Community based strategies for breastfeeding promotion and support in developing countries

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 the experiences 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.

Selected WHO publications of related interest

WHO. Global Strategy for infant and young child feeding. Geneva: World HealthOrganization, 2003http://www.who.int/child-adolescent-health/publications/NUTRITION/IYCF_GS.htm

Pan 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.pdf

WHO/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.htm

WHO. 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.htm

WHO. 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.htm

WHO. 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.pdf

WHO. 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.htm

WHO/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.htm

Other publications of interest can be consulted and ordered online at:http://bookorders.who.int

Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries

i

WORLD HEALTH ORGANIZATION

DEPARTMENT OF CHILD AND ADOLESCENTHEALTH AND DEVELOPMENT

Community-based StrCommunity-based StrCommunity-based StrCommunity-based StrCommunity-based Straaaaategiestegiestegiestegiestegiesfor Breastfeeding Pfor Breastfeeding Pfor Breastfeeding Pfor Breastfeeding Pfor Breastfeeding Promotion andromotion andromotion andromotion andromotion andSupport in DevelSupport in DevelSupport in DevelSupport in DevelSupport in Developing Countriesoping Countriesoping Countriesoping Countriesoping Countries

i i

WHO Library Cataloguing-in-Publication Data

Community-based strategies for breastfeeding promotion and support in developing countries.

1.Breastfeeding 2.Community networks - utilization 3.Consumer participation4.Strategic planning 5.Developing countries.

ISBN 92 4 159121 8 (NLM classification: WS 120)

© World Health Organization 2003

All 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: [email protected]). 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: [email protected]).

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


i i i

Acknowledgements vForeword viiIntroduction 1Chapter 1. Background and Context 3

Breastfeeding practices in developing countries 3Breastfeeding promotion and support: historical development 3Evidence of effectiveness 4

Improving breastfeeding practices 5Reducing morbidity and mortality 5

Framework and justification 6Chapter 2. Approaches to Community-based Breastfeeding Promotion and Support 7

Foundation for community behaviour change 7Partnerships 7Formative research 7Monitoring and evaluation 8Training and supervision 8Management and leadership 8

Community-level interventions 8Behaviour change communication 8Training community health-care providers 10Lay counsellors 10Women’s groups 11

Integration of breastfeeding with primary and preventive services 12Integration of breastfeeding and early childhood development strategies 13

Chapter 3. Case Studies of Community-based Breastfeeding Promotion and Support 14Madagascar 14Honduras 16India 17

Chapter 4. Application to Special Circumstances 20Mothers’ return to work 20Infants born to HIV-positive mothers 20Emergency situations 21

Summary and conclusions 23References 24Annex 1. Issues in breastfeeding measurement 28

Table of Contents

iv

Acknowledgements

Tables Table 1. Community-based breastfeeding support trials in developing countriesthat include healthy newborn infants and mothers 4

Table 2. Infant mortality (0–6 months) in Dhaka, Bangladesh comparingpartial and no breastfeeding to exclusive breastfeeding 5

Figures Figure 1. Key messages: what every family and community has a right toknow 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 integrationof 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 monthsin intervention vs control communities, India 19


v

The 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.

Acknowledgements


vii

Foreword

The 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

viii

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-GeneralFamily and Community Health

World Health Organization


1

Breastfeeding is an extension of maternal protectionthat transitions the young infant from the shelter

of the in utero environment to life in the ex utero worldwith its variety of potentially harmful exposures. Thepromotion, protection, and support of breastfeeding isan exceptionally cost-effective strategy for improvingchild survival and reducing the burden of childhooddisease, particularly in developing countries (Horton etal., 1996; Morrow et al., 1999; Sikorski et al., 2002;Arifeen et al., 2001; Black et al., 2003; Jones et al.,2003).

Scientific evidence has guided the development ofinternational recommendations for optimal infantfeeding practices, which include exclusive breastfeedingfor 6 months (breast milk only with no other liquidsor foods given) and continued breastfeeding up to 2years of age or beyond with timely addition ofappropriate complementar y foods. Theserecommendations were adopted following a systematicreview of current scientific evidence on the optimalduration of exclusive breastfeeding and an expertconsultation on the subject (Butte et al., 2002; Kramerand Kakuma, 2002; WHO, 2002). They are alsoincluded in UNICEF’s Facts for Life “Key Messages:What every family and community has a right to knowabout breastfeeding” (figure 1).

Compliance with these recommendations hassignificant child health and nutritional benefits. TheBellagio Child Survival Study Group has identifiedoptimal breastfeeding in the first year of life as one ofthe most important strategies for improving childsurvival (Black et al., 2003; Jones et al., 2003).Increasing optimal breastfeeding practices could saveas many as 1.5 million infant lives every year, giventhe significant protection that breastfeeding providesinfants against diarrhoeal disease, pneumonia, andneonatal sepsis (UNICEF, 2002; Black et al., 2003;

“…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 six

months and continued breastfeeding up to two years of age or beyond, while providing womenaccess to the support they require – in the family, community and workplace – to achieve

this goal.”

Global Strategy for Infant and Young Child Feeding, May 2002

Jones et al., 2003). Improved breastfeeding practicecan also have a positive effect on birth-spacing, whichcontributes to child survival (Labbok et al., 1997; Joneset al., 2003). Further, population-based studies in anumber of developing countries have shown that thegreatest risk of nutritional deficiency and growthretardation occurs in children between 3 and 15 months

Introduction

Key Messages: What every family andcommunity has a right to know aboutbreastfeeding

• Breastmilk alone is the only food and drink an infantneeds for the first six months. No other food or drink,not even water, is usually needed during this period.

• There is a risk that a woman infected with HIV can passthe disease on to her infant through breastfeeding.Women who are infected or suspect that they may beinfected should consult a trained health worker fortesting, counselling and advice on how to reduce therisk of infecting the child.

• Newborn babies should be kept close to their mothersand begin breastfeeding within one hour of birth.

• Frequent breastfeeding causes more milk to beproduced. Almost every mother can breastfeedsuccessfully.

• Breastfeeding helps protect babies and young childrenagainst dangerous illnesses. It also creates a specialbond between mother and child.

• Bottle-feeding can lead to illness and death. If a womancannot breastfeed her infant, the baby should be fedbreastmilk or a breastmilk substitute from an ordinaryclean cup.

• From the age of six months, babies need a variety ofadditional foods, but breastfeeding should continuethrough the child’s second year and beyond.

• A woman employed away from her home can continueto breastfeed her child if she breastfeeds as often aspossible when she is with the infant.

• Exclusive breastfeeding can give a woman more than98 percent protection against pregnancy for six monthsafter giving birth – but only if her menstrual periodshave not resumed, if her baby breastfeeds frequentlyday and night, and if the baby is not given any otherfood or drinks, or a pacifier or dummy.

(UNICEF, 2002)

Figure 1

2

Introduction

of age, associated with poor breastfeeding andcomplementary feeding practices (Shrimpton et al.,2001).

The Global Strategy for Infant and Young Child Feeding(2002), co-developed by WHO and UNICEF withbroad participation of governments and otherstakeholders, is a blueprint for current and future publichealth action to improve infant feeding practicesworldwide. The World Health Assembly and UNICEF’sExecutive Board adopted the strategy in 2002. Thefoundation of this strategy is built on two decades ofinternational and public health consensus and action,beginning with the Joint Meeting on Infant and YoungChild Feeding (1979), the International Code ofMarketing of Breast-milk Substitutes (1981), theInnocenti Declaration (1990), and the Baby-friendlyHospital Initiative (1991).

A novel contribution of the Global Strategy for Infantand Young Child Feeding is its comprehensive approach.The Global Strategy gives heightened attention tobreastfeeding and complementary feeding inexceptionally difficult circumstances, such as in HIV-prevalent areas and emergency situations. The strategyalso includes community-based interventions topromote and support infant and young child feedingas a new operational target. While significant progressin breastfeeding protection, promotion, and supporthas been made through emphasis on policy andmaternity health services, experience suggests thatachieving optimal infant and young child feedingrequires an integrated, comprehensive strategy thatincludes community-based interventions as well aspolicy and health services (figure 2).

The purpose of this document is to provide the rationaleand guideposts for community-based interventions topromote and support breastfeeding. This documentfocuses on the growing evidence that community-basedapproaches can significantly increase optimalbreastfeeding 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.

The first chapter of the paper places community-basedinterventions in an historical and communitydevelopment context and provides the scientificrationale for this approach. The second chapterdescribes key features of—and strategies for—community-based breastfeeding promotion andsupport, including integration with primary andpreventive health services. The third chapter presentsseveral countries’ experience implementing community-based strategies on a large population scale. The fourthchapter addresses challenging circumstances to considerin implementing community-based breastfeedingprogrammes around the world. The paper concludeswith a summary of key issues regarding community-based breastfeeding promotion and support.

