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Community based strategies for breastfeeding promotion and support in developing countries


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  • 1. WHO and UNICEF developed the Global Strategy on Infant and Young Child Feedingin 2002 to revitalize world attention to the substantial impact of feeding practices onthe growth and development, health, and survival of infants and young children.Thepresent review examines the evidence for the contribution that community-basedinterventions can make to improve infant and young child feeding, and identifiesfactors that are important to ensure that interventions are successful and sustainable.The findings show that families and communities are more than simple beneficiariesof interventions; they are also resources to shape the interventions and extend coverageclose to where mothers, other caregivers and young children live. It is intended that theexperiences presented here will help policy makers, programme planners, and healthprofessionals in the essential and challenging task of translating knowlege into actionat all levels: the health system, the community and civil society at large.
  • 2. Selected WHO publications of related interestWHO. Global Strategy for infant and young child feeding. Geneva: World HealthOrganization, 2003 American Health Organization. Guiding Principles for complementary feeding of thebreastfed child. Washington DC: Pan American Health Organization, World HealthOrganization, 2003 Bank. HIV andinfant feeding: framework for priority action. Geneva: World Health Organization, 2003 Complementary feeding: family foods for breastfed children. WHO/NHD/001,WHO/FCH/CAH/00.6. Geneva: World Health Organization, 2000 HIV and infant feeding counselling: a training course. WHO/FCH/CAH/002.6Geneva: World Health Organization, 2000 Evidence for the Ten Steps to Successful Breastfeeding. WHO/CHD/98.9. Geneva:World Health Organization, 1999 Improving family and community practices: a component of the IMCI strategy. WHO/CHD/98.18 Geneva: World Health Organization, 1998 Breastfeeding counselling: a training course. WHO/CDR/93.3, UNICEF/NUT/93.1 Geneva: World Health Organization, 1993 publications of interest can be consulted and ordered online at:
  • 3. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries WORLD HEALTH ORGANIZATION DEPARTMENT OF CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT Stra Community-based Strategies Promotion for Breastfeeding Promotion and Developing Support in Developing Countries i
  • 4. WHO Library Cataloguing-in-Publication DataCommunity-based strategies for breastfeeding promotion and support in developing countries. 1.Breastfeeding 2.Community networks - utilization 3.Consumer participation 4.Strategic planning 5.Developing countries. ISBN 92 4 159121 8 (NLM classification: WS 120)© World Health Organization 2003All rights reserved. Publications of the World Health Organization can be obtained from Marketing andDissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 7912476; fax: +41 22 791 4857; email: Requests for permission to reproduce or translateWHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications,at the above address (fax: +41 22 791 4806; email: designations employed and the presentation of the material in this publication do not imply the expressionof any opinion whatsoever on the part of the World Health Organization concerning the legal status of anycountry, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsedor recommended by the World Health Organization in preference to others of a similar nature that are notmentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initialcapital letters.The World Health Organization does not warrant that the information contained in this publication is completeand correct and shall not be liable for any damages incurred as a result of its use.Printed ii
  • 5. Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesTable of ContentsAcknowledgements vForeword viiIntroduction 1Chapter 1. Background and Context 3 Breastfeeding practices in developing countries 3 Breastfeeding promotion and support: historical development 3 Evidence of effectiveness 4 Improving breastfeeding practices 5 Reducing morbidity and mortality 5 Framework and justification 6Chapter 2. Approaches to Community-based Breastfeeding Promotion and Support 7 Foundation for community behaviour change 7 Partnerships 7 Formative research 7 Monitoring and evaluation 8 Training and supervision 8 Management and leadership 8 Community-level interventions 8 Behaviour change communication 8 Training community health-care providers 10 Lay counsellors 10 Women’s groups 11 Integration of breastfeeding with primary and preventive services 12 Integration of breastfeeding and early childhood development strategies 13Chapter 3. Case Studies of Community-based Breastfeeding Promotion and Support 14 Madagascar 14 Honduras 16 India 17Chapter 4. Application to Special Circumstances 20 Mothers’ return to work 20 Infants born to HIV-positive mothers 20 Emergency situations 21Summary and conclusions 23References 24Annex 1. Issues in breastfeeding measurement 28 iii
  • 6. AcknowledgementsTables Table 1. Community-based breastfeeding support trials in developing countries that include healthy newborn infants and mothers 4 Table 2. Infant mortality (0–6 months) in Dhaka, Bangladesh comparing partial and no breastfeeding to exclusive breastfeeding 5Figures Figure 1. Key messages: what every family and community has a right to know about breastfeeding 1 Figure 2. Elements of a comprehensive breastfeeding programme 2 Figure 3. Trends in breastfeeding patterns in developing countries 1989–1999 3 Figure 4. Model of determinants of breastfeeding behaviour 6 Figure 5. Stages of change and communication approaches 9 Figure 6. Models of women’s groups in breastfeeding promotion and support 11 Figure 7. Breastfeeding promotion and support as an approach to integration of primary health care services 14 Figure 8. Exclusive breastfeeding in the first 6 months of life, Madagascar 16 Figure 9. Initiation of breastfeeding within first hour, Madagascar 16 Figure 10. Exclusive breastfeeding in the first 4 and 6 months of life, Honduras 17 Figure 11. Prelacteal feedings and exclusive breastfeeding at 3 months in intervention vs control communities, India 19 iv
  • 7. Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesAcknowledgementsThe primary author of this review was Dr. Ardythe Morrow (Cincinnati Children’s Research Foundation and theLINKAGES Project, Academy for Educational Development [AED]). The primary editor was Ms. Luann Martin(LINKAGES Project, AED). Contributions to the writing and/or review of this document were made by a number ofAED experts: Dr. Nancy Keith, for behaviour change communication; Dr. Ellen Piwoz and Dr. Jay Ross, for HIVissues; Dr. Nadra Franklin, for evaluation issues; and Dr. Vicky Quinn and Dr. Agnès Guyon for the Madagascarproject description.Valuable assistance in reviewing the paper was provided by Dr. Bernadette Daelmans, Dr. Jose Martines, Dr. ConstanzaVallenas, and Dr. Carmen Casanovas in the WHO Department of Child and Adolescent Health and Development;Dr. Chessa Lutter (Pan American Health Organization, WHO/AMRO); Dr. Audrey Naylor (Wellstart, International);Dr. Fran Butterfoss (Eastern Virginia Medical School), and Dr Nita Bhandari (All India Institute of Medical Sciences).Funding for the development of this paper was provided by WHO and by USAID through the LINKAGES Project,under Cooperative Agreement No. HRN-A-00-97-00007-00.The material presented does not necessarily reflect the official position of either organization. v
  • 8. vi
  • 9. Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesForewordThe importance of appropriate infant and young child feeding for child survival, growth and development is wellknown. Exclusive breastfeeding for the first six months of life confers important benefits on the infant and themother. It protects infants against common childhood diseases, including repeated gastrointestinal infections andpneumonia, and hence against some of the major causes of childhood mortality. Timely introduction of adequate andsafe complementary foods at six months of age helps to fill the dietary gaps that cannot be met by breast milk alone.Continued breastfeeding for two years or beyond confers major nutritional benefits and is an essential component ofappropriate complementary feeding.Unfortunately, infant and young child feeding practices world-wide are not optimal. Global monitoring indicates thatonly 39% of all infants world-wide are exclusively breastfed, even when the assessment is made in children less than4 months of age. The timely complementary feeding rate is similarly low with a global average of 60% in 2002.Much has been learned about effective interventions during the past decades. It is clear that mothers need support toinitiate and sustain optimal breastfeeding and complementary feeding practices – within the family, community,workplace and health system. During the past decade, the Baby-friendly Hospital Initiative has been instrumental indirecting necessary resources to improve the quality of feeding care in maternity services. As a result, there is anupwards trend in breastfeeding rates in various countries.However, it is not enough to help a mother initiate exclusive breastfeeding. She needs to be able to go back to anenvironment that is conducive to sustaining appropriate feeding practices and to access skilled support when sheneeds it. This review examines the role of communities and community-based resource persons in providing thissupport. Based on a review of the literature and an analysis of three projects, it assesses the impact of interventions,the mechanisms through which behaviours can be changed, and the factors that are necessary to maximize andsustain the benefits of interventions.The findings confirm the expectations: communities can make a major difference in improving infant and youngchild feeding. This is particularly so when community members participate in the design of interventions and, withexpert support, contribute to shaping the content and mode of delivery. Full engagement of health care providers andsupportive policies are other elements important for success.Given the emphasis on breastfeeding as an issue of major public health importance over the past decades, experiencesare more abundant in this area. Nevertheless, evidence is accumulating rapidly that similar achievements are possiblefor complementary feeding and one case study specifically reports on this.WHO and UNICEF jointly developed the Global Strategy for Infant and Young Child Feeding to revitalize worldattention to the importance of infant and young child feeding for child survival, growth and development. Thestrategy calls upon governments to ‘ensure that the health and other relevant sectors protect, promote and supportexclusive breastfeeding for six months and continued breastfeeding for two years or beyond …. and to promotetimely, adequate, safe and appropriate complementary feeding with continued breastfeeding’.Families and communities can and should be partners in this endeavour. They are not only the beneficiaries but alsopart of the plethora of resources that can be mobilized to reinstate infant and young child feeding as an area of publichealth importance and concern. By adopting the Millennium Development Goals, the global community has committed vii
  • 10. to reducing childhood mortality by two-thirds and halving the proportion of people living with hunger by 2015.Improving childhood nutrition is essential to achieve these goals. It can be done – what is needed is increasedcommitment, investment, and innovation to engage all those who can help to make a difference. We hope that thisreview will provide all readers with new ideas and motivation for moving forward. Joy Phumaphi Assistant Director-General Family and Community Health World Health Organization viii
