WABA Research Task Force Newsletter

WABA Research Task Force Newsletter

2011-09-13T21:10:51+00:00

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WABA

Research

Task Force

(RTF)

e-newsletter

August 2011 issue

From the Editors

This issue

We are pleased to share with you the third issue of the WABA Research Task Force (RTF) E-newsletter. This issue focuses mainly on a few aspects of clinical breastfeeding and some of the determinants of breastfeeding behaviour. Hepatitis B in breastfeeding mothers is a hot topic for discussion as well as issues related to diarrhoeal morbidity and mortality. The issue also deals with the main determinants of exclusive breastfeeding in a few selected countries and how self confidence in breastfeeding can be improved among trained health workers. Finally we present an article that describes the profiles of working mothers who practice exclusive breastfeeding in Indonesia.

About the newsletter

There is an abundance of research and much of this can be accessed through journals and databases such as Medline. This newsletter aims to present some of this emerging research in a comprehensive and easy-to-read format. For each issue, we will choose a few current topics where we ask key researchers/programme experts to summarise the latest research and explain how these findings can be applied in the real world.

You will also find abstracts and commentaries on a few research studies and the links to the full text articles for further reading. We hope that this newsletter will enhance your work, whether programme, clinical or advocacy, as well as stimulate discussion about research findings, methodologies and ethics. Your comments on the current topics and articles are most welcome! If you have any suggestions for future topics, please let us know. The newsletter will be issued three times a year.

Enjoy reading!

Amal Omer-Salim & Khalid Iqbal

Co-coordinators of the WABA RTF

Emails: Amal: amal.omer-salim@kbh.uu.se

Khalid: kitfeed@gmail.com

Contents

From the Editors 1

Should chronic hepatitis B mothers breastfeed? A meta analysis 2

Breastfeeding and the risk for diarrhea morbidity and mortality 5

Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing

countries 8

Predictors of exclusive

breastfeeding in early infancy:

a survey report from Phnom Penh, Cambodia 9

Determinants of exclusive breastfeeding in Nigeria 10

The effects of Baby Friendly Initiative training on breastfeeding rates and the breastfeeding attitudes, knowledge and self-efficacy of community health-care

staff 11

Profiles of eight working mothers who practiced exclusive breastfeeding in Depok, Indonesia 12

WABA Research Task Force (RTF) e-newsletter: August 2011 issue

The authors use a meta-analytic technique to quantify the evidence of an association between breastfeeding and risk of chronic hepatitis B (CHB) infection among the infants vaccinated against HBV. The advantages of breastfeeding over formula feeding have been well documented. In the absence of evidence that breastfeeding poses any additional risk of infection to infants born of CHB mothers, World Health Organization (WHO) recommends breastfeeding even for area where HBV infection is highly endemic and HBV vaccine is not available. In the present paper, we conduct a meta analysis to assess the risk of CHB infection of vaccinated infants through breastfeeding associating with CHB mothers who are and are not positive for the HBV infectivity markers.

Methods

Criteria for inclusion of the studies

(1) Follow-up studies, prospective or retrospective, on the association between breastfeeding (BF) versus formula-feeding (FF) and risk of CHB infection among the infants born of CHB mothers.

(2) All infants must receive at least 3 doses of hepatitis B vaccines, with or without receiving hepatitis B immunoglobulin (HBIG) after birth.

(3) CHB infection is defined as the presence of any of the three HBV markers (HBsAg, HBeAg and HBV DNA) in blood, during prenatal care

visit and / or before delivery of their babies for the mothers and within one year after immunization with the third-dose hepatitis B vaccine for the infants.

Data extraction

Two independent investigators (Xia and Yao) were involved in data extraction. The third investigator (Lu) examined the results, and a consensus was reached. The outcome, CHB infection of the infants born of CHB mothers at the end of follow-up within one year after immunization with the third-dose hepatitis B vaccine was considered. We extracted the following data from the eligible studies: authors’ names, journal and year of publication, country of origin, enrolment periods, type of study, number of CHB and non-CHB among the infants by feeding methods, general characteristics of the babies and their mothers.

