Early Childhood Indicators

Increased rate of breastfeeding

Background

Breast milk is the “physiologically normal” food for human infants (Berry and Gribble, 2008, p. 78).  Support for the importance of breastfeeding for the short- and long-term development of infants is very well established (WHO, 1998; RACP, 2006).  There is strong evidence that non-breastfed babies are more likely to suffer ear, gastrointestinal and urinary tract infections, diabetes and childhood leukemia and are at greater risk of Sudden Infant Death Syndrome (Dyson, McCormick and Renfrew, 2005; Chung, Raman, Trikalinos, Lau and Ip, 2008).  Children who are fed infant formula are also more likely to become overweight or obese later in life, while mothers who do not breastfeed have an increased risk of developing breast or ovarian cancer (Chung et al., 2008).

Current National Health and Medical Research Council (NHMRC) recommendations are for sole breastfeeding until six months of age, and continuation of breastfeeding until age two or beyond with appropriate complementary feeds (NHMRC, 2003).  Nevertheless, a recent parliamentary inquiry noted that only a small proportion of Australian babies are exclusively breastfed to six months of age (House of Representatives, 2007).  Various reasons were suggested, including consistency of advice; beliefs about infant formula; and the level of community support.  The report also noted that “with the right advice and appropriate support it seems that many would breastfeed for longer” (HoR, 2007, p.4).

The most recent national data on breastfeeding in Australia comes from the 2001 National Health Survey (Australian Bureau of Statistics, 2003).  Although the vast majority (87%) of children aged 0-3 at the time of the survey had had some breast milk and just over half (54%) of infants aged 0-3 months were fully breastfed, no infants at age six months were being exclusively breastfed.

The NHMRC (2003) has identified four strategy areas for the promotion and support of breastfeeding, one of which is to strengthen breastfeeding friendly communities and families.  Two key processes are required to ‘scale up’ exclusive breastfeeding: (1) an evidence-based policy and science-driven technical guidelines; and (2) an implementation strategy and plan focusing on all strata of society, with sustainability built in (Bhandari, Kabir and Salam, 2008).

The evidence base

There have been numerous randomised controlled trials and several Cochrane Collaboration and other systematic reviews in this area, providing relatively strong evidence to indicate that interventions can be effective in the establishment and duration of breastfeeding.  Such initiatives need to include multiple strategies (Quinn et al. 2005) and can in some cases demonstrate increasing effectiveness over time (Gau, 2004).

Dyson and colleagues (2005) reviewed the evidence for interventions designed to improve breastfeeding initation rates.  Among low-income women in the United States – groups with traditionally low rates of breastfeeding – antenatal or postnatal health education was effective.  The reviewers concluded that larger effects are likely when the education is informal, tailored to the mother’s needs, and delivered one-to-one by a trained peer counsellor or professional (Dyson et al., 2005).  Antenatal education delivered in a group setting is not effective, unless it is interactive (Hannula, Kaunonen and Tarrka, 2008).

One study demonstrated that peer support for those planning to breastfeed increased the number who actually initiated breastfeeding, compared with a comparison group (Dyson et al., 2005).

Successful approaches in maternity hospitals include practical, hands-off teaching, but only if this is encouraging and empowering to women.  Education focusing only on technical aspects without support is not effective (Hannula et al., 2008).  The World Health Organisation (WHO) Breastfeeding Friendly Hospitals Initiative is well supported by evidence, both of increased initiation and greater duration of breastfeeding (Hannula et al., 2008).

Effective postnatal interventions include home visits, telephone support, breastfeeding centres and a combination of peer and professional support (Hannula et al., 2008).  Continuation of breastfeeding can be promoted in areas with low baseline rates by either professional or peer support, or a combination of the two, although the most effective components of this support are still unclear (Britton McCormick Renfrew Wade and King, 2007).

Short- and long-term breastfeeding rates can be improved by combining antenatal and postnatal interventions and by including peer or lay support in a multi-component program (Chung et al., 2008).

Selection of recommended interventions

The interventions reviewed here fall into two broad groups: hospital-focused strategies and community-focused strategies delivered by professionals and volunteers.