  • 11. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries “…the global strategy includes as a priority for all governments…to ensure that thehealth and other relevant sectors protect, promote and support exclusive breastfeeding for sixmonths and continued breastfeeding up to two years of age or beyond, while providing women access to the support they require – in the family, community and workplace – to achieve this goal.” Global Strategy for Infant and Young Child Feeding, May 2002Introduction Figure 1B reastfeeding is an extension of maternal protection that transitions the young infant from the shelterof the in utero environment to life in the ex utero world Key Messages: What every family and community has a right to know about breastfeedingwith its variety of potentially harmful exposures. Thepromotion, protection, and support of breastfeeding is • Breastmilk alone is the only food and drink an infant needs for the first six months. No other food or drink,an exceptionally cost-effective strategy for improving not even water, is usually needed during this period.child survival and reducing the burden of childhood • There is a risk that a woman infected with HIV can passdisease, particularly in developing countries (Horton et the disease on to her infant through breastfeeding. Women who are infected or suspect that they may beal., 1996; Morrow et al., 1999; Sikorski et al., 2002; infected should consult a trained health worker forArifeen et al., 2001; Black et al., 2003; Jones et al., testing, counselling and advice on how to reduce the2003). risk of infecting the child. • Newborn babies should be kept close to their mothers and begin breastfeeding within one hour of birth.Scientific evidence has guided the development of • Frequent breastfeeding causes more milk to beinternational recommendations for optimal infant produced. Almost every mother can breastfeedfeeding practices, which include exclusive breastfeeding successfully. • Breastfeeding helps protect babies and young childrenfor 6 months (breast milk only with no other liquids against dangerous illnesses. It also creates a specialor foods given) and continued breastfeeding up to 2 bond between mother and child.years of age or beyond with timely addition of • Bottle-feeding can lead to illness and death. If a woman cannot breastfeed her infant, the baby should be fedappropriate complementar y foods. These breastmilk or a breastmilk substitute from an ordinaryrecommendations were adopted following a systematic clean of current scientific evidence on the optimal • From the age of six months, babies need a variety of additional foods, but breastfeeding should continueduration of exclusive breastfeeding and an expert through the child’s second year and beyond.consultation on the subject (Butte et al., 2002; Kramer • A woman employed away from her home can continueand Kakuma, 2002; WHO, 2002). They are also to breastfeed her child if she breastfeeds as often as possible when she is with the infant.included in UNICEF’s Facts for Life “Key Messages: • Exclusive breastfeeding can give a woman more thanWhat every family and community has a right to know 98 percent protection against pregnancy for six monthsabout breastfeeding” (figure 1). after giving birth – but only if her menstrual periods have not resumed, if her baby breastfeeds frequently day and night, and if the baby is not given any otherCompliance with these recommendations has food or drinks, or a pacifier or dummy.significant child health and nutritional benefits. The (UNICEF, 2002)Bellagio Child Survival Study Group has identifiedoptimal breastfeeding in the first year of life as one ofthe most important strategies for improving child Jones et al., 2003). Improved breastfeeding practicesurvival (Black et al., 2003; Jones et al., 2003). can also have a positive effect on birth-spacing, whichIncreasing optimal breastfeeding practices could save contributes to child survival (Labbok et al., 1997; Jonesas many as 1.5 million infant lives every year, given et al., 2003). Further, population-based studies in athe significant protection that breastfeeding provides number of developing countries have shown that theinfants against diarrhoeal disease, pneumonia, and greatest risk of nutritional deficiency and growthneonatal sepsis (UNICEF, 2002; Black et al., 2003; retardation occurs in children between 3 and 15 months 1
  • 12. Introductionof age, associated with poor breastfeeding and The first chapter of the paper places community-basedcomplementary feeding practices (Shrimpton et al., inter ventions in an historical and community2001). development context and provides the scientific rationale for this approach. The second chapterThe Global Strategy for Infant and Young Child Feeding describes key features of—and strategies for—(2002), co-developed by WHO and UNICEF with community-based breastfeeding promotion andbroad participation of governments and other support, including integration with primar y andstakeholders, is a blueprint for current and future public preventive health services. The third chapter presentshealth action to improve infant feeding practices several countries’ experience implementing community-worldwide. The World Health Assembly and UNICEF’s based strategies on a large population scale. The fourthExecutive Board adopted the strategy in 2002. The chapter addresses challenging circumstances to considerfoundation of this strategy is built on two decades of in implementing community-based breastfeedinginternational and public health consensus and action, programmes around the world. The paper concludesbeginning with the Joint Meeting on Infant and Young with a summary of key issues regarding community-Child Feeding (1979), the International Code of based breastfeeding promotion and support.Marketing of Breast-milk Substitutes (1981), theInnocenti Declaration (1990), and the Baby-friendly Figure 2Hospital Initiative (1991). Elements of a comprehensive breastfeeding programmeA novel contribution of the Global Strategy for Infantand Young Child Feeding is its comprehensive approach. P OLICYThe Global Strategy gives heightened attention to • National Breastfeeding Commissionbreastfeeding and complementar y feeding in • Health System Normsexceptionally difficult circumstances, such as in HIV- • Code of Marketing of Breastmilk Substitutesprevalent areas and emergency situations. The strategy • Worksite laws and regulationsalso includes community-based interventions to • Information, education and communicationpromote and support infant and young child feedingas a new operational target. While significant progress H EALTH S ERVICES C OMMUNITYin breastfeeding protection, promotion, and support • Pre-service curriculum • Communityhas been made through emphasis on policy and reform participationmaternity health services, experience suggests that • Baby-friendly Hospital • Training andachieving optimal infant and young child feeding Initiative supervision ofrequires an integrated, comprehensive strategy that • In-service training counselling network • Supportive supervision • Communityincludes community-based interventions as well as educationpolicy and health services (figure 2). • Information, education and communicationThe purpose of this document is to provide the rationale • Monitoring, research and evaluationand guideposts for community-based interventions to • Health information systemspromote and support breastfeeding. This document • Referral and counter referralfocuses on the growing evidence that community-basedapproaches can significantly increase optimal (Wellstart International, 1996)breastfeeding in diverse settings, summarizes thelessons learnt from community-based breastfeedinginterventions in a number of developing countries, andrecommends approaches that can be applied byprogramme planners and managers worldwide. Fewefforts to promote improved infant and young childfeeding have yet expanded to a large scale. The lessonslearnt from breastfeeding programmes should also beapplied in the future to promotion of and advocacy forimproved complementary feeding and to other aspectsof child health and development. 2
  • 13. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries Chapter 1Background and ContextT hrough most of the twentieth century, initiation and duration of breastfeeding declined worldwide Trends in breastfeeding patterns in Figure 3as a result of rapid social and economic change, developing countries, 1989–1999including urbanization and marketing of breast milk 83 90%substitutes. In recent years the global trend has shifted 77 80%towards improved breastfeeding practices. However, the 70% 58prevalence of exclusive breastfeeding and other optimal 60% 50 52 50% 46infant feeding practices is still low in many countries. 39 41 40%Continued attention to breastfeeding is therefore 30%needed to achieve the sustained behaviour change that 20%will lead to significant improvement in child survival 10% %and development. Complementary Breastfeeding Breastfeeding Breastfeeding (12-15 mos) (20-23 mos) Feeding (6-9 (0-3 mos) Continued Continued ExclusiveBreastfeeding practices in developing mos)countriesIn the past two decades, breastfeeding initiation and Percent Change 1989-1999duration began to increase in many developing +18% +22% +8% +12%countries (Grummer-Strawn, 1996; Lutter, 2000;UNICEF, 2001). Survey data from 43 countries (UNICEF, 2002)indicate a significant increase in exclusive breastfeeding,from 39% to 46% between 1989 and 1999, with widevariations within and between geographic regions breastfeeding practices (Wellstart, 1996; Guerrero et(figure 3). For example, DHS surveys indicate that al., 1999; Green, 1989; de Zoysa et al., 1998).exclusive breastfeeding rates for infants 0–3 months ofage range from 25% (Dominican Republic, 1996) to Breastfeeding promotion and support:78% (Peru, 2000) in Latin America, and from 4% (Côte historical developmentd-Ivoire, 1998/99) to 63% (Malawi, 2000) in Africa. In May 1980 the World Health Assembly adopted theIn countries and regions where breastfeeding promotion recommendations for promotion and support ofand support programmes have been well enacted, breastfeeding that were made the previous year at anotably some Latin American countries, rates of WHO/UNICEF Meeting on Infant and Young Childexclusive breastfeeding and other optimal breastfeeding Feeding (WHO, 1980). In the 1980s, workshops onpractices appear to be improving more dramatically. infant and young child feeding were organized in nearlyNevertheless, in many developing countries certain 100 countries. National breastfeeding committees andcultural beliefs continue to interfere with optimal national breastfeeding promotion programmes werebreastfeeding, especially feeding colostrum and established in various countries (Jelliffe and Jelliffe,breastfeeding exclusively (Dimond and Ashworth, 1988). In 1990 policy-makers from 31 governments,1987; Martines et al., 1989). In every culture, specific representatives of 8 UN agencies, and other participantsbeliefs that impede optimal breastfeeding need to be at a WHO/UNICEF meeting in Italy produced andidentified through formative research and addressed adopted the Innocenti Declaration on the Protection,through effective, well-designed behaviour change Promotion, and Support of Breastfeeding. Thecommunication to promote and support optimal Innocenti Declaration established operational targets 3
  • 14. Background and Contextfor breastfeeding that focused primarily on policy and support by building on these past and continuinghealth services (WHO, 1989). concepts and achievements. Over the past few years, experience in enacting community-based strategies hasFrom that declaration emerged the Baby-friendly grown, along with a scientific evidence base to addressHospital Initiative (BFHI), which has made a the efficacy and effectiveness of certain supportsignificant impact on breastfeeding practices globally strategies (Green, 1999). As a result of the confluencethrough implementation of the “Ten Steps to Successful of policy development and the accumulation ofBreastfeeding,” focusing on maternity services and scientific evidence, the promotion and support ofnewborn care (WHO, 1998). The tenth step, the optimal breastfeeding through community-basedestablishment of breastfeeding support groups, initiatives is now more widely understood and accepted.connects mothers to community support after dischargefrom the hospital. Two other steps—antenatal care (step Evidence of effectiveness3) and breastfeeding guidance (step 5)—also involvematernal access to support and may reach beyond the This section describes 1) the evidence that community-health facility to the community. based breastfeeding promotion and support can improve breastfeeding practices in developing countriesThe Global Strategy for Infant and Young Child Feeding and 2) the efficacy of such interventions to reduceadvances breastfeeding protection, promotion, and infant morbidity and mortality. Table 1Community-based breastfeeding support trials in developing countries that include healthynewborn infants and mothers Bre astfe e ding status Study (de sign) Subje cts Inte rve ntion at last asse ssme nt, <6 mo. RR (95%CI) Barros et al 1994 U rban (Pelotas) Brazil, N=900 T hree hom e visits at 5, 10, 20 days A ny Breastfeeding Enrollm ent site: Maternity unit postpartum by a social assistant or Intervention - 38% (Random ized, controlled Inclusion criteria: Hospital stay 5 nutritionist experienced in Control - 35% trial but m ethod of days or less, wanted to breastfeed, breastfeeding and trained in random ization not stated) living in Pelotas, fam ily incom e breastfeeding counselling < twice m inim um Brazilian wage Froozani et al 1999 U rban Iran, N = 134 Contact by nutritionist in hospital A ny Breastfeeding Enrollm ent site: Single hospital im m ediately after birth and at Intervention - 84% (A lternating allocation to Inclusion criteria: Mothers without hom e or in clinic on days 10–15, Control - 75% intervention vs. usual breastfeeding experience or chronic and m onthly thereafter to 4 Exclusive Breastfeeding* care) disease giving birth to norm al m onths (5–6 visits) Intervention - 48% birthweight, term infant Control - 6% Haider et al 2000 Dhaka, Bangladesh, N=726 Peer counsellors, hom e visits up to Exclusive Breastfeeding* Enrollm ent site: Com m unity 15 occasions including 2 in last Intervention - 56% (Cluster random ized, Inclusion criteria: Wom en aged trim ester of pregnancy, 4 in m onth Control - 5% controlled trial) 16–35 with 3 children or less and 1 and every two weeks thereafter no serious illness, singleton birth, up to m onth 5. with no congenital birth Visit duration 20–40 m inutes abnorm alities, birth weight 1800 g or m ore Leite et al 1998 U rban Brazil, N = 1003 Peer counsellors m ade hom e visits A ny Breastfeeding* Enrollm ent site: 8 public health up to 6 occasions, 5, 15, 30, 60, Intervention - 65% (Random ized, controlled m aternity units 90 and 120 days, visits lasting Control - 53% trial) Inclusion criteria: Newborns 30–40 m inutes. Counsellors had Exclusive Breastfeeding* weighing < 3000 g, discharged personal experience with Intervention - 25% < 5 days, singleton birth, no breastfeeding and had been Control - 20% im portant health problem s in associated with m ilk bank for 5 or m other or infant m ore years. Trained with adapted WHO counselling course Morrow et al 1999 Periurban, Mexico, N=130 Peer counsellors m ade 3 or 6 hom e A ny Breastfeeding Enrollm ent site: Com m unity visits Intervention - 68% (Cluster random ized, Inclusion criteria: A ll pregnant Group 1: 6 visits (2 in pregnancy, Control - 63% controlled trial) m others wishing to be enrolled, and 1, 2, 4, 8 wks post-partum ) Exclusive Breastfeeding* perinatal deaths excluded Group 2: 3 visits (1 late pregnancy, Intervention - 55% and 1, 2 wks post-partum ) Control - 15%* Significant at two-sided p<0.05 (abstracted from Sikorski et al, 2002) 4
