Leeds Health Education Database 2015

Database entries with complete fields

5. Breastfeeding

September, 2015

5.1 General breastfeeding programmes

5.2 Breastfeeding programmes using mass media

Click on link for background information on Leeds Database Project, a list of all entries and details of breastfeeding interventions reviewed but not considered suitable for inclusion database.

5.1 General breast feeding programme

Akram, D.S., Agboatwalla, M. and Shamshad, S. (1997) Effect of intervention on promotion of exclusive breast feeding. JPMA - Journal of the Pakistan Medical Association 47, 46-48. Ref ID : 6700

Target Group /Country Urban slum area of Karachi

Intervention Methodology  Health education to promote exclusive breast feeding was provided through individual home visits and group discussions by lady health visitors and health workers beginning one month prior to anticipated date of delivery to six months post natal. Initially visits were weekly, and then one month after deliver were given bi-weekly. The objective was to improve breast feeding practices, including promotion of exclusive breast feeding and giving of colostrum to newborns. Pre-defined messages were presented in the form of pictorial flip charts , photographs representing different breastfeeding positions.

Evaluation Method   Sixty-seven mothers were registered in the intervention group and 53 in the control group. Information regarding prelacteal feeds and colostrums was collected within one week of delivery. Subsequent information regarding duration of breast feeding and supplemental feeds was collected every week through individual visits by health visitors and lady health visitors.

Impact Achieved  Sixty-six percent mothers in the control group gave prelacteals as compared to 31% in the intervention group (P < .0001). Colostrum was given by 97% mothers in the intervention group and 3% in the control group. Majority (94%) of intervention group mothers continued exclusive breast feeding till four months of age against 7% in the control group. It was concluded that health education programmes in the antenatal period as well as after birth can promote exclusive breast feeding practices

Alvarado, M., R, Atalah, S., E, Diaz, F., S, Rivero, V., S, Labbe, D., M and Escudero, P., Y (1996) Evaluation of a breastfeeding-support programme with health promoters' participation. Food and Nutrition Bulletin 17, 49-53. Ref ID : 6627

Target Group /Country Families of low socio-economic level living in the Northern district of Santiago in Conchali in Northern Chile

Intervention Methodology  Women living in the same geographic area with experience in health promotion activities were trained as breastfeeding and general health care promoters. They were involved in enrolling, educating (through both individual and group instruction) and following the mothers. Mothers in the intervention group received home visits from health promoters in the last three months of pregnancy. The health promoters also visited the maternity ward in the immediate postpartum period. Further follow-up was given in the health centre. Education was a combination of individual and group sessions.

Evaluation Method   The results obtained in a non-governmental health centre (experimental group) were compared with those obtained in a health centre of the same geographic area (control group), in a cohort of 62 and 66 infants, respectively.. Data were obtained from mothers' and children's records for both groups. Dietary information was obtained from a one week dietary history. The variables analysed were the type of feeding at the first, second, fourth and sixth moths; the child's weight and length at the same periods and the monthly weight gain.

Impact Achieved  The prevalence of exclusive breast-feeding was significantly greater in the experimental group during the entire period. At 6 months, 41.9% of the children in the experimental group and none of the children in the control group were exclusively breast-fed (P<0.01) and the percentages of children weaned were 1.6 and 37.8%, respectively. Height and weight were higher in the experimental group from the fourth to the sixth month, with a lower level of malnutrition (P<0.05).

Barros, F.C., Semer, T.C., Tonioli Filho, S., Tomasi, E., and Victora, C.G. The impact of lactation centres on breastfeeding patterns, morbidity and growth: a birth cohort study. Acta Paediatr. 84(11):1221-1226, 1995. Ref ID : 7583

Target Group /Country Women participating in lactation centres in Guaruja, Sao Paulo, Brazil

Intervention Methodology  The two lactation centres assist around 40 mothers and infants a day and group consultations (four mothers and babies) are offered when problems with breastfeeding are presented by the mothers and solutions are discussed by the group based on their own experience supervised by a paediatrician. Babies are schedule to attend once a week during th first month of life, each fortnight in the second month and once a month from the third to the sixth months of life

Evaluation Method   A longitudinal cohort study from birth up to the age of 6 months among 605 mothers and newborns at a maternity hospital. The sample were recruited in the maternity hospital between January and February, 1993. All babies kept with their mothers  in rooming-in were considered eligible. For ethical reasons a control was not used, however mothers that of their own volition decided to come to the lactation centres were considered the intervention group and those mothers who decided against it were the controls. Taking into account the families who dropped out and could not be contacted, at four months 289 (54%)children had attended the centre with the remaining 246 children who had never attended the centre. A baseline questionnaire was administered was collected at the maternity hospital and mothers were visited and given questionnaires at home and the babies weighed when the babies were 1, 4 and 6 months.

Impact Achieved  Children recruited in the perinatal period who subsequently attended the lactation centres (54%) were exclusively breastfed significantly more at 4 months (43 versus 18% p<0.001) and at 6 months of age (15 versus 6% p<0.001), than non-attenders, even after adjusting for confounders. Also, attenders presented less diarrhoea in the last fortnight than non-attenders (10 versus 17%, p=0.02), and their weight for age was significantly better (mean z-scores of 0.26 and 0.02, respectively p<0.01). The authors conclude that lactation centres are effective in promoting breastfeeding, and their use in areas with short breastfeeding duration should be considered. However, it should be noted (and the authors accept this) that subjects were not allocated at random to control and lactation centre and it is possible that the mothers attending the lactation centres were more highly motivated in their first instance to breastfeed.

Davies-Adetugbo, A.A. (1996) Promotion of breast feeding in the community: impact of health education programme in rural communities in Nigeria. Journal of Diarrhoeal Diseases Rese arch 14, 5-11. Ref ID : 6514

Davies-Adetegbu,A.A. and Adebawa,H.A. (1997)  The Ife South Breastfeeding Project: training community health extension workers to promote and manage breastfeeding in rural communities.  Bull. World Health Organ.  75, 323-332. Ref ID:7242

Target Group /Country Rural communities in Nigeria

Intervention Methodology  Project: training community health extension workers to promote and manage breastfeeding in rural communities. The intervention consisted of the training of the community health workers on UNICEF’s concept of baby friendly hospitals. The breast feeding education for the women included promotional posters in antenatal clinics and distributed to mothers for display in their homes, handouts on breastfeeding , breast feeding talks at the clinics and in their homes. One-to-one counselling was given by community health workers and their supervisors in the antenatal clinics and during the follow up home visits after delivery.

Evaluation Method   Late trimester pregnant women were enrolled into the study and given a questionnaire on knowledge, attitudes, and practices (KAP) about breast feeding. Women in the study group (n = 126) received breast feeding counselling before and after delivery, while those in control group (n = 130) did not receive any counselling. Both groups were monitored after delivery and followed with the KAP questionnaire.

