The impact of a hospital and clinic-based breastfeeding promotion programme in a middle class urban environment

A Scoping Review of Breastfeeding Interventions and Programs Conducted Across Spanish-Speaking Countries

Breastfeeding is vital to a child's lifelong health and has significant positive benefits to mother's health. World Health Organization recommends beginning exclusively breastfeeding within the first hour after birth and continuing during the first 6 months of infant's life. The purpose of this review is to identify and examine breastfeeding interventions conducted across the Spanish-speaking countries. A scoping review of the literature was conducted across 14 databases for relevant publications published through April 2023 to find studies in Spanish-speaking countries that involved breastfeeding as an intervention component. A total of 46 peer-reviewed articles were included in this review, across 12 Spanish-speaking countries. Participants ranged from pregnant women, mothers, mother-infant pair, and health care professionals. Intervention at the individual level in combination with support from trained health care professionals or peer counselors seemed to have higher improvements in breastfeeding rates. The greatest improvement in exclusively breastfeeding for 6 months was seen in interventions that included prenatal and postnatal intensive lactation education, for a period of 12 months. The most effective interventions that improved rates of any breastfeeding included promotional activities, educations workshop, and training of health care staff along with changes in hospital care. Breastfeeding promotion is an economical and effective intervention to increase breastfeeding behavior and thereby improving breastfeeding adherence across Spanish-speaking countries.

Social marketing applications in public policy programs: key learnings and applications

Purpose

Marketing tools used in public policy may not be purely commercial but based on non-commercial marketing exchanges also. This paper aims to make a case for the practice of social marketing principles to aid the context of public policy.

Design/methodology/approach

The approach is to draw out the key implementable learnings (KILs) from the analysis of the five public policy initiatives in the USA, India and Sri Lanka. A case situation with the context of child labour policy in India is proposed to use these KILs.

Findings

This paper concludes that the implementation of any policy is a challenging exercise and dependent on a large number of factors. However, KILs derived from successful social marketing programs deal with umbrella campaigns, prevailing socio-cultural environment, bottom-up communication, upstream approach to engage with stakeholders and targeted media advocacy could prove useful when the objective is to induce behaviour change as a part of the policy execution.

Originality/value

This paper evaluates the learnings from social marketing campaigns and their relevance to public policy programs. It also considers a case to demonstrate the application of the concept.

Impact of Routine Counseling on Breastfeeding Status in Hospitalized Infants Below 6 Months: Observation From a Large Diarrheal Disease Hospital in Bangladesh

Background. Breastfeeding counseling (BFC) plays a crucial role in improving infant and young child feeding practices. To evaluate the impact of activities of BFC unit (BFCU) on breastfeeding practices of infants who were hospitalized for diarrheal illness through their regular counseling, assistance and support, and motivation. Methods. In this retrospective chart analysis conducted at Dhaka Hospital of icddr,b using an electronic database, data were collected from mothers of infants younger than 6 months of age who visited the BFCU from 2011 to 2015. Results. Among a total of 3420 infants enrolled during study period, 429 (12.5%) were predominantly breastfed, 2457 (71.8%) partially breastfed, 531 (15.5%) non-breastfed, and 3 (0.1%) exclusively breastfed (EBF) at home. Through counseling of BFCU (following 24-hour recall technique), 2212 (65%) infants became EBF and 1186 (35%) failed to be EBF during discharge. Logistic regression analysis after adjusting for potential covariates, such as maternal age <18 years and receiving breast milk with other liquid at home, revealed that infants having severe underweight, maternal perception of “baby does not suck,” and “there is not enough milk” were less likely to be associated with EBF during discharge. Among 531 non-breastfed infants, 455 (85.7%) became partial breastfeeding and only 23 (4.3%) became EBF. Conclusion. Counseling of mothers even during acute illness of infants in the hospital can help promote breastfeeding. Therefore, there is great importance of robust counseling on breastfeeding practices and may help establish re-lactation of acutely ill babies.

The Role of Education in Breastfeeding Success

Many of the factors that have contributed to the decline in breastfeeding around the world can be overcome by education and support. Examples of successful approaches to education at different levels (mother, health professional, institution) that impact breastfeeding are discussed. For example, because breastfeeding is a learned behaviour for both mother and baby, providing the mother with information, skills, and support for the breastfeeding process is integral to her ability to breastfeed successfully. In addition, because the health professional plays a pivotal role in the success or failure of breastfeeding it is essential I that education and training of health professionals be adequately addressed. By using an approach to healthprofessional education that builds on a highly trained core and spreads to all levels through a built-in multiplier effect, improvement of breastfeeding practices can be assured. In order to sustain these results, however, health-professional school curricula must include adequate information on the science of lactation and the clinical management of breastfeeding The experience of Chile's National Breastfeeding Programme is used to illustrate the power of education at each of these levels in influencing the success of breastfeeding and the feasibility of using education of both mothers and health professionals as a way of preserving this incredible natural resource.

Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review

The Baby-friendly Hospital Initiative (BFHI) is a key component of the World Health Organization/United Nations Children's Fund Global Strategy for Infant and Young Child Feeding. The primary aim of this narrative systematic review was to examine the impact of BFHI implementation on breastfeeding and child health outcomes worldwide and in the United States. Experimental, quasi-experimental and observational studies were considered eligible for this review if they assessed breastfeeding outcomes and/or infant health outcomes for healthy, term infants born in a hospital or birthing center with full or partial implementation of BFHI steps. Of the 58 reports included in the systematic review, nine of them were published based on three randomized controlled trials, 19 followed quasi-experimental designs, 11 were prospective and 19 were cross-sectional or retrospective. Studies were conducted in 19 different countries located in South America, North America, Western Europe, Eastern Europe, South Asia, Eurasia and Sub-Saharan Africa. Adherence to the BFHI Ten Steps has a positive impact on short-term, medium-term and long-term breastfeeding (BF) outcomes. There is a dose-response relationship between the number of BFHI steps women are exposed to and the likelihood of improved BF outcomes (early BF initiation, exclusive breastfeeding (EBF) at hospital discharge, any BF and EBF duration). Community support (step 10) appears to be essential for sustaining breastfeeding impacts of BFHI in the longer term.