  • 15. Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesIMPROVING BREASTFEEDING PRACTICES. Sikorski et al. REDUCING MORBIDITY AND MORTALITY. The WHO(2002) conducted a systematic review and meta-analysis Collaborative Study Team on the Role of Breastfeedingof the efficacy of support for breastfeeding mothers. This on the Prevention of Infant Mortality found that instudy identified 20 randomized or quasi-randomized developing countries, any breastfeeding is associatedtrials of breastfeeding support conducted in 10 countries. with more than two-fold protection against infantBreastfeeding outcomes of interest were “any mortality compared with no breastfeeding in the firstbreastfeeding” or “exclusive breastfeeding” for specific year of life (WHO, 2000). A cohort study of 1,677age groups. Overall the meta-analysis revealed a infants living in the slums of Dhaka, Bangladesh, foundsignificant, beneficial effect of breastfeeding support on that the relative risk of mortality in the first 6 monthsduration of any breastfeeding, with the greatest effect was more than two-fold lower in infants who wereon exclusive breastfeeding. Both lay and professional exclusively breastfed than in infants who were partiallysupport appeared to be effective, although in different or not breastfed (Arifeen et al., 2001) (table 2).ways. Lay counsellors appeared to be most effective in Breastfeeding demonstrates a dose responseincreasing the duration of exclusive breastfeeding, while relationship to infectious disease morbidity andprofessional counsellors appeared to be most effective mortality in infancy, with exclusive breastfeedingin extending the duration of any breastfeeding. offering the most protection and partial breastfeeding intermediate protection when compared to noMost of the studies cited were conducted in breastfeeding (Brown et al., 1989; Victora et al., 1989;industrialized countries. Of the seven trials conducted Morrow et al., 1992). Thus, infants under 6 monthsin developing countries (Bangladesh, Brazil, Iran, of age who are not breastfed are estimated to have aMexico, and Nigeria), five examined community-based greater than 5-fold increased risk of morbidity andbreastfeeding counselling to mothers of normal mortality from diarrhoea and pneumonia compared tonewborn infants (table 1). The sample size of each infants who are exclusively breastfed (Victora et al.,individual study ranged from 130 to 1,003 (total for 1989; Black et al., 2003).all five studies, n=2,893 mother-infant pairs). In fourof these five studies, the intervention involved home Table 2visits by peer counsellors; the remaining study (Froozani Infant mortality (0-6 months) in Dhaka,et al., 1999) involved maternal contact in a hospital Bangladesh comparing partial and noby a trained nutritionist followed by home visits. The breastfeeding to exclusive breastfeedingnumber of visits made to mothers by breastfeeding RR (95% CI)counsellors in these trials ranged from 3 to 12 or more Causes of Infant Death Partial/no BF vs. EBF(Haider et al., 2000). In most of the studies, counsellorswere trained using the WHO breastfeeding counselling All Causes 2.2 (1.4 – 3.4)course in its original or adapted form; one study used Diarrhoea 3.9 (1.5 – 10.6)a training course developed by La Leche League Acute Respiratory Infection 2.4 (1.1 – 5.2)(Morrow et al., 1999). Four of five trials examinedexclusive breastfeeding, and each of these demonstrated (Arifeen et al, 2001)significant impact of counselling on exclusivebreastfeeding. Only one of the four trials that examinedthe duration of any breastfeeding as an outcome A randomized, controlled trial of healthy infants indemonstrated a significant impact of counselling (Leite Mexico City found that home-based breastfeedinget al., 1998). counselling was associated not only with a significant increase in exclusive breastfeeding, but also with aTwo other trials in developing countries included in significant decrease in the percentage of infants whothe Cochrane Review (Haider et al., 1996, in experienced a physician-diagnosed episode of diarrhoeaBangladesh and Davies-Adetugbo, 1997, in Nigeria) at any time during the first three months of life (one-tested the effectiveness of breastfeeding counselling of tailed p<0.05 [Morrow et al., 1999]). The trial bymothers whose infants were seen for diarrhoea in the Froozani et al. (1999) reported significantly fewer dayshospital or health care centre. In both studies, for the of diarrhoea among infants of mothers in the2–3 weeks following counselling, exclusive breastfeeding breastfeeding counselling group (1.2 [SD 2.7])was significantly increased, and infants experienced compared with those in the control group (4.0 [SDfewer repeat cases of diarrhoea. 7.1] days, p<0.004). Similarly, a randomized, controlled trial of community-based breastfeeding support conducted in Haryana, India (see Chapter 3), 5
  • 16. Background and Contextdescribed significant increases in exclusive breastfeeding terms, these elements translate into providing mothersand significant decreases in infant diarrhoea in with acceptance, encouragement, timely and salientintervention communities (Bhandari et al., 2003). information regarding breastfeeding, and practical skillsThese findings are consistent with a trial of the Baby- and strategies for overcoming socioeconomic, cultural,friendly Hospital Initiative intervention in Belarus, or biomedical obstacles to optimal breastfeeding.which reported that the rates of diarrhoea and of atopicdisease were significantly reduced among infants in the Involving community leaders, social support networks,intervention group compared with controls (Kramer the health sector, and community members inet al., 2001). Thus, observational and experimental data breastfeeding promotion and support provides aprovide compelling evidence that effective community- mechanism for shifting cultural knowledge, norms, andbased breastfeeding inter ventions can result in expectations (WHO, 2002). In short, community-basedsignificantly increased optimal breastfeeding and breastfeeding promotion and support can be justifiedsignificantly lower infant morbidity and mortality. on grounds not only of effective breastfeeding behaviour change leading to increased child survival,Framework and justification but also of women’s empowerment and community development. The following chapter addresses theOptimal breastfeeding requires maternal choice concepts and strategies that underlie community-basedcombined with the ability to implement that choice breastfeeding promotion and support.(figure 4), which is in turn affected by social, physical,and logistical factors that are immediate to the mother’sexperience. Influences that are a level removed fromthe mother’s personal experience, such as culturalattitudes and national policies, may or may not bedirectly perceived as affecting her choice. Nevertheless,they are powerful determinants that influence thedegree to which a mother experiences support orbarriers to optimal breastfeeding. Figure 4Model of determinants of breastfeedingbehaviour Infant Feeding BehavioursProximate Opportunities to act Maternal choicesdeterminants on these choices Infant feeding information and physicalIntermediate and social support during pregnancy,determinants childbirth and post-partum • Familial, medical, and cultural attitudes and normsUnderlying • Demographic and economic conditionsdeterminants • Commercial pressures • National and international policies and norms (Lutter, 2000)Social support for optimal breastfeeding can take manyforms. The elements of social support relevant tobreastfeeding are emotional, informational, andinstrumental (Raj and Plichta, 1998). In practical 6
  • 17. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries Chapter 2Approaches to Community-based BreastfeedingPromotion and SupportA n interagency working group including WHO, UNICEF, USAID, the World Bank, the Department individual mothers may not experience but that create and sustain the community’s capacity for breastfeedingfor International Development (DFID) and the CORE promotion and support. These latter elements, whichconsortium of nongovernmental organizations has can be considered the foundation for effective andtargeted the reduction of childhood morbidity and sustained action, include the development ofmortality using an approach that works with and through intersectoral partnerships or coalitions, formativecommunities, and extends integrated facility-based care research, monitoring and evaluation, training andfor management of common childhood illnesses to super vision, strong management, and visionar ysupport for prevention and good home care (WHO et, 2002). The working group advocates a community-based approach that involves people from the P ARTNERSHIPS . The formation of intersectoralcommunity, adapts to community needs, builds on partnerships or coalitions increases the capacity forexisting resources and avoids duplication, strengthens effective and sustainable community-based behaviourlinks and builds bridges between groups in the change (Butterfoss et al., 1993). At the community levelcommunity and between those groups and the formal in developing countries, such partnerships may includehealth system, focuses on outcomes, and is cost-effective the ministry of health, other ministries concerned withand sustainable. At the heart of efforts is the promotion social welfare, community health centre staff, identifiedand support of a set of key family behaviours to improve opinion leaders, nongovernmental agencies, andchild health and development. These behaviours include women’s groups.optimal infant and young child feeding practices. FORMATIVE RESEARCH . Formative research can beCommunity-based breastfeeding promotion and support invaluable to guide effective action on breastfeeding asis important insofar as this approach can achieve well as other public health concerns (Pelto et al., 1991;sustained population-level breastfeeding behaviour Guerrero et al., 1999; Martines et al., 1989). Thechange. This ambitious goal requires systematic purpose of such research is to clarify the values, beliefs,application of behaviour change theory to strategies that and practices that most significantly affect breastfeedingengage individuals and multiple levels of society. behaviour, and with that understanding to shapeCommunity-level change involves attention to messages and approaches that are likely to result incommunity capacity (the foundation for change) as well positive breastfeeding behaviour change. For example,as specific interventions intended to produce behaviour formative research conducted in Mexico indicated thatchange (Wandersman et al., 1996). The section below mothers believed they should introduce another liquidconsiders the foundation for community-level or food when the baby was “thirsty,” the baby or motherbreastfeeding behaviour change, describes specific was ill, or the mother was emotionally upset (Guerrerointerventions, discusses the integration of community- et al., 1999). These findings were used to developbased breastfeeding initiatives with preventive and messages, materials, and training programmes forprimary health care services, and considers the argument physicians and lay counsellors to influence attitudes andfor integration of breastfeeding and early childhood behaviours that impeded exclusive breastfeeding in thedevelopment initiatives. periurban Mexican setting. “Breast milk is sufficient to quench a baby’s thirst, even in hot weather” was one ofFoundation for community behaviour the messages developed in response to the formativechange research. “Mother’s milk is better than any other method of feeding a young infant, even when a mother isCommunity-based intervention strategies include those emotionally upset (has coraje or susto)” was another keythat mothers experience directly, as well as elements that message. These specific messages helped to ensure that 7
  • 18. Approaches to Community-based Breastfeeding Promotion and Supportthe lay counselling intervention achieved significant quench thirst. If giving only breast milk to her three-change in exclusive breastfeeding behaviour (Morrow month-old baby will result in the disapproval of heret al., 1999). mother-in-law and potentially her community, the woman may decide that the risk of adopting theMONITORING AND EVALUATION. Another way to tie data recommended practice is too great. Communicationto action is through monitoring and evaluation. Data strategies must therefore address not only individualcan provide potent motivation for action when specific behaviour change of the mother, but also the beliefs ofbehaviour change goals are identified, measured as those who influence her at all levels: health workers,indicators, and used for local ongoing evaluation of family members, elders, and community members.effectiveness. The development of a monitoring systemthat allows local and routine use of data builds capacity Two broad paradigms are currently used for improvingfor community-level change and creates a needed health behaviours: 1) the behaviour change approach,evidence base for effective pubic health action (De Zoysa with its roots in individual psychology andet al., 1998; Morrow, 2000). behaviourism and 2) community-based participatory approaches to empower people to improve theirTRAINING AND SUPERVISION. Training and supervision communities in a sustainable way. Successfulof health-care providers and lay volunteers for breastfeeding programmes have employed both of thesebreastfeeding counselling and community outreach are approaches. The Transtheoretical (Prochaska, 1982)also important elements of the foundation for change or Stages of Change Model is a useful tool for lookingand an effective community-based breastfeeding at the process of individual change. In this model thebehaviour strategy. Providers and volunteers need individual moves from pre-awareness of theaccurate information and mastery of skills in counselling recommended practice to awareness, contemplation ofand communication to support and motivate community trying the new practice, trial of the