Figure 2

Elements of a comprehensive breastfeedingprogramme

(Wellstart International, 1996)

• Pre-service curriculumreform

• Baby-friendly HospitalInitiative

• In-service training• Supportive supervision

• Communityparticipation

• Training andsupervision ofcounselling network

• Communityeducation

• National Breastfeeding Commission• Health System Norms• Code of Marketing of Breastmilk Substitutes• Worksite laws and regulations• Information, education and communication

HEALTH SERVICES COMMUNITY

• Information, education and communication• Monitoring, research and evaluation• Health information systems• Referral and counter referral

POLICY


3

Through most of the twentieth century, initiationand duration of breastfeeding declined worldwide

as a result of rapid social and economic change,including urbanization and marketing of breast milksubstitutes. In recent years the global trend has shiftedtowards improved breastfeeding practices. However, theprevalence of exclusive breastfeeding and other optimalinfant feeding practices is still low in many countries.Continued attention to breastfeeding is thereforeneeded to achieve the sustained behaviour change thatwill lead to significant improvement in child survivaland development.

Breastfeeding practices in developingcountries

In the past two decades, breastfeeding initiation andduration began to increase in many developingcountries (Grummer-Strawn, 1996; Lutter, 2000;UNICEF, 2001). Survey data from 43 countriesindicate a significant increase in exclusive breastfeeding,from 39% to 46% between 1989 and 1999, with widevariations within and between geographic regions(figure 3). For example, DHS surveys indicate thatexclusive breastfeeding rates for infants 0–3 months ofage range from 25% (Dominican Republic, 1996) to78% (Peru, 2000) in Latin America, and from 4% (Côted-Ivoire, 1998/99) to 63% (Malawi, 2000) in Africa.

In countries and regions where breastfeeding promotionand support programmes have been well enacted,notably some Latin American countries, rates ofexclusive breastfeeding and other optimal breastfeedingpractices appear to be improving more dramatically.Nevertheless, in many developing countries certaincultural beliefs continue to interfere with optimalbreastfeeding, especially feeding colostrum andbreastfeeding exclusively (Dimond and Ashworth,1987; Martines et al., 1989). In every culture, specificbeliefs that impede optimal breastfeeding need to beidentified through formative research and addressedthrough effective, well-designed behaviour changecommunication to promote and support optimal

Background and Context

breastfeeding practices (Wellstart, 1996; Guerrero etal., 1999; Green, 1989; de Zoysa et al., 1998).

Breastfeeding promotion and support:historical development

In May 1980 the World Health Assembly adopted therecommendations for promotion and support ofbreastfeeding that were made the previous year at aWHO/UNICEF Meeting on Infant and Young ChildFeeding (WHO, 1980). In the 1980s, workshops oninfant and young child feeding were organized in nearly100 countries. National breastfeeding committees andnational breastfeeding promotion programmes wereestablished in various countries (Jelliffe and Jelliffe,1988). In 1990 policy-makers from 31 governments,representatives of 8 UN agencies, and other participantsat a WHO/UNICEF meeting in Italy produced andadopted the Innocenti Declaration on the Protection,Promotion, and Support of Breastfeeding. TheInnocenti Declaration established operational targets

Chapter 1

Figure 3

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4

for breastfeeding that focused primarily on policy andhealth services (WHO, 1989).

From that declaration emerged the Baby-friendlyHospital Initiative (BFHI), which has made asignificant impact on breastfeeding practices globallythrough implementation of the “Ten Steps to SuccessfulBreastfeeding,” focusing on maternity services andnewborn care (WHO, 1998). The tenth step, theestablishment of breastfeeding support groups,connects mothers to community support after dischargefrom the hospital. Two other steps—antenatal care (step3) and breastfeeding guidance (step 5)—also involvematernal access to support and may reach beyond thehealth facility to the community.

The Global Strategy for Infant and Young Child Feedingadvances breastfeeding protection, promotion, and


support by building on these past and continuingconcepts and achievements. Over the past few years,experience in enacting community-based strategies hasgrown, along with a scientific evidence base to addressthe efficacy and effectiveness of certain supportstrategies (Green, 1999). As a result of the confluenceof policy development and the accumulation ofscientific evidence, the promotion and support ofoptimal breastfeeding through community-basedinitiatives is now more widely understood and accepted.

Evidence of effectiveness

This section describes 1) the evidence that community-based breastfeeding promotion and support canimprove breastfeeding practices in developing countriesand 2) the efficacy of such interventions to reduceinfant morbidity and mortality.

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(abstracted from Sikorski et al, 2002)* Significant at two-sided p<0.05

Table 1


5

IMPROVING BREASTFEEDING PRACTICES. Sikorski et al.(2002) conducted a systematic review and meta-analysisof the efficacy of support for breastfeeding mothers. Thisstudy identified 20 randomized or quasi-randomizedtrials of breastfeeding support conducted in 10 countries.Breastfeeding outcomes of interest were “anybreastfeeding” or “exclusive breastfeeding” for specificage groups. Overall the meta-analysis revealed asignificant, beneficial effect of breastfeeding support onduration of any breastfeeding, with the greatest effecton exclusive breastfeeding. Both lay and professionalsupport appeared to be effective, although in differentways. Lay counsellors appeared to be most effective inincreasing the duration of exclusive breastfeeding, whileprofessional counsellors appeared to be most effectivein extending the duration of any breastfeeding.

Most of the studies cited were conducted inindustrialized countries. Of the seven trials conductedin developing countries (Bangladesh, Brazil, Iran,Mexico, and Nigeria), five examined community-basedbreastfeeding counselling to mothers of normalnewborn infants (table 1). The sample size of eachindividual study ranged from 130 to 1,003 (total forall five studies, n=2,893 mother-infant pairs). In fourof these five studies, the intervention involved homevisits by peer counsellors; the remaining study (Froozaniet al., 1999) involved maternal contact in a hospitalby a trained nutritionist followed by home visits. Thenumber of visits made to mothers by breastfeedingcounsellors in these trials ranged from 3 to 12 or more(Haider et al., 2000). In most of the studies, counsellorswere trained using the WHO breastfeeding counsellingcourse in its original or adapted form; one study useda training course developed by La Leche League(Morrow et al., 1999). Four of five trials examinedexclusive breastfeeding, and each of these demonstratedsignificant impact of counselling on exclusivebreastfeeding. Only one of the four trials that examinedthe duration of any breastfeeding as an outcomedemonstrated a significant impact of counselling (Leiteet al., 1998).

Two other trials in developing countries included inthe Cochrane Review (Haider et al., 1996, inBangladesh and Davies-Adetugbo, 1997, in Nigeria)tested the effectiveness of breastfeeding counselling ofmothers whose infants were seen for diarrhoea in thehospital or health care centre. In both studies, for the2–3 weeks following counselling, exclusive breastfeedingwas significantly increased, and infants experiencedfewer repeat cases of diarrhoea.

REDUCING MORBIDITY AND MORTALITY. The WHOCollaborative Study Team on the Role of Breastfeedingon the Prevention of Infant Mortality found that indeveloping countries, any breastfeeding is associatedwith more than two-fold protection against infantmortality compared with no breastfeeding in the firstyear of life (WHO, 2000). A cohort study of 1,677infants living in the slums of Dhaka, Bangladesh, foundthat the relative risk of mortality in the first 6 monthswas more than two-fold lower in infants who wereexclusively breastfed than in infants who were partiallyor not breastfed (Arifeen et al., 2001) (table 2).Breastfeeding demonstrates a dose responserelationship to infectious disease morbidity andmortality in infancy, with exclusive breastfeedingoffering the most protection and partial breastfeedingintermediate protection when compared to nobreastfeeding (Brown et al., 1989; Victora et al., 1989;Morrow et al., 1992). Thus, infants under 6 monthsof age who are not breastfed are estimated to have agreater than 5-fold increased risk of morbidity andmortality from diarrhoea and pneumonia compared toinfants who are exclusively breastfed (Victora et al.,1989; Black et al., 2003).

A randomized, controlled trial of healthy infants inMexico City found that home-based breastfeedingcounselling was associated not only with a significantincrease in exclusive breastfeeding, but also with asignificant decrease in the percentage of infants whoexperienced a physician-diagnosed episode of diarrhoeaat any time during the first three months of life (one-tailed p<0.05 [Morrow et al., 1999]). The trial byFroozani et al. (1999) reported significantly fewer daysof diarrhoea among infants of mothers in thebreastfeeding counselling group (1.2 [SD 2.7])compared with those in the control group (4.0 [SD7.1] days, p<0.004). Similarly, a randomized,controlled trial of community-based breastfeedingsupport conducted in Haryana, India (see Chapter 3),

RR (95% CI)Causes of Infant Death Partial/no BF vs. EBF

All Causes 2.2 (1.4 – 3.4)

Diarrhoea 3.9 (1.5 – 10.6)

Acute Respiratory Infection 2.4 (1.1 – 5.2)

Infant mortality (0-6 months) in Dhaka,Bangladesh comparing partial and nobreastfeeding to exclusive breastfeeding

(Arifeen et al, 2001)

Table 2

6


described significant increases in exclusive breastfeedingand significant decreases in infant diarrhoea inintervention communities (Bhandari et al., 2003).These findings are consistent with a trial of the Baby-friendly Hospital Initiative intervention in Belarus,which reported that the rates of diarrhoea and of atopicdisease were significantly reduced among infants in theintervention group compared with controls (Krameret al., 2001). Thus, observational and experimental dataprovide compelling evidence that effective community-based breastfeeding interventions can result insignificantly increased optimal breastfeeding andsignificantly lower infant morbidity and mortality.