Postnatal Lactational Counseling and Neonatal Weight Pattern

OBJECTIVE

To compare the impact of postnatal lactational counseling on the weight gain and frequency of mixed feeding in full term neonates.

DESIGN

Observational study.

SETTING

Mother-infant pairs were observed in the maternity section of a multispecialty general hospital in Mumbai during two time periods.

PARTICIPANTS

260 mothers who delivered a full term, healthy, appropriate for gestational age neonate with birth weight >2.2 kg.

METHODS

Between 18 November, 2007 and 4 March, 2008, 126 mothers received unstructured verbal encouragement to maintain breastfeeding from the maternity staff. From 1 June, 2008 to 16 December, 2008, 134 mothers were counseled about breastfeeding by the pediatric residents and nurses with the help of charts, literature and verbal advice. They were supervised and helped during the first feed and subsequently until discharge.

MAIN OUTCOME MEASURES

Weight gain (g/kg/day) of neonate at 28 days of life.

RESULTS

The mean (SD) weight gain was significantly higher in the counseled group in comparison to historical control group [9.2 (4.5) g/kg/d vs. 7.9 (5.1) g/kg/d; P=0.03]. Mixed feeding occurred less frequently in [RR 0.36, 95% CI 0.13, 0.98; P=0.046] the counseled group (5/134) as compared to control group (13/126).

CONCLUSIONS

Postnatal lactational counseling leads to higher weight gain, and lesser chances of mixed feeding in the neonatal period.

Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis

AIM

To provide comprehensive evidence of the effect of interventions on early initiation, exclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health systems and services (ii) Home and family environment (iii) Community environment (iv) Work environment (v) Policy environment or a combination of any of above.

METHODS

Of 23977 titles identified through a systematic literature search in PUBMED, Cochrane and CABI, 195 articles relevant to our objective, were included. We reported the pooled relative risk and corresponding 95% confidence intervals as our outcome estimate. In cases of high heterogeneity, we explored its causes by subgroup analysis and meta-regression and applied random effects model.

RESULTS

Intervention delivery in combination of settings seemed to have higher improvements in breastfeeding rates. Greatest improvements in early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding rates, were seen when counselling or education were provided concurrently in home and community, health systems and community, health systems and home settings, respectively. Baby friendly hospital support at health system was the most effective intervention to improve rates of any breastfeeding.

CONCLUSION

To promote breastfeeding, interventions should be delivered in a combination of settings by involving health systems, home and family and the community environment concurrently.

From foundling homes to day care: a historical review of childcare in Chile

This article discusses significant changes in childcare policy and practice in Chile. We distinguish four specific periods of childcare history: child abandonment and the creation of foundling homes in the 19th century; efforts to reduce infant mortality and the creation of the health care system in the first half of the 20th century; an increasing focus on inequality and poverty and the consequences for child development in the second half of the 20th century; and, finally, the current focus on children’s social and emotional development. It is concluded that, although Chile has achieved infant mortality and malnutrition rates comparable to those of developed countries, the country bears the mark of a history of inequality and is still unable to fully guarantee the health of children from the poorest sectors of society. Recent initiatives seek to improve this situation and put a strong emphasis on the psychosocial condition of children and their families.

Associations of hospital staff training and policies with early breastfeeding practices

BACKGROUND

In 2009, the Centers for Disease Control and Prevention implemented the Maternity Practices in Infant Nutrition and Care (mPINC) survey in all US birth facilities to assess breastfeeding-related maternity practices. Maternity practices and hospital policies are known to influence breastfeeding, and Alabama breastfeeding rates are very low.

OBJECTIVE

Our objective was to assess whether staff training and structural-organizational aspects of care, such as policies, were associated with infants' breastfeeding behaviors 24 to 48 hours postpartum.

METHODS

We linked 2009 mPINC data from 48 Alabama hospitals with birth certificate and newborn screening databases. We used data collected 24 to 48 hours postpartum to classify 41 536 healthy, term, singleton infants as breastfed (any breast milk) or completely formula fed and examined associations with hospitals' mPINC scores in comparison with the state mean. We conducted multilevel analyses to assess infants' likelihood of being breastfed if their birth hospital scores were lower versus at least equal to the Alabama mean, accounting for hospital clustering, demographics, payment method, and prenatal care.

RESULTS

The odds of breastfeeding were greater in hospitals with a higher-than-state-mean score on the following: new employees' breastfeeding education, nurses' receipt of breastfeeding education in the past year, prenatal breastfeeding classes offered, having a lactation coordinator, and having a written breastfeeding policy. The number of recommended elements included in hospitals' written breastfeeding policies was positively associated with newborn breastfeeding rates.

CONCLUSION

Educating hospital staff to improve breastfeeding-related knowledge, attitudes, and skills; implementing a written hospital breastfeeding policy; and ensuring continuity of prenatal and postnatal breastfeeding education and support may improve newborn breastfeeding rates.

Breastfeeding promotion interventions and breastfeeding practices: a systematic review

Introduction

Exclusive Breastfeeding (EBF) rates remain low in both low-income and high-income countries despite World Health Organization recommendations for EBF till 6 months. Breastfeeding has been shown to have a protective effect against gastrointestinal infections, among other benefits. Large-scale interventions focusing on educating mothers about breastfeeding have the potential to increase breastfeeding prevalence, especially EBF, up to recommended standards and also to decrease infant morbidity.