Most widely recognised and used is the World Health Organisation’s Breastfeeding Friendly Hospital Initiative (BFHI) (WHO, 1998).  This initiative identifies 10 steps to successful initiation of breast feeding, which have been implemented in various ways throughout the world.  Evidence exists for improved effectiveness when the involved hospitals are externally audited for compliance and their involvement over a period of time (Gau, 2004).  Evidence is also available to support the various strategies recommended by the WHO, such as the review by Perez-Escamilla et al. (1994) of the infant feeding policies in maternity wards and their effect on breastfeeding success.

Studies report that the effectiveness of the BFHI in initiating breastfeeding is not sustained once the mother and infant leave the hospital (Coutinho et al. 2005; Gau, 2004).  Surveys of BFHI hospitals in Australia (Walsh, Pincombe and Stamp, 2006) and the United States (Rosenberg, Stull, Adler, Kasehagen and Crivelli-Kovach, 2008) have shown that despite accreditation, some hospitals are not implementing all of the 10 steps.  Mothers who experience more of these breastfeeding-friendly hospital practices tend to continue breastfeeding for longer (Walker, 2007; Rosenberg et al., 2008).

Community support programs need to be implemented to support maintenance of breastfeeding for the recommended six months of sole breastfeeding, with continuation into the second year and beyond.  Strong evidence exists for the impact of antenatal education by health professional staff (nurses and lactation specialists) (Guise et al. 2003; Lana, Lamounier and Cesar 2003).  The education interventions reviewed by Guise and colleagues (2003) had structured content and were delivered by professionals (nurses or lactation specialists) in sessions ranging from 30 to 90 minutes. Such interventions were found to increase short- and long-term duration of breastfeeding.  This same meta-analysis identified that written materials alone had no effect and when used in conjunction with education did not increase the effectiveness of the education alone.  This has important implications for the education of pregnant women (and others), when busy health professionals hand out printed materials or, increasingly, identify websites for information, rather than provide the personal education themselves.  Gau (2004) also found that women prefer to receive information about breastfeeding from nurses (58.6%) and doctors (46%), and that breastfeeding initiation and duration was directly proportional to mothers’ breastfeeding knowledge and attitude.

There is also some evidence that extension of health care services through either home visits (Barros et al. 1994; Coutinho et al. 2005) or community and health worker mobilisation to support breastfeeding (Bhandari et al. 2005) has a significant impact on breastfeeding duration.  A randomised controlled trial of home visits to women at five, ten and twenty days after birth found delayed introduction of bottle feeding (90 days versus 60 days, p = 0.01) and greater duration of breastfeeding (120 days versus 105 days, p = 0.03) (Barros et al. (1994). 

Bhandari and colleagues (2005) conducted a randomised trial of paired communities designed to test the impact of health and nutrition worker training to counsel women at multiple contact points in the community.  The training package used was the WHO integrated management of childhood illness training manual, Counselling the Mother, which included specific guidance relating to breastfeeding.  The most effective avenue for counselling varied with the age of the baby.  At three months of age, immunisation clinics (56.7%) and home visits (28.4%) were the most common sources of counselling, while at nine months of age, home visits (48.6%), weigh sessions (31.3%) and immunisation sessions (27.1%) were more common.  Clearly mapping new mothers’ contact points with services and targeting those services with training may prove an effective strategy to help maintain breastfeeding.

Large scale, multi-strategy, community-based interventions have also demonstrated significant improvements in the initiation and maintenance of exclusive breastfeeding.  A study by Quinn et al. (2005) reported on the effectiveness of the Linkages Project, a broad scale community-based intervention in Africa and Latin America.  Significant improvements were achieved in the initiation of breastfeeding within one hour of birth and also in the exclusivity of breastfeeding of infants from birth to six months of age.  Population reach was one million in Bolivia, 3.5 million in Ghana and six million in Madagascar.  The projects aimed to maximise existing government and NGO resources and focussed on four main community components - building partnerships, capacity building, behaviour change communication and community activities to reach mothers, together with training, monitoring and evaluation.  Improvements were detected as early as nine months after initiation of the programs.