Statistical analysis

The risk difference (RD) with 95% confidence interval (CI) was used as a measure of effect between breastfeeding (BF) versus formula-feeding (FF) and risk of infantile used to pool the RDs across studies in Stata version 10.0 (Stata Corp). Heterogeneity was explored by x 2 test, with a significance set at a P value 0.10. The extent of heterogeneity was measured by Higgins’ I2. Subgroup analysis and Meta-regression were carried out to examine the effect in relation to quality and type of study, language of paper, study sites, hepatitis B vaccination of the mothers and infants, and mothers’ infectivity if available. We used the test for interaction to estimate the difference between two subgroups CHB infection across studies. The Dersimonian and Laird random-effects model was used to pool the RDs across studies

Should chronic hepatitis B mothers breastfeed?

A meta analysis

Yingjie Zheng, et al

WABA Research Task Force (RTF) e-newsletter: August 2011 issue

in Stata version 10.0 (Stata Corp). Heterogeneity was explored by x 2 test, with a significance set at a P value 0.10. The extent of heterogeneity was measured by Higgins’ I2. Subgroup analysis and Meta-regression were carried out to examine the effect in relation to quality and type of study, language of paper, study sites, hepatitis B vaccination of the mothers and infants, and mothers’ infectivity if available. We used the test for interaction to estimate the difference between two subgroups.

Results

The search retrieved 517 papers, and 99 out of which were potentially relevant to current analysis. Further backward search produced 3 additional papers. Only 32 papers [7, 10-13, 22-48] which offered 32 independent studies were included in our analysis and the reasons for exclusion of the others were listed in additional. The 32 studies included in present analysis were published between 1985 and 2010. One study was conducted in the United States, one in Italy and the other 30 in China, including Hongkong. Mothers decided the feeding methods in all studies except one in which they were randomized. The sample size of the studies ranged from 38 to 436 (median, 143), with the ratio of BF versus FF infants of 0.09 – 5.07 (median, 0.94). The 32 studies contributed 5650 infants and 244 CHB outcomes with an overall transmission rate of 4.32%. The difference between the risk of infantile CHB infection among BF and FF infants (RD) determined by the random-effects model was -0.8%, (95% confidence interval [CI]: -1.6%, 0.1%) and that determined by the fixed-effects model was -0.4% (95% CI: -1.6%, 0.7%). The findings suggest that BF is not associated with additional risk of infantile CHB infection concurred with that of all the individual studies, except one, which suggests that BF is associated with a lower risk than FF.

Data on HBV infectivity available from 16 of the 32 studies showed that 42.0% (1648/3924) of mothers were designated with “high infectivity”, being positive for either the HBeAg and/or the HBV DNA, and that the proportion of these mothers was lower among those who elected to BF (36.9%, 739/2001) than those who elected to FF (44.1%, 812/1843) (Table 2). The overall RD was -0.4% (95% CI: -1.4%, 0.7%), which was not modified by language of paper, quality and type of study, study sites or infantmother vaccination by both subgroup analysis and Meta regression. And the RD determined for mothers with high infectivity was 0.7% (95% CI: -2.0%, 3.5%), which was not significantly different (Z=0.789,P

>0.05) from

that determined for mothers with low infectivity, -0.5% (95% CI: -1.7%,

0.6%.

Publication bias and its correction

Visual inspection of the funnel plots demonstrated a possible publication bias. After trim and fill methods were performed, the pooled RDs were – 1.0% (95%CI: -1.8%, – 0.1%) and -0.6% (95%CI: -1.6%, 0.5%) respectively for

the 32 and 16 studies.