Methods

A systematic literature search was conducted for RCTs and quasi-experimental studies comparing breastfeeding education or support to routine care. The effect of interventions was observed for exclusive, predominant, partial and no breastfeeding rates. The time intervals of interest were day 1, <1 month, and 1 to 5 months. Outcome-specific evidence was graded according to the Child Health Epidemiology Reference Group (CHERG) rules using the adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria and recommendations were made from studies in developing countries for inclusion into the Lives Saved Tool (LiST) model.

Results

After reviewing 4600 abstracts, 372 studies were selected for full text screening and 110 of these studies were finally included. Statistically significant increases in EBF rates as a result of breastfeeding promotion interventions were observed: 43% at day 1, 30% at <1 month, and 90% at 1-5 months. Rates of ‘no breastfeeding’ reduced by 32% at 1 day, 30% at <1 month, and 18% at 1-5 months. The effect of interventions on the rates of predominant and partial breastfeeding were non-significant.

Conclusion

Breastfeeding education and/or support increased EBF rates and decreased no breastfeeding rates at birth, <1 month and 1-5 months. Combined individual and group counseling appeared to be superior to individual or group counseling alone. Interventions in developing countries had a greater impact than those in developed countries.

Breastfeeding promotion interventions and breastfeeding practices: a systematic review

INTRODUCTION

Exclusive Breastfeeding (EBF) rates remain low in both low-income and high-income countries despite World Health Organization recommendations for EBF till 6 months. Breastfeeding has been shown to have a protective effect against gastrointestinal infections, among other benefits. Large-scale interventions focusing on educating mothers about breastfeeding have the potential to increase breastfeeding prevalence, especially EBF, up to recommended standards and also to decrease infant morbidity.

METHODS

A systematic literature search was conducted for RCTs and quasi-experimental studies comparing breastfeeding education or support to routine care. The effect of interventions was observed for exclusive, predominant, partial and no breastfeeding rates. The time intervals of interest were day 1, <1 month, and 1 to 5 months. Outcome-specific evidence was graded according to the Child Health Epidemiology Reference Group (CHERG) rules using the adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria and recommendations were made from studies in developing countries for inclusion into the Lives Saved Tool (LiST) model.

RESULTS

After reviewing 4600 abstracts, 372 studies were selected for full text screening and 110 of these studies were finally included. Statistically significant increases in EBF rates as a result of breastfeeding promotion interventions were observed: 43% at day 1, 30% at <1 month, and 90% at 1-5 months. Rates of 'no breastfeeding' reduced by 32% at 1 day, 30% at <1 month, and 18% at 1-5 months. The effect of interventions on the rates of predominant and partial breastfeeding were non-significant.

CONCLUSION

Breastfeeding education and/or support increased EBF rates and decreased no breastfeeding rates at birth, <1 month and 1-5 months. Combined individual and group counseling appeared to be superior to individual or group counseling alone. Interventions in developing countries had a greater impact than those in developed countries.

Mudança organizacional: implantação da Iniciativa Hospital Amigo da Criança

Evidências empíricas apontam o relevante papel do aleitamento materno para a redução da mortalidade infantil. A Iniciativa Hospital Amigo da Criança (IHAC) é uma ação mundial, idealizada pelo Fundo das Nações Unidas para a Infância (UNICEF) e pela Organização Mundial da Saúde (OMS), que visa promover, proteger e apoiar a prática do aleitamento materno e a prevenção do desmame precoce. O objetivo deste artigo é identificar as principais mudanças organizacionais ocorridas em duas instituições hospitalares, localizadas em Minas Gerais, que implementaram a IHAC. A análise realizada baseou-se em seis perspectivas, tomando como base o quadro analítico de Motta: estratégica, estrutural, cultural, humana, tecnológica e política. Realizou-se uma pesquisa qualitativa, utilizando-se como método de coleta de dados a entrevista semiestruturada, aplicada em todos os níveis hierárquicos. Para a interpretação dos dados, adotou-se a análise de conteúdo. Nos casos estudados, concluiu-se que a implantação da IHAC implicou mudanças e melhorias na gestão, principalmente pelo estabelecimento de padronização de procedimentos e de treinamento de pessoal. Verificou-se que as mudanças culturais e tecnológicas ocorreram de forma mais intensa e que as menos percebidas foram as mudanças políticas e as estratégicas.

What works? Interventions for maternal and child undernutrition and survival

We reviewed interventions that affect maternal and child undernutrition and nutrition-related outcomes. These interventions included promotion of breastfeeding; strategies to promote complementary feeding, with or without provision of food supplements; micronutrient interventions; general supportive strategies to improve family and community nutrition; and reduction of disease burden (promotion of handwashing and strategies to reduce the burden of malaria in pregnancy). We showed that although strategies for breastfeeding promotion have a large effect on survival, their effect on stunting is small. In populations with sufficient food, education about complementary feeding increased height-for-age Z score by 0.25 (95% CI 0.01-0.49), whereas provision of food supplements (with or without education) in populations with insufficient food increased the height-for-age Z score by 0.41 (0.05-0.76). Management of severe acute malnutrition according to WHO guidelines reduced the case-fatality rate by 55% (risk ratio 0.45, 0.32-0.62), and recent studies suggest that newer commodities, such as ready-to-use therapeutic foods, can be used to manage severe acute malnutrition in community settings. Effective micronutrient interventions for pregnant women included supplementation with iron folate (which increased haemoglobin at term by 12 g/L, 2.93-21.07) and micronutrients (which reduced the risk of low birthweight at term by 16% (relative risk 0.84, 0.74-0.95). Recommended micronutrient interventions for children included strategies for supplementation of vitamin A (in the neonatal period and late infancy), preventive zinc supplements, iron supplements for children in areas where malaria is not endemic, and universal promotion of iodised salt. We used a cohort model to assess the potential effect of these interventions on mothers and children in the 36 countries that have 90% of children with stunted linear growth. The model showed that existing interventions that were designed to improve nutrition and prevent related disease could reduce stunting at 36 months by 36%; mortality between birth and 36 months by about 25%; and disability-adjusted life-years associated with stunting, severe wasting, intrauterine growth restriction, and micronutrient deficiencies by about 25%. To eliminate stunting in the longer term, these interventions should be supplemented by improvements in the underlying determinants of undernutrition, such as poverty, poor education, disease burden, and lack of women's empowerment.