Framework and justification

Optimal breastfeeding requires maternal choicecombined with the ability to implement that choice(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.

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

Model of determinants of breastfeedingbehaviour

(Lutter, 2000)

Proximatedeterminants

Intermediatedeterminants

Underlyingdeterminants

Opportunities to acton these choicesMaternal choices

Infant feeding information and physicaland social support during pregnancy,

childbirth and post-partum

• Familial, medical, and cultural attitudesand norms

• Demographic and economic conditions• Commercial pressures• National and international policies and

norms

Infant Feeding Behaviours

Figure 4

terms, these elements translate into providing motherswith acceptance, encouragement, timely and salientinformation regarding breastfeeding, and practical skillsand strategies for overcoming socioeconomic, cultural,or biomedical obstacles to optimal breastfeeding.

Involving community leaders, social support networks,the health sector, and community members inbreastfeeding promotion and support provides amechanism for shifting cultural knowledge, norms, andexpectations (WHO, 2002). In short, community-basedbreastfeeding promotion and support can be justifiedon grounds not only of effective breastfeedingbehaviour change leading to increased child survival,but also of women’s empowerment and communitydevelopment. The following chapter addresses theconcepts and strategies that underlie community-basedbreastfeeding promotion and support.


7

Approaches to Community-based BreastfeedingPromotion and Support

Chapter 2

An interagency working group including WHO,UNICEF, USAID, the World Bank, the Department

for International Development (DFID) and the COREconsortium of nongovernmental organizations hastargeted the reduction of childhood morbidity andmortality using an approach that works with and throughcommunities, and extends integrated facility-based carefor management of common childhood illnesses tosupport for prevention and good home care (WHO etal, 2002). The working group advocates a community-based approach that involves people from thecommunity, adapts to community needs, builds onexisting resources and avoids duplication, strengthenslinks and builds bridges between groups in thecommunity and between those groups and the formalhealth system, focuses on outcomes, and is cost-effectiveand sustainable. At the heart of efforts is the promotionand support of a set of key family behaviours to improvechild health and development. These behaviours includeoptimal infant and young child feeding practices.

Community-based breastfeeding promotion and supportis important insofar as this approach can achievesustained population-level breastfeeding behaviourchange. This ambitious goal requires systematicapplication of behaviour change theory to strategies thatengage individuals and multiple levels of society.Community-level change involves attention tocommunity capacity (the foundation for change) as wellas specific interventions intended to produce behaviourchange (Wandersman et al., 1996). The section belowconsiders the foundation for community-levelbreastfeeding behaviour change, describes specificinterventions, discusses the integration of community-based breastfeeding initiatives with preventive andprimary health care services, and considers the argumentfor integration of breastfeeding and early childhooddevelopment initiatives.

Foundation for community behaviourchange

Community-based intervention strategies include thosethat mothers experience directly, as well as elements that

individual mothers may not experience but that createand sustain the community’s capacity for breastfeedingpromotion and support. These latter elements, whichcan be considered the foundation for effective andsustained action, include the development ofintersectoral partnerships or coalitions, formativeresearch, monitoring and evaluation, training andsupervision, strong management, and visionaryleadership.

PARTNERSHIPS. The formation of intersectoralpartnerships or coalitions increases the capacity foreffective and sustainable community-based behaviourchange (Butterfoss et al., 1993). At the community levelin developing countries, such partnerships may includethe ministry of health, other ministries concerned withsocial welfare, community health centre staff, identifiedopinion leaders, nongovernmental agencies, andwomen’s groups.

FORMATIVE RESEARCH. Formative research can beinvaluable to guide effective action on breastfeeding aswell as other public health concerns (Pelto et al., 1991;Guerrero et al., 1999; Martines et al., 1989). Thepurpose of such research is to clarify the values, beliefs,and practices that most significantly affect breastfeedingbehaviour, and with that understanding to shapemessages and approaches that are likely to result inpositive breastfeeding behaviour change. For example,formative research conducted in Mexico indicated thatmothers believed they should introduce another liquidor food when the baby was “thirsty,” the baby or motherwas ill, or the mother was emotionally upset (Guerreroet al., 1999). These findings were used to developmessages, materials, and training programmes forphysicians and lay counsellors to influence attitudes andbehaviours that impeded exclusive breastfeeding in theperiurban Mexican setting. “Breast milk is sufficient toquench a baby’s thirst, even in hot weather” was one ofthe messages developed in response to the formativeresearch. “Mother’s milk is better than any other methodof feeding a young infant, even when a mother isemotionally upset (has coraje or susto)” was another keymessage. These specific messages helped to ensure that

8

the lay counselling intervention achieved significantchange in exclusive breastfeeding behaviour (Morrowet al., 1999).

MONITORING AND EVALUATION. Another way to tie datato action is through monitoring and evaluation. Datacan provide potent motivation for action when specificbehaviour change goals are identified, measured asindicators, and used for local ongoing evaluation ofeffectiveness. The development of a monitoring systemthat allows local and routine use of data builds capacityfor community-level change and creates a neededevidence base for effective pubic health action (De Zoysaet al., 1998; Morrow, 2000).

TRAINING AND SUPERVISION. Training and supervisionof health-care providers and lay volunteers forbreastfeeding counselling and community outreach arealso important elements of the foundation for changeand an effective community-based breastfeedingbehaviour strategy. Providers and volunteers needaccurate information and mastery of skills in counsellingand communication to support and motivate communitymembers.

MANAGEMENT AND LEADERSHIP. Finally, the foundationfor change requires vision and managerial and leadershipskills. Implementation falters in the absence of theseelements. Managers’ failure to adjust programmes tonew realities jeopardizes programme sustainability.

Community-level interventions

With the elements outlined above in place, the specificcommunity-based interventions are more likely tosucceed. An effective community-based breastfeedingbehaviour change strategy is multifaceted, with attentionto behaviour change communication, partnership withthe health sector, and involvement or mobilization ofthe community through engaged opinion leaders,women’s support groups, and trained health-care workersand lay counsellors.

BEHAVIOUR CHANGE COMMUNICATION. Improvedbreastfeeding practices are more likely to occur ifwomen perceive them as beneficial, feasible, andsocially acceptable. Improving practices at thecommunity level requires behaviour change strategiesthat lead to changes in community norms, includingindividual and group approaches. A breastfeedingwoman typically does not make decisions alone. Forexample, a woman may hear about exclusivebreastfeeding at the health facility but then be told byher mother-in-law that babies need additional water to

Approaches to Community-based Breastfeeding Promotion and Support

quench thirst. If giving only breast milk to her three-month-old baby will result in the disapproval of hermother-in-law and potentially her community, thewoman may decide that the risk of adopting therecommended practice is too great. Communicationstrategies must therefore address not only individualbehaviour change of the mother, but also the beliefs ofthose who influence her at all levels: health workers,family members, elders, and community members.

Two broad paradigms are currently used for improvinghealth behaviours: 1) the behaviour change approach,with its roots in individual psychology andbehaviourism and 2) community-based participatoryapproaches to empower people to improve theircommunities in a sustainable way. Successfulbreastfeeding programmes have employed both of theseapproaches. The Transtheoretical (Prochaska, 1982)or Stages of Change Model is a useful tool for lookingat the process of individual change. In this model theindividual moves from pre-awareness of therecommended practice to awareness, contemplation oftrying the new practice, trial of the practice, adoptionof the practice, maintenance, and finally advocacy ofthe new practice. This model enables practitioners firstto identify the stage of the target audience and then tostructure interventions to move individuals along theprocess of change.

In the past health communicators often focused entirelyor disproportionately on one or more stages, such asproviding information to increase knowledge, only tofind themselves frustrated when practices did notchange. The Stages of Change Model indicates that“knowledge” is not enough. A woman may be able torecite messages about exclusive breastfeeding(“knowledge”) but may not think that they apply toher. If health workers ask the woman to try a newpractice such as not giving water to her baby for a week,the woman and her family will immediately see forthemselves the advantages of exclusive breastfeedingand may be convinced to adopt it. Thus, the individualis persuaded through negotiation to move along thechange process from “knowledge” to “trial,” increasingthe chances of adoption. Figure 5 shows specificinterventions that can be used to promote change inindividual behaviour or community norms at variousstages.