Impact Achieved  32% of the deliveries reported early initiation of breastfeeding (within 30 minutes) in the intervention group compared to 6% in the control group (p<0.001). The prevalence of exclusive breast feeding at 4 months was 39.8% in the intervention group compared to 13.9% for the controls. Multivariate analysis showed that the intervention was a powerful and the only significant predictor of the increase in breast feeding behaviours (p = 0.0000), and that an early initiation of breast feeding is a strong predictor of exclusive breast feeding at 4 months of age. Note that it is of interest that there was no significant difference in the averaged knowledge scores of intervention and control women (although there were significant differences for knowledge of benefits of colostrums and expressing milk -=p=0.0000). The study showed substantial increases in health worker knowledge towards breastfeeding suggesting that the crucial factor was encouragement and support by health workers rather than specific changes in knowledge of the health workers that was critical to success)

Flores,M. and Filteau,S. (2015) Effect of lactation counselling on subclinical mastitis among Bangladeshi women. Annals of Tropical Paediatrics 22, 85-88.Ref. ID: 8978

Target Group/Country Ante-natal women in rural Chittagong, Bangladesh

Intervention Methodology Sub-clinical mastitis, defined as raised milk sodium/potassium (Na/K) in the absence of clinical symptoms, is associated with poor infant weight gain and increased risk of mother-to-child HIV transmission. Similarly to clinical mastitis, sub-clinical mastitis appears to have multiple causes, one being poor lactation practice. Two female field workers were trained to counsel women and assess practice afterwards. Counseling consisted of a single session of lactation counseling around the time of delivery. The counseling messages included the importance of giving colostrum, exclusive breastfeeding, feeding on demand and how to achieve good positioning and attachment.

Evaluation Method The intervention group was an opportunistic sample of antenatal women attending the local hospital. Women for the control group (n=66) were contacted at a vaccination clinic at the hospital. At 4 weeks post-partum, all women were administered questionnaire about infant feeding practices and were observed during a feed and asked to donate an approximately 5ml spot milk sample from each breast. These were analysed by flame photometry for sodium and potassium and by ELISA for interleukin-8 (IL8) by a technician who was unaware which samples were control and intervention. According to the report the non-counseled women differed from the counseled women only in that a higher percentage deliverd at home (83% vs. 70%; p=0.084) and their infants had been delivered a month before the intervention took place. However comparison data on education and economic status are not provided to support this.

Impact Achieved At 1 month postpartum, sodium and potassium were measured in spot milk samples from each breast by flame photometry. Geometric mean Na/K ratios and the proportion of milk samples with raised Na/K ratio were significantly (p < 0.05) lower in the counseled group [mean 0.42, 95% confidence interval (CI) 0.39-0.45, n = 116 samples; 10% Na/K ratio > 0.6] than in the non-counseled group [mean 0.49, 95% CI 0.45-0.53, n = 127; 25% Na/K ratio > 0.6]. Milk IL8 concentration did not differ between groups. The results show that among Bangladeshi women a simple lactation counseling intervention reduced sub-clinical mastitis. An important point in the validity of these findings is the assumption that the control and intervention group are equivalent and the higher proportion of birts at home in the control group is not indicative of other differences which could affect the outcome.

Froozani, M.D., Permehzadeh, K., Dorosty Motlagh, A.R. and Golestan, B. (1999) Effect of breastfeeding education on the feeding pattern and health of infants in their first 4 months in the Islamic Republic of Iran. Bull. World Health Organ. 5, 381-385.Ref ID : 8527

Target Group /Country Mothers and their babies in Shiraz, the Islamic Republic of Iran

Intervention Methodology  The maternity hospital had a rooming in programme. The mothers in the study group participated in the breastfeeding education programme during their postpartum stay (usually for 24 hours) in the maternity ward of the hospital, with follow-ups in the hospital lactation clinic or at home. The instruction was given by a trained nutritionist in a 40 hour breastfeeding course based on WHO/CDR/93.3-6666 Breastfeeding a training course in which each mother learned about the advantages of breastfeeding for herself and her child. On the day of discharge, the baby's position on the breast was observed and corrected (if necessary) and educational materials on breastfeeding supplied. Follow-up visits in the location clinic or at the patient's home were conducted between day 10 and day 15 after delivery, after 30 days and at monthly intervals until the end of the fourth month. Mothers were also encouraged to attend the clinic at any time if they were worried about the baby's condition or on their breastfeeding performance.

Evaluation Method   This quasi-experimental study on 120 pairs of mothers and infants in a maternity hospital - 59 in the experimental group and 61 in the controls. The subjects were randomly assigned, according to their delivery on odd or even days, to the study and control group. The mothers in both groups were asked to record the number of suckling episodes during the day and night and the days when the infant had diarrhoea or a respiratory illness, At each visit, the breastfeeding pattern and the infant's medical condition were noted. Measurements of the mothers' weight and height before delivery, and the infant's weight, length and head circumference were recorded by the nutritionist after delivery and during follow-up visit of all subjects in the study group. For the control group, the infants were measured only at birth and at the end of 4 months.

Impact Achieved  Exclusive breastfeeding rates were significantly higher (p<0.01)in the study group (54% ) than in the control group (6.5%), but 5% and 18% of infants, respectively, in the study and control groups had stopped breastfeeding by the age of 4 months. The mean number of days of diarrhoea experienced by infants in the study group were significantly lower P<=0.004 than in the control group. At the end of 4 months, the mean weight and length of the infants were significantly higher (both p<=0.05) in the study group than in the control group. The findings indicate that rooming-in is very important for promoting exclusive breastfeeding and that there is a need for continuous breastfeeding education of mothers

Garcia-Montrone, V. and Rose, J.C.,de Education in the promotion of breast feeding and infant stimulation by women of low socioeconomic level - a preliminary study. Cadernos de Saude Publica 12(1):61-68, 1996. Ref ID : 6519 (in Portuguese)

Target Group /Country Women of low socioeconomic status living in Sao Paulo State, Brazil.

Intervention Methodology  The educational programme on breast-feeding and infant stimulation.  The programme which was

covered in 5 sessions lasting about 1 h once weekly.

Evaluation Method   Women , who had been pregnant for 17-29 weeks, when the programme started, were divided into experimental and control groups of ten each matched for age, educational level and experience in breast feeding. The programme was evaluated by direct observation of mother-infant interactions and interviews with mothers up to 6 months after childbirth. One pair dropped out from the control and experimental group.

Impact Achieved  By the time the infants had reached 6 months old, 5 of the experimental and 2 of the control mothers were still breast feeding. The experimental mothers are claimed to show a 'significantly' higher frequency of stimulation of their infant during and after feeding than did the controls but no statistical tests are provided. This study is of interest in that it extends the evaluation of a breastfeeding education programme beyond breastfeeding performance to consider stimulation of the baby. However the sample size in this preliminary study is very small which severely limits the value of the publication.

Haider, R., Kabir, I., Hamadani, J.D. and Habte, D. (1997) Reasons for failure of breast-feeding counselling: mothers' perspectives in Bangladesh. Bull. World Health Organ. 75, 191-196. 7297 Ref ID: 7297

Target Group/Country Urban mothers of children aged 1-12 weeks hospitalised for diarrhoea in Dacca, Bangladesh

Intervention Methodology  During the hospitalization in the Dhaka hospital of the international Centre for Diarrhoeal Disease Research, Bangladesh, of a group of partially breast-fed infants aged 1-12 weeks who had been admitted with acute diarrhoea, their mothers were individually counselled by breast- feeding counsellors to start exclusive breast-feeding. The counselling was repeated 1 week later at home.

