at baseline (2010, n = 2188), endline (2014, n = 2001), and follow-up (2016, n = 2400) in the same communities, among households with children 0-23.9 mo of age. Within-group differences over time and differences between groups in changes were tested.

Results

In intensive areas, exposure to IPC decreased slightly between endline and follow-up (88.9% to 77.2%); exposure to CM activities decreased significantly (29.3% to 3.6%); and MM exposure was mostly unchanged (28.1-69.1% across 7 TV spots). Exposure to interventions did not expand in nonintensive areas. Most IYCF indicators in intensive areas declined from endline to follow-up, but remained higher than at baseline. Large differential improvements of 12-17 percentage points in intensive, compared with nonintensive areas, between baseline and follow-up remained for early initiation of and exclusive breastfeeding, timely introduction of foods, and consumption of iron-rich foods. Differential impact in breastfeeding knowledge remained between baseline and follow-up; complementary feeding knowledge increased similarly in both groups.

Conclusions

Continued IPC exposure and sustained impacts on IYCF knowledge and practices in intensive areas indicated lasting benefits from A&T's interventions as they underwent major scale-up with reduced intensity. This trial was registered at clinicaltrials.gov as NCT02740842.

The Baby-friendly Hospital Initiative and Qatar, 2016

Breastfeeding instills countless benefits that extend beyond the infant and child to the entire nation. One of the global targets set by the WHO to improve maternal, infant, and young child nutrition is to increase the rate of exclusive breast-feeding “in the first 6 months” up to at least 50% by 2025.³ Thus, as a global endeavor to promote and sustain breastfeeding, the WHO and UNICEF launched the Baby-friendly Hospital Initiative (BFHI) 1 year after the Innocenti Declaration of 1990. Regarding the State of Qatar, there was a 34% rate of early initiation of breastfeeding “within the first hour of birth” and a 29% rate of exclusive breastfeeding between 2010 and 2015. In Qatar during 2016, many obstacles in achieving the aforementioned global target remained. In addition, there are still no hospitals with a BFHI accreditation.

What influences feeding decisions for HIV-exposed infants in rural Kenya?

BACKGROUND

Infant feeding in the context of human immunodeficiency virus (HIV) poses unique challenges to mothers and healthcare workers in balancing the perceived risks of HIV transmission and nutritional requirements. We aimed to describe the decision-making processes around infant feeding at a rural HIV clinic in Kenya.

METHODS

We used a qualitative study design. Between March and August 2011, we conducted in-depth interviews (n = 9) and focus group discussions (n = 10) with purposively selected hospital and community respondents at Kilifi County Hospital, Kenya. These respondents had all experienced of infant feeding in the context of HIV. These interviews were informed by prior structured observations of health care worker interactions with carers during infant feeding counselling sessions.

RESULTS

Overall, women living with HIV found it difficult to adhere to the HIV infant feeding guidance. There were three dominant factors that influenced decision making processes: 1) Exclusive breastfeeding was not the cultural norm, therefore practising it raised questions within the family and community about a mother's parenting capabilities and HIV status. 2) Women living with HIV lacked autonomy in decision-making on infant feeding due to socio-cultural factors. 3) Non-disclosure of HIV status to close members due to the stigma.

CONCLUSION

Infant feeding decision-making by women living with HIV in rural Kenya is constrained by a lack of autonomy, stigma and poverty. There is an urgent need to address these challenges through scaling up psycho-social and gender empowerment strategies for women, and introducing initiatives that promote the integration of HIV infant feeding strategies into other child health services.

Opportunities for strengthening infant and young child feeding policies in South Asia: Insights from the SAIFRN policy analysis project

BACKGROUND

South Asian countries experience some of the highest levels of child undernutrition in the world, strongly linked to poor infant and young child feeding (IYCF) practices. Strong and responsive policy support is essential for effective interventions to improve IYCF. This study aimed to identify opportunities for strengthening the policy environment in the region to better support appropriate infant and young child feeding.