To maintain the new practice, a woman needs supportfrom her family and community. Successfulbreastfeeding programmes have used group approachesthat address special audiences or the collectivecommunity while strengthening the capacity of


9

community organizations. Encouraging communitygroups to identify and solve problems increases supportfor the mother’s decision and increases the likelihoodthat she will maintain the new behaviour.

The Diffusion of Innovation Theory (Rogers, 1983) isuseful for examining how innovative ideas areintroduced and adopted in a community. “Earlyadopters” are the risk takers; “late adopters” are theones who wait to see how well the innovation works.Innovations are more easily adopted when they havecertain characteristics, such as ease of adoption,similarity to current practice, low level of risk in tryingout the practice, and benefits that outweigh thedisadvantages. When an innovation is introduced to acommunity by a risk-taking early adopter, othersobserve the results and gradually adopt the practicethemselves. Long-term change of a community norm

occurs when a critical mass of community membershave tried the innovation and begun to see its benefits.Communication strategies can hasten this processthrough the use of lay counsellors to facilitatediscussions in mother support groups, communitydevelopment groups, credit associations, or religiousgroups for men or women.

Formative research can help target clear and effectivemessages to specific populations or community groups.Such tailored messages can help reduce the perceivedrisk of trying the new behaviour and enable people tounderstand how adopting the new practice bringsbenefits to them and to the community. Strengtheningcommunity organizations can increase the community’scapacity to change norms and improve infant feedingbehaviours.

Movement from one stage of change to another requires a mix of appropriate communication interventions from the followingcategories:

• 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.

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Stages of change and communication approaches

(LINKAGES Project)

Figure 5

10


TRAINING COMMUNITY HEALTH-CARE PROVIDERS.Mothers in many countries cite the advice of health-care providers as the reason for their making specificinfant feeding decisions. Unfortunately, advice fromhealth-care providers is too often uninformed,undermining efforts to support mothers who elect tobreastfeed. Breastfeeding has been neglected in pre-service and in-service training of most health workers,leaving a serious gap in their knowledge and skills. Asa result WHO, UNICEF, and others have placed a majoremphasis on training health-care workers in thefundamentals of lactation and breastfeeding counselling(Rea et al., 1999; Cattaneo et al., 2001). WHO andUNICEF have created several standardizedbreastfeeding courses. These include an 18-hour coursedesigned to help staff of maternity facilities makematernity care “baby-friendly” (UNICEF, 1993) and a40-hour course to develop clinical skills in breastfeedingcounselling for health-care workers in all parts of thehealth system (WHO, 1993). Basic knowledge andskills promoted in these tools are also applied in casemanagement guidelines and an 11-day training coursefor first-level health workers developed as part of theIntegrated Management of Childhood Illness (IMCI)strategy (see discussion on integration of breastfeedingwith primary and preventive health services – page12).

A randomized controlled trial of the effectiveness of the40-hour WHO training course was conducted in Brazilwith health workers from 60 health units. This studyfound that participants’ knowledge and skills inbreastfeeding counselling improved significantly, bothimmediately after the course and three months later (Reaet al., 1999). The responses of participants andobservation, however, suggested that the skills involvedin clinical practice and management of lactation neededmore time for development and reinforcement.

Although increasing the breastfeeding knowledge andskills of health-care providers has been an importantand necessary element to promote and sustainbreastfeeding behaviour change, this training is notreadily available to all health-care workers and tends tobe expensive and hard to sustain. To address the traininggap, some countries are undertaking a systematic reviewof their pre-service curricula for training doctors, nurses,and midwives and are strengthening the lactationmanagement and infant feeding components of thosecurricula so that providers do not need to be retrainedafter they have started practice. Use of the 40-hour and18-hour breastfeeding courses continues to berecommended for health-care providers who typicallylack appropriate pre-service education in this arena.

LAY COUNSELLORS. Even community healthprofessionals who are well trained in breastfeeding andlactation management typically lack sufficient time topromote and support breastfeeding. As a result, laycounsellors have become critical to providing accessiblebreastfeeding counselling in many communities. Whenlay breastfeeding counsellors, who are not professionalhealth-care workers, are trained to provide breastfeedingcounselling to mothers of their communities, they canbe highly effective in increasing exclusive breastfeedingand, potentially, early initiation and longer duration ofbreastfeeding (see Evidence of effectiveness, Chapter 1).

The terms “lay counsellor” or “peer counsellor” are oftenused interchangeably. More precisely, however, peercounsellors are typically women who have given birthto at least one child and have breastfed successfully. Peercounsellors have a background similar to that of thepeople they are counselling. Some propose that to becredible, lay counsellors should be peers. However,experience in many circumstances suggests thatcommitted and well-trained lay counsellors, like healthprofessionals, can be successful even when theythemselves have not had personal breastfeedingexperience. Indeed, La Leche League International,which has been training breastfeeding peer counsellorssince 1987, notes that the demand for peer counsellorsis so great that many such counsellors are now womenand men who do not meet the traditional concept ofpeers.

Haider and others (2002) recommend systematic andwell-supervised training, recruitment, and deploymentof lay breastfeeding counsellors. Lay counsellors alsoneed ongoing connection to an organization that cansustain their efforts. Such a connection could be to anongovernmental organization such as La Leche Leagueor through the community outreach activities of thehealth system. Depending on the community andcircumstances, lay counsellors may serve entirely asvolunteers or receive stipends to help support theiractivities. Some organizations have reported a highturnover rate among volunteer counsellors and havefound that some form of stipend helps volunteers tocontinue in this role. Others have retained volunteersprimarily through personal connection, praise,recognition, and continuing education (Green, 1998).

Studies of the effectiveness of lay counsellors inincreasing breastfeeding have examined their role inhome visitation. The specific activities of lay counsellorscan vary substantially. Depending on circumstances,lay counsellors may work alongside community healthworkers in clinic settings or may focus on making


11

routine visits to the homes of pregnant or breastfeedingmothers. Lay counsellors may provide individual-levelcounselling to mothers, lead breastfeeding supportgroups, or give talks to community groups aboutbreastfeeding. The 40-hour WHO/UNICEF course onbreastfeeding counselling, originally developed forhealth-care professionals, has been successfully usedas the basis for training lay and peer counsellors. LaLeche League International also offers a peer counsellortraining programme.

WOMEN’S GROUPS. Community-based support forbreastfeeding mothers often focuses on breastfeedingsupport groups. The first formal recognition of abreastfeeding support group might be the 1956formation of La Leche League, which provides theprototype for such groups. The purpose of abreastfeeding support group is to provide “mother-to-mother” encouragement and assistance to initiate andsustain breastfeeding. Trained volunteers lead groupmeetings. The focus of the meetings is almost entirelyon breastfeeding, with consideration of related topics.The atmosphere of breastfeeding support groups is oneof acceptance and equal participation. In thisatmosphere mothers feel comfortable sharingexperiences, asking questions, and obtaining answersregarding their experience with breastfeeding. Thismodel is now being used in many countries.

In addition to women’s groups focused primarily onbreastfeeding, other forms of women’s groups havebecome involved in breastfeeding promotion andsupport (figure 6). Some women’s groups addressbreastfeeding as part of their discussion of parentingor nutrition and health topics. Other women’s groups,founded for economic development, communityservice, or social, political, or religious reasons, havealso participated in breastfeeding promotion andsupport. These groups may include breastfeeding-related topics as part of their programmes to educateand support members or attendees and may providevolunteers for breastfeeding education support as partof their community service and outreach. Available datasuggest that participants in women’s support groupsimprove their breastfeeding behaviour, but questionsremain whether volunteer groups alone are sufficientto affect and sustain population-level behaviour change.

Despite their growing popularity for breastfeedingpromotion and support, women’s groups have not beenstudied extensively (Green, 1998). La Leche League’smodel, however, has been evaluated in Honduras andGuatemala, which have had exceptional programmes.In Honduras La Leche League trained peer counsellors

in a low-income, periurban area. On follow-up, mothersof infants under 6 months of age who had contact withthe peer counsellors practiced exclusive breastfeedingfor an average of 10 weeks compared with 4 weeks formothers in the control group (Rivera et al., 1993). Inanother study La Leche League of Honduras trainedpeer counsellors in 20 rural communities to leadmonthly breastfeeding support meetings and visit 1–2mothers each at home. Mothers who had contact withthe peer counsellors were three times more likely thanother mothers to practice exclusive breastfeeding atthree months postpartum (AHLACMA et al., 1993).In Guatemala, La Leche League trained peer counsellorsand formed breastfeeding support groups in about 10periurban communities. A study conducted more thanthree years after the end of funding found that theprogramme had been sustained: one-quarter of womenin the community had contact with a breastfeeding peercounsellor either through support groups, home visits,or other contacts (de Maza et al., 1997).

A community intervention trial undertaken inperiurban Guatemala as a collaboration of La LecheLeague and the LINKAGES Project found that afterone year the rate of exclusive breastfeeding inintervention areas with peer counsellors did notsignificantly increase compared with the controlcommunities (Dearden et al., 2002a). However, only

Model 1a. Breastfeeding Support Group

• Convened specifically to support breastfeeding mothers.• Interested women attend meetings held in health centres,

homes, or other accessible locations. Meetings are oftenled by trained volunteer leaders who invite and encourageparticipants.