Evaluation Method   The infant-feeding practices of 104 mother-infant pairs were evaluated 2 weeks after their infants had been discharged from hospital. There were no controls. Note that 19 of the original 125 recruited could not be traced for follow-up)

Impact Achieved  75% of the mothers exclusively breast fed their babies. There was not significant difference between the mothers who had received two and three counselling sessions. A total of 25% of the mothers failed to breast-feed exclusively despite having been counselled. The case studies of these mothers illustrate that although they generally complained about having "insufficient breast milk" various factors such as domineering grandmothers, lack of financial support by their husbands, too much housework, or disinterest contributed to their failure to breast-feed exclusively. This study provides a useful and practical follow-up to a counselling programme. Limitations of this study are the absence of information on the breast-feeding practices prior to admission to the hospital for diarrhoea and the lack of a control (though the latter might be justified on ethical grounds). The authors comment that anxiety of the mothers over the health of their sick children may have distracted their attention from the counselling ( an argument for including such counselling as part of normal maternity care).

Haider,R., Ashworth,A., Kabir,I. and Huttly,S.R. (2011) Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial Lancet 356, 1643-1647. Ref ID: 8778

Target group/Country Lactating mothers in Dhaka, Bangladesh

Intervention Methodology An intervention using home visits by peer counselors - local mothers who had themselves breastfed received 10 days' training (40hrs). 1 peer counselor was recruited for each intervention zone and was responsible for 12-25 mothers and received an honorarium of US$22.50 per month. In the intervention group, 15 home-based counselling visits of typical length 20-40 minutes were scheduled, with two visits in the last trimester, three early postpartum (within 48 h, on day 5, between days 10 and 14), and fortnightly thereafter until the infant was 5 months old.

Evaluation method 40 adjacent zones in Dhaka were randomized to intervention (final number n=288) or control groups (final number 285). 363 women were enrolled in each group. Women were enrolled during the last trimester of pregnancy between February and December, 1996. Exclusive breastfeeding status was measured by 24 hour dietary recall through monthly interviews over the first five months. Individual semi structured interviews were held with intervention mothers at the end of 5 months and focus group discussions were held separately within the zones for groups of meothers who had breast fed exclusively for five months and those who had discontinued

Impact Achieved The prevalence of exclusive breastfeeding at 5 months was 202/228 (70%) for the intervention group and 17/285 (6%) for the control group (difference=64%; 95% CI 57%-71%, p>0.0001). Mothers in the intervention group initiated breastfeeding earlier than control mothers (p<0.0001)and were less likely to give prelacteal and postlacteal foods V. At day 4, significantly more mothers in the intervention group breastfed exclusively than controls (p<0.0001).No other breastfeeding promotion activities took place in the study communities during this period. The time intensive nature of the process and the honorarium required raise issues of sustainability and the authors themselves comment that a cost-effectiveness study would have been helpful. While the peer counselors reported considerable fulfillment from their role, 6 months after the project (and honoraria) had finished 69% had stopped providing breastfeeding support.

Hardy, E.E., Vichi, A.M., Sarmento, R.C., Moreira,L.E. and Bosquerio,C.M. Breastfeeding promotion: effect of an educational programme in Brazil. Stud.Fam.Plann. 13(3):79-86, 1982. Ref ID : 968

Target Group/Country Women in Brazil

Intervention Methodology  Educational material was presented to intervention groups (36 colour slides and a tape recording, presented over 15 minutes) followed by group discussion. Topics: importance of breastfeeding, care of breasts and nipples, characteristics of colostrum and milk, ejection reflex,  breastfeeding techniques, differences in breast and bottle fed babies. 48% of women attended one presentation, 36% attended two and 16% three or more. Training of health workers: lecture and discussion

Evaluation Method   Intervention study with control (n= 200 women) and intervention groups (n= 200 women) at different hospitals. Women interviewed re breastfeeding at postpartum check up 40 days after hospital discharge and then followed up until breast feeding stopped or until 9 months of age (same percentage of women followed up in both groups, 56.5%). Women in intervention group were also advised re breastfeeding but women in the control group "not  given any special instruction/ advice".

Impact Achieved  Any breastfeeding (A) and full breastfeeding (B) continuation rates: were significantly larger in intervention group at each month of age of child than control group. (A: Chi squared p<0.023, B: Chi squared p < 0.001). The influence of the program was significant for women over 25, for those whose partners were aged 30 or more, and for those with less education. The program failed to produce a significantly longer duration of breastfeeding among the younger women and among those with a relatively higher education and with younger partners.

Haider,R., Ashworth,A., Kabir,I. and Huttly,S.R. (2011)  Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. Lancet  356, 1643-1647. Ref ID: 8778

Target Group/Country Lactating mothers in Dhaka, Bangladesh

Intervention Methodology  An intervention using home visits by peer counselors - local mothers who had themselves breastfed received 10 days' training (40hrs). 1 peer counselor was recruited for each intervention zone and was responsible for 12-25 mothers and received an honorarium of US$22.50 per month. In the intervention group, 15 home-based counselling visits of typical length 20-40 minutes were scheduled, with two visits in the last trimester, three early postpartum (within 48 h, on day 5, between days 10 and 14), and fortnightly thereafter until the infant was 5 months old.

Evaluation Method   40 adjacent zones in Dhaka were randomized to intervention (final number n=288) or control groups (final number 285). 363 women were enrolled in each group. Women were enrolled during the last trimester of pregnancy between February and December, 1996. Exclusive breastfeeding status was measured by 24 hour dietary recall through monthly interviews over the first five months. Individual semi structured interviews were held with intervention mothers at the end of 5 months and focus group discussions were held separately within the zones for groups of mothers who had breast fed exclusively for five months and those who had discontinued

Impact Achieved  The prevalence of exclusive breastfeeding at 5 months was 202/228 (70%) for the intervention group and 17/285 (6%) for the control group (difference=64%; 95% CI 57%-71%, p>0.0001). Mothers in the intervention group initiated breastfeeding earlier than control mothers  (p<0.0001)and were less likely to give prelacteal and postlacteal foods V. At day 4, significantly more mothers in the intervention group breastfed exclusively than controls (p<0.0001).No other breastfeeding promotion activities took place in the study communities during this period. The time intensive nature of the process and the honorarium required raise issues of sustainability and the authors themselves comment that a cost-effectiveness study would have been helpful. While the peer counselors reported considerable fulfilment from their role, 6 months after the project (and honoraria) had finished 69% had stopped  providing breastfeeding support.