WABA Research Task Force (RTF) e-newsletter: August 2011 issue

Conclusion

Our results suggest that breastfeeding by CHB mothers does not pose a

significant risk of infection by the virus, provided that the infants have been

vaccinated against HBV at birth. Even by mothers with high infectivity, is not

associated with demonstrable risk of infection of infantile CHB. This may be

partly because infection mainly occurs during delivery and the protection

by vaccination. The finding concurs with that of individual studies and

supports the WHO recommendation of BF, irrespective of the HBV status

of the mothers. In our meta analysis, reference search, data extraction

and quality evaluation were done by two independent investigators and

examined by the third one before a consensus was reached, thus the

completeness and appropriateness of the studies included for analysis

were ensured. We used RD instead of OR or risk ratio (RR) as effect measure,

which ensured that a reasonable estimation of effect measurement

remained untouched and the 2

nd

shortcoming mentioned above was

overcome simultaneously. Routine hepatitis B vaccination allows the infant

to enjoy breastfeeding, the nutritional, immunological and psychological

advantages of which are well known. And breastfeeding would also greatly

benefit the mother, especially in weakening or eliminating her fear and

guilt which occur often. Unfortunately, contrary to our findings that risk of

breastfed transmission of infantile CHB infection simply does not exist, the

current clinical practices seem discouraging: any breastfeeding rate is about

30% lower for those mothers with than without CHB, and even lower (5.4%

only) for those with high infectivity; there is still 25% – 50% of the medical

professionals did not recommend infantile breastfeeding by CHB mothers.

Thus, health education of breastfeeding with correct knowledge, attitude

and behaviour on the decision makers, such as medical professional and

CHB mothers, seems to be urgent, especially in those epidemic countries,

like China.

Article URL

http://www.biomedcentral.com/1471-2458/11/502

Comments from the editor:

This meta analysis demonstrates no association

between breastfeeding and risk ofinfantile CHB infection from a CHB

mother to her infant. Large number of studies had concluded no risk of

transmission of HBV by mothers with chronic Hepatitis B in continuing

breastfeeding. In this meta-analysis majority of the studies are from China

and recommends routine vaccination, it is a dilemma that still many

health care professionals are not fully aware of this fact. There is great

need to create awareness among medical professionals through trainings,

workshops and seminars especially in the regions of high epidemic like

China.

WABA Research Task Force (RTF) e-newsletter: August 2011 issue

L

ack of exclusive breastfeeding among infants 0-5 months of age and

no breastfeeding among children 6-23 months of age are associated

with increased diarrhea morbidity and mortality. Studies show that

human milk glycans, which include oligosaccharides in their free and

conjugated forms, are part of a natural immunological mechanism that

accounts for the way in which human milk protects breastfed infants

against diarrheal disease. Breastfeeding reduces exposure to contaminated

fluids and foods, and contributes to ensuring adequate nutrition and thus

non-specific immunity. Diarrheal disease accounts for approximately 1.34

million deaths among children ages 0-59 months and continues to act as

the second leading cause of death in this age group. This systematic review

and meta-analyses use carefully developed and standardized methods to

focus on the effects of breastfeeding practices as they relate to diarrhea

incidence, prevalence, mortality and hospitalization among children 0-23

months of age. Here we present a comprehensive systematic review and

meta-analysis as evidence to be utilized by the Lives Saved Tool (LiST) to

model the effect of breastfeeding practices on diarrhea-specific morbidity

and mortality.

Methods

All literature published from 1980 to 2009 systematically reviewed to

identify studies with data assessing levels of suboptimal breastfeeding

as a risk factor for diarrhea morbidity and mortality outcome. The studies

included were randomized controlled trials (RCT), cohort and observational

studies that assessed suboptimal breastfeeding as a risk factor for at least

one of the following outcomes: diarrhea incidence, diarrhea prevalence,

diarrhea mortality, all-cause mortality, and diarrhea hospitalizations.

Included studies were published in any language from 1980 – 2009 and were

conducted in developing countries with a target population of children 0-

23 months of age. We excluded studies reporting diarrhea as a result of

only one microbial cause, and those with unclear methodology or data

in a form that could not be extracted for meta-analysis. We also excluded

studies reporting exclusive breastfeeding for children beyond 6 months

of age and those failing to restrict the allocation of diarrhea outcomes

to concurrent breastfeeding status. Additionally, we excluded morbidity

studies with diarrhea recall beyond two weeks and mortality studies

where the removal of deaths occurring within the first three to seven days

of life was not possible. For studies reporting outcomes stratified by HIV

status, we only abstracted data on HIV-negative infants and children. We

abstracted data for each diarrhea outcome by breastfeeding exposure

levels. By current standards, ‘exclusive breastfeeding’ does not include the

ingestion of anything other than breastmilk and prescribed vitamins and

medications, and infants receiving non-nutritive liquids, such as waters

and teas, are classified as ‘predominantly breastfed’. In cases where relative

risk (RR) was not reported, we generated RR and 95% confidence intervals

using reported numerators and denominators.