The literature has some information on the impact of community-based peer support programs.  Peer support is defined as “an approach in which women who have personal, practical experience of breastfeeding offer support to other mothers” (Phipps, 2006).  The Australian Breastfeeding Association (formerly Nursing Mothers Association of Australia) has been providing peer support by volunteers since 1964.  There has been no systematic evaluation of the effectiveness of its strategies.  However, a recent review for the United States Preventive Services Task Force (Chung et al., 2008) concluded that interventions with a component of lay or peer counselling or support were more effective than usual care, at least in the short term.  Their meta-analysis suggested that the rate of any breastfeeding increased by 22% (CI, 8% to 48%) and the rate of exclusive breastfeeding rose by 65% (CI, 3% to 263%) when peer support was provided. 

A small (N = 130 women) randomised community-based intervention in Mexico City studied the effect of home-based peer counselling on duration of breast feeding rates (Morrow et al. 1999).  Significant differences in the rate of exclusive breastfeeding at three months were found between the women who received peer counselling visits compared with the mothers who did not receive the visits.  This same result was not found with a similar, quasi-experimental study in Glasgow (McInnes, Love and Stone, 2000).  A randomised trial involving 225 women in Ayrshire, Scotland, found that peer support did not significantly increase breastfeeding in the first 120 days after birth (Muirhead, Butcher, Rankin and Munley, 2006). 

One difficulty with evaluating peer support is the variety of ways in which it is delivered, and how peer counsellors are trained, in different studies.  For example, peer counsellors in the Ayrshire study received two full days and four evenings of training, plus regular follow-up sessions to discuss cases (Muirhead et al., 2006).  This contrasts with the training undertaken by the ABA’s volunteer breastfeeding counsellors, who complete a Certificate IV course over a period of at least 12 months.  The ABA is currently developing a comprehensive national training program for peer support workers from CALD and Indigenous backgrounds.  This will be a Certificate II course incorporating units from the mainstream counselling training (Pam Halnon, personal communication, 25 November 2008).  It is notable that positive effects were found in the Mexican study in which peer counsellors were trained by the La Leche League and provided one-to-one visits (Morrow et al., 1999) and in a Scottish study involving home visitors and midwives as facilitators of peer support groups (Hoddinott, Lee and Pill, 2006).

Breastfeeding support groups run locally under the auspices of the ABA are another medium for providing peer support.  In its submission to the recent parliamentary inquiry, the ABA noted that the groups ‘normalise’ the experience of breastfeeding and provide psychosocial support as well as tips on making breastfeeding easier and more relaxed (HoR, 2007).

A systematic review of proactive telephone support found that this strategy positively influenced duration of all and of exclusive breastfeeding (Dennis and Kingston, 2008).  The 24-hour helpline service provided by ABA volunteers is reactive – that is, mothers telephone when they require advice or reassurance.  Australian Government funding has been allocated to make this helpline into a toll-free national service.

The workplace, although recognised as an important, negative, influence on breastfeeding continuation, does not appear to have been a location for breastfeeding interventions or their evaluation.  This area should continue to be monitored, as government workplaces at least could provide useful locations for pilot interventions and possible role models for private sector in the future.

Discussion

Breastfeeding has been identified as a fundamental base on which a person’s future health is founded. It is so fundamental that perhaps it has not been given the due recognition by the community and health services that it deserves. Breastfeeding rates by Australian women are not optimal for good health of their infants and yet it is a single issue intervention that could become a clear focus for public health intervention. This will require a strong commitment by health leaders and health professionals, and decisive interventions at two key points — leading up to and during the immediate post birth period, when hospital policies and health professionals have a significant role to play, and on-going support for at least the first six months of age, utilising existing community-based services, non-government organisations and trained lactation support counsellors. A combination of full implementation of the WHO BFHI strategies, health professional training, personal education of mothers by health professionals and then broadly based community-based support is required.