Evolução do aleitamento materno em uma capital da Região Centro-Oeste do Brasil entre 1999 e 2004

Um estudo de caráter transversal foi realizado durante o primeiro dia da Campanha Nacional de Vacinação de 2004, em Cuiabá, Mato Grosso, Brasil, com o objetivo de conhecer a evolução do aleitamento materno entre 1999 e 2004, no primeiro ano de vida. A determinação da amostra seguiu dois passos, considerando o número de unidades de vacinação e as crianças em cada unidade. Um inquérito nutricional contendo um recordatório alimentar de 24 horas foi aplicado a 921 acompanhantes das crianças menores de um ano. Houve incremento positivo em todas as faixas etárias na modalidade de aleitamento materno exclusivo. Observou-se, ao final dos 180 dias, baixo percentual de crianças em aleitamento materno exclusivo, sendo menos de 5% (em 1999) e de 10% (em 2004). A prevalência do aleitamento materno exclusivo dobrou em cinco anos nas crianças menores de 120 dias, passou de 17,7% para 28,5%. As ações realizadas para promoção do aleitamento materno foram efetivas, porém, insuficientes para a grave situação. Mais ações são necessárias, bem como o aperfeiçoamento dos programas existentes.

Patient education in the developing world--a discipline comes of age

OBJECTIVE

To review evaluated studies of health education within health facilities in developing countries.

METHOD

Extensive searchers were carried out of electronic databases and other sources to identify published evaluations of heath education within health service settings in developing countries. Those reports providing evidence of impact were selected for further consideration and included in the review.

RESULTS

Examples of successful practice are presented for a wide range of health topics that include family health, antenatal care, nutrition education, reduction of use of injections, improve adherence to regimes for antibiotics and other, prevention and control of parasitic and infectious diseases, reproductive health including AIDS and sexually transmitted diseases.

CONCLUSIONS

There are now many examples of effective patient education within the challenging situations found in the developing world.

PRACTICE IMPLICATIONS

Strategies adopted by successful patient education programmes are listed including initial needs research, training of staff in communication skills, cultural sensitivity, including family members, using lay volunteers, development of improved packaging for medicines, clear written instructions with simple (and pre-tested) pictorial advice, participatory learning methods, and patient self-help groups, mail reminders and reminder stickers, practical demonstrations and more effective use of waiting areas including use of video.

Primeira avaliação do cumprimento dos "Dez Passos para o Sucesso do Aleitamento Materno" nos Hospitais Amigos da Criança do Brasil

RESUMO OBJETIVOS: avaliar o cumprimento dos "Dez Passos para o Sucesso do Aleitamento Materno" nos hospitais "Amigos da Criança" (HAC) no Brasil. MÉTODOS: estudo descritivo transversal de avaliação dos "Dez Passos..." dos HAC, realizado nos anos de 1999 e 2000, por avaliadores da Iniciativa Hospital Amigo da Criança (IHAC), credenciados pelo Ministério da Saúde, usando o formulário de pré-avaliação da IHAC. RESULTADOS: foram analisados os questionários de 137 HAC (90%) do total de 152 HAC credenciados na época no país. Observou-se que 92% dos HAC atenderam todos os "Dez Passos..." Os passos um, três, seis, sete, oito e nove apresentaram mais de 98% de cumprimento. O passo cinco foi o menos atendido. Comparando as regiões do país, observou-se que, no Nordeste, no Sul e no Sudeste, 90% dos hospitais foram aprovados em todos os "Dez Passos..." Na região Norte, apenas 50% dos hospitais cumpriram todos os "Dez Passos..." CONCLUSÕES: analisando a folha de dados gerais dos hospitais com pendências na avaliação dos passos, observa-se que 73,7% foram credenciados antes de 1997, sugerindo a necessidade de avaliações periódicas. A implantação de um sistema de monitoramento dessa iniciativa, contribuirá para a melhoria da qualidade da assistência e dos índices de aleitamento materno no país.

Randomized trials and public health interventions: time to end the scientific double standard

Randomized controlled trials have become the acceptedstandard for testing the efficacy and safety of clinical treatments but are rarely used in evaluating public health interventions. This article reviews the types of interventions and outcomes for which randomized trials are necessary to provide a scientifically rigorous evaluation. It also presents the results from two trials analyzed both experimentally and observationally to illustrate why observational studies can yield highly biased findings. This article provides a brief historical account of controlled human experiments, which reveals a surprising earlier tradition of rigorous experimental studies in the social sciences. After contrasting that tradition with the status quo, this article concludes with a plea to reject the double scientific standard of what constitutes acceptable evidence of efficacy for clinical versus public health interventions.