METHODS

We mapped policies relevant to infant and young child feeding in India, Pakistan, Bangladesh, Sri Lanka and Nepal, based on a common matrix. The matrix described potentially relevant policies ranging from high-level strategic policy documents to implementation-level guidelines. We analyzed the data based on themes focused on caregiver interactions with IYCF interventions: provision of correct information to mothers, training of frontline workers, enabling mothers to engage with service providers and strategic support for IYCF.

RESULTS

Policy support for IYCF was present in relation to each of the themes assessed. In all countries, there was support for nutrition in National Development Plans, and all countries had some level of maternity protection and restrictions on marketing of breast milk substitutes. Sectoral and implementation-level policy documents contained provisions for system strengthening for IYCF and for training of frontline workers.

CONCLUSIONS

The key opportunities for strengthening IYCF policy support were in relation to translating strategic directives into implementation level documents; improving multi-sectoral support and coordination; and increased clarity regarding roles and responsibilities of frontline workers interacting with mothers. These findings can support efforts to strengthen IYCF policy at the national and regional level.

Policy and stakeholder analysis of infant and young child feeding programmes in Sri Lanka

BACKGROUND

Infant and young child feeding practices (IYCF) play a critical role in growth and development of children. A favourable environment supported by appropriate policies and positive contributions from all stakeholders are prerequisites for achieving optimal IYCF practices. This study aimed to assess the IYCF-related policy environment and role of stakeholders in policy making in Sri Lanka, in order to identify opportunities to strengthen the policy environment to better support appropriate IYCF and reduce childhood malnutrition.

METHODS

We mapped national level policy-related documents on IYCF, and conducted a stakeholder analysis of IYCF policy making. A matrix was designed to capture data from IYCF policy-related documents using a thematic approach. A narrative synthesis of data from different documents was conducted to achieve the first objective. We then conducted an analysis of technical and funding links of stakeholders who shape IYCF policies and programmes in Sri Lanka using the Net-Map technique, to achieve the second objective. A total of 35 respondents were purposively selected based on their knowledge on the topic, and individual interviews were conducted.

RESULTS

Twenty four policies were identified that contained provisions in line with global recommendations for best-practice IYCF, marketing of breast milk substitutes, strengthening health and non-health systems, maternity benefits, inter-sectoral collaboration, capacity building, health education and supplementation. However, there is no separate, written policy on IYCF in Sri Lanka. Participants identified 56 actors involved in shaping IYCF policies and programmes through technical support, and 36 through funding support. The Government Health Sector was the most connected as well as influential, followed by development partners. Almost all actors in the networks were supportive for IYCF policies and programmes.

CONCLUSIONS AND RECOMMENDATIONS

All evidence-based recommendations are covered in related policies. However, advocacy should be targeted towards strategic support for IYCF in high-level policy documents. The stakeholder analysis confirmed a network led by the government health sector. Enhancing the multi-sectoral commitments stressed in policy documents is an opportunity to strengthen IYCF policy process in Sri Lanka.

Challenges and predictors of exclusive breastfeeding among mothers attending the child welfare clinic at a regional hospital in Ghana: a descriptive cross-sectional study

BACKGROUND

The challenges and predictors of exclusive breastfeeding (EBF) have been examined in many parts of the world. Considering the socio-cultural dynamics and the few research studies in Ghana, the factors that hinder and predict EBF practice in other countries may be different in the Ghanaian setting. The study therefore sought to assess the challenges and predictors of EBF among mothers attending a child welfare clinic at a regional hospital in Ghana.

METHODS

A descriptive cross-sectional study was carried out between January and March, 2015 to elicit information from 240 mothers who were sampled using simple random sampling technique. A validated structured questionnaire was used in collecting data on participants' socio-demographic characteristics and reported breastfeeding practices. Participants' breastfeeding challenges were rated on a Likert scale from 1 (not at all), 2 (mild), 3 (moderate), 4 (severe) to 5 (unbearable). In this study, EBF refers to birth of the infants up to six months.