practice, adoptionmembers. of the practice, maintenance, and finally advocacy of the new practice. This model enables practitioners firstMANAGEMENT AND LEADERSHIP. Finally, the foundation to identify the stage of the target audience and then tofor change requires vision and managerial and leadership structure interventions to move individuals along theskills. Implementation falters in the absence of these process of change.elements. Managers’ failure to adjust programmes tonew realities jeopardizes programme sustainability. In the past health communicators often focused entirely or disproportionately on one or more stages, such asCommunity-level interventions providing information to increase knowledge, only to find themselves frustrated when practices did notWith the elements outlined above in place, the specific change. The Stages of Change Model indicates thatcommunity-based interventions are more likely to “knowledge” is not enough. A woman may be able tosucceed. An effective community-based breastfeeding recite messages about exclusive breastfeedingbehaviour change strategy is multifaceted, with attention (“knowledge”) but may not think that they apply toto behaviour change communication, partnership with her. If health workers ask the woman to try a newthe health sector, and involvement or mobilization of practice such as not giving water to her baby for a week,the community through engaged opinion leaders, the woman and her family will immediately see forwomen’s support groups, and trained health-care workers themselves the advantages of exclusive breastfeedingand lay counsellors. and may be convinced to adopt it. Thus, the individual is persuaded through negotiation to move along theB EHAVIOUR CHANGE COMMUNICATION . Improved change process from “knowledge” to “trial,” increasingbreastfeeding practices are more likely to occur if the chances of adoption. Figure 5 shows specificwomen perceive them as beneficial, feasible, and interventions that can be used to promote change insocially acceptable. Improving practices at the individual behaviour or community norms at variouscommunity level requires behaviour change strategies stages.that lead to changes in community norms, includingindividual and group approaches. A breastfeeding To maintain the new practice, a woman needs supportwoman typically does not make decisions alone. For from her family and community. Successfulexample, a woman may hear about exclusive breastfeeding programmes have used group approachesbreastfeeding at the health facility but then be told by that address special audiences or the collectiveher mother-in-law that babies need additional water to community while strengthening the capacity of 8
  • 19. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries Figure 5 Stages of change and communication approaches Movement from one stage of change to another requires a mix of appropriate communication interventions from the following categories: • Mass, electronic, and print media (e.g., radio, TV, newspaper, flyers) • Community advocacy and events (e.g., theatre, fairs, community gatherings) • Interpersonal communication (community groups, individual counselling, mother-to-mother support groups, home visits) These approaches help change individual behaviours and social norms and are directed to mothers as well as to family members, community leaders, and other social, religious, and political influentials. Stage s of Change Le ve l of knowle dge and attitude P urpose of appropriate communication inte rve ntions toward or e xpe rie nce with the to move individual to ne xt stage ne w practice Pre-awareness Has not heard of new practice Provide inform ation A wareness Has heard of new practice Provide m ore inform ation and begin to focus on persuasion Contem plation Considers the resources and tasks Provide encouragem ent that practice is "do-able" and needed to actually perform the introduce role playing, role m odeling practice Intention Intends to try new practice Focus on appreciating benefits and overcom ing obstacles; introduce negotiation of trying new practice; hom e visits are very appropriate Trial of new practice Tries new practice to experience Reinforce benefits and overcom ing of obstacles with fam ily benefits and overcom e obstacles and com m unity influentials; provide additional support to m other through hom e visits and support groups A doption of new A ppreciates benefits and has Continue to reinforce and support practice, including praise practice overcom e obstacles during trial of from influentials new practice; adopts practice Maintenance Decides to continue new practice Continue to reinforce and support practice, including praise from influentials Telling others Believes in new practice and wants to Provide opportunities for practitioners to com m unicate their tell others m essages to other wom en widely (m ass electronic and print m edia) or within the com m unity (com m unity events and advocacy; interpersonal com m unication) (LINKAGES Project)community organizations. Encouraging community occurs when a critical mass of community membersgroups to identify and solve problems increases support have tried the innovation and begun to see its benefits.for the mother’s decision and increases the likelihood Communication strategies can hasten this processthat she will maintain the new behaviour. through the use of lay counsellors to facilitate discussions in mother support groups, communityThe Diffusion of Innovation Theory (Rogers, 1983) is development groups, credit associations, or religioususeful for examining how innovative ideas are groups for men or women.introduced and adopted in a community. “Earlyadopters” are the risk takers; “late adopters” are the Formative research can help target clear and effectiveones who wait to see how well the innovation works. messages to specific populations or community groups.Innovations are more easily adopted when they have Such tailored messages can help reduce the perceivedcertain characteristics, such as ease of adoption, risk of trying the new behaviour and enable people tosimilarity to current practice, low level of risk in trying understand how adopting the new practice bringsout the practice, and benefits that outweigh the benefits to them and to the community. Strengtheningdisadvantages. When an innovation is introduced to a community organizations can increase the community’scommunity by a risk-taking early adopter, others capacity to change norms and improve infant feedingobserve the results and gradually adopt the practice behaviours.themselves. Long-term change of a community norm 9
  • 20. Approaches to Community-based Breastfeeding Promotion and SupportTRAINING COMMUNITY HEALTH - CARE PROVIDERS . L AY C O U N S E L L O R S . Even community healthMothers in many countries cite the advice of health- professionals who are well trained in breastfeeding andcare providers as the reason for their making specific lactation management typically lack sufficient time toinfant feeding decisions. Unfortunately, advice from promote and support breastfeeding. As a result, layhealth-care providers is too often uninformed, counsellors have become critical to providing accessibleundermining efforts to support mothers who elect to breastfeeding counselling in many communities. Whenbreastfeed. Breastfeeding has been neglected in pre- lay breastfeeding counsellors, who are not professionalservice and in-service training of most health workers, health-care workers, are trained to provide breastfeedingleaving a serious gap in their knowledge and skills. As counselling to mothers of their communities, they cana result WHO, UNICEF, and others have placed a major be highly effective in increasing exclusive breastfeedingemphasis on training health-care workers in the and, potentially, early initiation and longer duration offundamentals of lactation and breastfeeding counselling breastfeeding (see Evidence of effectiveness, Chapter 1).(Rea et al., 1999; Cattaneo et al., 2001). WHO andUNICEF have created several standardized The terms “lay counsellor” or “peer counsellor” are oftenbreastfeeding courses. These include an 18-hour course used interchangeably. More precisely, however, peerdesigned to help staff of maternity facilities make counsellors are typically women who have given birthmaternity care “baby-friendly” (UNICEF, 1993) and a to at least one child and have breastfed successfully. Peer40-hour course to develop clinical skills in breastfeeding counsellors have a background similar to that of thecounselling for health-care workers in all parts of the people they are counselling. Some propose that to behealth system (WHO, 1993). Basic knowledge and credible, lay counsellors should be peers. However,skills promoted in these tools are also applied in case experience in many circumstances suggests thatmanagement guidelines and an 11-day training course committed and well-trained lay counsellors, like healthfor first-level health workers developed as part of the professionals, can be successful even when theyIntegrated Management of Childhood Illness (IMCI) themselves have not had personal breastfeedingstrategy (see discussion on integration of breastfeeding experience. Indeed, La Leche League International,with primary and preventive health services – page12). which has been training breastfeeding peer counsellors since 1987, notes that the demand for peer counsellorsA randomized controlled trial of the effectiveness of the is so great that many such counsellors are now women40-hour WHO training course was conducted in Brazil and men who do not meet the traditional concept ofwith health workers from 60 health units. This study peers.found that participants’ knowledge and skills inbreastfeeding counselling improved significantly, both Haider and others (2002) recommend systematic andimmediately after the course and three months later (Rea well-supervised training, recruitment, and deploymentet al., 1999). The responses of participants and of lay breastfeeding counsellors. Lay counsellors alsoobservation, however, suggested that the skills involved need ongoing connection to an organization that canin clinical practice and management of lactation needed sustain their efforts. Such a connection could be to amore time for development and reinforcement. nongovernmental organization such as La Leche League or through the community outreach activities of theAlthough increasing the breastfeeding knowledge and health system. Depending on the community andskills of health-care providers has been an important circumstances, lay counsellors may serve entirely asand necessar y element to promote and sustain volunteers or receive stipends to help support theirbreastfeeding behaviour change, this training is not activities. Some organizations have reported a highreadily available to all health-care workers and tends to turnover rate among volunteer counsellors and havebe expensive and hard to sustain. To address the training found that some form of stipend helps volunteers togap, some countries are undertaking a systematic review continue in this role. Others have retained volunteersof their pre-service curricula for training doctors, nurses, primarily through personal connection, praise,and midwives and are strengthening the lactation recognition, and continuing education (Green, 1998).management and infant feeding components of thosecurricula so that providers do not need to be retrained Studies of the effectiveness of lay counsellors inafter they have started practice. Use of the 40-hour and increasing breastfeeding have examined their role in18-hour breastfeeding courses continues to be home visitation. The specific activities of lay counsellorsrecommended for health-care providers who typically can vary substantially. Depending on circumstances,lack appropriate pre-service education in this arena. lay counsellors may work alongside community health workers in clinic settings or may focus on making 10