Avaliação do impacto de centros de lactação sobre padrões de amamentação, morbidade e situação nutricional: um estudo de coorte

JUSTIFICATIVA: A OMS financiou a criação de centros de lactação em Guarujá, São Paulo, e solicitou uma avaliação de seu impacto sobre os padrões de amamentação, morbidade e situação nutricional infantis. OBJETIVOS: medir a prevalência de amamentação, a morbidade e a situação nutricional de um grupo de crianças, em que algumas haviam freqüentado centros de lactação e outras não. DELINEAMENTO: estudo de coorte desde o nascimento até os 6 meses de idade. RESULTADOS: Das 605 crianças recrutadas no período perinatal, 54% foram subseqüentemente levadas para consultar em centros de lactação. Este grupo foi amamentado exclusivamente em maior proporção do que aquele das crianças que não freqüentaram tais centros, aos 4 meses (43% e 18%, respectivamente) e aos 6 meses de idade (15% vs. 6%). Estas diferenças se mantiveram após o ajuste para variáveis de confundimento. Além disso, as crianças que freqüentaram os centros de lactação apresentaram menos diarréia nas duas semanas prévias ao estudo do que aquelas que não os freqüentaram (10% e 17%, respectivamente) e seu peso para a idade era mais apropriado - (médias de escorre z de 0.26 e 0.02, respectivamente). CONCLUSÕES: este não é um estudo aleatorizado, e sempre existe a possibilidade que variáveis de confundimento não estudadas possam ter influenciado os resultado. Parece, entretanto, que Centros de Lactação são formas efetivas de promover a amamentação e seu uso é uma alternativa que deve ser considerada, principalmente em áreas com baixas prevalências de amamentação.

Extending breastfeeding duration through primary care: a systematic review of prenatal and postnatal interventions

This literature review provides an overview of the effectiveness of strategies and procedures used to extend breastfeeding duration. Interventions carried out during pregnancy and/or infant care conducted in primary health care services, community settings, or hospital clinics were included. Interventions covering only the delivery period were excluded. Interventions that were most effective in extending the duration of breastfeeding generally combined information, guidance, and support and were long term and intensive. During prenatal care, group education was the only effective strategy reported. Home visits used to identify mothers' concerns with breastfeeding, assist with problem solving, and involve family members in breastfeeding support were effective during the postnatal period or both periods. Individual education sessions were also effective in these periods, as was the combination of 2 or 3 of these strategies in interventions involving both periods. Strategies that had no effect were characterized by no face-to-face interaction, practices contradicting messages, or small-scale interventions.

Ecological study of effect of breast feeding on infant mortality in Latin America

OBJECTIVE

To estimate the effect of exclusive breast feeding and partial breast feeding on infant mortality from diarrhoeal disease and acute respiratory infections in Latin America.

DESIGN

Attributable fraction analysis of national data on infant mortality and breast feeding.

SETTING

Latin America and the Caribbean.

MAIN OUTCOME MEASURES

Mortality from diarrhoeal disease and acute respiratory infections and nationally representative breastfeeding rates.

RESULTS

55% of infant deaths from diarrhoeal disease and acute respiratory infections in Latin America are preventable by exclusive breast feeding among infants aged 0-3 months and partial breast feeding throughout the remainder of infancy. Among infants aged 0-3 months, 66% of deaths from these causes are preventable by exclusive breast feeding; among infants aged 4-11 months, 32% of such deaths are preventable by partial breast feeding. 13.9% of infant deaths from all causes are preventable by these breastfeeding patterns. The annual number of preventable deaths is about 52 000 for the region.

CONCLUSIONS

Exclusive breast feeding of infants aged 0-3 months and partial breast feeding throughout the remainder of infancy could substantially reduce infant mortality in Latin America. Interventions to promote breast feeding should target younger infants.

Can improvements in breast-feeding practices reduce neonatal mortality in developing countries?

OBJECTIVE

to review the literature on the relationship between breast-feeding practices in the first month of life and neonatal mortality.

METHODS

Medline and Cochrane databases were searched using the keywords breastfeeding, and neonatal mortality, supplemented with additional searches using the keywords developing countries, colostrum, infant feeding and infant mortality, hypoglaecemia, hypothermia, breastfeeding practices, and suckling.

FINDINGS

breast feeding helps prevent hypothermia and hypoglycaemia in newborn babies, which are contributory causes of early neonatal deaths especially among low birth weight and premature babies. During the late neonatal period, most deaths in developing countries are due to infections such as sepsis, acute respiratory tract infection, meningitis, omphalitis and diarrhoea. Feeding colostrum and breast feeding, especially exclusive breast feeding, protects against such deaths.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

in most developing countries, nearly all women breast feed in the first month of life, but often breast feeding is delayed beyond the first hour after birth, and exclusive breast feeding is not usually practised. Policies and training of staff of maternity centres and hospitals can encourage early initiation of breast feeding and exclusive breast feeding. Midwives can support community-based efforts to support exclusive breast feeding. Breast feeding plays an important role in reducing neonatal mortality and should be strongly emphasised by programmes attempting to reduce neonatal mortality.

Knowledge of newborn health care among pregnant women: basis for promotional and educational programs on breastfeeding

CONTEXT

Promotional and educational programs relating to breast feeding are important for reversing the decline in this practice. Most programs are centered exclusively on breast feeding, although general knowledge about newborn health care may be important, especially among pregnant women.

OBJECTIVE

To study pregnant women's knowledge about general health care of newborns, including breast feeding aspects.

TYPE OF STUDY

Cross-sectional.

SETTING

Prof. Samuel Barnsley Pessoa Health School Center, Faculty of Medicine, University of São Paulo, Brazil.

PARTICIPANTS

All pregnant women who were registered in the prenatal care program during six consecutive months.