We organized data into the following age strata: 0-28 days, 0-5 mos, 0-11

mos, 6-11 mos, 12-23 mos, and 6- 23 mos. We excluded studies with over

arching age categories that could not be collapsed; however, we included

one diarrhea mortality study grouping children 12-35 mos and applied its

Breastfeeding and

the risk for diarrhea

morbidity and

mortality

Laura M Lamberti et al

WABA Research Task Force (RTF) e-newsletter: August 2011 issue

RR to the 12-23 mos analysis. For infants aged 0-5 mos, we generated pooled

effect measures using exclusive, predominant, and partial breastfeeding as

reference categories. For infants in the 0-11 mos category, we used partial

and any breastfeeding as reference categories, and for all age categories

extending from 6 or 12 months, we used any breastfeeding as the only

reference category. For each outcome of interest, we summarized the

evidence by conducting an assessment of study quality and quantitative

measures as per CHERG guidelines. As per the CHERG grading system, the

overall quality of evidence for each effect estimate receives a score on a

four point continuum (‘high’, ‘moderate’, ‘low’, ‘very low’), which is then used

to either support or oppose its inclusion in the LiST model. Although, it has

been reported that self-selection or reverse causation can also create bias in

the opposite direction, with some mothers less likely to wean sick children.

These biases can be reduced by the following four methods: (1) exclusion

of deaths or episodes occurring within the first 7 days of life; (2) exclusion

of infants and young children from non-singleton and/or premature births

and those with low birth weight, congenital abnormalities, and any other

serious illnesses unrelated to the outcome of interest; (3) identification

of breastfeeding exposure immediately prior to the onset of illness or

mortality as opposed to that concurrent with outcome; (4) assessment of

whether weaning was a direct consequence of illness or poor growth and

exclusion of such infants or young children if their inclusion significantly

changes the effect measure.

Results

The systematic literature review yielded 2375 unique publications, 71 of

which contained data on suboptimal breastfeeding as a risk factor for

the identified outcomes of interest. A total of 18 studies met all inclusion,

exclusion, and analytical criteria and were included in the analysis. Of

these, 11 were prospective cohort, 4 were cross-sectional observational,

and 3 were case-control studies. The majority were conducted in Latin

America (n=7) but also took place in Africa (n=4), South Asia (n=5), the

Middle East (n=2) and the Western Pacific (n=2) regions, with one study

reporting three different study locations.

Diarrhea incidence

Among infants 0-5 mos of age, predominant (RR: 1.26), partial (RR: 1.68) and

not breastfeeding (RR: 2.65) resulted in an excess risk of incident diarrhea

in comparison to exclusive breastfeeding. Similarly, the estimated relative

risk of incident diarrhea was elevated when comparing not breastfed (RR:

1.32) to breastfed infants 6-11 mos of age. No studies reported diarrhea

incidence comparing exclusive breastfeeding to suboptimal feeding

among neonates.

Diarrhea prevalence

In comparison to exclusively breastfed infants 0-5 mos of age, the estimated

relative risk of prevalent diarrhea was statistically significantly elevated in

predominantly (RR: 2.15), partially (RR: 4.62), and not (RR: 4.90) breastfed

infants. Among infants and young children 6-23 mos of age (Table 3), not

WABA Research Task Force (RTF) e-newsletter: August 2011 issue

breastfeeding (RR: 2.07) resulted in an excess risk of prevalent diarrhea as

compared to breastfeeding. There were no studies comparing diarrhea

prevalence among exclusively and sub-optimally breastfed neonates.