  • 21. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countriesroutine visits to the homes of pregnant or breastfeeding Figure 6mothers. Lay counsellors may provide individual-level Models of women’s groups incounselling to mothers, lead breastfeeding support breastfeeding promotion and supportgroups, or give talks to community groups about Model 1a. Breastfeeding Support Groupbreastfeeding. The 40-hour WHO/UNICEF course onbreastfeeding counselling, originally developed for • Convened specifically to support breastfeeding professionals, has been successfully used • Interested women attend meetings held in health centres,as the basis for training lay and peer counsellors. La homes, or other accessible locations. Meetings are often led by trained volunteer leaders who invite and encourageLeche League International also offers a peer counsellor programme. • La Leche League is the prototype for this approach. Model 1b. Mother’s Support Group with a broaderWOMEN’S GROUPS . Community-based support for purposebreastfeeding mothers often focuses on breastfeedingsupport groups. The first formal recognition of a • Convened to further a maternal and child health behaviour and/or nutrition agenda inclusive of, andbreastfeeding support group might be the 1956 compatible with, breastfeeding.formation of La Leche League, which provides the Model 2. Community mobilization that engagesprototype for such groups. The purpose of a existing social groupsbreastfeeding support group is to provide “mother-to-mother” encouragement and assistance to initiate and • Groups convened for purposes other than breastfeeding, such as social, economic, educational, or religioussustain breastfeeding. Trained volunteers lead group purpose.meetings. The focus of the meetings is almost entirely • Groups provide volunteer base for peer counsellors andon breastfeeding, with consideration of related topics. a channel for behaviour change communication (social marketing).The atmosphere of breastfeeding support groups is one • Groups provide support and encouragement to the peerof acceptance and equal participation. In this volunteers.atmosphere mothers feel comfortable sharingexperiences, asking questions, and obtaining answersregarding their experience with breastfeeding. This in a low-income, periurban area. On follow-up, mothersmodel is now being used in many countries. of infants under 6 months of age who had contact with the peer counsellors practiced exclusive breastfeedingIn addition to women’s groups focused primarily on for an average of 10 weeks compared with 4 weeks forbreastfeeding, other forms of women’s groups have mothers in the control group (Rivera et al., 1993). Inbecome involved in breastfeeding promotion and another study La Leche League of Honduras trainedsupport (figure 6). Some women’s groups address peer counsellors in 20 rural communities to leadbreastfeeding as part of their discussion of parenting monthly breastfeeding support meetings and visit 1–2or nutrition and health topics. Other women’s groups, mothers each at home. Mothers who had contact withfounded for economic development, community the peer counsellors were three times more likely thanservice, or social, political, or religious reasons, have other mothers to practice exclusive breastfeeding atalso participated in breastfeeding promotion and three months postpartum (AHLACMA et al., 1993).support. These groups may include breastfeeding- In Guatemala, La Leche League trained peer counsellorsrelated topics as part of their programmes to educate and formed breastfeeding support groups in about 10and support members or attendees and may provide periurban communities. A study conducted more thanvolunteers for breastfeeding education support as part three years after the end of funding found that theof their community service and outreach. Available data programme had been sustained: one-quarter of womensuggest that participants in women’s support groups in the community had contact with a breastfeeding peerimprove their breastfeeding behaviour, but questions counsellor either through support groups, home visits,remain whether volunteer groups alone are sufficient or other contacts (de Maza et al., 1997).to affect and sustain population-level behaviour change. A community inter vention trial undertaken inDespite their growing popularity for breastfeeding periurban Guatemala as a collaboration of La Lechepromotion and support, women’s groups have not been League and the LINKAGES Project found that afterstudied extensively (Green, 1998). La Leche League’s one year the rate of exclusive breastfeeding inmodel, however, has been evaluated in Honduras and intervention areas with peer counsellors did notGuatemala, which have had exceptional programmes. significantly increase compared with the controlIn Honduras La Leche League trained peer counsellors communities (Dearden et al., 2002a). However, only 11
  • 22. Approaches to Community-based Breastfeeding Promotion and Support31% of mothers in the intervention communities with and through the media and other channels ofinfants under 6 months of age had any contact with a communication. Reproductive health services, includingpeer breastfeeding counsellor. As in previous studies, maternity care and family planning services, are criticalexclusive breastfeeding was higher among women in avenues for breastfeeding promotion and support. Manyintervention communities who were exposed to La studies have shown that early initiation of breastfeedingLeche League support groups and home visits than and later breastfeeding practices are strongly associatedamong women who were not exposed (Dearden et al., with the support or the barriers experienced with2002a). maternity services. The Baby-friendly Hospital Initiative was designed to address this issue, although the conceptMicroenterprise programmes represent another model should be extended to perinatal care delivered in homesof women’s groups. An evaluation of Freedom from and clinics.Hunger’s Credit with Education Programme, managedby the Lower Pra Rural Bank in Ghana, found major A natural point of integration between reproductiveimprovements in breastfeeding practices among health services and breastfeeding is education andprogramme participants between the 1993 baseline and support of mothers regarding use of the lactational1996 follow-up surveys. Women not involved in the amenorrhoea method (LAM), a well-documentedprogramme did not show improved practices: 98% of method of contraception. This method has been shownprogramme participants gave colostrum, compared with to have 98% efficacy for the first 6 months postpartumonly 71% of non-participants and 78% of women in (Labbok et al., 1997). Use of LAM requires thatcontrol communities. Further, programme participants mothers practice full or nearly full breastfeeding1, dodelayed introduction of water to their infants until an not experience return of their menses, and have notaverage of 125 days of age, compared with 63 days for passed the first six months postpartum. Mothers whonon-participants and 51 days for women in control practice this method are also encouraged to switch tocommunities (McNelly, 1997; Green, 1998). other family planning methods when any of one of these criteria is no longer met.As experience with community-based breastfeedingpromotion and support deepens, diverse approaches are Breastfeeding promotion and support is also a keybeing used for forming and involving women’s groups. intervention in the IMCI strategy (WHO, 1999). ThisIn some regions existing women’s groups provide strategy is championed by WHO and health agenciesvolunteers to work with the breastfeeding initiatives of worldwide as the foundation for pediatric primary carethe health sector. In other regions new support groups and improved child health outcomes in developingare formed focused on the breastfeeding experiences of countries. The strategy involves strengthening thethe women who attend. More rapid change may be quality and accessibility of primary care by addressingachieved by using existing women’s groups for outreach three major dimensions of the care delivery process—purposes than by establishing new groups focused on the health system, the skills of health staff, and familybreastfeeding support. However, experience suggests that and community practices. Based on this comprehensiveeither approach may be effective for breastfeeding approach, IMCI encompasses a range of specificpromotion and support, depending on the aims, time interventions to prevent and manage the major causesframe, culture, and circumstances. of childhood morbidity and mortality, integrating feeding counselling as an essential aspect of clinicalIntegration of breastfeeding with primary care. At this stage of implementation, substantialand preventive health services integration of IMCI with other breastfeeding promotion and support initiatives has been achieved in only a fewCommunity-based approaches to breastfeeding are places in the world, but emphasis has been given tounlikely to succeed or to be sustained without the creating more effective approaches to outreach andinvolvement of the health sector. Breastfeeding developing community-based breastfeeding supportcounselling should be supported within the health care that is well integrated with IMCI. There is a need forsystem at a number of contact points that correspond additional well-designed trials to examine the impactto time points along the maternal-child life course,including antenatal, postnatal, well-baby, sick-baby, and 1 Full breastfeeding is the term applied to both exclusiveimmunization health service visits. In other words, breastfeeding (no other liquid or solid given to infant) andsupport for breastfeeding should be interwoven with almost exclusive breastfeeding (vitamins, water, juice, orreproductive health, primary care, and maternal and ritualistic feeds given infrequently in addition to breastfeeds). Nearly full breastfeeding means that the vastchild nutrition messages delivered in clinical settings majority of feeds are breastfeeds. 12
  • 23. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countriesof breastfeeding support in the primary care setting(Guise et al., 2003).Integration of breastfeeding and earlychildhood development strategiesTo maximize resources and population coverage,breastfeeding promotion and support should, to theextent possible, be effectively integrated with allinitiatives and services that affect infant and youngchild health and development. UNICEF encouragescountries to integrate breastfeeding promotion andsupport in their early childhood developmentinitiatives. A number of studies have reportedbreastfeeding to be associated significantly withmeasures of psychological development (de Andracaet al., 1998; Lucas et al., 1992; WHO, 1999).Mechanisms for the psychoneurologic impact ofbreastfeeding may include improved mother-infantbonding and communication and the presence of long-chain polyunsaturated fatty acids in human milk thathave been shown to be important to infant neurologicdevelopment (Lanting et al., 1994; Innis et al., 2001).The beneficial effects of feeding human milk to infantsis best evidenced in preterm infants. Lucas et al. (1992)examined the effects of tube feeding of preterm infants(<1,850 grams) using human milk vs formula feedings.Infants fed human milk had higher cognitive scores at18 months and at 7–8 years of age compared with thosewho did not receive their own mothers’ milk. This studycontrolled for potential confounding factors but maynot have fully controlled for differences in parentingand genetic capacity. While randomized trials have notbeen conducted to address the impact of breastfeedingpromotion on psychological development of infants indeveloping countries, evidence suggests thatbreastfeeding has a modest but significant impact onboth physical and psychological development in theinfant. Thus, breastfeeding should be considered thefoundation for effective early childhood developmentprogrammes in developing countries. 13
  • 24. Case Studies of Community-based Breastfeeding Promotion Chapter 3Case Studies of Community-basedBreastfeeding PromotionT his section provides case studies of community- based breastfeeding promotion and support in nutrition advocates at the national level; the harmonization of nutrition messages by this group; andthree developing countries: Madagascar, Honduras, and the group’s development and use of the sameIndia. The Madagascar and Honduras case studies communication materials, nutrition guidelines, andrepresent large-scale projects that involve major regions protocols helped create a favorable environment forof each country. The case study in Haryana, India, was behaviour change (LINKAGES, 2002).a large randomized, controlled trial. The Haryana studyis included because it was designed to provide a pilot In 1999 LINKAGES, in partnership with Jereo Salamafor sustainable ser vices at scale through the Isika (JSI), initiated district and community activitiesmobilization of existing community resources. It also in 10 districts in 2 of the country’s 6 provinces and inprovides evidence that it is possible to improve 2001 expanded to 13 more districts. These activitiescomplementary feeding practices through well-targeted now reach about 6 million people. Grassrootscommunity interventions. organizations and district and local “champions of change” implement the vast majority of the activities,Each case study builds on intersectoral partnerships with LINKAGES providing technical assistance,and uses community-based approaches to increase training modules, and materials to help them succeedexclusive breastfeeding. Core elements of successful in their efforts. By integrating behaviour changecommunity-based breastfeeding promotion and support interventions with existing community programmes,are evident in these three examples, but each has unique LINKAGES was able to expand its reach and coverageelements and strategies. Different approaches used in and “fast track” the programme.these programmes in measuring breastfeeding statusare discussed in the annex to this paper. The community approach in Madagascar builds on the IMCI strategy adopted by the Ministry of Health andMadagascar: Integrated child survival, supported by other donors and organizations. Elementsfamily planning, and nutrition of reproductive health related to breastfeeding, such as LAM, are incorporated in the approach. As illustratedIn Madagascar the Ministr y of Health and the in Figure 7, breastfeeding serves as an entry point toLINKAGES Project developed a programme to improve the community to address nutrition, child health, andbreastfeeding practices at a scale that would achieve family planning issues.significant public health impact. LINKAGES is a global Figure 7project funded by the United States Agency for Breastfeeding promotion and support as anInternational Development (USAID) and managed by approach to integration of primary healththe Academy for Educational Development. The care servicesproject’s goal is to improve breastfeeding and relatedcomplementary feeding and maternal dietary practicesand to increase the offering of the lactational R EPRODUCTIVE IMCI H EALTHamenorrhea method of family planning.During the first two years of the programme (1997– B REASTFEEDING1999), LINKAGES provided support to the Ministry N UTRITIONof Health for national policy activities, particularly the E SSENTIALSestablishment and coordination of an intersectoralnutrition action group representing approximately 50 (LINKAGES Project, Madagascar)organizations. The mobilization of a critical mass of 14