MAIN MEASUREMENTS

Aspects of the current gestation, previous gestations and childbirth, knowledge of the general aspects of newborn health care and of breast feeding practices.

RESULTS

The results show that only a little over half of the pregnant women had received any information on newborn health care. Misinformation was clearly present regarding proper care of the umbilical stump and the nature of jaundice, and worst regarding how to treat oral thrush and jaundice, and about vaccination. In relation to breast feeding, even though almost all the pregnant women declared their intention to breast feeding, less than half had a concrete response regarding how long to do it for. The low rates obtained in the topics dealing with the duration, nursing intervals and the attitude to be taken towards hypogalactia show unfamiliarity with the breast feeding technique. The "weak milk" belief, the misinformation about contraceptive methods during breast feeding and the cost of artificial formulas also have a negative impact on this practice.

CONCLUSIONS

Pregnant women's knowledge of newborn health care is low, as much in the aspects of general care as in relation to the practice of breast feeding. These findings must be taken into consideration in educative programs promoting breast feeding.

The efficacy of the lactational amenorrhea method (LAM) among working women

The purpose of this study was to assess the efficacy of the lactational amenorrhea method (LAM) for family planning among mothers who are separated from their infants by work. The study population, 170 urban middle class women who planned to return to work before 120 days postpartum, were interviewed monthly for 6 months postpartum and contacted at 12 months. The study population received clinical support for expressing their milk and exclusively breast-milk feeding the infants and for the use of LAM for birth spacing. The cumulative life table pregnancy rate by 6-month was 5.2%, with 3 pregnancies, one at each of months 4, 5, and 6. LAM for working women, as described in this article, might be associated with a higher pregnancy risk than LAM use among non-working women. Therefore, women using LAM should be informed that separation from the infant might increase their risk of pregnancy.

Health system factors contributing to breastfeeding success

OBJECTIVE

To identify and characterize health care system factors that contribute to successful breastfeeding in the early postpartum period.

STUDY DESIGN

A prospective 8-week cohort study of 522 women at five area hospitals who had a vaginal delivery of a healthy, full-term single child and who intended to breastfeed. Mothers and infants had free access to each other for breastfeeding during the hospital stay. Data were obtained through chart review and surveys. In-person postpartum interviews in the hospital and 4- and 8-week telephone interviews were used to determine participants' perceptions of breastfeeding support by hospital personnel, home visit nurses, and family and friends. The hospital in-person interview with each mother was conducted before discharge to confirm maternal interest and intent to breastfeed. Questions were asked regarding breastfeeding information and support provided by medical and nursing personnel. Mothers were asked to rate the quality of information, as well as the degree of support they received for breastfeeding. Mothers also were asked to rate their hospital breastfeeding experience. A second interview was conducted by telephone 4 weeks after birth. The focus of this interview was to ascertain the rating of their breastfeeding experience, the quality of their interactions with health care professionals, and whether supplemental formula was being provided to the infant. If supplemental formula was being provided, the mothers were asked to quantify the volume and frequency of supplementation. A final telephone interview was conducted when the infants were 8 weeks of age. This interview determined the continuance or cessation of breastfeeding and information about formula supplementation, as in the 4-week interview. Mothers were given a journal and asked to note all telephone calls, clinic visits, and home nurse visits that related to breastfeeding issues and concerns. Demographic data examined included maternal age, marital status, highest level of education reached, race, employment, insurance coverage, and length of stay in the hospital. Pregnancy characteristics included prenatal care, parity, and gravity. Infant characteristics included gestational age and birth weight. Other factors examined included maternal rating of the support received from the infant's father for the decision to breastfeed, the time the infant spent in the mother's hospital room, and whether the infant was breastfed in the delivery room.

RESULTS

The women were mostly white (90%), educated (82% had some college education), married, older (mean maternal age of 29.3 years), and insured (92% commercial). The primary outcome of interest was success at breastfeeding. Success was determined based on each mother's initial estimate of the planned duration of breastfeeding. Of the participants, 76% breastfed successfully for at least as long as they had initially planned. Seventeen percent of the mothers had stopped breastfeeding at the time of the 4-week interview, and 29% had stopped by the 8-week interview. Of the infants' fathers, 97% were reported by the mothers to be supportive of the decision to breastfeed. Once discharged, 98% of mothers expected to have help with the household chores. Eighty percent rated their hospital breastfeeding experience as good or very good. However, only 56% rated hospital breastfeeding support as good or very good, and only 44% spoke with a lactation consultant while in the hospital. Of those who spoke with the lactation consultant, 85% felt more confident afterward. Hospital nurses talked with 82% of women, and 97% of these found this helpful. Seventy-four percent reported receiving a home nursing visit after discharge, and of these, 82% found it helpful. Successful mothers were significantly more likely to report that the visiting nurse watched them breastfeed and asked how it was going. Mothers were more likely to call or visit family and friends with concerns about breastfeeding than

Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial

BACKGROUND

Exclusive breastfeeding is recommended worldwide but not commonly practised. We undertook a randomised controlled study of the efficacy of home-based peer counselling to increase the proportion of exclusive breastfeeding among mothers and infants residing in periurban Mexico City.

METHODS

Two intervention groups with different counselling frequencies, six visits (44) and three visits (52), were compared with a control group (34) that had no intervention. From March, 1995, to September, 1996, 170 pregnant women were identified by census and invited to participate in the study. Home visits were made during pregnancy and early post partum by peer counsellors recruited from the same community and trained by La Leche League. Data were collected by independent interview. Exclusive breastfeeding was defined by WHO criteria.

