WHO and UNICEF developed the Global Strategy on Infant and Young Child Feedingin 2002 to revitalize world attention to the...
Selected WHO publications of related interestWHO. Global Strategy for infant and young child feeding. Geneva: World Health...
Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries              WORLD HEALTH ORGAN...
WHO Library Cataloguing-in-Publication DataCommunity-based strategies for breastfeeding promotion and support in developin...
Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesTable of ContentsAcknowledgement...
AcknowledgementsTables    Table 1.   Community-based breastfeeding support trials in developing countries                 ...
Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesAcknowledgementsThe primary auth...
Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesForewordThe importance of approp...
to reducing childhood mortality by two-thirds and halving the proportion of people living with hunger by 2015.Improving ch...
Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries   “…the global strategy include...
Introductionof age, associated with poor breastfeeding and                   The first chapter of the paper places communi...
Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries                                ...
Background and Contextfor breastfeeding that focused primarily on policy and                      support by building on t...
Community-based Strategies for Breastfeeding Promotion and Support in Developing CountriesIMPROVING BREASTFEEDING PRACTICE...
Background and Contextdescribed significant increases in exclusive breastfeeding          terms, these elements translate ...
Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries                                ...
Approaches to Community-based Breastfeeding Promotion and Supportthe lay counselling intervention achieved significant    ...
Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries                                ...
Approaches to Community-based Breastfeeding Promotion and SupportTRAINING     COMMUNITY HEALTH - CARE PROVIDERS .         ...
Community-based Strategies for Breastfeeding Promotion and Support in Developing Countriesroutine visits to the homes of p...
Approaches to Community-based Breastfeeding Promotion and Support31% of mothers in the intervention communities with      ...
Community-based Strategies for Breastfeeding Promotion and Support in Developing Countriesof breastfeeding support in the ...
Case Studies of Community-based Breastfeeding Promotion                                                                   ...
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
Community based strategies for breastfeeding promotion and support in developing countries
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Community based strategies for breastfeeding promotion and support in developing countries

  1. 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. 2. Selected WHO publications of related interestWHO. Global Strategy for infant and young child feeding. Geneva: World HealthOrganization, 2003http://www.who.int/child-adolescent-health/publications/NUTRITION/IYCF_GS.htmPan American Health Organization. Guiding Principles for complementary feeding of thebreastfed child. Washington DC: Pan American Health Organization, World HealthOrganization, 2003http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/guiding_principles.pdfWHO/UNAIDS/UNFPA/UNHCR/UNICEF/FAO/WFP/IAEA/World Bank. HIV andinfant feeding: framework for priority action. Geneva: World Health Organization, 2003http://www.who.int/child-adolescent-health/publications/NUTRITION/HIV_IF_Framework.htmWHO. Complementary feeding: family foods for breastfed children. WHO/NHD/001,WHO/FCH/CAH/00.6. Geneva: World Health Organization, 2000http://www.who.int/child-adolescent-health/publications/NUTRITION/WHO_FCH_CAH_00.6.htmWHO. HIV and infant feeding counselling: a training course. WHO/FCH/CAH/002.6Geneva: World Health Organization, 2000http://www.who.int/child-adolescent-health/publications/NUTRITION/HIVC.htmWHO. Evidence for the Ten Steps to Successful Breastfeeding. WHO/CHD/98.9. Geneva:World Health Organization, 1999http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/WHO_CHD_98.9.pdfWHO. Improving family and community practices: a component of the IMCI strategy. WHO/CHD/98.18 Geneva: World Health Organization, 1998http://www.who.int/child-adolescent-health/publications/IMCI/WHO_CHD_98.18.htmWHO/UNICEF. Breastfeeding counselling: a training course. WHO/CDR/93.3, UNICEF/NUT/93.1 Geneva: World Health Organization, 1993http://www.who.int/child-adolescent-health/publications/NUTRITION/BFC.htmOther publications of interest can be consulted and ordered online at:http://bookorders.who.int
  3. 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. 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: bookorders@who.int). 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: permissions@who.int).The 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. 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. 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. 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. 8. vi
  9. 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. 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. 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 cup.review 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. 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. 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. 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. 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. 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. 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 leadership.al, 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. 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. 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. 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. 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 mothers.health-care 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 participants.training 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. 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. 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. 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