Hoffman, M.N., Durcan, N.M., and Disler, P.B. Breast-feeding in a socio-economically disadvantaged area of Cape Town. Part II The introduction of an educational and support programme. S.Afr.Med.J. 66(14 July):66-67, 1984. Ref ID : 7860

Target Group/Country Mothers, the community, health professionals in a socially disadvantaged area of Cape Town Hoffman,

Intervention Methodology  Breastfeeding clinics introduced and conducted at the same time as antenatal clinics. Prospective mothers could see breastfeeding in action and learn by example. The name of volunteers who would help mothers with breastfeeding problems provided. Talks given in the community on the advantages of breastfeeding. Lectures, demonstrations and a symposium for local clinic staff. Letters sent to local doctors to encourage them to promote breastfeeding.

Evaluation Method   Evaluation of breastfeeding among mothers 2 years after the initiation of an intervention. Pre intervention questionnaire used. Mothers attending the clinic with infants < 6 weeks of age classified as fully breastfed or mixed/bottle fed. Breastfeeding mothers interviewed after 6 weeks. Pre and post intervention data compared.

Impact Achieved  Breastfeeding at < 6 weeks: significant increase over the two year period from 52.7% to 75.8% (P < 0.01). Breastfeeding in the following 6 week period: significant increase over the two year period from 23.7% to 38.7% (P < 0.01). While there was an overall increase in the numbers of women breastfeeding after the intervention the percentage of women who continued breastfeeding remained similar (50% pre intervention and 50.1% post intervention). The program resulted in possible behavioural change ie. increase in initiation of breastfeeding but not in maintenance of breastfeeding. Authors point to the "infinite number of other variables" that could have affected breastfeeding rates

Jakobsen, M.S., Sodemann, M., Molbak, K., Alvarenga, I. and Aaby, P. (1999) Promoting breastfeeding through health education at the time of immunizations: a randomized trial from Guinea Bissau. Acta Paediatr. 88, 741-747. Ref ID : 8559

Target Group/Country Mothers with children attending health centres in Guinea Bissau

Intervention Methodology  Prior to the intervention, focus group discussion and individual interviews were carried out to determine reasons for early termination of breastfeeding. The intervention was designed to be feasible within existing infrastructure and was carried out as individual health education at the local health centre when the mother made routine visits; i.e.  at the first antenatal consultation, at vaccination sessions in weeks 6, 10 and 14 and when the child reached 9 months of age. At the health centre the mother and child's randomisation status was determined and mothers from the intervention group then received health education individually in a separate room. The intervention was performed by two local female health workers who both lived in the area and who had both breastfed themselves. The health education messages were given orally in a 10 minute session. The mothers were encouraged to breastfeed for at least two years, to avoid introduction of weaning food and water for the first 4-5 months and to continue to breastfeed ill children.

Evaluation Method A cluster sample method was used to randomly select and allocate to control/intervention groups 1226 mothers from 86 clusters of 20 households. After accounting for mothers moving out of the area, children stillborn or having died there were 368 in the study group and 329 in the control group at the end of the study. Apart from the individual sessions on breastfeeding, both control and study groups received the same care and made the same number of health centre consultations. At weekly visits in the home of children from both groups, data on breastfeeding status were collected. When breastfeeding was terminated, a special questionnaire was completed including the mothers' reasons for terminating breastfeeding. At 5-6 months after birth interviews were initiated regarding feeding habits of the child. Mothers were asked for the age at which the child was first introduced to water and weaning food. The interviews were carried out by local female nurses and the home was visited until the interview was obtained or until it became clear that it could not be completed (e.g. the mother going away)

Impact Achieved Of children who survived at least 7 days, 100% in the intervention group and 98.9% of the control started breastfeeding within the first week of life. There was no difference in the rates of termination at 12, 18 and 24 months between the intervention and control group. Introduction of weaning food was delayed in the intervention group (risk rate 1.18 (95% CI 1.03-1.38) but there was no difference in the time of introduction of water. The median length of breastfeeding was 23 mo in both groups. Although exclusive breastfeeding was promoted by the intervention, early weaning of children in special risk groups was not avoided. Note - raw data on weaning not presented and the term 'almost exclusively breast-fed' used but not defined. The authors comment that their concern to use existing infrastructure meant that they were not able to use more powerful but difficult to sustain approaches such as involvement of fathers. Furthermore they comment that the high level of initiation of breastfeeding in their communities meant that health education should concentrate on the post-natal period. While showing a negative result, this study demonstrates the value of evaluating health education practice.

Jingheng,H., Yindi,X., Yongxin,J. and Jie,X. (1994)  Evaluation of a health education programme in China to increase breast-feeding rates.  Health Promotion International  9, 95-98. Ref ID: 3561 (Borderline for inclusion in database)

Abstract: Target group/Country Women at maternal and child health centre in Luwan District, China

Intervention methodology Health education program, "A Friend of Pregnant Women," to provide information and skills in breast feeding (BF) at the Maternal and Child Health Center. The health education messages included the importance of massaging breasts and washing breasts with warm water

Evaluation Method The program involved follow-up visits at the 3rd and 42nd day after delivery and at 4 and 6 mo after delivery. 131 women were initially registered for the study, 24 had miscarriages and subsequently 106 formed the treatment group. 30% of these did not take part in the health education programme. Breast feeding was defined as babies receiving no more than 120 ml of formula milk/day, but the paper does not specify how this was measured.

Impact Achieved The program was effective in increasing knowledge about BF among attenders, with 44% of women correctly responding to knowledge items at pretest compared with 60% at posttest. In addition, the rate of BF at 4 mo was significantly greater in the group receiving the program compared to a control group who did not receive the program (44% vs 21%). Insufficient milk was  claimed to be the most important factor contributing to a failure to do BF. 76% of mothers did not was breasts and 88% did not massage breasts. Note that given the lack of control, lack of information on measurement of breast feeding, and unnecessary nature of the advice given, this would not seem a particularly relevant study and is likely to be eliminated from the database.

Ladzani,R., Steyn,N.P. and Nel,J.H. (2011) An evaluation of the effectiveness of nutrition advisers in three rural areas of northern province. S. Afr. Med. J. 90, 811-816. Ref ID: 8913 (Borderline for inclusion in database)

Target Group/Country Caregivers of infants living in rural villages in Northern Province, South Africa

Intervention Methodology A nutrition education programme was undertaken by 6 trained local women (nutrition advisers). They received intensive and ongoing nutrition training that included both content and nutrition education methods. Two nutrition advisers were stationed at each clinic in each of 3 villages. Over the 2 year intervention programme these advisers carried out nutrition education which included individual and group talks to local women, dietary advice to mothers of underweight infants, home visits to families with underweight children and demonstrations on vegetable gardens and economical nutritious meals. Details are not provided of how women were selected or their backgrounds.

Evaluation Method Female caregivers of infants living in three study villages (study area (SA)) and three control villages (control area (CA)) in Northern Province. Households were randomly selected. A baseline study was undertaken in the SA (n=590) and CA (n=450) in 1989. A questionnaire eliciting sociodemographic data and information on dietary practices and nutritional knowledge was developed and used in the baseline study and 2 years later after intervention SA n=600), CA n=663). The study and control areas were compared with regard to breast-feeding and infant feeding practices; use of milk, brown bread, legumes and nuts; and use of school lunch boxes by older children.