RESULTS

The top three breastfeeding challenges of mothers were: belief that breast milk alone was not sufficient in meeting their babies' nutritional needs [mean 3.43 (standard deviation {SD} 1.35)], short maternity leave period [mean 3.41 (SD 1.29)], and socio-cultural pressure to introduce water and artificial feeds [mean 3.39 (SD 1.28)]. Independent predictors of EBF were: infant's age [Adjusted Odds Ratio (AOR) 0.82 (95% Confidence Interval [CI] 0.71, 0.95)], and self-employment [AOR 2.67 (95% CI 1.11, 6.41)].

CONCLUSION

Mothers are confronted with numerous EBF challenges both at the individual and societal levels, and stakeholders need to consider these in order to support breastfeeding mothers to maximize outcomes. Reviewing the labour laws on Ghana's maternity leave to accommodate an extended maternity leave in addition to the employee's annual leave could further improve EBF practice rates.

Exposure to Large-Scale Social and Behavior Change Communication Interventions Is Associated with Improvements in Infant and Young Child Feeding Practices in Ethiopia

Optimal breastfeeding (BF) practices in Ethiopia are far below the government’s targets, and complementary feeding practices are poor. The Alive & Thrive initiative aimed to improve infant and young child feeding (IYCF) practices through large-scale implementation of social and behavior change communication interventions in four regions of Ethiopia. The study assessed the effects of the interventions on IYCF practices and anthropometry over time in two regions–Southern Nations, Nationalities and Peoples Region and Tigray. A pre- and post-intervention adequacy evaluation design was used; repeated cross-sectional surveys of households with children aged 0–23.9 mo (n = 1481 and n = 1494) and with children aged 24–59.9 mo (n = 1481 and n = 1475) were conducted at baseline (2010) and endline (2014), respectively. Differences in outcomes over time were estimated using regression models, accounting for clustering and covariates. Plausibility analyses included tracing recall of key messages and promoted foods and dose-response analyses. We observed improvements in most WHO-recommended IYCF indicators. Early BF initiation and exclusive BF increased by 13.7 and 9.4 percentage points (pp), respectively. Differences for timely introduction of complementary foods, minimum dietary diversity (MDD), minimum meal frequency (MMF), minimum acceptable diet (MAD), and consumption of iron-rich foods were 22.2, 3.3, 26.2, 3.5, and 2.7 pp, respectively. Timely introduction and intake of foods promoted by the interventions improved significantly, but anthropometric outcomes did not. We also observed a dose-response association between health post visits and early initiation of BF (OR: 1.8); higher numbers of home visits by community volunteers and key messages recalled were associated with 1.8–4.4 times greater odds of achieving MDD, MMF, and MAD, and higher numbers of radio spots heard were associated with 3 times greater odds of achieving MDD and MAD. The interventions were associated with plausible improvements in IYCF practices, but large gaps in improving children’s diets in Ethiopia remain, particularly during complementary feeding.

Impacts on Breastfeeding Practices of At-Scale Strategies That Combine Intensive Interpersonal Counseling, Mass Media, and Community Mobilization: Results of Cluster-Randomized Program Evaluations in Bangladesh and Viet Nam

BACKGROUND

Despite recommendations supporting optimal breastfeeding, the number of women practicing exclusive breastfeeding (EBF) remains low, and few interventions have demonstrated implementation and impact at scale. Alive & Thrive was implemented over a period of 6 y (2009-2014) and aimed to improve breastfeeding practices through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM) intervention components delivered at scale in the context of policy advocacy (PA) in Bangladesh and Viet Nam. In Bangladesh, IPC was delivered through a large non-governmental health program; in Viet Nam, it was integrated into government health facilities. This study evaluated the population-level impact of intensified IPC, MM, CM, and PA (intensive) compared to standard nutrition counseling and less intensive MM, CM, and PA (non-intensive) on breastfeeding practices in these two countries.