• La Leche League is the prototype for this approach.

Model 1b. Mother’s Support Group with a broaderpurpose

• Convened to further a maternal and child healthbehaviour and/or nutrition agenda inclusive of, andcompatible with, breastfeeding.

Model 2. Community mobilization that engagesexisting social groups

• Groups convened for purposes other than breastfeeding,such as social, economic, educational, or religiouspurpose.

• Groups provide volunteer base for peer counsellors anda channel for behaviour change communication (socialmarketing).

• Groups provide support and encouragement to the peervolunteers.

Models of women’s groups inbreastfeeding promotion and support

Figure 6

12

31% of mothers in the intervention communities withinfants under 6 months of age had any contact with apeer breastfeeding counsellor. As in previous studies,exclusive breastfeeding was higher among women inintervention communities who were exposed to LaLeche League support groups and home visits thanamong women who were not exposed (Dearden et al.,2002a).

Microenterprise programmes represent another modelof women’s groups. An evaluation of Freedom fromHunger’s Credit with Education Programme, managedby the Lower Pra Rural Bank in Ghana, found majorimprovements in breastfeeding practices amongprogramme participants between the 1993 baseline and1996 follow-up surveys. Women not involved in theprogramme did not show improved practices: 98% ofprogramme participants gave colostrum, compared withonly 71% of non-participants and 78% of women incontrol communities. Further, programme participantsdelayed introduction of water to their infants until anaverage of 125 days of age, compared with 63 days fornon-participants and 51 days for women in controlcommunities (McNelly, 1997; Green, 1998).

As experience with community-based breastfeedingpromotion and support deepens, diverse approaches arebeing used for forming and involving women’s groups.In some regions existing women’s groups providevolunteers to work with the breastfeeding initiatives ofthe health sector. In other regions new support groupsare formed focused on the breastfeeding experiences ofthe women who attend. More rapid change may beachieved by using existing women’s groups for outreachpurposes than by establishing new groups focused onbreastfeeding support. However, experience suggests thateither approach may be effective for breastfeedingpromotion and support, depending on the aims, timeframe, culture, and circumstances.

Integration of breastfeeding with primaryand preventive health services

Community-based approaches to breastfeeding areunlikely to succeed or to be sustained without theinvolvement of the health sector. Breastfeedingcounselling should be supported within the health caresystem at a number of contact points that correspondto time points along the maternal-child life course,including antenatal, postnatal, well-baby, sick-baby, andimmunization health service visits. In other words,support for breastfeeding should be interwoven withreproductive health, primary care, and maternal andchild nutrition messages delivered in clinical settings


1 Full breastfeeding is the term applied to both exclusivebreastfeeding (no other liquid or solid given to infant) andalmost exclusive breastfeeding (vitamins, water, juice, orritualistic feeds given infrequently in addition tobreastfeeds). Nearly full breastfeeding means that the vastmajority of feeds are breastfeeds.

and through the media and other channels ofcommunication. Reproductive health services, includingmaternity care and family planning services, are criticalavenues for breastfeeding promotion and support. Manystudies have shown that early initiation of breastfeedingand later breastfeeding practices are strongly associatedwith the support or the barriers experienced withmaternity services. The Baby-friendly Hospital Initiativewas designed to address this issue, although the conceptshould be extended to perinatal care delivered in homesand clinics.

A natural point of integration between reproductivehealth services and breastfeeding is education andsupport of mothers regarding use of the lactationalamenorrhoea method (LAM), a well-documentedmethod of contraception. This method has been shownto have 98% efficacy for the first 6 months postpartum(Labbok et al., 1997). Use of LAM requires thatmothers practice full or nearly full breastfeeding1, donot experience return of their menses, and have notpassed the first six months postpartum. Mothers whopractice this method are also encouraged to switch toother family planning methods when any of one of thesecriteria is no longer met.

Breastfeeding promotion and support is also a keyintervention in the IMCI strategy (WHO, 1999). Thisstrategy is championed by WHO and health agenciesworldwide as the foundation for pediatric primary careand improved child health outcomes in developingcountries. The strategy involves strengthening thequality and accessibility of primary care by addressingthree major dimensions of the care delivery process—the health system, the skills of health staff, and familyand community practices. Based on this comprehensiveapproach, IMCI encompasses a range of specificinterventions to prevent and manage the major causesof childhood morbidity and mortality, integratingfeeding counselling as an essential aspect of clinicalcare. At this stage of implementation, substantialintegration of IMCI with other breastfeeding promotionand support initiatives has been achieved in only a fewplaces in the world, but emphasis has been given tocreating more effective approaches to outreach anddeveloping community-based breastfeeding supportthat is well integrated with IMCI. There is a need foradditional well-designed trials to examine the impact


13

of breastfeeding support in the primary care setting(Guise et al., 2003).

Integration of breastfeeding and earlychildhood development strategies

To 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.

14

Case Studies of Community-based Breastfeeding Promotion

Case Studies of Community-basedBreastfeeding Promotion

Chapter 3

This section provides case studies of community-based breastfeeding promotion and support in

three developing countries: Madagascar, Honduras, andIndia. The Madagascar and Honduras case studiesrepresent large-scale projects that involve major regionsof each country. The case study in Haryana, India, wasa large randomized, controlled trial. The Haryana studyis included because it was designed to provide a pilotfor sustainable services at scale through themobilization of existing community resources. It alsoprovides evidence that it is possible to improvecomplementary feeding practices through well-targetedcommunity interventions.

Each case study builds on intersectoral partnershipsand uses community-based approaches to increaseexclusive breastfeeding. Core elements of successfulcommunity-based breastfeeding promotion and supportare evident in these three examples, but each has uniqueelements and strategies. Different approaches used inthese programmes in measuring breastfeeding statusare discussed in the annex to this paper.

Madagascar: Integrated child survival,family planning, and nutrition

In Madagascar the Ministry of Health and theLINKAGES Project developed a programme to improvebreastfeeding practices at a scale that would achievesignificant public health impact. LINKAGES is a globalproject funded by the United States Agency forInternational Development (USAID) and managed bythe Academy for Educational Development. Theproject’s goal is to improve breastfeeding and relatedcomplementary feeding and maternal dietary practicesand to increase the offering of the lactationalamenorrhea method of family planning.

During the first two years of the programme (1997–1999), LINKAGES provided support to the Ministryof Health for national policy activities, particularly theestablishment and coordination of an intersectoralnutrition action group representing approximately 50organizations. The mobilization of a critical mass of

nutrition advocates at the national level; theharmonization of nutrition messages by this group; andthe group’s development and use of the samecommunication materials, nutrition guidelines, andprotocols helped create a favorable environment forbehaviour change (LINKAGES, 2002).

In 1999 LINKAGES, in partnership with Jereo SalamaIsika (JSI), initiated district and community activitiesin 10 districts in 2 of the country’s 6 provinces and in2001 expanded to 13 more districts. These activitiesnow reach about 6 million people. Grassrootsorganizations and district and local “champions ofchange” implement the vast majority of the activities,with LINKAGES providing technical assistance,training modules, and materials to help them succeedin their efforts. By integrating behaviour changeinterventions with existing community programmes,LINKAGES was able to expand its reach and coverageand “fast track” the programme.

The community approach in Madagascar builds on theIMCI strategy adopted by the Ministry of Health andsupported by other donors and organizations. Elementsof reproductive health related to breastfeeding, suchas LAM, are incorporated in the approach. As illustratedin Figure 7, breastfeeding serves as an entry point tothe community to address nutrition, child health, andfamily planning issues.

Breastfeeding promotion and support as anapproach to integration of primary healthcare services

(LINKAGES Project, Madagascar)

Figure 7

NUTRITION

ESSENTIALS

IMCIREPRODUCTIVE

HEALTH

BREASTFEEDING


15

In Madagascar LINKAGES promotes breastfeeding aspart of seven action areas: exclusive breastfeeding forthe first six months, appropriate complementaryfeeding beginning at six months with continuedbreastfeeding to two years and beyond, feeding of thesick child, women’s nutrition, control of vitamin Adeficiency, control of anemia, and consumption ofiodized salt by all families. These behaviours arepromoted at six critical health contact points: 1)antenatal, 2) delivery and immediate postpartum, 3)postnatal and family planning, 4) immunization, 5)growth monitoring and well child consultations, and6) sick child consultations. This integrated strategygreatly expands nutrition contacts beyond traditionalgrowth monitoring and promotion programmes.