Impact Achieved The percentage of women who initiated breast-feeding on the day of birth improved significantly in the study area from 60% to 90%. There was no difference between control and intervention area in women breastfeeding at 12 months. In both study and control groups there was a decline in giving solid food on the first day of life and an increase in giving complementary feeds and breast-milk (levels in study group not significantly different from controls). There were no significant differences in the intervention area with regard to use of milk, brown bread, legumes, nuts, and school lunch boxes. Given that the programme lasted for 2 years and that the communities may have been exposed to other sources of nutrition education the lack of impact of the nutrition education workers is not surprising. It is disappointing that authors provide no information either on the coverage and quality of the nutrition education carried out or on the presence of other nutrition education activities e.g. mass media that might explain the increases in the control villages

Lutter, C.K., Perez-Escamilla, R., Segall, A., Sanghvi, T., Teruya, K. and Wickham, C. (1997) The effectiveness of a hospital-based program to promote exclusive breast-feeding among low-income women in Brazil. American Journal of Public Health 87, 659-663. Ref ID : 6733

Target Group/Country Women at a maternity hospital in Santos, Brazil

Intervention Methodology For 20 years the programme hospital has had a comprehensive breastfeeding promotion programme characterized by rooming-in, early initiation of breastfeeding and breastfeeding assistance and talks during hospitalisation. These talks include information on the importance of exclusive breastfeeding for the first six months of infancy, how to solve common breast-feeding problems and where to find postpartum breastfeeding help. The control hospital was of similar size but had no breastfeeding programme although it had recently instituted several reforms mandated by Brazilian law which included rooming-in and prohibition of free gifts of infant formula.

Evaluation Method In a prospective design, women who delivered at a hospital with an active breast-feeding promotion program (n = 236) were compared with women who delivered at a nearby control hospital (n = 206). Data were collected from hospital records and by interviewing the women just prior to hospital discharge and at home at 30 and 90 days post-partum. Prior to discharge exposure to hospital breastfeeding practices and activities was assessed by maternal recall. Information was also collected on breastfeeding history and plans and exposure to breastfeeding information. Exclusive breastfeeding was assessed at each follow-up visit by 24 hr maternal recall in response to a list of liquids (including water) and foods. There was about 20% of both sample lost to follow-up (with no major differences in characteristics of those lost)

Impact Achieved The two groups had similar demographic characteristics and previous breast-feeding histories. Exposure to breast-feeding activities, assessed by maternal recall prior to discharge, was higher for the intervention group both during the ante-natal period (p<0.05), during the period in hospital (p<0.01) and in the period up to the first follow-up visit (p<0.001) but the difference in exposure to breast feeding information was not significant between the 1st and 2nd follow-up visit. The differences in extent of advice/demonstrations received during the stay in hospital on management of expressing, engorgement, sore nipples, knowing whether infant received enough breast milk  and increasing breast milk supply, time to introduce liquids and solids were particularly striking with % recall by the mothers in programme hospital varying between 31-76% and in the control hospital between 1.5-5.4% (P<0.01). Multivariate survival analysis showed that exclusive breast-feeding lasted 53 days longer among women who delivered at the program hospital (p<0.0001).

Morrow, A.L., Guerrero, M.L., Shults, J., Calva, J.J., Lutter, C., Bravo, J., Ruiz-Palacios, G., Morrow, R.C. and Butterfoss, F.D. (1999) Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet 353, 1226-1331. Ref ID : 8433

Target Group/Country Mothers in peri-urban in the southwestern outskirts of Mexico City

Intervention Methodology Study of the efficacy of home-based peer counselling to increase the proportion of exclusive breastfeeding among mothers. Peer counsellors were selected from that community were had previously worked as field data collectors for the Instituto Nacional de la Nutricion, aged 25-30 yrs with high school education and a commitment to breastfeeding although not necessarily with breastfeeding experience. The peer counsellor training, run by  trained by La Leche League, consisted of 1 week of classes, 2 months in lactation clinics and with mother-to-mother support groups , and 1 day of observation and demonstration by visiting experts. The peer counsellors practised in a nearby neigbourhood for 6 months before the intervention trial, during which the content of messages and problem-solving skills were refined. In the 6 visit group mothers were visited in mid and late pregnancy, in the first week and weeks 2, 4 and 8 post partum. In the 3 visit intervention group mothers were visited in late pregnancy, in the first week and week 32 post-partum. Peer counsellors responded to occasional requests for additional support that were initiated by intervention-group mothers,

Evaluation Method Two intervention groups with different counselling frequencies, six visits (44) and three visits (52), were compared with a control group (34) that had no intervention. From March, 1995, to September, 1996, 170 pregnant women were identified by census and invited to participate in the study. Home visits were made during pregnancy and early post partum by peer counsellors recruited from the same community and trained by La Leche League. Data were collected by independent interview. Exclusive breastfeeding was defined by WHO criteria. 130 women participated in the study. Only 12 women refused participation. Study groups did not differ in baseline factors.

Impact Achieved  At 3 months post partum, exclusive breastfeeding was practised by 67% of six-visit, 50% of three-visit, and 12% of control mothers (intervention groups vs controls, p<0·001; six-visit vs three-visit, p=0·02). Duration of breastfeeding was significantly (p=0·02) longer in intervention groups than in controls, and fewer intervention than control infants had an episode of diarrhoea (12% vs 26%, p=0·03). This is the first reported community-based randomised trial of breastfeeding promotion. Early and repeated contact with peer counsellors was associated with a significant increase in breastfeeding exclusivity and duration. The two-fold decrease in diarrhoea demonstrates the importance of breastfeeding promotion to infant health. Note that given the background of the persons selected as counsellors, the term peer counsellors is misleading and they were clearly not peers.

Savina,G. and Kennedy,K. (1989)  The effect of a breastfeeding education program on lactational amenorrhea in the Philippines.  Stud. Fam. Plann.  20, 203-215. Ref ID: 5924

Nakao, R.M., Kennedy, K.I. and Savina, G. (1992) Breastfeeding education and infant health in the rural Philippines. Ecology of Food and Nutrition 27, 115-126. Ref ID : 6677

Target Group/Country Women in two communities of population 15,000 each in eastern Negros oriental, central Phillippines.

Intervention Methodology Two health educators hired by the study worked with local midwives to establish small classes of 5 to 10 women, usually neighbours. The classes were conducted in the women's homes or in local health centres, The health educators used lectures, pictorials, games and activities and maintained to social and informal atmosphere. Midwives and others were often present and health topics other than breastfeeding were discussed. The health educators also visited the study participants in their homes once or more each month th answer questions about breastfeeding and other concerns. Referrals between midwives and health educators took place frequently. Education in the experimental group began two to three months before birth and continued up to 12 months post-partum. Each mother attended a two-hour class and one individual counselling session per month. The mothers in the control group received no special education about infant feeding.

Evaluation Method   There were 68 mothers in the experimental group and 67 in the controls. Each month a 24 hr self-report form was completed, recording each breastfeeding episode an any supplemental feeds. Each mother was also interviewed monthly about feeding practices, health status/illness episodes of the children. The respondents were given watches to time their feeding episodes and monthly photographs of their children which are socially valued items. The accuracy and reliability of data were monitored by random rechecks of respondents by a supervisor. Data collectors were trained to inspect the respondents' homes visually for evidence of feeding bottles and to ensure that observations matched interview data.