References

Australian Bureau of Statistics (2003) Breastfeeding in Australia 2001. Canberra: Australian Bureau of Statistics.  Downloaded 25/11/08 from http://www.abs.gov.au

Barros FC, Halpern R, Victora CG, Teixeira AM and Beria JU (1994) Promotion of breastfeeding in urban localities of southern Brazil: a randomized intervention study. Revista de Saude Publica. Vol.28, No.4, pp.277-283.

Berry NJ and Gribble KD (2008) Breast is no longer best: promoting normal infant feeding. Maternal and Child Nutrition, Vol. 4, pp. 74-79.

Bhandari N, Kabir AKMI and Salam MA (2008) Mainstreaming nutrition into maternal and child health programmes: scaling up of exclusive breastfeeding. Maternal and Child Nutrition, Vol. 4, pp. 5-23.

Bhandari N, Mazumder S, Bahl R, Martines J, Black RE, Bhan MK, and other members of the Infant Feeding Study Group (2005) Use of multiple opportunities for improving feeding practices in under-twos within child health programs. Health Policy and Planning. Vol.20, No.5, pp.328-336.

Britton C, McCormick FM, Renfrew MJ, Wade A and King SE (2007) Support for breastfeeding mothers. Cochrane Database of Systematic Reviews, Issue 1, Art. No.: CD001141. DOI: 10.1002/14651858.

Bryant CA (1982) The impact of kin, friend and neighbour networks on infant feeding practices. Cuban, Puerto Rican and Anglo families in Florida. Social Science Medicine. Vol.16, pp.1757-1765.

Cardenas RA and Major DA (2003) Combining employment and breastfeeding: utilizing a work-family conflict framework to understand obstacles and solutions. Journal of Business and Psychology. Vol.20, No.1, pp.31-51.

Chung M, Raman G, Trikalinos T, Lau J and Ip S (2008) Interventions in primary care to promote breastfeeding: an evidence review for the US Preventive Services Task Force. Annals of Internal Medicine, Vol. 149, pp. 565-582.

Coutinho SB, de Lira PIC, de Carvalho Lima M and Ashworth A (2005) Comparison of the effect of two systems for the promotion of exclusive breastfeeding. The Lancet. Vol.366, pp.1094-100.

Dennis CL and Kingston D (2008) A systematic review of telephone support for women during pregnancy and the early postpartum period. JOGNN, Vol. 37, pp. 301-314.

Dyson L, McCormick FM and Renfrew MJ (2005) Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews, Issue 2, Art. No. CD001688. DOI: 10.1002/14651858.

Gau ML (2004) Evaluation of a lactation intervention program to encourage breastfeeding: a longitudinal study. International Journal of Nursing Studies. Vol.41, pp.425-435.

Guise JM, Palda V, Westhoff C, Chan BKS, Helfand M and Lieu TA (2003) The Effectiveness of Primary Care-Based Interventions to Promote Breastfeeding: Systematic Evidence Review and Meta-Analysis for the US Preventative Services Task Force. Annals of Family Medicine. Vol.1, No.2, pp.70-80.

Hannula L, Kaunonen M and Tarkka MT (2008) A systematic review of professional support interventions for breastfeeding. Journal of Clinical Nursing, Vol. 17, pp. 1132-1143.

Hector D, Webb K and S Lymer (2005) State of Food and Nutrition in NSW Series. Report on breastfeeding in NSW 2004. N. Health, NSW Centre for Public Health Nutrition.

Hoddinott P, Lee AJ and Pill R (2006a) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland. Birth, Vol. 33, pp. 27-36.

Hoddinott P, Pill R and Chalmers M (2006b) Health professionals, implementation and outcomes: reflections on a complex intervention to improve breastfeeding rates in primary care. Family Practice, Vol. 24, pp. 84-91.

House of Representatives (2007) The Best Start. Report on the inquiry into the health benefits of breastfeeding. Canberra: House of Representatives Standing Committee on Health and Ageing.

Lana APB, Lamounier JA and Cesar CC (2004) The impact of a breastfeeding promotion program at a health center. Journal de Pediatria. Vol.80, No.3, pp.235-240.