Diarrhea mortality

In comparison to exclusive breastfeeding, predominant (RR: 2.28), partial

(RR: 4.62) and not (RR: 10.52) breastfeeding led to an elevated risk of diarrhea

mortality among infants 0-5 mos of age. Among infants 0-11 mos of age,

the estimated risk of diarrhea mortality was higher in partially (RR:4.19)

and not (RR: 11.73) breastfed infants as compared to those predominantly

breastfed. For infants and young children 6-23 mos of age, not breastfeeding

(RR: 2.18) resulted in an excess risk of diarrhea mortality as compared to

breastfeeding. There were no studies comparing the outcome of diarrhea

mortality in exclusively versus sub-optimally breastfed neonates.

All-cause mortality

As compared to exclusively breastfed infants 0-5 mos of age, the estimated

relative risk of all-cause mortality was statistically significantly elevated

among those predominantly (RR: 1.48), partially (RR: 2.84) and not (RR:

14.40) breastfed. The estimated relative risk of all-cause mortality was

higher when comparing not breastfed (RR: 3.69) to breastfed infants and

young children 6-23 mos of age. Among neonates, predominant (RR: 1.41),

partial (RR: 2.96), and no (RR:1.75) breastfeeding resulted in elevated risk of

mortality as compared to exclusive breastfeeding.

Diarrhea hospitalizations

The estimated relative risk of hospitalization for diarrhea illness was

elevated among predominantly (RR: 2.28), partially (RR: 4.43) and not (RR:

19.48) breastfed infants 0-5 mos of age as compared to those exclusively

breastfed . Among infants 6-11 mos of age, not breastfeeding continued

to result in a higher risk of hospitalization for diarrhea when compared

to any breastfeeding (RR: 6.05). There were no studies reporting diarrhea

hospitalizations as an outcome for neonates.

CONCLU SION

In conclusion, this data confirm and highlight the importance

of breastfeeding for the prevention of diarrhea morbidity and

mortality. This review also provides updated risk estimates across age

categories. Among infants 0-5 mos of age, these findings support the

recommendation for exclusive breastfeeding during the first 6 months

of life as a key child survival intervention. Furthermore, results among

infants and children beyond the first 6 mos of age reveal the importance

of continued breastfeeding as a critical intervention to protect against

diarrhea-specific morbidity and mortality throughout the first two years

of life. So there is a sizable body of evidence for the protective effects of

breastfeeding against diarrhea incidence, prevalence, hospitalizations,

diarrhea mortality, and all-cause mortality. The results of random

WABA Research Task Force (RTF) e-newsletter: August 2011 issue

effects meta analyses of eighteen included studies indicated varying

degrees of protection across levels of breastfeeding exposure. For all

outcomes among infants 0-5 mos of age, the protection conferred by

exclusive breastfeeding was incrementally greater than that granted

by predominant and partial breastfeeding. The protection conferred by

breastfeeding appears to operate via two pathways, decreasing diarrhea

incidence as well as duration.

Article URL

http://www.biomedcentral.com/1471-2458/11/S3/S15

Comments from the editor:

While the current analysis was limited by a

lack of geographic variety by outcome, the geographic diversity of the

overall analysis was actually quite wide with studies taking place in

eleven unique countries and in all WHO regions except Europe.

WHO and UNICEF currently recommend exclusive breastfeeding for the

first 6 months of life with continued feeding through the first year among

HIV positive mothers, provided that they or their infants receive ARV

drugs during the breastfeeding period.

There is great need at national level to evaluate the breastfeeding

promotion strategies or the operational challenges of inspiring mothers to

commit to exclusive breastfeeding for the first 6 months and to continued

breastfeeding for the following 18 months. Operations research is needed

to identify methods for maximizing the effectiveness of breastfeeding

promotion programs and policies on behaviour change among mothers. I

would emphasise that health care professionals can play vital role in this

regard.