Impact Achieved 97% of the experimental mothers reported feeding colostrums to their infants compared to 72% of controls (p<0.001). Significantly more experimental mothers (p<0.001) reported feeding colostrums to the study infant compared to their previous child with no significant difference in the controls. The mean age for giving a first taste of any food and for introducing regular supplements (either liquid of solids) was significantly younger for the control infants (p<0.01) but there was no difference between the two groups in the mean age when regular solids were started). The authors state that significantly more control mothers (56%) ever used bottles compared with mothers in the experimental group (35%) but raw data and p values are not provided. A greater percentage of infants had fewer self-reported illness episodes in the education community from month 2-7 ( values each moth varied between <0.01 and <0.1), even after results were controlled for maternal age and education (data from clinic attendance confirmed the difference).There was no significant difference between the two groups in the mean duration of postpartum amenorrhea. Note that while demonstrating an impressive impact on breastfeeding and health, the resources deployed in this intervention were considerable and issues of sustainability are not addressed.

Popkin, B.M., Canahuati, J., Bailey, P.E., and O'Gara, P.E. An evaluation of a national breast-feeding promotion programme in Honduras. Journal of Biosocial Science 23:5-21, 1991.  Ref ID : 4750

Target Group/Country Women in Honduras

Intervention Methodology  PROALAMA breast-feeding promotion programme (Proyecto de Apoyo a la Lactancia Materna) focused on training of docutrs and nurses, changing hospital policies to promote early (first hou after birth) breastfeeding and rooming in and eliminating the giving of baby bottles or formular to mothers. Trained health care providers gave prenbatal education, counselling at delivery and post-partum support for women with breastfeeding prblmes. The project's activities ran from December 1982 to December 1988.A mass media campaign began with radio spots in 1981 and early 1983 with a radio course on breastfeeding

Evaluation Method Data used was based on the last child in each of three national surveys of women of childbearing age were 1981 9n=1540), 1984 (n=1471) and 1987 (n=3354) (numbers refer to the number of children data refers to).In 1982 and 1985 community surveys had been carried out on 868 and 521 women living in nineteen low income neighbourhoods served by the teaching hospital in Tegucigalpa. There were no controls.

Impact Achieved  The median duration of breastfeeding increased by 2.5 and 1.7 months in the periods 1981-1984 and 1984-1987 respectively. A significant increase occurred in the initiation and duration of breast-feeding among Honduran women between 1981 and 1987. Data from the community survyews showed that while 93% of the infants in 1982 commenced to breastfeed, over 98% were breastfed in 1985. The authors suggest that the reason for this increase in breastfeeding was due to a combination of the PROLAMA programme, the mass media education and the economic decline which reduced the importation of baby milk. Data is not presented to ascribe causes to either of these possible explanations and significance testing is not used to demonstrate the significance of the apparent decline.

Prasad, B. and Costello, A.M. Impact and sustainability of a "baby friendly" health education intervention at a district hospital in Bihar, India. BMJ 310:621-623, 1995. Ref ID : 4279

Target Group/Country Mothers at a district hospital in a small town in Bihar, India

Intervention Methodology  A baby friendly training intervention for staff at an Indian district hospital 10 day training programme for doctors, nurses, and midwives, explaining the benefits and feasibility of early breast feeding and dangers of prelacteal feeds together with instruction on explaining this information to mothers. Messages: "initiate breast feeding within the first hours after birth", benefits of colostrum, that breast milk is all the child needs for the first 4 months of life and advice on some common breast feeding problems

Evaluation Method   Intervention study with assessment by interviewing mothers. 172 mothers were recruited before the intervention, 195 recruited immediately after the intervention, and 101 recruited six months later.  The interview recorded : Age of infant when breastfeeding started, use of prelacteal feeds and colostrum feeding.

Impact Achieved  Breast feeding was started within 24 hours of birth by 53 (29%) of control mothers, 164 (84%) in the early follow up group, and 60 (59%) in the late follow up group. Prelacteal feeds were used by 165 (96%), 84 (43%), and 78 (77%) respectively. Only 36 mothers in the late follow up group reported receiving education on feeding. Mothers in this group who had received the education were significantly more likely than mothers who received no education to breast feed early (28 (78%) v 11 (17%), P < 0.001) and not use prelacteal feeds (21 (58%) v 2 (3%), P < 0.001). Training doctors and midwives greatly improves the feeding practices of mothers. However, the impact of the training fell off quickly and authors concluded that refresher training is needed to sustain the improvement.  . In addition, approval needed of guardian, mother in law or religious advisor indicating a need to  target these groups for health education intervention.

Pugin, E., Valdes, V., Labbok, M.H., Perez, A., and Aravena, R. Does prenatal breastfeeding skills group education increase the effectiveness of a comprehensive breastfeeding promotion program? Journal of Human Lactatation 12(1):15-19, 1996. Ref ID : 7573

Valdes, V., Perez, A., Labbok, M., Pugin, E., Zambrano, I., and Catalan, S. The impact of a hospital and clinic-based breastfeeding promotion programme in a middle class urban environment. J.Trop.Pediatr. 39(3):142-151, 1993. Ref ID : 6326

Target Group/Country Middle class urban women at the maternity unit of the  Catholic Hospital of Chile in Santiago, Chile

Intervention Methodology All mothers received a breast-feeding intervention of five activities: training of health workers, activities at pre-natal clinic and hospital, outpatient lactation clinic and offering the lactation ammenorrhoea method as a form of birth control. A subgroup group received a further breastfeeding skills group education at pre-natal consisting of three 20 minute small group sessions where women were encouraged o discuss various aspects of breastfeeding and share their own personal experiences. Prior to the above experimental programme mothers received a normal breastfeeding support programme details of which are not provided.

Evaluation Method A prospective intervention study with a control group. The control group of 313 urban middleclass mother-child pairs were recruited in the hospital in the postpartum period and were followed for 6 months. A group of 422 mother-child pairs of the same socio-economic status were recruited for the intervention. The selection criteria for the participation of the mothers in the control and intervention group included age between 18 and 39 years, parity of 5 or less, healthy mother, stable union with partner, term vaginal delivery weighing over 2500 g at delivery and a work situation compatible with 6 months of exclusive breastfeeding.313 control infants received the normal breastfeeding support, 422 received the breastfeeding intervention of whom 59 also received the pre-natal education intervention. Women were recruited if they intended to breastfeed.

Impact Achieved In the control group 32% were still fully breastfeeding at six months compared to 67% of the complete intervention group (p<0.0001). 80% of the women who had received prenatal education were fully breastfeeding after six months compared with 65% of those who did not receive this intervention (p<0.026). It is not clear from the report why this 65% differs from the 67% also cited. Note that the definition of fully breastfeeding allowed for only two supplemental feeds per week. Both were higher than the control group 32% who received the standard package (p<0.0001). Note also that a goal of fully breastfeeding at six months appears rather strict given that by then many infants might require the commencement of weaning.  Also the selection criteria of middle class background, an intention to breastfeed and also lack of restrictions from employment make this a clearly very special sample and the results cannot be generalised to other groups.