Madden, J. M., Soumerai, S.B., Lieu, T.A., Mandl, K.D., Zhang, F., Ross-Degnan, D. (2003). ‘Effects on Breastfeeding of Changes in Maternity Length-of-Stay Policy in a Large Health Maintenance Organization.’ Pediatrics 111(3): 519-524.

McInnes RJ, Love JG and Stone DH (2000) Evaluation of a community-based intervention to increase breastfeeding prevalence. Journal of Public Health Medicine. Vol.22, No.2, pp.138-145.

Morrow A, Guerrero ML, Shults J, Calva J, Lutter C, Bravo J, Ruiz-Palacios G, Morrow R and Butterfoss F (1999) Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. The Lancet. Vol.353, No.9160, pp.1226-31.

Muirhead PE, Butcher G, Rankin J and Munley A (2006) The effect of a programme of organised and supervised peer support on the initiation and duration of breastfeeding: a randomised trial. British Journal of General Practice, Vol. 56, pp. 191-197.

National Health and Medical Research Council (2003) Dietary guidelines for children and adolescents in Australia incorporating the Infant feeding guidelines of Health workers. National Health and Medical Research Council, Commonwealth of Australia.

Perez-Escamilla R, Pollitt E, Lonnerdal B and Dewey K (1994) Infant feeding policies in maternity wards and their effect on breastfeeding success: An analytic overview. American Journal of Public Health. Vol.84, No.1, pp.89-97.

Phipps B (2006) Peer support for breastfeeding in the UK. British Journal of General Practice, Vol. 56, pp. 166-167.

Quinn VJ, Guyon AG, Schubert JW, Stone-Jimenez M, Hainsworth MD and Martin LH (2005) Improving breastfeeding practices on a broad scale a the community level: Success stories from Africa and Latin America. Journal of Human Lactation. Vol.21, No.3, pp.345-354.

Quinn VJ, Guyon AG, Schubert JW, Stone-Jimenez M, Hainsworth MD and Martin LH (2005) Improving breastfeeding practices on a broad scale a the community level: Success stories from Africa and Latin America. Journal of Human Lactation. Vol.21, No.3, pp.345-354.

Raine, P. (2003). ‘Promoting breastfeeding in a deprived area: the influence of a peer support initiative.’ Blackwell Synergy: Health ∧ Social Care in the community 11(6): 463.

Rosenberg KD, Stull JD, Adler MR, Kasehagen LJ and Crivelli-Kovach A (2008) Impact of hospital policies on breastfeeding outcomes. Breastfeeding Medicine, Vol. 3, pp. 110-116.

The Royal Australian College of Physicians (2006). Paediatric Policy. Breastfeeding.

Stover, R. (2006). Best Start Breastfeeding Project July 2004 - December 2005. M. C. Council, Maribyrnong City Council.

Vittoz, J.-P., Labarere, J., Castell, M., Durand, M., and Pons, J-C. (2004). ‘Effect of a training program for maternity ward professionals on duration of breastfeeding.’ Birth 31(4): 302-307.

Walker M (2007) International breastfeeding initiatives and their relevance to the current state of breastfeeding in the United States. Journal of Midwifery and Women’s Health, Vol. 52, pp. 549-555.

Walsh AD, Pincombe J and Stamp GE (2006) The ten steps to successful breastfeeding in Australian hospitals. Breastfeeding Review, Vol. 14, pp. 25-31.

Witters-Green, R. (2003). ‘Increasing breastfeeding rates in working mothers.’ Families, Systems and Health 21(4): 415-434.

World Health Organisation (1998) Evidence for the Ten Steps to Successful Breastfeeding. Division of Child Health and Development, WHO.

Key

Supporting evidence

  1. Well-supported practice — evaluated with a prospective randomised controlled trial.
  2. Supported practice — evaluated with a comparison group and reported in a peer-reviewed publication.
  3. Promising practice – evaluated with a comparison group.
  4. Acceptable practice – evaluated with an independent assessment of outcomes, but no comparison group (such as pre and post-testing, post-testing only or qualitative methods) or historical comparison group (such as normative data).
  5. Emerging practice – evaluated without an independent assessment of outcomes (such as formative evaluation, service evaluation conducted by host organisation).

