Comprehensive Strategies Needed
Comprehensive strategies to support optimal breastfeeding can do much to improve infant and child health. Comprehensive strategies can support both a woman's initial decision to breastfeed and her ability to maintain and succeed with her breastfeeding choice. Such strategies include health care workers and facilities, communities and families, and government laws and policies.
Health Care Services Are Key
Health care services offer a valuable point of contact for both mothers-to-be and breastfeeding mothers. In fact, in many countries women report that the advice of health care providers is the main reason for their infant feeding decisions (76, 93, 118, 140, 209). To help mothers achieve the best breastfeeding practices, hospitals and other health care facilities can:
Change policies and procedures. Health care providers can inform women about breastfeeding during their pregnancies, for example, during antenatal visits and in childbirth education classes. Information given during pregnancy about immediate and exclusive breastfeeding helps mothers start breastfeeding sooner and breastfeed exclusively for longer (36, 183, 219). Hospitals and birthing centers also can support breastfeeding immediately after a child's birth. For instance, rooming-in practices—that is, placing newborns with their mothers during the hospital stay—encourage early mother-infant contact and suckling (73, 187).
Train health care workers. Health care providers who serve women in health care facilities and in communities (such as community midwives and health promoters) need to be trained in good breastfeeding practices. They can advise women on optimal breastfeeding, on the dangers of first giving the newborn liquids other than colostrum and of complementary feeding before six months, on breast care, and on dealing with discomfort or difficulties while breastfeeding (see companion INFO Reports "Breastfeeding Questions Answered: A Guide For Providers"). Providers also can be trained in good breastfeeding counseling-including that women should never be pressured, obliged, or shamed into choosing breastfeeding or how much to breastfeed.
Preservice and in-service training for health care providers has often neglected the topic of breastfeeding. As a result, providers' practices and recommendations about breastfeeding may be uninformed (1, 6, 83). For example, some hospital staff bottle-feed newborns without approval from mothers. Others advise mothers to give their baby complementary food before six months of age (1, 6, 83).
Changing these unhelpful practices can improve a mother's breastfeeding practices. In a study in the Philippines, for instance, more mothers breastfed their infants exclusively and for longer when health care staff did not give the infants breastmilk substitutes (1). Similarly, a study in an Istanbul hospital found that 66% of infants breastfed by mothers in the hospital were exclusively breastfed at four months-more than twice the percentage of infants who had been given formula in the hospital, at 32% (6).
The Baby-FriendlyT Hospital Initiative. The Baby-Friendly Hospital Initiative, launched by UNICEF and WHO in 1991, encourages maternity facilities to adopt positive breastfeeding policies and services. Facilities are considered Baby-Friendly when they have taken 10 specific steps to support breastfeeding (see 'Taking Ten Steps to Successful Breastfeeding').
Since 1991 more than 19,000 facilities in over 130 countries have been designated Baby-Friendly (236, 254) by WHO and UNICEF. Studies in Bangladesh, Belarus, Brazil, Croatia, Nigeria, and Taiwan report that more mothers are initiating breastfeeding earlier and exclusively breastfeeding their infants longer in areas served by Baby-Friendly hospitals (76, 82, 120, 168, 210, 225, 244).
For example, in Croatia between 1994 and 2000, after hospital staff received Baby-Friendly training, the average percentage of infants breastfed in these facilities rose from 30% to 66% at 3 months, from 11% to 49% at 6 months, and from 2% to 23% at 12 months (29). Similarly, in Bangladesh in 1997 and 1998 more mothers who delivered at a Baby-Friendly hospital in Dhaka exclusively breastfed their infants and breastfed more than twice as long as mothers who delivered in other Dhaka hospitals (5).
Community-Based Strategies Support Mothers' Success at Breastfeeding
Mothers who give birth in health facilities need continuing support to maintain breastfeeding once they return home (48). Mothers who give birth without a trained attendant rely even more on community information and support for breastfeeding, since they do not have the benefit of advice in a health facility. In developing countries about 6 births in every 10 are not attended by trained health care workers (251).
Community support—within a woman's home, in neighborhood facilities and programs, and at her workplace—leads to better breastfeeding practices. An effective community-based strategy for breastfeeding involves three key elements (257):
Extending health care services into communities. After a new mother leaves a health care facility, providers should follow up to provide accurate information and continuing support and to manage or refer any health problems that arise. If misinformed, many women give their infants supplemental foods and liquids too early, rather than continuing exclusive breastfeeding.
Community health workers can reassure women that they are breastfeeding correctly and in a way that is effectively nurturing the infant and is frequent enough to maintain their milk supply (166). Several developing countries have included breastfeeding support in their postpartum follow-up strategies. Women may visit maternal and child health clinics, or health care providers may visit women's homes (82).
Programs in many countries report that extending health services into communities helps more women breastfeed exclusively and longer (17, 82, 87, 160, 185, 239). An analysis of 20 studies from 10 countries-Bangladesh, Brazil, Iran, Mexico, Nigeria, and 5 developed countries-found that levels and durations of both exclusive and any breastfeeding increased significantly where professional or community health care workers offered women support in their homes for breastfeeding (210). On average, the more often a counselor has contact with a mother outside the clinic, the longer the mother maintains exclusive breastfeeding (154).