  • 25. Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesIn Madagascar LINKAGES promotes breastfeeding as behaviour changes that are feasible and “do-able”part of seven action areas: exclusive breastfeeding for to achieve the desired outcomes)the first six months, appropriate complementar y • Targeted, concise messages to promote “do-able”feeding beginning at six months with continued actionsbreastfeeding to two years and beyond, feeding of the • Short, periodic, and practical training for healthsick child, women’s nutrition, control of vitamin A workers, community volunteers, and members ofdeficiency, control of anemia, and consumption of women’s groups, in counselling techniques so theyiodized salt by all families. These behaviours are can negotiate trial of small do-able actionspromoted at six critical health contact points: 1) • Consistent messages and materials across allantenatal, 2) delivery and immediate postpartum, 3) programme channels to address critical behaviourspostnatal and family planning, 4) immunization, 5) • Saturation of specific audiences with messages throughgrowth monitoring and well child consultations, and all appropriate media (electronic, print,6) sick child consultations. This integrated strategy interpersonal, traditional)greatly expands nutrition contacts beyond traditionalgrowth monitoring and promotion programmes. LINKAGES’ multifaceted behaviour change approach has resulted in measurable change in knowledge andThe programme uses a combination of interpersonal behaviour within a short period of time. Using a rapidcommunication strategies, group activities, and media assessment procedure (RAP), LINKAGES collectedto change individual behaviour, while at the same time quantitative and qualitative data in October 2000,educating and engaging those who influence mothers’ October 2001, and November 2002 to evaluate thechoices. Home visits and counselling at health facilities effectiveness of its district-level behaviour changeprovide opportunities for health workers and strategy to improve breastfeeding and complementarycommunity volunteers to negotiate with mothers to feeding practices.“try out” a new practice. Nutrition promoters drawnfrom women’s groups engage in outreach activities, The rapid assessments were conducted in communesincluding lay counselling, health talks, and facilitated in each of the 10 districts where LINKAGES haddrama to stimulate participants to think about trying initiated activities in 1999 and in 1 control district.the new behaviour and supporting their family Because the goal of the evaluation was to assess themembers’ decisions. In addition to scheduled activities, effectiveness of the behaviour change strategy,the volunteers promote better infant and young child communes with active women’s groups that showedfeeding practices during informal contacts with women evidence of embracing this strategy were their communities. Participants were selected to represent all activity targetMedia strategies feature radio and television spots, groups, both those trained directly by LINKAGES or,traditional singers, and songs by a popular singer who in the case of mothers, the intended beneficiaries ofserves as the country’s breastfeeding and nutrition the training. The findings are based on interviews withambassador. Journalists participate in many of the mothers of children less than 12 months of age (303training activities and project events, resulting in free women in 2000, 693 in 2001, and 670 in 2002). Thepress and media time, stories, and special shows. 1997 Demographic Health Survey, the project’sCommunity events such as village theatre and festivals baseline surveys, control data, and other countryoffer forums for conveying key messages. Service studies serve as points of comparison.providers and community volunteers receive trainingin the Essential Nutrition Actions; key messages; In the 2000 RAP, the rate of exclusive breastfeeding ofcounselling and negotiation techniques; and the use of infants less than 6 months of age in the past 24 hourscounselling cards, job aids, and child health booklets. was 68% in the programme area, compared with 45%–In this way specific audiences repeatedly hear the same 47% from DHS, baseline, and control sur veyskey messages from health professionals, community (p<0.001). In the 2001 RAP, the exclusivevolunteers, and the media. breastfeeding rate rose to 79%. In 2002, after one year of no direct programme intervention because of politicalIn sum, LINKAGES’ behaviour change strategy crisis, the rate was 76% (figure 8). The most dramaticincludes the following elements: increases in exclusive breastfeeding were among infants 4 and 5 months of age—12% at baseline to 61% at the• Formative research to identify factors (benefits and 2001 RAP, although this dropped to 58% in 2002 barriers) to change and key actions (specific 15
  • 26. Case Studies of Community-based Breastfeeding Promotion Figure 8 Figure 9Exclusive breastfeeding in the first 6 Initiation of breastfeeding within first hour,months of life, Madagascar Madagascar Programme Programme 90% 90% Baseline 79 76 77 80% 4321 80% 73 71 68 4321 4321 432 4321 4321 Baseline 4321 4321 43211 4321 4321 4321 4321 70% 4321 4321 4321 70% 4321 4321 4321 Control 4321 Control 4321 DHS DHS 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 60% 4321 4321 4321 4321 4321 60% 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 47 4321 4321 50% 46 45 4321 4321 4321 50% 44 4321 4321 4321 42 4321 4321 4321 4321 4321 4321 40 4321 4321 4321 4321 4321 4321 4321 321 4321 4321 4321 4321 4321 4321 4321 1 4321 4321 35 35 4321 4321 4321 34 34 321 4321 4321 4321 4321 4321 40% 40% 321 4321 4321 4321 4321 4321 4321 4321 4321 4321 321 4321 4321 4321 4321 4321 4321 4321 4321 432 4321 4 4321 321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 1 4321 4321 1 4321 4321 4321 30% 4321 4321 4321 432 30% 321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 321 321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 32 4321 4321 4321 321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 20% 4321 4321 4321 4321 321 321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 20% 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 321 4321 4321 4321 4321 4321 4321 4321 10% 321 321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 10% 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 % % 321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 4321 1997 Jan Oct Oct Oct Oct Oct Oct 1997 Jan Oct Oct Oct Oct Oct Oct 2000 2000 2001 2002 2000 2001 2002 2000 2000 2001 2002 2000 2001 2002 (LINKAGES Project, Madagascar. (LINKAGES Project, Madagascar. Guyon et al., 2001 and Rahantanirina et al., 2002) Guyon et al., 2001 and Rahantanirina et al., 2002)during a political crisis in the country (Guyon et al., The approach used by LINKAGES in Madagascar2001; Rahantanirina et al., 2002). encouraged the coordination of efforts to improve child survival, growth, and development and broughtData collected in the 2000 RAP indicated that early partners together to achieve results. The Madagascarinitiation of breastfeeding more than doubled in the programme can serve as a model for countries wantingprogramme area to 73%, compared with 34% in the an integrated approach that can be adapted to addressDHS, baseline survey, and control site (p<0.001), as specific nutrition problems.shown in figure 9. The slight decrease (to 71%) in the2001 RAP is not statistically significant and the rate Honduras: Growth monitoring andincreased in 2002 to 77%. promotionIn both 2001 and 2002 RAP surveys, infants less than In Honduras the Ministry of Health developed and6 months old who were not exclusively breastfed were championed a national growth monitoring andsignificantly more likely to have had a diarrhoeal episode promotion strategy known as Atención Integral a la Niñezin the 2 weeks prior to the survey than infants who (AIN), or Integrated Child Care. This programme haswere exclusively breastfed. In 2001 infants who were been advanced in partnership with BASICS, a globalnot exclusively breastfed had a relative risk of diarrhoea child survival project funded by the United Statesof 3.75 compared with exclusively breastfed infants Agency for International Development.(p=0.02). In 2002 infants who were not exclusivelybreastfed had a 2.7-fold relative risk of diarrhoea BASICS in Honduras focuses on four strategiccompared with exclusively breastfed infants (p=0.04). objectives to achieve sustainable improvements in family health: 1) increased use of oral rehydrationIn the first year of the programme, complementary therapy (ORT) for diarrhoea, 2) appropriate carefeeding was not a major focus. Consequently no data seeking for acute respiratory infections (ARI), 3)on complementary feeding were collected during the appropriate child feeding, and 4) appropriatebaseline survey or the 2000 rapid assessment. In 2001 breastfeeding. Major partners include UNICEF, PAHO,the programme placed greater emphasis on this critical the American and Honduran Red Cross, Mercy Corps,aspect of infant and young child nutrition. The 2001 Save the Children, CARE, and PRAF (a governmentRAP showed no difference in the programme and control social welfare programme). AIN has become a modelareas in the proportion of mothers of infants 6–<10 for targeting services to those most in need by focusingmonths who fed their infants complementary foods in on health promotion as well as disease treatment andthe previous 24 hours (92% and 89%). In 2002 the by empowering community management of healthrespective rates were 93% and 80%. services. To strengthen household practices related to 16
  • 27. Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesAIN themes, the programme Comunicación en salud frequently they breastfed, and generally how they wereinfantil, or Communication in Child Health, was feeding their children (breastfeeding exclusively, givingdeveloped. This programme reinforces key practices and breast milk with other liquids, giving breast milk withmobilizes important community agents, such as radio other foods, or only giving other foods with no breastbroadcasters and religious leaders. milk).The AIN programme in Honduras began in the early In both AIN and control communities, nearly all mothers1990s when the Ministry of Health chose adequate indicated that their children under two years of age weregrowth—measured by assessing monthly weight gain— ever breastfed. However, 39% of mothers of childrenas the primar y indicator of child health. The under six months of age in the AIN communities,programme emphasized solving problems of illness, compared with 13% in the control communities,poor feeding practices, and general child care at the practiced exclusive breastfeeding (p<0.001). Thehousehold level in the critical first two years of life, pattern was similar for children under four months ofwhen children are most susceptible to permanent age (figure 10). In addition, the mean age for introducingdamage from malnutrition. To maximize population specific liquids or complementary foods was significantlycoverage, the Ministr y of Health offered growth higher in AIN communities than in control communities.promotion in the community in selected areas in 1992 Figure 10and 1993. In 1994 the ministry defined AIN as its Exclusive breastfeeding in the first 4 and 6primary child health strategy, implemented AIN in months of life, Hondurasgover nment facilities, included standard casemanagement in the strategy, and expanded the 60% Baselinecommunity programme. 49 321 50% 54321 321 Midterm 54321 54321 54321 54321 39From 1995 to 1997 the Ministr y of Health, in 40% 54321 54321 54321 654321 654321 54321 654321 54321 654321partnership with BASICS, introduced new strategies 30% 27 54321 54321 54321 654321 654321 654321to strengthen the AIN programme, including simple, 54321 54321 54321 20 21 654321 654321 654321 20% 54321 54321 17 654321 654321 15 13standardized information feedback to each community 54321 54321 54321 654321 5432 654321 654321 654321 654321 654321 54321 654321 6 654321 54321on its progress; a stronger emphasis on illness 10% 54321 54321 54321 654321 654321 1 654321 654321 654321 54321 54321 54321 654321 654321 54321 54321management; development and use of counselling cards; 54321 54321 54321 654321 654321 654321 654321 654321 654321 54321 54321 % 54321and application of the trials of improved practices AIN Control AIN Control(TIPS) methodology to identify appropriate feeding Under 4 months Under 6 monthsrecommendations and engage families in improving thedietary intake of their children. Using newly developed (AIN, Honduras. Van Roekel et al., 2002)materials for the community programme, AIN beganin 1997 to train nursing staff from 9 of its 42 healthareas. The programme was then introduced in Caregivers’ knowledge about optimal infant and youngintervention communities, with IMCI instituted at the child feeding practices improved significantly. AINfacility level to strengthen the clinical component. households were more likely than control households to identify improved growth as a benefit of breastfeeding.The midterm evaluation of the AIN programme The majority of women in AIN households were awarecompares intervention communities with control of exclusive breastfeeding, and 80% of those womencommunities served by the same health centres. The correctly identified 6 months as the appropriate durationevaluation included 474 AIN households and 464 of exclusive breastfeeding. As the AIN programmecontrol households in the 1998 baseline survey and continues to grow, the expectation is that it will reach596 AIN households and 572 control households in approximately 60% of Honduran children under 2 yearsthe 2000 follow-up survey. The follow-up survey results of age.demonstrated that the AIN programme coverage washigh in the intervention communities: 92% of children India: Integrated community-basedunder 2 years of age were enrolled in growth monitoring interventions to promote infant andand promotion programmes compared with only 21% young child feedingof children under 2 years of age in control communities.Breastfeeding was assessed by asking mothers whether A large-scale cluster randomized controlled trial wasthey had ever breastfed their children, whether they conducted in Haryana, India, from January 1998 towere currently breastfeeding their children, how March 2002 to evaluate the effect of community-based 17