Replication

Has the intervention been implemented and independently evaluated at more than one site?  (yes or no)

Documentation

Are the content and methods of the intervention well documented (such as provider training courses and user manuals) and standardised to control quality of service delivery?  (yes or no)

Theoretical basis

Is the intervention based upon a well-accepted theory or developed from a continuing body of work in its field?  (yes or no)

Cultural reach

Has the program been trialed with people in disadvantaged communities, Indigenous people or people from culturally and linguistically diverse backgrounds?  (LOW SES/INDIGENOUS/CALD)

 Supporting evidenceReplicationDocumentationTheoretical basisCultural reach
Peer support 2YesYesYesUniversal
Health professional education initiatives 1YesYesYesUniversal
Community Outreach 1YesYesYesLOW SES; CALD
Multi-strategy, community intervention 1YesNoYesUniversal
Baby-friendly Hospital Initiative 1YesYesYesLOW SES; CALD

Recommended strategy 1: Peer support

Name of Intervention

Peer support.

Organisation

Australian Breastfeeding Association.

Brief literature review

The Australian Breastfeeding Association (ABA) (formerly Nursing Mothers Association of Australia) has been providing peer support to Australian mothers since 1964. Its primary aim is to provide motherto-mother support through a network of local groups and voluntary counsellors, who assist breastfeeding women through face-to-face and telephone counselling and providing written materials. ABA breastfeeding counsellors are experienced mothers who have completed an intensive training program and have successfully breastfed their own children. They are bound by a code of ethics.

How and why does this intervention work?

Peer support works by providing timely assistance when it is needed. Although the ABA has been operating for some decades, and is based on the work of the La Leche League in the USA, its work has not been formally evaluated. Nevertheless, its website states that: ‘the Association is supported by health authorities and specialists in infant and child health and nutrition, including a panel of distinguished honorary advisers. ABA is recognised internationally as a source of accurate information about breastfeeding management and research'. See Australian Breastfeeding Association (http://www.breastfeeding.asn.au).

The literature has some information on the impact of communitybased peer support programs, but findings are mixed. A small (n = 130 women) randomised community-based intervention in Mexico City studied the effect of home-based peer counselling (trained by the La Leche League) on duration of breastfeeding (Morrow et al.,1999). Women who received peer-counselling visits were significantly more likely to be still breastfeeding their child at three months of age compared with women who did not receive the visits. However, this same result was not found with a similar, quasiexperimental study in Glasgow (McInnes, Love and Stone, 2000).

On what population does this intervention work best?

This is a universal approach targeting all pregnant women and new mothers.

Where will this intervention work best?

Where a peer support organisation is well established, it can complement the professional advice given in health care settings.

What is required to implement this intervention?

Effective communication between health services and the peer support organisation is desirable.

Resources and contact information

See Australian Breastfeeding Association

References

Bryant (1982)
McInnes, Love and Stone (2000)
Morrow et al. (1999)
Hoddinott et al., 2006a, 2006b
Chung et al., 2008

Recommended strategy 2: Health professional education initiatives

Name of Intervention

Health professional education initiatives.

Organisation

Health services.

Brief literature review

When education alone has been implemented, it was conducted by nurses or lactation specialists in the antepartum period, of variable duration (30-90 minutes), in individual or group situations and with structured content (Guise, 2003). Written materials alone were insufficient and, when used in conjunction with education, did not increase the effectiveness of the education alone.

How and why does this intervention work?

The breastfeeding message is reinforced by professionals who are perceived to be trustworthy in relation to health messages. Practical advice and reliable information on breastfeeding was also provided. Gau (2004) found that women prefer to receive information about breastfeeding from nurses (58.6 per cent) and doctors (46 per cent), and that breastfeeding initiation and duration was directly proportional to mother’s knowledge and attitude.

On what population does this intervention work best?

This is a universal approach targeting all pregnant women and new mothers.

Where will this intervention work best?

Education interventions rely on the credibility of the person delivering the information and are best implemented within health services.

What is required to implement this intervention?

Training of health professionals in counselling mothers and health service commitment to service reorientation.

Resources and contact information

WHO training information on website.