Counseling by lay counselors (community members trained in breastfeeding counseling), peer counselors (women in the community with children), or mother-to-mother (by women with children who have themselves successfully breastfed) all can be effective ways to provide support (257). Women's support groups or mother-to-mother groups also help mothers (82).
In Croatia in 1999-2000, for example, Baby-Friendly health facilities established breastfeeding support groups in communities. After discharge from the facility, mothers joined a community group that met every four weeks. Between meetings, members also could consult with the group leader. A visiting nurse helped to set up the group and to coordinate and supervise activities. After this phase of the program, the percentage of children who were breastfed increased at all ages between 1 and 12 months (29).
Also, in rural Ghana between 1993 and 1996, a self-managed credit association combined weekly meetings with health-education sessions. The sessions offered information on the benefits of exclusive breastfeeding and of giving colostrum to infants. Evaluation found that the proportion of mothers in the program group who gave colostrum to their newborns was more than twice that in a comparison group. Also, mothers in the program group introduced water into their infants' diets much later (82, 151).
Building support in the household and community. Breastfeeding strategies should address not only mothers but also the people who influence mothers-their mothers, spouses, other family members, friends, and community leaders. The advice and opinions of family and friends influence many women in their breastfeeding practices (83, 100).
A woman may not follow the advice of her health care provider if influential family members disagree. For instance, in Jos, Nigeria, nursing mothers cited family pressure- from either the mother or mother-in-law-as the main reason for giving water to their infants in the first six months, rather than breastfeeding exclusively, as health care providers recommend (166).
National media campaigns can encourage community support for mothers who breastfeed (80, 82, 90, 142). Campaigns work best when developed in collaboration with the community they are meant to reach. For example, from 1998 to 2002 in Haryana, India, community members helped to identify and develop solutions to common problems that breastfeeding women faced. Their observations helped shape broadcast messages that encouraged good breastfeeding practices. Evaluation of the program found that 31% of newborns received liquids other than colostrum in the program area compared with 75% in a comparison area. Also, at three months postpartum, rates of exclusive breastfeeding were substantially higher in the program area-79% compared with 48% (23, 257).
Supportive spouses. Husbands' preferences influence their wives' breastfeeding practices, too. For example, in Hong Kong nearly 80% of mothers agreed that their husbands' encouragement and support for breastfeeding was important. Of women whose husbands approved of breastfeeding, 70% breastfed. Of women whose husbands preferred artificial feeding, 36% breastfed (118).
Involving husbands in community breastfeeding support groups also can encourage breastfeeding. In Istanbul, Turkey, in 1997 a community-based program increased men's knowledge of breastfeeding and improved their attitudes more than a previous clinic-based program had. Before attending the community meetings, about 50% of men said a father's support for breastfeeding was important, while 10% said giving birth in a Baby-Friendly hospital was important. After the meetings these percentages rose to more than 80% and 50%, respectively (230).
National Policies, Laws, and Partnerships Support Breastfeeding
Many governments have taken steps to support breastfeeding. They have enacted legislation and adopted policies and standards that help breastfeeding mothers in the workplace and that limit the marketing of breastmilk substitutes. In other countries, however, support for breastfeeding has weakened in the face of misunderstandings and challenges posed by the AIDS crisis. Especially in these countries, the UN has called upon governments to renew their commitment to breastfeeding as a key public health measure to improve infant health and survival.
Government efforts have improved hospital breastfeeding policies. For example, in the late 1980s the Kenyan Ministry of Health began a breastfeeding training and promotion program and instructed hospitals to stop routinely feeding newborns other fluids before their mothers' colostrum. After the policy changes, the percentage of health care providers who did so dropped from 93% to 48% (30). In Bolivia, Ghana, and Madagascar, levels of breastfeeding have risen in response to new policies combined with reform of practices in health care facilities and community support (185) (see 'Spotlight: Madagascar's Comprehensive Approach Improves Breastfeeding').
Supporting breastfeeding mothers in the workplace. Around the world, studies find that women who resume full-time employment when their infants are young are less likely to continue exclusive breastfeeding and tend to breastfeed for fewer months (57, 140, 172, 277). Women often say that it is difficult or impossible to continue breastfeeding, particularly exclusive breastfeeding, while at work (188). In Guatemala City women who were not employed were 3.2 times more likely to breastfeed exclusively than women with jobs (56).
Breastfeeding is the right of every woman worker (55), but many employers do not want to bear the short-term cost of providing benefits to nursing mothers. They overlook the long-term savings in avoiding employee absenteeism (137). For one thing, because breastfed infants experience fewer and less severe illnesses, employed women who have breastfed their children have fewer absences from work to care for sick children.