The programme uses a combination of interpersonalcommunication strategies, group activities, and mediato change individual behaviour, while at the same timeeducating and engaging those who influence mothers’choices. Home visits and counselling at health facilitiesprovide opportunities for health workers andcommunity volunteers to negotiate with mothers to“try out” a new practice. Nutrition promoters drawnfrom women’s groups engage in outreach activities,including lay counselling, health talks, and facilitateddrama to stimulate participants to think about tryingthe new behaviour and supporting their familymembers’ decisions. In addition to scheduled activities,the volunteers promote better infant and young childfeeding practices during informal contacts with womenin their communities.

Media strategies feature radio and television spots,traditional singers, and songs by a popular singer whoserves as the country’s breastfeeding and nutritionambassador. Journalists participate in many of thetraining activities and project events, resulting in freepress and media time, stories, and special shows.Community events such as village theatre and festivalsoffer forums for conveying key messages. Serviceproviders and community volunteers receive trainingin the Essential Nutrition Actions; key messages;counselling and negotiation techniques; and the use ofcounselling cards, job aids, and child health booklets.In this way specific audiences repeatedly hear the samekey messages from health professionals, communityvolunteers, and the media.

In sum, LINKAGES’ behaviour change strategyincludes the following elements:

• Formative research to identify factors (benefits andbarriers) to change and key actions (specific

behaviour changes that are feasible and “do-able”to achieve the desired outcomes)

• Targeted, concise messages to promote “do-able”actions

• Short, periodic, and practical training for healthworkers, community volunteers, and members ofwomen’s groups, in counselling techniques so theycan negotiate trial of small do-able actions

• Consistent messages and materials across allprogramme channels to address critical behaviours

• Saturation of specific audiences with messages throughall appropriate media (electronic, print,interpersonal, traditional)

LINKAGES’ multifaceted behaviour change approachhas resulted in measurable change in knowledge andbehaviour within a short period of time. Using a rapidassessment procedure (RAP), LINKAGES collectedquantitative and qualitative data in October 2000,October 2001, and November 2002 to evaluate theeffectiveness of its district-level behaviour changestrategy to improve breastfeeding and complementaryfeeding practices.

The rapid assessments were conducted in communesin each of the 10 districts where LINKAGES hadinitiated activities in 1999 and in 1 control district.Because the goal of the evaluation was to assess theeffectiveness of the behaviour change strategy,communes with active women’s groups that showedevidence of embracing this strategy were included.

Participants were selected to represent all activity targetgroups, both those trained directly by LINKAGES or,in the case of mothers, the intended beneficiaries ofthe training. The findings are based on interviews withmothers of children less than 12 months of age (303women in 2000, 693 in 2001, and 670 in 2002). The1997 Demographic Health Survey, the project’sbaseline surveys, control data, and other countrystudies serve as points of comparison.

In the 2000 RAP, the rate of exclusive breastfeeding ofinfants less than 6 months of age in the past 24 hourswas 68% in the programme area, compared with 45%–47% from DHS, baseline, and control surveys(p<0.001). In the 2001 RAP, the exclusivebreastfeeding rate rose to 79%. In 2002, after one yearof no direct programme intervention because of politicalcrisis, the rate was 76% (figure 8). The most dramaticincreases in exclusive breastfeeding were among infants4 and 5 months of age—12% at baseline to 61% at the2001 RAP, although this dropped to 58% in 2002

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during a political crisis in the country (Guyon et al.,2001; Rahantanirina et al., 2002).

Data collected in the 2000 RAP indicated that earlyinitiation of breastfeeding more than doubled in theprogramme area to 73%, compared with 34% in theDHS, baseline survey, and control site (p<0.001), asshown in figure 9. The slight decrease (to 71%) in the2001 RAP is not statistically significant and the rateincreased in 2002 to 77%.

In both 2001 and 2002 RAP surveys, infants less than6 months old who were not exclusively breastfed weresignificantly more likely to have had a diarrhoeal episodein the 2 weeks prior to the survey than infants whowere exclusively breastfed. In 2001 infants who werenot exclusively breastfed had a relative risk of diarrhoeaof 3.75 compared with exclusively breastfed infants(p=0.02). In 2002 infants who were not exclusivelybreastfed had a 2.7-fold relative risk of diarrhoeacompared with exclusively breastfed infants (p=0.04).

In the first year of the programme, complementaryfeeding was not a major focus. Consequently no dataon complementary feeding were collected during thebaseline survey or the 2000 rapid assessment. In 2001the programme placed greater emphasis on this criticalaspect of infant and young child nutrition. The 2001RAP showed no difference in the programme and controlareas in the proportion of mothers of infants 6–<10months who fed their infants complementary foods inthe previous 24 hours (92% and 89%). In 2002 therespective rates were 93% and 80%.

The approach used by LINKAGES in Madagascarencouraged the coordination of efforts to improve childsurvival, growth, and development and broughtpartners together to achieve results. The Madagascarprogramme can serve as a model for countries wantingan integrated approach that can be adapted to addressspecific nutrition problems.

Honduras: Growth monitoring andpromotion

In Honduras the Ministry of Health developed andchampioned a national growth monitoring andpromotion strategy known as Atención Integral a la Niñez(AIN), or Integrated Child Care. This programme hasbeen advanced in partnership with BASICS, a globalchild survival project funded by the United StatesAgency for International Development.

BASICS in Honduras focuses on four strategicobjectives to achieve sustainable improvements infamily health: 1) increased use of oral rehydrationtherapy (ORT) for diarrhoea, 2) appropriate careseeking for acute respiratory infections (ARI), 3)appropriate child feeding, and 4) appropriatebreastfeeding. Major partners include UNICEF, PAHO,the American and Honduran Red Cross, Mercy Corps,Save the Children, CARE, and PRAF (a governmentsocial welfare programme). AIN has become a modelfor targeting services to those most in need by focusingon health promotion as well as disease treatment andby empowering community management of healthservices. To strengthen household practices related to

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Exclusive breastfeeding in the first 6months of life, Madagascar

Figure 8


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AIN themes, the programme Comunicación en saludinfantil, or Communication in Child Health, wasdeveloped. This programme reinforces key practices andmobilizes important community agents, such as radiobroadcasters and religious leaders.

The AIN programme in Honduras began in the early1990s when the Ministry of Health chose adequategrowth—measured by assessing monthly weight gain—as the primary indicator of child health. Theprogramme emphasized solving problems of illness,poor feeding practices, and general child care at thehousehold level in the critical first two years of life,when children are most susceptible to permanentdamage from malnutrition. To maximize populationcoverage, the Ministry of Health offered growthpromotion in the community in selected areas in 1992and 1993. In 1994 the ministry defined AIN as itsprimary child health strategy, implemented AIN ingovernment facilities, included standard casemanagement in the strategy, and expanded thecommunity programme.

From 1995 to 1997 the Ministry of Health, inpartnership with BASICS, introduced new strategiesto strengthen the AIN programme, including simple,standardized information feedback to each communityon its progress; a stronger emphasis on illnessmanagement; development and use of counselling cards;and application of the trials of improved practices(TIPS) methodology to identify appropriate feedingrecommendations and engage families in improving thedietary intake of their children. Using newly developedmaterials for the community programme, AIN beganin 1997 to train nursing staff from 9 of its 42 healthareas. The programme was then introduced inintervention communities, with IMCI instituted at thefacility level to strengthen the clinical component.

The midterm evaluation of the AIN programmecompares intervention communities with controlcommunities served by the same health centres. Theevaluation included 474 AIN households and 464control households in the 1998 baseline survey and596 AIN households and 572 control households inthe 2000 follow-up survey. The follow-up survey resultsdemonstrated that the AIN programme coverage washigh in the intervention communities: 92% of childrenunder 2 years of age were enrolled in growth monitoringand promotion programmes compared with only 21%of children under 2 years of age in control communities.Breastfeeding was assessed by asking mothers whetherthey had ever breastfed their children, whether theywere currently breastfeeding their children, how

frequently they breastfed, and generally how they werefeeding their children (breastfeeding exclusively, givingbreast milk with other liquids, giving breast milk withother foods, or only giving other foods with no breastmilk).

In both AIN and control communities, nearly all mothersindicated that their children under two years of age wereever breastfed. However, 39% of mothers of childrenunder six months of age in the AIN communities,compared with 13% in the control communities,practiced exclusive breastfeeding (p<0.001). Thepattern was similar for children under four months ofage (figure 10). In addition, the mean age for introducingspecific liquids or complementary foods was significantlyhigher in AIN communities than in control communities.

Caregivers’ knowledge about optimal infant and youngchild feeding practices improved significantly. AINhouseholds were more likely than control householdsto identify improved growth as a benefit of breastfeeding.The majority of women in AIN households were awareof exclusive breastfeeding, and 80% of those womencorrectly identified 6 months as the appropriate durationof exclusive breastfeeding. As the AIN programmecontinues to grow, the expectation is that it will reachapproximately 60% of Honduran children under 2 yearsof age.