  • 28. Case Studies of Community-based Breastfeeding Promotioninterventions to improve infant and young child In collaboration with representatives from differentfeeding, specifically, exclusive breastfeeding during the categories of health workers, health authorities, andfirst six months, complementary feeding at later ages, community members, the project team selected theand the impact on infant diarrhoeal illness and growth. channels for delivery of nutrition messages and theThe study was conducted under the auspices of a team points at which families would receive counselling.of researchers from the All India Institute of Medical Routine interactions between families and differentSciences and involved health workers from the district, categories of workers were observed to learn how theythe integrated child development services (ICDS) could be used for nutrition counselling without affectingprogramme, and a local nongovernmental organization. their other work. In intervention communities theWHO funded the study and provided technical opportunities used for counselling were deliveriesoversight. The study covered a population of about assisted by traditional birth attendants and monthly40,000, out of which a cohort of 552 infants in 4 home visits by anganwadi workers (women selected fromcommunities in the intervention group and 473 infants within the communities and trained to provide nutritionin 4 matched communities in the control group and preschool education services) to mothers and their(Bhandari et al., 2003) were followed to evaluate infants during the first year of life. Nutrition counsellingintervention impact. also occurred during quarterly weighing of children under two years of age, immunization clinics run byAt baseline, exclusive breastfeeding was uncommon and auxiliary nurse midwives, and sick child contacts withcomplementary feeding practices were poor in the target health-care providers.population. In developing the project, problemidentification was followed by formative research, At each contact with the caregivers, health workersparticipator y design of the inter vention, assessed infant feeding practices, identified specificimplementation, and evaluation. Formative research problems, and then counselled the caregivers. Inassessed barriers to appropriate feeding practices and addition, four workers — one for each interventionmotivating factors for behaviour change. To develop community — were selected by the local healthfeeding recommendations, the project team identified authorities from an existing local nongovernmentalcommon feeding problems and local ways to solve them. organization to support the government team in theHousehold trials were conducted to test acceptability community-based components of the intervention.of different recommendations. Opportunities used to deliver nutrition messages included monthly meetings held by the auxiliary nurseDesign of the intervention was highly participatory and midwives with community representatives,involved the community from the outset. Community neighbourhood meetings conducted by communityrepresentatives and health workers helped convert representatives with caregivers of children under twonutrition recommendations to messages in the local years of age, fairs, school debates, and other communityvernacular, identify themes for songs and theatre, and appropriate pictures for posters. Thecommunications materials developed included clinic To increase breastfeeding knowledge and skills, a three-posters, flip books, and feeding recommendation cards day training course was conducted for health andfor ready reference by health workers. nutrition workers. Half of the training time was used to practice counselling individuals or groups of caregivers.Nutrition messages included initiating breastfeeding The training was based on an adaptation of the IMCIimmediately after birth, feeding only breast milk for the training manual on breastfeeding counselling andfirst 6 months of life, and breastfeeding the infant day included training on communication skills, detectionand night and at least 8 times in 24 hours. The of problems with positioning and attachment to thecommunications strategy targeted specific foods and breast, and resolving breastfeeding difficulties.fluids commonly given to non-exclusively breastfedinfants, such as water and ghutti (an herbal mixture) The trial results indicated significant positive impact ofand their adverse effects. The intervention messages also the intervention (Bhandari et al., 2003). In the first 3included introduction of complementary foods at six months postpartum, 33% of the intervention groupmonths; the types of foods, meal frequencies, and mothers recalled having been counselled on exclusiveamounts to be fed at different ages; continued breastfeeding immediately after birth, 45% recalledbreastfeeding; ways to encourage children to eat more having been counselled at an immunization session, 32%food; hand washing before a meal; and continued feeding at a home visit, and 26% at a weighing session.during illness. 18
  • 29. Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesEvaluation data indicated that prelacteal feeds of honey, Figure 11tea, and diluted milk were fed to newborns less often Prelacteal feedings and exclusive(31% vs 75%) in the intervention communities than in breastfeeding at 3 months in interventionthe control communities (p<0.001). The corresponding vs control communities, Indiarates for exclusive breastfeeding in the previous 24 hours 90% 79among infants at 3 months of age in the intervention 75 80%and control communities were 79% and 48% 0987654321 0987654321 70% 0987654321 0987654321(p<0.001). The positive effect of the intervention on 60% 0987654321 0987654321 48 0987654321 0987654321exclusive breastfeeding was also seen up to six months 50% 0987654321 0987654321 0987654321 0987654321 0987654321 09876543211 0987654321of age. Further, the seven-day diarrhoea prevalence rate 40% 31 0987654321 0987654321 0987654321 0987654321 0987654321 0987654321 0987654321 0987654321was significantly lower in intervention group infants at 30% 0987654321 098765432 0987654321 0987654321 0987654321 0987654321 20% 0987654321 0987654321three months and six months of age in the intervention 0987654321 0987654321 0987654321 0987654321 10% 0987654321 0987654321 0987654321 0987654321communities compared with control communities. 0987654321 0987654321 0987654321 0987654321 0987654321 0987654321 %Infant growth up to six months of age was similar in Prelacteal feedings Exclusive breastfeedingintervention and control communities (Bhandari et al., at 3 months2003). 321 Intervention Communities Control Communities 321 321The impact of counselling on complementary feeding (India. Bhandari et al., 2003)practices was also assessed in the study. Mealfrequencies, protein, energy, and micronutrient intakeswere significantly higher among infants in theintervention communities at 9 and 18 months of age.The increase in calories resulted from increased intakeof milk, other foods, and the extra oil added to foods inthe intervention communities. When the infants were9 months of age, 35% of mothers in the interventiongroup, compared with 8% in the control group, reportedthat they encouraged them to eat more food. At 18months of age, practices that were reported more oftenin the intervention than the control communitiesincluded feeding with love and affection, repeatedlyencouraging the child who refuses to eat, and holdingthe child in the mother’s lap during feedings. Moremothers in the intervention group reported washing theirhands and their child’s hands before feeding.Intervention group children also had significantly highermean attained length at 12 months of age.This large community-based trial conducted in ruralnorth India demonstrated an effective and potentiallysustainable educational intervention to promoteoptimal infant and young child feeding. Programmeactivities continue without donor involvement one yearafter conclusion of the study. The intervention,integrated into existing services and designed to besustainable at scale, illustrates an effective approachto community IMCI that could serve as a model inmany regions. 19
  • 30. Application to Special Circumstances Chapter 4Application to Special CircumstancesT he studies and experiences described in this paper are intended as a general overview but must be breastfeeding at work, did not do shift work, and did not work on weekends.applied thoughtfully to particular communities andcircumstances. In some communities a significant Valdes et al. (2000) conducted a prospective, controlledproportion of women return to work outside the home intervention trial among working mothers in Santiago,in the first few months postpartum. Mothers’ return to Chile. Breastfeeding support that included anticipatorywork deserves special attention and can be considered counselling combined with monthly postpartum clinicala difficult circumstance in which to maintain optimal follow-up visits significantly increased the proportioninfant feeding. Two other exceptionally difficult of working women who exclusively breastfed theircircumstances that require special attention to infants to 6 months of age (53% of women in thebreastfeeding are HIV-prevalent areas and emergency intervention group compared with 6% of women in thesituations. control population). Most of the working women who maintained exclusive breastfeeding expressed and storedMothers’ return to work their breast milk.In many areas of the world, maternal work outside the Community-based breastfeeding initiatives shouldhome in the first few months postpartum is associated identify the extent to which work outside the home is awith shortened duration of breastfeeding or lower rates barrier to optimal breastfeeding and offer practicalof exclusive breastfeeding (Ashworth et al., 2000; alternatives to working women and their families. SeveralDearden et al., 2002b; Valdes et al., 2000). When a options should be considered to sustain breastfeeding,mother resumes work outside the home, optimal including supporting the mother to keep the baby withbreastfeeding can be sustained. However, if the infant her or with a caregiver at or near the workplace. In theis young, exclusive breastfeeding often becomes more latter situation, the caregiver brings the infant to thecomplicated because of the geographic separation of the working mother or the working mother visits the infantmother and infant and, in many cases, greater maternal when the child is ready to nurse. Another option is fortime constraints. The 88 session of the International th the caregiver to feed the infant expressed breast milk,Labour Conference held in June 2000 adopted a revised although in some cultures breast milk expression mayMaternity Protection Convention that significantly not be common. Any option requires levels of supportstrengthened the previous convention adopted in 1952. from family members, employers, caregivers, andProvisions of the 2000 Convention include an increase individuals in the community, such as lay breastfeedingin the minimum length of maternity leave from 12 to counsellors and health-care providers. Education and14 weeks, entitlement to paid breastfeeding breaks, and support of working women and their families can openapplication of the convention to women in nonformal new and helpful options for infant care and feeding.forms of work. Infants born to HIV-positive mothersBreastfeeding counselling and lactation supportprogrammes in the work environment can contribute Each year approximately 800,000 children becometo success (O’Gara et al., 1994). In a study of working infected with HIV largely in developing countries and ,mothers in Turkey, Yilmaz et al. (2002) concluded that mainly through mother-to-child transmission duringsupport for breastfeeding women should involve longer pregnancy, delivery, or breastfeeding (UNAIDS/WHOleave from work and improved breastfeeding conditions 2002). Research indicates that 5%–20% of infants ofat work. Rea and others (1999) reported that duration HIV-infected mothers who breastfeed become infectedof exclusive breastfeeding in Sao Paulo, Brazil, was longer through breastfeeding (de Cock et al., 2000).among factor y workers who had support for 20