Ross, S.M., Loening, W.E. and Van Middelkoop, A. (1983) Breastfeeding-evaluation of a health education programme. S. Afr. Med. J. 64, 361-363. Ref ID : 1081

Target Group/Country Women in South Africa

Intervention Methodology Over an 8 month period health education was given by an experienced midwife to women during the antenatal period. Teaching was presented to groups of 3-6 primigravidas/ multigravidas in two half hour sessions 1) advantages of breastfeeding 2) technique. Materials: photographs and "motivational literature", discussion encouraged

Evaluation Method   Intervention study with treatment group and controls. Mothers at the clinic interviewed after delivery: Group A received health education (n=59); Group B controls (n= 66). Long term: Mothers from the clinic interviewed 24 weeks after delivery: Group C had received health education (n=74); Group D controls (n=48). There was no baseline.

Impact Achieved  Significant increase in knowledge post delivery of nutritional advantages of breast milk and value of colostrums (p=0.02). Higher but reduced knowledge level 24 weeks later. 72% of the infants had commenced formula feeding at between 1 and 5 weeks. The commonest reason for supplementary feeding "not enough milk", "baby not satisfied". The authors draw attention to marketing of baby milks, their use by higher socio economic groups and their sale by health personnel as contributing towards difficulties in achieving behaviour change. This study is limited by the lack of a base line or measures to prevent contamination of control group by intervention.

Seema, Patwari, A.K. and Satyanarayana, L. (1997) Relactation: an effective intervention to promote exclusive breastfeeding. Journal of Tropical Paediatrics 43, 213-216. Ref ID : 7244 (Borderline for inclusion in database)

Target Group/Country Nursing mothers in India

Intervention Methodology  Relactation was attempted in both the groups with motivation, support, and repeated suckling. Group II mothers, in addition, were given metoclopramide

Evaluation Method  ifty mothers of hospitalized infants less than 4 months old with partial or complete lactation failure (LF) from a hospital in India (name unspecified) were randomly assigned to two groups of 25 each for relactation. The primary outcome variables measured included the time of appearance of first breast milk secretion (in complete LF), time for partial and complete relactation.

Impact Achieved  Relactation attempt was successful in 49 mothers (98 per cent), wlth complete relactation in 46 (92 per cent) and only partial relactation in three mothers (6 per cent). All the outcome variables of the two groups were comparable (P > 0.05). The pattern of weight gain, the rate of reduction in the amount of top milk and subsequent weight gain in the follow-up was also comparable in both the groups (P > 0.05). Maternal factors like breast conditions, nutrition, parity, feeding practices in previous babies, lactation gap, and infants' initial refusal to suck at the breast did not influence the outcome variables as long as repeated suckling was ensured. The authors conclude that that relactation is possible in most of the mothers without the help of lactagogues. Apart from educating and motivating the mother for exclusive breastfeeding during the first 4-6 months, strong proressional support by a skilled health worker is needed to overcome the initial problems during relactation

Valdes,V., Pugin,E., Schooley,J., Catalan,S. and Aravena,R. (2011) Clinical support can make the difference in exclusive breastfeeding success among working women. Journal of Tropical Paediatrics 46, 149-154. Ref ID: 8914

Target Group/Country Working mothers from Chile

Intervention Methodology Following a hospital based breastfeeding support programme mothers attended a clinic at 30 days, were explained the benefits of exclusive breastfeeding for 6 months. Hand expression was demonstrated to groups of mothers. Mothers and infants were seen at the clinic by a paediatrician and nurse-midwife monthly for first six months and again at 12 months. During the vist they were invited to share concerns about health issues and other anxieties. If the infant was in good health they were encouraged to continue exclusive breastfeeding. Detailed information on the educational methods are not provided.

Evaluation Method All women entered to study at 30 days post-partum and had received the similar hospital breastfeeding support programme and were exclusively breastfeeding at time of enrolment. 146 women were in the intervention group. 116 women were in the control group who received the standard care during monthly attendance at the Well baby clinics. Information on feeding practices were collected at the monthly and final clinic.

Impact Achieved Only 6 per cent of women in the control group were able to complete 6 months of exclusive breastmilk feeding compared to 53 per cent of those in the intervention group (p value not given). The most important difference between the strategies used by both groups of mothers for maintaining exclusive breastmilk feeding after returning to work was that only 23 per cent of the control group practiced milk expression compared to 66 per cent in the intervention group (pvalues not given). 39 infants were weaned at 6 months in the control group (34%) and 12 in intervention group (8.2%, p<0.0005). The authors comment that even with "relatively supportive" legislation on maternity leave and delivery in a hospital committed to the baby-friendly initiative the numbers in the control group practicing exclusive breastfeeding at 6 months were low and achievement of the levels of the intervention group required an additional educational input. It is disappointing that the additional input is not described in more detail and costed. Also given that the control group were regular attenders at their well baby clinic - it would have been of interest to know whether levels might have been increased with a minor changes to these existing services without recourse to the programme of intensive support that was provided. It is worth noting that both the controls and intervention samples were drawn from women already exclusively breastfeeding at 30 days which represents a highly motivated self-selected sample.


5.2 Breast feeding - Mass media programmes

Hugo, J. and Skibbe, A. Facing visual illiteracy in South African health education: a pilot study. Journal of Audiovisual Media in Medicine 14(2):47-50, 1991. Ref ID : 2513  (borderline for inclusion in the database)

Target Group/Country Women at ante-natal clinics at a hospital in South Africa

Intervention Methodology A talk using illustrations to clarify the basic concepts of breast and bottle feeding. The illustrations, designed by a medical illustrator and validated by specialists, attempted to convey the following information: 1) breastfeeding creates a stronger bond between mother and baby than does bottle feeding; and 2) clean water, sterilized bottles, and correct formula mixture all directly affect the health of bottle-fed babies.

Evaluation Method For the purposes of the study, the researchers conducted 2 successive antenatal clinics at Tygerberg Hospital in 1989. During the first clinic, following real-life situations, a health education nurse gave a 10-minute talk. During the 2nd clinic, a follow-up questionnaire was conducted. 47 pregnant women attended both clinics.

Impact Achieved  In the follow-up session, 45 (96%) women indicated a positive preference for breastfeeding and 40 (85%) stated that bottle feeding may be harmful to the baby. The study revealed that while only 9% of the women could correctly identify both simplified and detailed black-and-white illustration, 66% were able to identify colour pictures. The finding indicate an ability by illiterate patients to read and interpret instructional illustrations. As an intervention evaluation this is not of a high standard but the publication does provide a good example of the issues involved in understanding of visuals and has therefore been retained in the database.

Haider,R., Kabir,I. and Ashworth,A. (1999)  Are breastfeeding promotion messages influencing mothers in Bangladesh?45, 315-318. Ref ID: 8651

Target Group/Country
Women in Bangladesh

Intervention Methodology  A national breastfeeding promotion campaign in Bangladesh in 1989 which should to reach mothers who delivered at home and promote the following three messages: 1)feed the baby colostrums immediately after birth; 2) for the first 5 months breastmilk alone is insufficient; 3) when the baby is 5 months old, along with breastmilk feed him/her family foods. No information is provided on the methods used, timing and appeals.