References

Gau (2004)
Guise (2003)

Recommended strategy 3: Community Outreach

Name of Intervention

Community outreach.

Organisation

Health services.

Brief literature review

Community support programs need to be implemented to support maintenance of exclusive breastfeeding for the recommended six months, with continuation into the second year and beyond. Strong evidence exists for the impact of education by health professional staff (nurses and lactation specialists) alone (Guise, 2003, Lana, Lamounier and Cesar, 2003), integration of breastfeeding counselling within multiple community-based services (Bhandari, 2005) and for home visits (Morrow et al.,1999). The latter two approaches have been preceded by specific training of health staff using WHO breastfeeding counselling materials or training by the La Leche League.

How and why does this intervention work?

This interventions works through providing ongoing support to the mother, as she deals with the everyday issues that may impact on her health and her capacity to breastfeed her child. It also serves to reinforce the breastfeeding information that she has received during her antenatal contacts with the health services. Increases in initiation (23 per cent increase) and duration (39 per cent increase) were found with education programs (Guise, 2003). Increasing the number of channels providing breastfeeding counselling increased breastfeeding prevalence at three months (p = 0.002).

On what population does this intervention work best?

Mothers who have initiated breastfeeding while in the hospital.

Where will this intervention work best?

In home and community settings, where professional support for new mothers is provided within the community.

What is required to implement this intervention?

Training of staff and reorientation of service provision.

Resources and contact information

Training materials available at WHO website

References

Bhandari (2005)
Guise (2003)
Lana, Lamounier and Cesar (2003)
Morrow et al. (1999)

Recommended strategy 4: Multi-strategy, community intervention

Name of Intervention

Multi-strategy, community intervention.

Organisation

Lead by health services.

Brief literature review

Large scale, multi-strategy, community-based interventions have demonstrated significant improvements in the initiation and maintenance of exclusive breastfeeding. A study by Quinn et al. (2005) reported on the effectiveness of the Linkages Project, a broad scale community-based intervention in Africa and Latin America. Significant improvements were achieved in the initiation of breastfeeding within one hour of birth and also in the exclusivity of breastfeeding of infants up to six months of age. Population reach was one million in Bolivia, 3.5 million in Ghana and six million in Madagascar.

How and why does this intervention work?

The projects aimed to maximise existing government and NGO resources and focused on four main community components: building partnerships, capacity building, behaviour change communication and community activities to reach mothers. These were combined with staff training, monitoring and evaluation. Improvements were detected as early as nine months after initiation of the programs.

On what population does this intervention work best?

This is a universal approach aimed at pregnant women and new mothers.

Where will this intervention work best?

In a location with integrated, community-based services.

What is required to implement this intervention?

These kinds of interventions provide an opportunity for community health services and non-government organisations to work together.

References

Quinn et al. (2005)

Recommended strategy 5: Baby-friendly Hospital Initiative

Name of Intervention

Baby-friendly Hospital Initiative.

Organisation

World Health Organisation.

Brief literature review

The World Health Organisation’s Baby-friendly Hospital Initiative (World Health Organisation, 1998) identifies 10 steps to successful initiation of breastfeeding, which have been implemented in various ways throughout the world. Evidence exists for improved effectiveness when the involved hospitals are externally audited for compliance and their involvement over a period of time (Gau, 2004). Evidence is also available to support the various strategies recommended by the WHO, such as the review by Perez-Escamilla et al. (1994) of the infant feeding policies in maternity wards and their effect on breastfeeding success.

How and why does this intervention work?

This is an integrated approach that involves policy and practice change at the institutional level (hospital), training and best practice at the professional level. A trial involving 4,614 women found that exclusive and overall breastfeeding rates were higher in women attending hospitals with changed policies (in line with WHO), and the rates continued to increase significantly each year (n = 4,614).

On what population does this intervention work best?

Pregnant women and immediately after birth.

Where will this intervention work best?

Hospital setting.

What is required to implement this intervention?

Organisational and professional commitment.

Resources and contact information

World Health Organisation website

References

Perez-Escamilla et al. (1994)
Gau (2004)
World Health Organisation (1998)