G

iven the recognized benefits of breastfeeding for the health of

the mother and infants, the World Health Organization (WHO)

recommends exclusive breastfeeding (EBF) for the first six months

of life. However, the prevalence of EBF is low globally in many of the

developing and developed countries around the world. There is much

interest in the effectiveness of breastfeeding promotion interventions on

breastfeeding rates in early infancy. A systematic literature was conducted

to identify all studies that evaluated the impact of breastfeeding

promotional strategies on any breastfeeding and EBF rates at 4-6 weeks

and at 6 months. Data were abstracted into a standard excel sheet by

two authors. Meta-analyses were performed with different sub-group

analyses. The overall evidence were graded according to the Child Health

Epidemiology Reference Group (CHERG) rules using the adapted Grading

of Recommendations, Assessment, Development and Evaluation (GRADE)

criteria and recommendations made from developing country studies for

inclusion into the Live Saved Tool (LiST) model. After reviewing 968 abstracts,

268 studies were selected for potential inclusion, of which 53 randomized

and quasi-randomized controlled trials were selected for full abstraction.

Thirty two studies gave the outcome of EBF at 4-6 weeks postpartum.

There was a statistically significant 43% increase in this outcome, with

89% and 20% significant increases in developing and developed countries

Effect of

breastfeeding

promotion

interventions on

breastfeeding rates,

with special focus

on developing

countries

Imdad A, Yakoob MY, Bhutta ZA.

BMC Public Health. 2011 Apr 13;11

Suppl 3:S24.

WABA Research Task Force (RTF) e-newsletter: August 2011 issue

respectively. Fifteen studies reported EBF outcomes at 6 months. There

was an overall 137% increase, with a significant 6 times increase in EBF in

developing countries, compared to 1.3 folds increase in developed country

studies. Further sub-group analyses proved that prenatal counseling had

a significant impact on breastfeeding outcomes at 4-6 weeks, while both

prenatal and postnatal counseling were important for EBF at 6 months.

Conclusion: Breastfeeding promotion interventions increased exclusive

and any breastfeeding rates at 4-6 weeks and at 6 months. A relatively

greater impact of these interventions was seen in developing countries

with 1.89 and 6 folds increase in EBF rates at 4-6 weeks and at 6 months

respectively.

Comments from the editor:

This review of all interventions to promote

and support breastfeeding is an added value to an earlier Cochrane

review on support interventions. It is interesting to note that breastfeeding

promotion appears to be more effective in developing countries compared

to developed countries. One explanation that the authors offer is that

knowledge and support may not be the limiting factors in the developed

countries, rather early employment, availability of formula and social

factors. This review also supports breastfeeding interventions during

pregnancy. However to achieve increases in exclusive breastfeeding

we need to have a combination of prenatal and postnatal promotion.

Interestingly, lay and professional support and education are needed,

especially in settings where most deliveries take place in the home.

E

xclusive breast-feeding (EBF) is recommended in the first 6 months of

an infant’s life. This study aims to investigate the present status of infant

feeding practices and identify factors that affect EBF practices during

the first 6 months following infant birth in Phnom Penh, Cambodia. A crosssectional

survey with a semi-structured questionnaire was given to 312

mothers with children aged 6 to 24 months who visited the immunization

clinic in the National Maternal and Child Health Centre in Phnom Penh,

Cambodia, from December 2005 to February 2006. Eighty-three percent of

mothers fed breast milk exclusively in the first month, whereas only 51.3%

continued EBF in the first 6 months. Within 30 minutes after delivery, 39%

of mothers began breast-feeding. Results from logistic regression analysis

indicate that the lack of a maternal antenatal EBF plan, working and lack of

paternal attendance at breast-feeding classes have independently positive

associations with cessation of EBF during the first 6 months of infant life.

The findings have helped to identify some important factors affecting EBF

practices in the study area in Cambodia. The findings revealed that it is

important to educate pregnant mothers, probably through exposure to

trained midwives and media, so they may recognize the significance of

EBF and will develop intention and plan to feed their babies, keeping in

mind the benefits it may yield. Paternal involvement in breast-feeding

classes may increase their awareness and consequently complement EBF

practices. Finally, development of conducive working environments and

policies for working mothers should be carefully explored.