FINDINGS

130 women participated in the study. Only 12 women refused participation. Study groups did not differ in baseline factors. At 3 months post partum, exclusive breastfeeding was practised by 67% of six-visit, 50% of three-visit, and 12% of control mothers (intervention groups vs controls, p<0.001; six-visit vs three-visit, p=0.02). Duration of breastfeeding was significantly (p=0.02) longer in intervention groups than in controls, and fewer intervention than control infants had an episode of diarrhoea (12% vs 26%, p=0.03).

INTERPRETATION

This is the first reported community-based randomised trial of breastfeeding promotion. Early and repeated contact with peer counsellors was associated with a significant increase in breastfeeding exclusivity and duration. The two-fold decrease in diarrhoea demonstrates the importance of breastfeeding promotion to infant health.

Policy considerations for the introduction and promotion of the lactational amenorrhea method: advantages and disadvantages of LAM

Some attributes of LAM are unquestionably positive, such as the fact that it is effective. Clinical trials of LAM have upheld the Bellagio Consensus that the chance of pregnancy is less than 2% in the first 6 months postpartum in amenorrheic women who are fully or nearly fully breastfeeding. Secondary data analyses in numerous settings have drawn the same conclusion. Whether as a strategy or a method, used correctly or even if used imperfectly, LAM is a reliable way to avoid pregnancy. To the extent that LAM represents an additional contraceptive option, this is also clearly positive since a broad array of contraceptive options maximizes the likelihood of finding a good fit between user and method, and increases contraceptive use. Other characteristics of LAM represent potentially positive impacts. If LAM is shown to be an effective conduit to other modern methods, the implications are profoundly positive. If LAM is cost effective, for households and/or for programs, this will also make the method extraordinarily attractive. Conversely, some aspects of LAM are negative, such as the fact that it affords no protection against STDs, it requires counseling from a well-informed provider, and intensive breastfeeding can make heavy demands on the woman's time. Many of the remaining attributes of LAM may not be important to a policy decision about LAM promotion. For example, whether LAM is actualized as a strategy or a method may not be important to a decision to promote LAM, although it has a huge impact on how services are delivered. Some factors may be profound on a local or individual level. For example, one simple factor, such as the absence of full/nearly full breastfeeding, can rule out the method as an option, while another, such as the fact that it provides the needed waiting period during vasectomy counseling, can make LAM the method of choice. Although LAM seems unlikely to have widespread popularity in societies like the United States, within such settings are breastfeeding women for whom other contraceptive choices are not satisfactory and to whom LAM is attractive. Although clinicians cannot be expected to directly provide LAM education in every setting, women should be informed about LAM as an effective contraceptive choice, and clinicians should be prepared to make referrals to competent sources. The future of LAM, especially in terms of formal, programmatic initiatives, may continue to be focussed in transitional and less developed settings. Comparative cost/benefit analyses for both the family planning program and the household will contribute meaningfully to decisions about whether to use LAM and whether to include LAM in national and local family planning policies and programs. The most important call to action is to implement operations research designed to determine what factors, if any, will maximize the uptake of a second modern contraceptive method after LAM protection expires among never-users of family planning, to compare this with other contraceptive strategies, and to evaluate the cost aspects. If the potential of LAM to be a conduit to other modern contraceptive methods is effectively realized, the method can be profoundly important in the development of communities and in family formation. Because LAM is effective in preventing pregnancies, and because it extends the range of contraceptive choices, considering LAM on the policy level is always appropriate. Despite the array of drawbacks to LAM, as with any other family planning method, the potential assets of LAM, especially the promise to introduce nonusers to contraception, are sufficiently important to warrant the introduction of LAM within an operations research framework to both capitalize on its intrinsic strengths and determine its programmatic robustness. In the 10 years since the concept of LAM was pronounced as the Bellagio Consensus, claims have been made both for and against its use. During this time, program and policy leaders have been giv

Using cultural knowledge in health promotion: breastfeeding among the Navajo

Although many attempts have been made to promote breastfeeding in a variety of contexts, few programs have explicitly incorporated cultural beliefs in these efforts. This article describes a breastfeeding promotion program conducted on the Navajo reservation. This program was designed to be culturally appropriate. Background information regarding beliefs and factors affecting infant feeding practices in this setting is provided, followed by a description of the intervention. The intervention, which incorporated both social marketing and community participation techniques, consisted of three components: an intervention in the health care system, a community intervention, and an individual intervention. Based on medical records review of feeding practices of all the infants born the year before (n = 988) and the year after (n = 870) the intervention, the program was extremely successful. This combination of techniques, including qualitative and quantitative research into local definitions of the problem, collaboration with local institutions and individuals, reinforcement of traditional understandings about infant feeding, and institutional change in the health care system, is an effective way of facilitating behavioral change.

The effectiveness of a hospital-based program to promote exclusive breast-feeding among low-income women in Brazil

OBJECTIVES

This study examined the effectiveness of a hospital program to promote exclusive breast-feeding in Santos, Brazil.

METHODS

In a prospective design, women who delivered at a hospital with an active breast-feeding promotion program (n = 236) were compared with women who delivered at a nearby control hospital (n = 206).

RESULTS

The two groups had similar demographic characteristics and previous breast-feeding histories. Exposure to breast-feeding activities, assessed by maternal recall prior to discharge, was universally high at the program hospital and universally low at the control hospital. Multivariate survival analysis showed that exclusive breast-feeding lasted 53 days longer among women who delivered at the program hospital.

CONCLUSIONS

Hospital-based breast-feeding promotion programs may be effective in extending the duration of exclusive breast-feeding.