India: Integrated community-basedinterventions to promote infant andyoung child feeding

A large-scale cluster randomized controlled trial wasconducted in Haryana, India, from January 1998 toMarch 2002 to evaluate the effect of community-based

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interventions to improve infant and young childfeeding, specifically, exclusive breastfeeding during thefirst six months, complementary feeding at later ages,and the impact on infant diarrhoeal illness and growth.The study was conducted under the auspices of a teamof researchers from the All India Institute of MedicalSciences and involved health workers from the district,the integrated child development services (ICDS)programme, and a local nongovernmental organization.WHO funded the study and provided technicaloversight. The study covered a population of about40,000, out of which a cohort of 552 infants in 4communities in the intervention group and 473 infantsin 4 matched communities in the control group(Bhandari et al., 2003) were followed to evaluateintervention impact.

At baseline, exclusive breastfeeding was uncommon andcomplementary feeding practices were poor in the targetpopulation. In developing the project, problemidentification was followed by formative research,participatory design of the intervention,implementation, and evaluation. Formative researchassessed barriers to appropriate feeding practices andmotivating factors for behaviour change. To developfeeding recommendations, the project team identifiedcommon feeding problems and local ways to solve them.Household trials were conducted to test acceptabilityof different recommendations.

Design of the intervention was highly participatory andinvolved the community from the outset. Communityrepresentatives and health workers helped convertnutrition recommendations to messages in the localvernacular, identify themes for songs and theatre, andselect appropriate pictures for posters. Thecommunications materials developed included clinicposters, flip books, and feeding recommendation cardsfor ready reference by health workers.

Nutrition messages included initiating breastfeedingimmediately after birth, feeding only breast milk for thefirst 6 months of life, and breastfeeding the infant dayand night and at least 8 times in 24 hours. Thecommunications strategy targeted specific foods andfluids commonly given to non-exclusively breastfedinfants, such as water and ghutti (an herbal mixture)and their adverse effects. The intervention messages alsoincluded introduction of complementary foods at sixmonths; the types of foods, meal frequencies, andamounts to be fed at different ages; continuedbreastfeeding; ways to encourage children to eat morefood; hand washing before a meal; and continued feedingduring illness.

In collaboration with representatives from differentcategories of health workers, health authorities, andcommunity members, the project team selected thechannels for delivery of nutrition messages and thepoints at which families would receive counselling.Routine interactions between families and differentcategories of workers were observed to learn how theycould be used for nutrition counselling without affectingtheir other work. In intervention communities theopportunities used for counselling were deliveriesassisted by traditional birth attendants and monthlyhome visits by anganwadi workers (women selected fromwithin the communities and trained to provide nutritionand preschool education services) to mothers and theirinfants during the first year of life. Nutrition counsellingalso occurred during quarterly weighing of childrenunder two years of age, immunization clinics run byauxiliary nurse midwives, and sick child contacts withhealth-care providers.

At each contact with the caregivers, health workersassessed infant feeding practices, identified specificproblems, and then counselled the caregivers. Inaddition, four workers — one for each interventioncommunity — were selected by the local healthauthorities from an existing local nongovernmentalorganization to support the government team in thecommunity-based components of the intervention.Opportunities used to deliver nutrition messagesincluded monthly meetings held by the auxiliary nursemidwives with community representatives,neighbourhood meetings conducted by communityrepresentatives with caregivers of children under twoyears of age, fairs, school debates, and other communityevents.

To increase breastfeeding knowledge and skills, a three-day training course was conducted for health andnutrition workers. Half of the training time was used topractice counselling individuals or groups of caregivers.The training was based on an adaptation of the IMCItraining manual on breastfeeding counselling andincluded training on communication skills, detectionof problems with positioning and attachment to thebreast, and resolving breastfeeding difficulties.

The trial results indicated significant positive impact ofthe intervention (Bhandari et al., 2003). In the first 3months postpartum, 33% of the intervention groupmothers recalled having been counselled on exclusivebreastfeeding immediately after birth, 45% recalledhaving been counselled at an immunization session, 32%at a home visit, and 26% at a weighing session.



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Evaluation data indicated that prelacteal feeds of honey,tea, and diluted milk were fed to newborns less often(31% vs 75%) in the intervention communities than inthe control communities (p<0.001). The correspondingrates for exclusive breastfeeding in the previous 24 hoursamong infants at 3 months of age in the interventionand control communities were 79% and 48%(p<0.001). The positive effect of the intervention onexclusive breastfeeding was also seen up to six monthsof age. Further, the seven-day diarrhoea prevalence ratewas significantly lower in intervention group infants atthree months and six months of age in the interventioncommunities compared with control communities.Infant growth up to six months of age was similar inintervention and control communities (Bhandari et al.,2003).

The impact of counselling on complementary feedingpractices 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.

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Application to Special Circumstances

Chapter 4

The studies and experiences described in this paperare intended as a general overview but must be

applied thoughtfully to particular communities andcircumstances. In some communities a significantproportion of women return to work outside the homein the first few months postpartum. Mothers’ return towork deserves special attention and can be considereda difficult circumstance in which to maintain optimalinfant feeding. Two other exceptionally difficultcircumstances that require special attention tobreastfeeding are HIV-prevalent areas and emergencysituations.

Mothers’ return to work

In many areas of the world, maternal work outside thehome in the first few months postpartum is associatedwith shortened duration of breastfeeding or lower ratesof exclusive breastfeeding (Ashworth et al., 2000;Dearden et al., 2002b; Valdes et al., 2000). When amother resumes work outside the home, optimalbreastfeeding can be sustained. However, if the infantis young, exclusive breastfeeding often becomes morecomplicated because of the geographic separation of themother and infant and, in many cases, greater maternaltime constraints. The 88th session of the InternationalLabour Conference held in June 2000 adopted a revisedMaternity Protection Convention that significantlystrengthened the previous convention adopted in 1952.Provisions of the 2000 Convention include an increasein the minimum length of maternity leave from 12 to14 weeks, entitlement to paid breastfeeding breaks, andapplication of the convention to women in nonformalforms of work.

Breastfeeding counselling and lactation supportprogrammes in the work environment can contributeto success (O’Gara et al., 1994). In a study of workingmothers in Turkey, Yilmaz et al. (2002) concluded thatsupport for breastfeeding women should involve longerleave from work and improved breastfeeding conditionsat work. Rea and others (1999) reported that durationof exclusive breastfeeding in Sao Paulo, Brazil, was longeramong factory workers who had support for

breastfeeding at work, did not do shift work, and didnot work on weekends.

Valdes et al. (2000) conducted a prospective, controlledintervention trial among working mothers in Santiago,Chile. Breastfeeding support that included anticipatorycounselling combined with monthly postpartum clinicalfollow-up visits significantly increased the proportionof working women who exclusively breastfed theirinfants to 6 months of age (53% of women in theintervention group compared with 6% of women in thecontrol population). Most of the working women whomaintained exclusive breastfeeding expressed and storedtheir breast milk.

Community-based breastfeeding initiatives shouldidentify the extent to which work outside the home is abarrier to optimal breastfeeding and offer practicalalternatives to working women and their families. Severaloptions should be considered to sustain breastfeeding,including supporting the mother to keep the baby withher or with a caregiver at or near the workplace. In thelatter situation, the caregiver brings the infant to theworking mother or the working mother visits the infantwhen the child is ready to nurse. Another option is forthe caregiver to feed the infant expressed breast milk,although in some cultures breast milk expression maynot be common. Any option requires levels of supportfrom family members, employers, caregivers, andindividuals in the community, such as lay breastfeedingcounsellors and health-care providers. Education andsupport of working women and their families can opennew and helpful options for infant care and feeding.

Infants born to HIV-positive mothers

Each year approximately 800,000 children becomeinfected with HIV, largely in developing countries andmainly through mother-to-child transmission duringpregnancy, delivery, or breastfeeding (UNAIDS/WHO2002). Research indicates that 5%–20% of infants ofHIV-infected mothers who breastfeed become infectedthrough breastfeeding (de Cock et al., 2000).



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Transmission of HIV through breastfeeding is associatedwith several factors including infant age (<6 weeks),longer breastfeeding duration, poor breast health(mastitis or lesions), poor maternal immune status,increased maternal viral load, and infant oral andgastrointestinal tract health. There is some evidencethat feeding mode may also be a factor, with exclusivebreastfeeding being of lower risk than mixed feeding.Given the benefits of breastfeeding for infant survival,the problem of HIV transmission through breastfeedinghas made safer infant feeding counselling for HIV-positive mothers a complex task.

WHO (2000) provides the following globalrecommendations on infant feeding for HIV-positivemothers:

• When replacement feeding is acceptable, feasible,affordable, sustainable and safe, avoidance of allbreastfeeding by HIV-infected mothers isrecommended. Otherwise, exclusive breastfeedingis recommended during the first months of life.

• To minimize HIV transmission risk, breastfeedingshould be discontinued as soon as feasible, takinginto account local circumstances, the individualwoman’s situation, and risks of replacementfeeding (including malnutrition and infectionsother than HIV).

• When HIV-infected mothers choose not tobreastfeed from birth or stop breastfeeding later,they should be provided with specific guidanceand support for at least the first two years of thechild’s life to ensure adequate replacementfeeding.