Predictors

of exclusive

breastfeeding in

early infancy:

a survey report

from Phnom Penh,

Cambodia

Yuri Sasaki et al

Journal of Pediatric Nursing (2010)

25, 463–469

WABA Research Task Force (RTF) e-newsletter: August 2011 issue

10

Comments from the editor:

Although this is a retrospective study with the

usual limitations of recall bias which may affect the validity of the mothers’

responses, it is interesting to note that the main independent factor for

the duration of exclusive breastfeeding in this urban Cambodian context

was lack of a maternal antenatal plan for exclusive breastfeeding. This

is supported by other studies.In Phnom Penh the exclusive breastfeeding

rate is much higher than in more rural parts of the country. This could be

explained by the fact that almost 2/3 of babies were delivered in a Baby-

Friendly Hospital thus increasing the chances of access to appropriate

education by trained midwives. The authors stress the importance of

influencing intentions and plans before delivery and including fathers in

breastfeeding education.

E

xclusive breast feeding (EBF) has important protective effects on the

survival of infants and decreases risk for many early-life diseases. The

purpose of this study was to assess the factors associated with EBF

in Nigeria. Data on 658 children less than 6 months of age were obtained

from the Nigeria Demographic and Health Survey (NDHS) 2003. The 2003

NDHS was a multi-stage cluster sample survey of 7864 households. EBF

rates were examined against a set of individual, household and community

level variables using a backward stepwise multilevel logistic regression

method.

The average EBF rate among infants younger than 6 months of age was

16.4% (95%CI: 12.6%-21.1%) but was only 7.1% in infants in their fifth

month of age. After adjusting for potential confounders, multivariate

analyses revealed that the odds of EBF were higher in rich households than

poor households. Increasing infant age was associated with significantly

less EBF. Mothers who had four or more antenatal visits were significantly

more likely to engage in EBF (AOR = 2.70, 95%CI = 1.04-7.01). Female infants

were more likely to be exclusively breastfed than male infants (AOR = 2.13,

95%CI = 1.03-4.39). Mothers who lived in the North Central geopolitical

region were significantly more likely to exclusively breastfeed their babies

than those mothers who lived in other geopolitical regions.

The EBF rate in Nigeria is low and falls well short of the expected levels

needed to achieve a substantial reduction in child mortality. Antenatal

care was strongly associated with an increased rate of EBF. Appropriate

infant feeding practices are needed if Nigeria is to reach the child survival

Millennium Development Goal of reducing infant mortality from about

100 deaths per 1000 live births to a target of 35 deaths per 1000 live births

by the year 2015.

Comments from the editor:

This study is based on a nationally representative

sample and uses the standard WHO definitions making comparison with

other similar studies easier. Interestingly enough mothers from more

privileged groups were more likely to exclusively breastfeed than those from

lesser privileged groups, even though the level of exclusive breastfeeding

is still far below that in Asian countries and actually declining in Nigeria

Determinants

of exclusive

breastfeeding

in Nigeria

Agho et al

BMC Pregnancy and Childbirth

2011, 11:2

WABA Research Task Force (RTF) e-newsletter: August 2011 issue

11

as a whole. The authors suggest that a significant improvement could be

achieved by targeting practices such giving water in addition to breastmilk

and focusing on poor, illiterate families and those who deliver at home,

not reached by antenatal and delivery services. Community-based peer

counseling might be the most appropriate intervention in these cases.

T

he aim was to evaluate the effects of Baby Friendly Initiative (BFI)

community training on breastfeeding rates, staff and mothers in a

large Primary Care Trust (PCT). UK Government policy promotes the

adoption and implementation of the World Health Organization/United

Nations Children’s Fund BFI as the best evidence to raise breastfeeding

initiation and prevalence. Methods: A total of 141 health visitors and

nursery nurses were trained on mandatory three-day BFI courses during

2008; 137 staff (100 health visitors, 37 nursery nurses) took part in the

evaluation.

Breastfeeding attitudes, knowledge and staff confidence in helping

mothers to breastfeed were measured using a validated Breastfeeding

Questionnaire and a self-efficacy tool at three time points before and after

training. Breastfeeding rates at eight weeks increased significantly, and a

baby born in 2009 was 1.57 times more likely to be breastfed than one

born in 2006. Statistically significant improvements in staff breastfeeding

attitudes, knowledge and self-efficacy were seen after attending the course,

in addition to increases in the appropriate management of breastfeeding

problems.