Ten steps to successful breastfeeding: a summary of the rationale and scientific evidence

Ample evidence is available on the impact of health care practices and hospital routines and procedures on breastfeeding. Good practices enhance successful initiation and establishment of breastfeeding and contribute to increased duration, just as inappropriate practices, and failure to support and encourage mothers, have the opposite effect. In 1991 the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) jointly launched the Baby-Friendly Hospital Initiative, which aims to give every baby the best start in life by ensuring a health care environment where breastfeeding is the norm. The initiative is based on the principles summarized in a joint statement issued by the two organizations in 1989 on the role of maternity services in protecting, promoting, and supporting breastfeeding. To become truly baby-friendly, hospitals and maternity wards around the world are giving practical effect to the principles described in the joint WHO/UNICEF statement that have been synthesized into Ten Steps To Successful Breastfeeding. This summary of the rationale and scientific basis for the Ten Steps is presented in the light of cumulative experience demonstrating the crucial importance of these principles for the successful initiation and establishment of breastfeeding.

Does prenatal breastfeeding skills group education increase the effectiveness of a comprehensive breastfeeding promotion program?

A control/intervention study carried out in Santiago, Chile assessed the impact of five interventions on breastfeeding patterns and duration, and demonstrated a significant increase in full breastfeeding at six months (32 percent to 67 percent). Fifty-nine of 422 post-intervention women were included in a sixth intervention: prenatal group educational sessions emphasizing the skills necessary to initiate and maintain breastfeeding past the neonatal period. A significantly higher percentage of this subset of women were fully breastfeeding at six months compared to those who received only the five basic interventions (80 percent and 65 percent, respectively). The effect was greater among primiparous women. We conclude that prenatal group education with hands-on skills reinforcement is a significant and additive component of breastfeeding support, especially among those who have no previous breastfeeding experience.

The impact of lactation centres on breastfeeding patterns, morbidity and growth: a birth cohort study

The influence of lactation centres on breastfeeding patterns, morbidity and nutritional status was assessed through a longitudinal study from birth up to the age of 6 months among 605 mothers and newborns in Guarujá, São Paulo, Brazil. Children recruited in the perinatal period who subsequently attended the lactation centres (54%) were exclusively breastfed significantly more at 4 months (43 versus 18%) and at 6 months of age (15 versus 6%), than non-attenders, even after adjusting for confounders. Also, attenders presented less diarrhoea in the last fortnight than non-attenders (10 versus 17%), and their weight for age was significantly better (mean z-scores of 0.26 and 0.02, respectively). Lactation centres are effective in promoting breastfeeding, and their use in areas with short breastfeeding duration should be considered. This is the first report of a significant impact of a breastfeeding promotion programme on children's morbidity and growth.

Effectiveness of the lactational amenorrhea method in Pakistan

OBJECTIVE

To determine the efficacy of the lactational amenorrhea method of family planning (amenorrhea during full or nearly full breastfeeding for 6 months postpartum).

DESIGN

Prospective noncomparative study.

SETTING

Normal breastfeeding women in Karachi and Multan, Pakistan, most delivered at home by a midwife.

PATIENTS

Three hundred ninety-nine newly delivered mothers who successfully had breastfed a previous child and chose the lactational amenorrhea method to prevent a subsequent pregnancy, 391 of whom were followed for a full year.

INTERVENTIONS

Mothers were taught, before or shortly after delivery, to use the method and were interviewed in their homes each month by a Lady Health Visitor.

MAIN OUTCOME MEASURE

Life-table pregnancy rates. Periods of postpartum or lactational abstinence were excluded in the calculation of the pregnancy rates.

RESULTS

During full or nearly full breastfeeding, while the women were amenorrheic and not otherwise contracepting, the rate of pregnancy was 0.6%. The pregnancy rate during lactational amenorrhea alone was 1.1% at 1 year postpartum.

CONCLUSION

The lactational amenorrhea method was found to be highly effective for 6 months. A high degree of contraceptive protection endures for a full year during lactational amenorrhea, but not after the return of menses during breastfeeding.

The effects on professional practices of a three-day course on breastfeeding

This study assessed reported changes in clinical breastfeeding support practices following a three-day (approximately 24 hour) course. The course, presented at the Catholic University in Santiago, Chile, included the physiology of lactation and lactational infertility, related policy, clinical skills, the Lactational Amenorrhea Method (LAM), and program-related findings. A questionnaire was sent to all participants and an additional systematic sample was telephoned to assure a statistically valid sample. Sixty-nine percent of respondents reported changes in clinical practices resulting from attendance at the course. The results support the concept, now being advanced by the Baby-Friendly Hospital Initiative, that an 18-24 hour course can change clinical practices.

The Lactational Amenorrhea Method (LAM): a postpartum introductory family planning method with policy and program implications

It is well accepted that breastfeeding contributes significantly to child survival and child nutrition. Healthful child spacing is associated with improved birth outcomes and maternal recovery. On a population basis, breastfeeding may contribute more to birth spacing than all family planning use combined in many countries. However, while breastfeeding does provide a period of infertility, until recently, there was no reliable way for an individual woman to capitalize on this lactational infertility for her own efficacious child spacing. The Lactational Amenorrhea Method (LAM) is a new introductory family planning method that simultaneously promotes child spacing and breastfeeding, with its optimal nutrition and disease preventive benefits for the infant. LAM, as it is called, is based on the utilization of lactational infertility for protection from pregnancy and indicates the time for the introduction of a complementary family planning method. LAM is recommended for up to six months postpartum for women who are fully or nearly fully breastfeeding and amenorrheic, and relies on the maintenance of appropriate breastfeeding practices to prolong lactational infertility, with the concomitant delay in menses return. A recent clinical trial confirmed the theoretical 98% or higher effectiveness of the method and field trials are demonstrating its acceptability. Nonetheless, some demographers and family planning organizations continue to debate its value. The development, efficacy, and sequelae of the method are presented using data from several studies by the authors.