• Programmes should strive to improve conditionsthat will make replacement feeding safer for HIV-infected mothers and families.

Global policy on infant feeding and HIV emphasizesthe importance of informed choice. Women need toknow their status to make a choice, becausebreastfeeding is the recommended mode of feeding forwomen who are HIV negative or of unknown status.Programmes should provide HIV-positive women withinformation and support to enable them to make fullyinformed infant feeding decisions. The infant feedingoptions for HIV-infected women include commercialinfant formula, home-prepared infant formula,breastfeeding (with early cessation where appropriate),expressed and heat-treated breast milk, donor milk frommilk banks, and wet nursing.

A cohort study conducted in South Africa suggests thatexclusive breastfeeding may be safer than mixed feeding

in terms of reducing mother-to-child transmission ofHIV through breastfeeding (Coutsoudis et al., 2001).Further research is on-going to confirm this result.

In areas where HIV infection is present, the promotionand support of breastfeeding remains critical from apopulation perspective. Special care is needed to avoidinadvertently discouraging breastfeeding andinappropriate distribution of breast milk substitutes,which could undermine optimal breastfeeding by HIV-negative mothers and mothers who do not know theirstatus. Community-based care and support for HIV-positive mothers and their infants requires a high levelof confidentiality and sensitivity. HIV-positive mothersshould have access to appropriate individual counsellingand care regarding prevention of mother-to-childtransmission of HIV and safer infant feeding practices.

The Ndola Demonstration Project1 in Zambia is anexample of a programme that aimed at promoting betterinfant and young child feeding practices among allwomen, in an area of high HIV prevalence. Healthworkers and community-level workers were trained intopics related to infant feeding, and also related to HIV.Due to a combination of health-facility and community-level counselling and support activities, rates of exclusivebreastfeeding in the community increased, from 57%at baseline in April 2000 to 70% at endline in April2002. It was concluded that increasing knowledge ofMTCT did not erode good breastfeeding practices.However, acceptance of HIV testing and counsellingremained low, so that mothers could not receive specificcounselling and support based on their HIV status. HIV-positive mothers did not practice the recommendationfor early cessation, because it was considered contraryto community norms (Horizons, 2003).

Emergency situations

The care and feeding of infants is especially importantin emergencies such as famine or refugee situations,when infants and young children are particularlyvulnerable. In emergency situations misconceptions andadverse living conditions may present special barriersto breastfeeding that need to be addressed and overcome.A common but unfounded belief is that malnourishedmothers in emergency situations cannot breastfeed. Onthe contrary, malnourished mothers can breastfeed; the

1 The Ndola Demonstration Project was a partnership of theNational Food and Nutrition Commission, Central Board ofHealth, District Health Management Team, Hope Humana,and three USAID-supported projects (LINKAGES, Horizons,and the Zambia Integrated Health Program).

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amount 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)


23

Summary and Conclusions

Ideally, infant and young child feeding should beviewed from a life course perspective that begins with

a well-nourished woman and proceeds through a healthypregnancy and a safe and supportive delivery andpostpartum period. Following childbirth, womencontinue to need timely and accurate information,encouragement, and support to address their concernsand to enable them to practice optimal breastfeeding,which includes timely initiation of breastfeeding;exclusive breastfeeding for six months; the introductionof adequate, safe, and appropriate complementary foodsat six months; and continued breastfeeding up to twoyears of age or beyond.

In the life course perspective, infant and young childfeeding is the concern of mothers, families, communities,and the health sector. Community-based strategies,health system strategies, and national policies all havea role in creating a supportive environment for optimalinfant and young child feeding, growth, anddevelopment.

The development of community-based initiatives forbreastfeeding promotion and support is an extension ofmore than two decades of global advocacy andsystematic research. Evidence indicates that community-based breastfeeding promotion and support can beeffective in increasing optimal breastfeeding andimproving infant health. As experience with community-based approaches increases, the elements that definethe capacity for behaviour change and specific strategiesfor success are becoming clear.

The capacity for breastfeeding behaviour change at thecommunity level requires effective leadership, formingintersectoral partnerships, informing and engagingopinion leaders, conducting formative research to shapeexplicit and effective messages, and monitoring andevaluating 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

behaviour change communication, training of health-care workers and lay counsellors to provide accessibleand appropriate counselling support to mothers, andactive involvement of women’s groups are importantelements of effective breastfeeding behaviour changestrategies that may be applied somewhat differently indiverse circumstances.

Attention is required to integrate breastfeeding withmultiple programmes affecting maternal and child healthand nutrition in the formal health sector and thecommunity at large. Attention is also needed to supportbreastfeeding mothers in circumstances that requirethem to return to work in the first few weeks or monthspostpartum. Special care must also be taken regardingbreastfeeding promotion and support in HIV-prevalentareas and emergency situations.

The Global Strategy for Infant and Young Child Feedingcalls on countries to “mobilize all concerned social andeconomic resources within civil society, includingscientific, professional, nongovernmental, voluntary, andcommercial groups and associations, and to engage themactively in implementing the global strategy andachieving its aim and objectives….” The researchliterature and case studies cited in this paper indicatethat such mobilization can be highly effective inincreasing optimal infant feeding and decreasing infantmorbidity and mortality. This document aims to providehelpful guidance and support to governmental andnongovernmental agencies that are working towardseffectively reaching all mothers through community-based approaches to breastfeeding promotion andsupport. We hope that this document will encouragecommitment to breastfeeding promotion and supportfrom all sectors and result in gains in optimal infantfeeding that in turn produce significant gains in childsurvival.

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Issues in Breastfeeding Measurement

Standardized breastfeeding indicators arerecommended by the World Health Organization

(1991) and endorsed by the Demographic and HealthSurveys (DHS) and UNICEF’s Multiple IndicatorCluster Surveys (MICS) to provide valid data that arecomparable across studies and populations.Recommended international indicators for assessingbreastfeeding include the following:

• Percentage of infants less than 12 months of agebreastfed within 1 hour of birth (timely initiationof breastfeeding rate)

• Percentage of infants less than 6 months breastfedexclusively (exclusive breastfeeding rate)

• Percentage of infants 6–9 months (180–299 days)fed breast milk and complementary foods (timelycomplementary feeding rate)

WHO defines exclusive breastfeeding as maternal milkbeing the only food source, with no other liquids orfood given except medicines, minerals, and vitamins.Infants described as predominantly breastfed mayreceive breast milk as the main source of nourishmentbut also receive water, water-based drinks, fruit juice,herbal mixtures, and vitamins, minerals, or medicines.

All of the studies cited in this monograph wereunderstood to adhere in principle to theseinternationally accepted breastfeeding definitions.However, studies and evaluations cited differed in someaspects of measurement, such as time frame forclassifying infants as exclusively breastfed (since birth,in the past 24 hours, in the past month) and employeddiffering wording of items used to assess exclusivebreastfeeding. These differences in methods may havesome implications for data interpretation across studies.

The internationally recognized set of standardbreastfeeding questions used by DHS includes thefollowing:

• Did you ever breastfeed (CHILD’S NAME)?• How long after birth did you first put (NAME) to

the breast?

Issues in Breastfeeding Measurement

Annex 1

• Are you still breastfeeding (NAME)?• IF NO: For how many months did you breastfeed

(NAME)?• How many times did you breastfeed last night

between sunset and sunrise?• How many times did you breastfeed yesterday

during the daylight hours?• Did (NAME) drink anything from a bottle with a

nipple yesterday or last night?• At any time yesterday or last night, was (NAME)

given any of the following:- Plain water?- Milk other than breast milk?- Fruit juice?- Any other liquids such as sugar water, tea,

coffee, carbonated drinks, or soup broth?- Any food made from wheat, maize, rice,

sorghum (OR LOCAL GRAIN) such as …?- Any food made from pumpkins, carrots, red

sweet potatoes, green leafy vegetables, mango,papaya?

- Any other food made from cassava, plaintain,yams (OR LOCAL TUBER) such as…?

- Any other fruits and vegetables (e.g. bananas,apples, avocados, tomatoes)?

- Meat, eggs, fish, poultry, cheese, or yoghurt?- Any food made from legumes (e.g. lentils,

beans, soybeans, pulses, or peanuts]?- Any food made with oil, fat, or butter?- Any other solid or semi-solid foods?

Answers to the 24-hour food recall question (items givenduring the previous night and day) are required tocalculate the exclusive breastfeeding rate. TheLINKAGES Project used these standardized items toguide its project evaluations, but not all projectspresented in the case studies used these methodsprecisely in this way. For example, the AIN programmeevaluation in Honduras used a 24-hour food recallquestion at baseline but at midterm surveyed caregiverson the current status of breastfeeding using acombination of questions that included currentbreastfeeding status coupled with a question on whetherthe infant had begun receiving foods and liquids. For


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validation 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.

Community based strategies for breastfeeding promotion and support in developing countries

Health & Medicine

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