METHODS AND FINDINGS

A cluster-randomized evaluation design was employed in each country. For the evaluation sample, 20 sub-districts in Bangladesh and 40 communes in Viet Nam were randomized to either the intensive or the non-intensive group. Cross-sectional surveys (n ~ 500 children 0-5.9 mo old per group per country) were implemented at baseline (June 7-August 29, 2010, in Viet Nam; April 28-June 26, 2010, in Bangladesh) and endline (June 16-August 30, 2014, in Viet Nam; April 20-June 23, 2014, in Bangladesh). Difference-in-differences estimates (DDEs) of impact were calculated, adjusting for clustering. In Bangladesh, improvements were significantly greater in the intensive compared to the non-intensive group for the proportion of women who reported practicing EBF in the previous 24 h (DDE 36.2 percentage points [pp], 95% CI 21.0-51.5, p < 0.001; prevalence in intensive group rose from 48.5% to 87.6%) and engaging in early initiation of breastfeeding (EIBF) (16.7 pp, 95% CI 2.8-30.6, p = 0.021; 63.7% to 94.2%). In Viet Nam, EBF increases were greater in the intensive group (27.9 pp, 95% CI 17.7-38.1, p < 0.001; 18.9% to 57.8%); EIBF declined (60.0% to 53.2%) in the intensive group, but less than in the non-intensive group (57.4% to 40.6%; DDE 10.0 pp, 95% CI -1.3 to 21.4, p = 0.072). Our impact estimates may underestimate the full potential of such a multipronged intervention because the evaluation lacked a "pure control" area with no MM or national/provincial PA.

CONCLUSIONS

At-scale interventions combining intensive IPC with MM, CM, and PA had greater positive impacts on breastfeeding practices in Bangladesh and Viet Nam than standard counseling with less intensive MM, CM, and PA. To our knowledge, this study is the first to document implementation and impacts of breastfeeding promotion at scale using rigorous evaluation designs. Strategies to design and deliver similar programs could improve breastfeeding practices in other contexts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01678716 (Bangladesh) and NCT01676623 (Viet Nam).

Breastfeeding Rates and Growth Charts--the Zhejiang Infant Feeding Trial

A randomised control trial was undertaken in Hangzhou, China, to study the influence of the growth chart used on breastfeeding rates. Mothers with infants who were being fully breastfed at 6 weeks after birth (n = 1602) were invited to participate in the trial; 1415 agreed to participate and 1295 completed the study. Two growth charts were used, one that was heavier for the first six months of life (Chart A, n = 686) and a lighter growth chart (Chart B, n = 609). Mothers were interviewed and infants measured at 6 weeks and 3, 4, 5 and 6 months after delivery. At 6 months the full breastfeeding rates were 18.1% in the group using the heavier growth chart compared to 22.8% in the lighter growth chart group. After adjusting for potential confounders this difference remained significant (aOR 1.41, 95% confidence intervals 1.02, 1.93). These results suggest that breastfeeding rates may be influenced by the type of growth chart used. Mothers who perceive that their infants are not growing adequately (i.e., using the heavier charts) may introduce other foods to their infants earlier than mothers using the lighter chart. While a larger trial is required to confirm the results, in the interim it is suggested that if heavier growth charts are used, a lower percentile line could be used to assess adequacy of growth.

Cognitive-behavioral counseling for exclusive breastfeeding in rural pediatrics: a cluster RCT

OBJECTIVE

To test the effectiveness of cognitive-behavioral counseling on the rate and duration of exclusive breastfeeding (EBF) during the first 6 months of an infant's life compared with routine counseling.

METHODS

A single blind cluster-randomized controlled trial was undertaken in 40 Union Councils of a rural district in the northwest province of Pakistan between May 2009 and April 2010. By simple unmatched randomization, 20 Union Councils were each allocated to intervention and control arms. Two hundred twenty-four third trimester pregnant women in the intervention and 228 third trimester pregnant women in the control arm were enrolled and followed-up biweekly until 6 months postpartum. Analyses were by intention to treat. Mothers in the intervention group received 7 sessions of cognitive-behavioral counseling from antenatal to 6 months postpartum, whereas the control group received an equal number of routine sessions. Proportion of mothers exclusively breastfeeding at 6 months postpartum and duration of EBF through these 6 months was assessed.