Evaluation Method A random sample of 1100 lower middle class mothers in Dhaka, with infants aged 0-6 months, were interviewed in 1995. There was no baseline and no controls.

Impact Achieved Although 99 per cent of mothers fed colostrum within 3 days of delivery, 92 per cent also gave one or more traditional prelacteals, and 68 per cent gave postlacteals. This could be due to ambiguity of the message, which simply advocated giving colostrum without indicating its exclusive use, thereby appearing compatible with traditional perceptions that colostrum alone is insufficient. Ninety-nine per cent of mothers reported hearing the breastfeeding messages or receiving advice, and 97 per cent stated that they understood the meaning of exclusive breastfeeding. But this concept was not correctly understood, as many thought it meant feeding breastmilk and water. The prevalence of exclusive breastfeeding was 15 per cent, and complementary foods were introduced early (median 30 days). Many mothers doubted the message that breastmilk alone is sufficient for 5 months. This study provided valuable information on the status of breastfeeding but the absence of a baseline and controls severely limits its value as an evaluation of the mass media campaign.

McDivitt, J.A., Zimicki, S., Hornik, R., and Abulaban, A. The impact of the Healthcom mass media campaign on timely initiation of breastfeeding in Jordan. Stud.Fam.Plann. 24(5):295-309, 1993. Ref ID : 30

Target Group/Country Communities in Jordan

Intervention Methodology  A two day lactation seminar on lactation management for health professionals Two intensive radio and television campaigns involving drama, testimonials and advice from a fictitious female Doctor (May 15 - July 15 1989, mid March - end April 1990). Messages: "initiate breast feeding within the first hours after birth", benefits of colostrum, that breast milk is all the child needs for the first 4 months of life and advice on some common breast feeding problems

Evaluation Method Intervention study using mass media/seminars given by health professionals evaluated through a systematic random sample of mothers. Two surveys: Baseline survey (1988), before seminar/ media campaigns, mothers n= 800 *Post intervention survey (1990), after the seminar/media campaigns, mothers (with children < 20 months) n=777 interviews followed baseline survey format with additional questions regarding breast feeding. Measures: 1) behavioural outcomes: change in whether mother breast fed or not, change in early supplementation, change in timely initiation of breast feeding 2) knowledge of breast feeding initiation and colostrum 3) exposure to media breast feeding programme.

Impact Achieved  The mass media breast feeding campaign reached 73% of mothers (1990). Significant increases in: Initiation of breast feeding 90.5% to 97.2% (p< 0.0001), timely initiation of breast feeding 40% to 54% (p 0.001), Slight, but not significant, decrease in early supplementation of breast feeding before 3 months 50% to 60%. Knowledge: significant increases that breast feeding should start within 6 hours of birth 51% to 75% (p<0.0001) and the benefits of colostrum 40% to 70% (p<0.0001). It had a positive impact on mothers knowledge and timely initiation of breast feeding at home and in public hospitals but not in private hospitals. Authors conclude that providing information to mothers needs to be part of a programme supported by hospital policy and staff practices.

Monteiro, C., Rea, M. and Victora, C. (1990) Can infant mortality be reduced by promoting breastfeeding? Evidence from Sao Paulo City. Health Policy and Planning 5, 23-29. Ref ID : 7239

Target Group/Country Women in Brazil

Intervention Methodology An ambitious breastfeeding promotion programme was launched in Brazil in 1981 which included the use of mass media,  health personnel training and re-organization of health service routines,

Evaluation Method A total of 300 children aged under 8 months attending health services in metropolitan São Paulo was sampled 1981 and 380 in 1987. Data were collected form the mother or caretaker on the type of milk consumed and infants were classified as either fully breastfed (breast milk only), partially breastfed (breast milk and any type of cow's milk) or artificially fed (cows milk only). Cause specific infant mortality rates were obtained from the vital statistics office. São Paulo  was used for the evaluation because of the high coverage or vital registration data. The potential impact of the programme on infant mortality rates was estimated using the relative risks associated with breastfeeding obtained in a case-control study in a similar urban population in southern Brazil

Impact Achieved  A comparison of two health surveys carried out in Greater Sao Paulo before (1981) and after (1987) the implementation of the programme showed an important increase in the median duration of breastfeeding from 84 to 146 days respectively., During this period the infant mortality rate in Sao Paulo fell by 49%. The observed change in feeding practices may have been responsible for a reduction of 12% of this 49%  - one quarter of the observed decline in infant mortality. The calculations suggest that the programme may have led to reductions in deaths caused by diarrhoea of 32%, in respiratory infections of 22% and in deaths due to other infections of 17%. In the absence of controls and supporting information on reasons for breastfeeding it is difficult to attribute the increase in breastfeeding to the campaign. However, this evaluation provides a good example of what can be achieved with macro-level data to evaluate a national campaign. 

Rea, M.F. and Berquo, E.S. Impact of the Brazilian national breast-feeding programme on mothers in greater Sao Paulo. Bull.World Health Organ. 68(3):365-371, 1990. Ref ID : 5846

Target Group/Country Women in Brazil

Intervention Methodology A broad-based national breast-feeding programme using radio and television was launched in Brazil in 1981 that was preceded by an evaluation of infant feeding habits in two metropolitan areas of the country. In the first phasein 1981  there were intensive TV and radio advertisements which sought to communicate the advantages of breast milk and dispel some of the myths that existed with messages such as "Breast feed for at least 6 months" and "weak milk does not exist "In the later phase Aug 1982 to Dec 1983 national celebrities were used to promote the messages and the campaign was longer. The international Code for Marketing Baby Milk Substitutes was introduced in 1981 but only in 1982 were stricter controls on marketing implemented. In the 3rd phase (Jan to Dec 1984)there was a concerted drive to train health personnel and set up mothers' groups and other groups began to campaign on breastfeeding.

Evaluation Method This paper reports the initial findings of an evaluation of the programme in Greater Sao Paulo that was carried out in 1987, 6 years after the programme started. The method employed was analogous to that used before the start of the programme in 1981. For this purpose, a representative sample of mothers who were attending child care services open to all income groups were interviewed, together with a number of health professionals. A total of 497 mothers with children aged 0-12 months were covered. A recall interview was also administered on the duration of breast-feeding for all children born to the mothers since 1981

Impact Achieved The mean duration of breast-feeding rose from 89.4 days to 127.5 days and of feeding only breast-milk from 43.2 days to 66.6 days. The proportion of previous children who were breast-fed for more than 6 months rose from 18.9% for those born in 1981-82 to 37.7% for those born in 1984, when the programme activities were at their highest, and slipped back again to 27.6% in 1985-86. Note that the campaign also included stricter controls on the promotion of infant milk substitutes. There were no controls but this paper does seek to relate breastfeeding to exposure to the campaign - however is not clearly stated how exposure was measured and the data is not clearly expressed.


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