Process evaluation interviews with 43 health visitors, nursery nurses

and managers explored views of the training and changes in practice.

The response to the course was overwhelmingly positive and felt to be

extremely worthwhile. It has led to renewed enthusiasm, improved the

consistency of advice among team members and raised confidence

levels of all staff who help mothers with breastfeeding. Health visitors

felt confident about enabling nursery nurses to take a greater role in

breastfeeding support. A small survey of mothers reported increases in

exclusive breastfeeding and signs of increased breastfeeding self-efficacy.

Making the training mandatory across the whole PCT has improved the

consistency of breastfeeding advice and confidence of all health-care staff

who help breastfeeding mothers.

Comments from the editor:

Although it is not possible to say for certain that the improvements in breastfeeding rates are due to the training, as this would require a randomized study design, it is encouraging that

the authors have followed process evaluation techniques to evaluate

the training. This and the triangulation of interviewing health visitors,

managers and a sample of mothers lends credibility to the conclusions

drawn. Self efficacy in dealing with breastfeeding problems and situations

is important not only for mothers themselves, but also the health worker

who aims to help her.

The effects of

Baby Friendly

Initiative training

on breastfeeding

rates and the

breastfeeding

attitudes,

knowledge and

self-efficacy of

community healthcare

staff

Jenny Ingram, Debbie Johnson and

Louise Condon

Prim Health Care Res Dev. 2011

Jul;12(3):266-75

WABA Research Task Force (RTF) e-newsletter: August 2011 issue

12

Exclusive breastfeeding practice is generally low because of multifaceted factors internally within mothers themselves and also the surroundings. In addition, studies have consistently found that maternal employment outside the home is related to shorter duration of exclusive breastfeeding. With all these challenges, it is interesting that there are some mothers who manage to exclusively breastfeed their infants. Therefore, this report aims at exploring the characteristics of working mothers who are able to practice exclusive breastfeeding. The original study population was non-working and working mothers who have infants around 16 months old. The study design is an observational study with a mixed methods approach using a quantitative study (survey) and qualitative methods (in-depth interview) in sequential order. In addition, in-depth interviews with family members, midwives, supervisors at work, and community health workers were also included to accomplish a holistic picture of the situation. The study concludes that self-efficacy and confidence of the breastfeeding mothers characterize the practice of exclusive breastfeeding. Good knowledge that was acquired way before the mothers got pregnant suggests a predisposing factor to the current state of confidence. Home support from the father enhances the decision to sustain breastfeeding.

Comments from the editor:

Working outside the home and being separated for long hours from the baby are factors often associated with a shorter
duration of exclusive breastfeeding. In this article, the few mothers who did practice exclusive breastfeeding were interviewed to find out what made them stand out from the majority. This kind of formative research that explores patterns among so-called positive deviants is very useful for understanding complex behaviours such as exclusive breastfeeding.

Once again, the important role of the supportive father reinforcing selfconfidence in the mother is highlighted. The World Alliance for Breastfeeding Action (WABA) is a global network of individuals and organisations concerned with the protection, promotion and support of breastfeeding worldwide based on the Innocenti Declaration, the Ten Links for Nurturing the Future and the WHO/UNICEF Global Strategy for Infant and Young Child Feeding. Its core partners are International Baby Food Action Network (IBFAN), La Leche League International (LLLI), International Lactation Consultant Association (ILCA), Wellstart International, and the Academy of Breastfeeding Medicine (ABM). WABA is in consultative status with UNICEF and an NGO in Special Consultative Status with the Economic and Social Council of the United Nations (ECOSOC).

WABA, PO Box 1200, 10850 Penang, Malaysia

Tel: 604-658 4816

Fax: 604-657 2655

Email: waba@waba.org.my

Website: www.waba.org.my

Profiles of eight

working mothers

who practiced

exclusive

breastfeeding in

Depok, Indonesia

Judhiastuty Februhartanty, Yulianti

Wibowo, Umi Fahmida

and Airin Roshita

BREASTFEEDING MEDICINE

Volume 6, Number 0, 2011

About the Author:

Leonard is a website designer and graphic designer for the North Park Group. He has been working with SDCBC for the past year on developing the website.