RESULTS

At 6 months postpartum, 59.6% of mothers in the intervention arm and 28.6% in the control arm were exclusively breastfeeding. This translates into a 60% reduced risk of stopping exclusively breastfeeding during the first 6 months (adjusted hazard ratio, 0.40 [95% confidence interval: 0.27-0.60], P < .001). Mothers in the intervention group were half as likely to use prelacteal feeds with their infants (adjusted relative risk, 0.51 [95% confidence interval: 0.34-0.78]).

CONCLUSIONS

Compared with routine counseling, cognitive-behavioral counseling significantly prolonged the duration of EBF, doubling the rates of EBF at 6 months postpartum.

Promotion of exclusive breast-feeding at scale within routine health services: impact of breast-feeding counselling training for community health workers in Recife, Brazil

OBJECTIVE

Breast-feeding counselling has been identified as the intervention with the greatest potential for reducing child deaths, but there is little experience in delivering breast-feeding counselling at scale within routine health systems. The study aim was to compare rates of exclusive breast-feeding associated with a breast-feeding counselling intervention in which community health agents (CHA) received 20 h of training directed at counselling and practical skills with rates pre-intervention when CHA received 4 h of didactic teaching.

DESIGN

Cross-sectional surveys of breast-feeding practices were conducted pre- and post-intervention in random samples of 1266 and 1245 infants aged 0-5.9 months, respectively.

SETTING

Recife, Brazil, with a population of 2 million.

SUBJECTS

CHA (n 1449) of Brazil's Family Health Programme were trained to provide breast-feeding counselling at home visits.

RESULTS

Rates of exclusive breast-feeding improved when CHA were trained to provide breast-feeding counselling and were significantly higher by 10-13 percentage points at age 3-5.9 months when compared with pre-intervention rates (P < 0.05). Post-intervention point prevalence of exclusive breast-feeding for infants aged <4 months was 63% and for those aged <6 months was 50%.

CONCLUSIONS

Multifunctional CHA were able to deliver breast-feeding counselling at scale within a routine health service and this was associated with a significant increase in rates of exclusive breast-feeding. The study reinforces the need to focus training on counselling and practical skills; a key component was an interactive style that utilized the knowledge and experience of CHA. The findings are relevant to the call by international organizations to scale up breast-feeding counselling.

Global burden of maternal and child undernutrition and micronutrient deficiencies

Maternal and child undernutrition and micronutrient deficiencies affect approximately half of the world's population. These conditions include intrauterine growth restriction (IUGR), low birth weight, protein-energy malnutrition, chronic energy deficit of women, and micronutrient deficiencies. Although the rates of stunting or chronic protein-energy malnutrition are increasing in Africa, the absolute numbers of stunted children are much higher in Asia. The four common micronutrient deficiencies include those of iron, iodine, vitamin A, and zinc. All these conditions are responsible directly or indirectly for more than 50% of all under-5 deaths globally. According to more recent estimates, IUGR, stunting and severe wasting are responsible for one third of under-5 mortality. About 12% of deaths among under-5 children are attributed to the deficiency of the four common micronutrients. Despite tremendous progress in different disciplines and unprecedented improvement with many health indicators, persistently high undernutrition rates are a shame to the society. Human development is not possible without taking care to control undernutrition and micronutrient deficiencies. Poverty, food insecurity, ignorance, lack of appropriate infant and young child feeding practices, heavy burden of infectious illnesses, and poor hygiene and sanitation are factors responsible for the high levels of maternal and child undernutrition in developing countries. These factors can be controlled or removed by scaling up direct nutrition interventions and eliminating the root conditions including female illiteracy, lack of livelihoods, lack of women's empowerment, and poor hygiene and sanitation.