  • 31. Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesTransmission of HIV through breastfeeding is associated in terms of reducing mother-to-child transmission ofwith several factors including infant age (<6 weeks), HIV through breastfeeding (Coutsoudis et al., 2001).longer breastfeeding duration, poor breast health Further research is on-going to confirm this result.(mastitis or lesions), poor maternal immune status,increased maternal viral load, and infant oral and In areas where HIV infection is present, the promotiongastrointestinal tract health. There is some evidence and support of breastfeeding remains critical from athat feeding mode may also be a factor, with exclusive population perspective. Special care is needed to avoidbreastfeeding being of lower risk than mixed feeding. inadvertently discouraging breastfeeding andGiven the benefits of breastfeeding for infant survival, inappropriate distribution of breast milk substitutes,the problem of HIV transmission through breastfeeding which could undermine optimal breastfeeding by HIV-has made safer infant feeding counselling for HIV- negative mothers and mothers who do not know theirpositive mothers a complex task. status. Community-based care and support for HIV- positive mothers and their infants requires a high levelWHO (2000) provides the following global of confidentiality and sensitivity. HIV-positive mothersrecommendations on infant feeding for HIV-positive should have access to appropriate individual counsellingmothers: and care regarding prevention of mother-to-child transmission of HIV and safer infant feeding practices.• When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all The Ndola Demonstration Project1 in Zambia is an breastfeeding by HIV-infected mothers is example of a programme that aimed at promoting better recommended. Otherwise, exclusive breastfeeding infant and young child feeding practices among all is recommended during the first months of life. women, in an area of high HIV prevalence. Health• To minimize HIV transmission risk, breastfeeding workers and community-level workers were trained in should be discontinued as soon as feasible, taking topics related to infant feeding, and also related to HIV. into account local circumstances, the individual Due to a combination of health-facility and community- woman’s situation, and risks of replacement level counselling and support activities, rates of exclusive feeding (including malnutrition and infections breastfeeding in the community increased, from 57% other than HIV). at baseline in April 2000 to 70% at endline in April• When HIV-infected mothers choose not to 2002. It was concluded that increasing knowledge of breastfeed from birth or stop breastfeeding later, MTCT did not erode good breastfeeding practices. they should be provided with specific guidance However, acceptance of HIV testing and counselling and support for at least the first two years of the remained low, so that mothers could not receive specific child’s life to ensure adequate replacement counselling and support based on their HIV status. HIV- feeding. positive mothers did not practice the recommendation• Programmes should strive to improve conditions for early cessation, because it was considered contrary that will make replacement feeding safer for HIV- to community norms (Horizons, 2003). infected mothers and families. Emergency situationsGlobal policy on infant feeding and HIV emphasizesthe importance of informed choice. Women need to The care and feeding of infants is especially importantknow their status to make a choice, because in emergencies such as famine or refugee situations,breastfeeding is the recommended mode of feeding for when infants and young children are particularlywomen who are HIV negative or of unknown status. vulnerable. In emergency situations misconceptions andProgrammes should provide HIV-positive women with adverse living conditions may present special barriersinformation and support to enable them to make fully to breastfeeding that need to be addressed and overcome.informed infant feeding decisions. The infant feeding A common but unfounded belief is that malnourishedoptions for HIV-infected women include commercial mothers in emergency situations cannot breastfeed. Oninfant formula, home-prepared infant formula, the contrary, malnourished mothers can breastfeed; thebreastfeeding (with early cessation where appropriate),expressed and heat-treated breast milk, donor milk frommilk banks, and wet nursing. 1 The Ndola Demonstration Project was a partnership of the National Food and Nutrition Commission, Central Board of Health, District Health Management Team, Hope Humana,A cohort study conducted in South Africa suggests that and three USAID-supported projects (LINKAGES, Horizons,exclusive breastfeeding may be safer than mixed feeding and the Zambia Integrated Health Program). 21
  • 32. Application to Special Circumstancesamount of breast milk produced depends primarily onthe frequency of breastfeeds and the effectiveness ofthe baby suckling on the breast. The best solution is tofeed the mother, not the infant, and to give her whateversupport she needs for breastfeeding. Providing themother with additional foods and fluids will improveher nutritional status and provide additional energy tocare for herself and her child.Additional barriers to breastfeeding may arise from theenvironmental conditions that occur during emergencies,such as the need to queue for food and to fetch water.These barriers can be overcome by giving breastfeedingmothers priority access to food, water, and shelter. Inmany emergencies, an extraordinary quantity of freebreast milk substitutes is provided in a misguided effortto assist. Negative effects that have been associated withfree breast milk substitutes include increased risk ofmorbidity and mortality in formula-fed infants who donot receive the benefits of immunologic protectionconveyed through breast milk, unintentional marketingof formula products to mothers who would otherwisebreastfeed, and undermining of mothers’ confidence andmotivation to breastfeed. While the availability ofsubstitutes is important for infants who do not haveaccess to breast milk, access to breast milk substitutesshould be controlled.Because emergency situations often arise in HIV-prevalent areas, concerns about HIV and breastfeedingmay need to be addressed, as noted in the HIV andbreastfeeding discussion above. Additional guidance onthis topic is available in a publication of the EmergencyNutrition Network (ENN), developed in collaborationwith WHO, UNICEF, the International Baby FoodAction Network (IBFAN), and the LINKAGES Project(Emergency Nutrition Network et al., 2001) 22
  • 33. Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesSummary and ConclusionsI deally, infant and young child feeding should be viewed from a life course perspective that begins with behaviour change communication, training of health- care workers and lay counsellors to provide accessiblea well-nourished woman and proceeds through a healthy and appropriate counselling support to mothers, andpregnancy and a safe and supportive delivery and active involvement of women’s groups are importantpostpartum period. Following childbirth, women elements of effective breastfeeding behaviour changecontinue to need timely and accurate information, strategies that may be applied somewhat differently inencouragement, and support to address their concerns diverse circumstances.and to enable them to practice optimal breastfeeding,which includes timely initiation of breastfeeding; Attention is required to integrate breastfeeding withexclusive breastfeeding for six months; the introduction multiple programmes affecting maternal and child healthof adequate, safe, and appropriate complementary foods and nutrition in the formal health sector and theat six months; and continued breastfeeding up to two community at large. Attention is also needed to supportyears of age or beyond. breastfeeding mothers in circumstances that require them to return to work in the first few weeks or monthsIn the life course perspective, infant and young child postpartum. Special care must also be taken regardingfeeding is the concern of mothers, families, communities, breastfeeding promotion and support in HIV-prevalentand the health sector. Community-based strategies, areas and emergency system strategies, and national policies all havea role in creating a supportive environment for optimal The Global Strategy for Infant and Young Child Feedinginfant and young child feeding, growth, and calls on countries to “mobilize all concerned social anddevelopment. economic resources within civil society, including scientific, professional, nongovernmental, voluntary, andThe development of community-based initiatives for commercial groups and associations, and to engage thembreastfeeding promotion and support is an extension of actively in implementing the global strategy andmore than two decades of global advocacy and achieving its aim and objectives….” The researchsystematic research. Evidence indicates that community- literature and case studies cited in this paper indicatebased breastfeeding promotion and support can be that such mobilization can be highly effective ineffective in increasing optimal breastfeeding and increasing optimal infant feeding and decreasing infantimproving infant health. As experience with community- morbidity and mortality. This document aims to providebased approaches increases, the elements that define helpful guidance and support to governmental andthe capacity for behaviour change and specific strategies nongovernmental agencies that are working towardsfor success are becoming clear. effectively reaching all mothers through community- based approaches to breastfeeding promotion andThe capacity for breastfeeding behaviour change at the support. We hope that this document will encouragecommunity level requires effective leadership, forming commitment to breastfeeding promotion and supportintersectoral partnerships, informing and engaging from all sectors and result in gains in optimal infantopinion leaders, conducting formative research to shape feeding that in turn produce significant gains in childexplicit and effective messages, and monitoring and survival.evaluating programme progress. Strategies for improvingbreastfeeding behaviour include approaches that focuson individual as well as group behaviour based onbehaviour change theory and address stages of change,including trials of improved practices. Well-designed 23
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  • 38. Issues in Breastfeeding Measurement Annex 1Issues in Breastfeeding MeasurementS tandardized breastfeeding indicators are recommended by the World Health Organization • Are you still breastfeeding (NAME)? • IF NO: For how many months did you breastfeed(1991) and endorsed by the Demographic and Health (NAME)?Surveys (DHS) and UNICEF’s Multiple Indicator • How many times did you breastfeed last nightCluster Surveys (MICS) to provide valid data that are between sunset and sunrise?comparable across studies and populations. • How many times did you breastfeed yesterdayRecommended international indicators for assessing during the daylight hours?breastfeeding include the following: • Did (NAME) drink anything from a bottle with a nipple yesterday or last night?• Percentage of infants less than 12 months of age • At any time yesterday or last night, was (NAME) breastfed within 1 hour of birth (timely initiation given any of the following: of breastfeeding rate) - Plain water?• Percentage of infants less than 6 months breastfed - Milk other than breast milk? exclusively (exclusive breastfeeding rate) - Fruit juice?• Percentage of infants 6–9 months (180–299 days) - Any other liquids such as sugar water, tea, fed breast milk and complementary foods (timely coffee, carbonated drinks, or soup broth? complementary feeding rate) - Any food made from wheat, maize, rice, sorghum (OR LOCAL GRAIN) such as …?WHO defines exclusive breastfeeding as maternal milk - Any food made from pumpkins, carrots, redbeing the only food source, with no other liquids or sweet potatoes, green leafy vegetables, mango,food given except medicines, minerals, and vitamins. papaya?Infants described as predominantly breastfed may - Any other food made from cassava, plaintain,receive breast milk as the main source of nourishment yams (OR LOCAL TUBER) such as…?but also receive water, water-based drinks, fruit juice, - Any other fruits and vegetables (e.g. bananas,herbal mixtures, and vitamins, minerals, or medicines. apples, avocados, tomatoes)? - Meat, eggs, fish, poultry, cheese, or yoghurt?All of the studies cited in this monograph were - Any food made from legumes (e.g. lentils,understood to adhere in principle to these beans, soybeans, pulses, or peanuts]?internationally accepted breastfeeding definitions. - Any food made with oil, fat, or butter?However, studies and evaluations cited differed in some - Any other solid or semi-solid foods?aspects of measurement, such as time frame forclassifying infants as exclusively breastfed (since birth, Answers to the 24-hour food recall question (items givenin the past 24 hours, in the past month) and employed during the previous night and day) are required todiffering wording of items used to assess exclusive calculate the exclusive breastfeeding rate. Thebreastfeeding. These differences in methods may have LINKAGES Project used these standardized items tosome implications for data interpretation across studies. guide its project evaluations, but not all projects presented in the case studies used these methodsThe internationally recognized set of standard precisely in this way. For example, the AIN programmebreastfeeding questions used by DHS includes the evaluation in Honduras used a 24-hour food recallfollowing: question at baseline but at midterm surveyed caregivers on the current status of breastfeeding using a• Did you ever breastfeed (CHILD’S NAME)? combination of questions that included current• How long after birth did you first put (NAME) to breastfeeding status coupled with a question on whether the breast? the infant had begun receiving foods and liquids. For 28
  • 39. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countriesvalidation this rate was compared to a question thatasked the caregiver to classify the infant as beingbreastfed exclusively, receiving breast milk with otherliquids, receiving breast milk with other foods, orreceiving only other foods with no breast milk. Becauseof the differences in calculating the exclusivebreastfeeding rate between baseline and midtermsurveys, there are some limitations to the comparabilityof the data.The study by Bhandari et al.(2003) classified infants at3 months of age as exclusively breastfed based on 24-hour recall as described above. However, classificationsof infants as being exclusively breastfed during the first4, 5, and 6 months of life were based on recall dataobtained at the 9-month visit, when the age was askedat which the mother had introduced any other liquidsor foods to the infant. A 24-hour recall provides reliabledietary recall, but because infant feeding behaviour isnot constant from day to day, some infants may bemisclassified as exclusively breastfed for the entire periodbetween birth and 6 months of age when they have beengiven other liquids or foods at least once by that age.Maternal recall at 9 months is likely to be reasonablefor classifying the age at which a liquid or food wasroutinely introduced into the infant diet, but the validityof this approach is not clearly established and the resultsare not necessarily consistent with the results obtainedfrom age-specific 24-hour recalls.The issue of breastfeeding status measurement is notedhere to alert readers to issues of data interpretation andcomparability of results across studies discussed in thisand other publications. 29
  • 40. 30