As more and more women take jobs, breastfeeding in the workplace is becoming an important issue. Governments can promote public health and women's status by encouraging businesses to improve conditions for breastfeeding in the workplace. They can urge employers to allow women employees breastfeeding breaks without loss of wages and to provide clean and safe spaces in the workplace for women to express and store breastmilk (188). Governments also can negotiate with businesses to see that they provide women with long enough maternity leave to breastfeed optimally and that they offer medical benefits that include antenatal and postnatal care.
Limiting commercial formula marketing. Government policies can help protect mothers and health care providers from misleading promotions by commercial manufacturers of breastmilk substitutes. Breastmilk substitutes should not be promoted as an alternative to breastfeeding in general. Rather, they should be marketed for use with children over six months of age as a complement to breastmilk, or as an option for HIV-positive women who choose not to breastfeed (253).
The International Code of Marketing of Breastmilk Substitutes, which was adopted by the World Health Assembly in 1981 and has been strengthened over the years, is a worldwide effort to control international and local company marketing activities (223, 252). The code forbids manufacturers of breastmilk substitutes from providing free samples of their products, offering medical advice, or giving financial or material inducements to mothers and health care facilities to use their products. It also forbids manufacturers from marketing to the general public, particularly using words and pictures that idealize bottle feeding.
The code applies to artificial milk for babies, feeding bottles, and other products used to feed babies such as teats (artificial nipples), especially when they are marketed for babies less than six months of age (252). The code can restrict these marketing activities only if governments enact legislation or other policies that put it into practice. As of December 2004, 27 countries had approved laws implementing the entire code, and 55 countries had some provisions of the code in place (45). Worldwide, however, widespread violations of the code have been reported ever since it was introduced (3, 221).
Renewing support for breastfeeding in the era of AIDS. Government support for breastfeeding appears to have dropped off in some of the countries most affected by HIV/AIDS, according to a 2000 review of efforts in Botswana, Kenya, Namibia, and Uganda (129). This decline in support reflects a widely held but incorrect view that all HIV-positive mothers will infect their infants through breastfeeding. Also, the 2000 review reports that many people-including some Ministry of Health officials, health care providers, UN staff, and community leaders-have overlooked the life-saving and nutritional benefits of breastfeeding for all babies (129).
To address misunderstandings about HIV and breastfeeding, eight UN agencies together have developed the HIV and Infant Feeding Framework for Priority Action. The UN recommends that governments take a number of "priority actions" that address issues of exclusive breastfeeding and replacement feeding in HIV-affected areas. Their goal is to encourage appropriate feeding practices for all infants while doing more to reduce HIV transmission. To achieve this goal, people within different branches of the health infrastructure must coordinate to develop effective breastfeeding strategies (260).
Among other recommendations, the UN framework encourages governments to enforce the International Code of Marketing of Breastmilk Substitutes. According to WHO and the UN, mothers who are HIV-negative or do not know whether they are infected should avoid using breastmilk substitutes until their infants are six months of age (260). Private companies, however, promote breastmilk substitutes heavily in areas of high HIV prevalence. Such promotion can influence mothers who are not HIV-positive and for whom breastfeeding is often the only safe feeding choice, given the poor living conditions in most areas affected by the HIV/AIDS epidemic. Aggressive and misleading promotion of commercial formula could discourage women who would otherwise breastfeed (119).
Another recommendation in the UN framework is to provide adequate support to HIV-positive women so they can make an informed infant feeding decision and successfully carry it out (260). Providers can learn the facts about HIV and breastfeeding so that they are able to counsel women accurately. Also, mass-media campaigns and educational materials can reach community members and help decrease the stigma surrounding HIV infection, so that a woman with HIV does not feel obliged to breastfeed for fear that community members will assume that she is HIV-positive if she does not breastfeed (119).
Ensuring breastfeeding in crisis situations. The protection that breastfeeding can provide against disease is particularly important in crisis situations-when conflicts or natural disasters disrupt communities and displace large numbers of people. Often, donors supply breastmilk substitutes as part of emergency relief, but this well-intentioned practice causes more harm than good. For example, in Guinea-Bissau during the first three months of the 1998 war, weaned children were six times more likely to die than breastfed children (101).
UNICEF recommends that in crisis situations governments refuse donations of unnecessary replacement food (199). Instead, providing better maternal health care, more food rations, and an adequate supply of clean drinking water for pregnant and nursing women is a healthier and safer alternative. It is important that women receive additional food during both pregnancy and lactation (135, 234, 253). Lactating women need extra calories, protein, and other nutrients. Without enough calories and nutrients they continue producing enough breastmilk for their babies but at the expense of their own energy and nutrient reserves.
Also, the heightened stress caused by a crisis situation can temporarily interfere with a mother's flow of breastmilk. If this stress continues, breastmilk production will decrease because the mother is not emptying her breasts. Eventually, she will stop producing breastmilk. WHO and UNICEF urge that relief efforts pay immediate attention to pregnant and breastfeeding women and offer safe havens where they will feel more secure, can remain with their infants, and will receive adequate food and support to breastfeed (264).
|
Order this report
Download PDF
E-mail this page 
See Companion INFO Report