Better Breastfeeding, Healthier Lives

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Population Reports March 2006 Published by the INFO Project, Center for Communication Programs, The Johns Hopkins Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA www.infoforhealth.org Better Breastfeeding, Healthier Lives How programs and providers can help women improve breastfeeding practices Roger Lemoyne/UNICEF Key Points Only breastmilk offers infants and young children complete nutrition, early protection against illness, and safe, health
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  Published by the INFOProject,Center forCommunicationPrograms,The JohnsHopkins BloombergSchool of Public Health,111 Market Place,Suite 310,Baltimore,Maryland 21202,USAwww.infoforhealth.org How programsand providerscan help womenimprovebreastfeeding practices Population Reports  Series L,Number 14Issues in World Health March 2006 Better Breastfeeding,Healthier Lives  Photo: A husband helpshis wife breastfeedtheir newborn in thematernity ward atSingburi Hospital,Thailand. Involvingspouses is an importantaspect of building sup-port for breastfeedingmothers in the house-hold and community. Only breastmilk offers infants and young children complete nutrition,early protectionagainst illness,and safe,healthy food—all at once.Nearly all babies are breastfed to someextent,but far less than half are breastfed in the most beneficial way.Better breastfeed-ing offers triple value:important improvements in child survival and health,better healthfor mothers,and temporary contraception.What can governments,programs,and healthcare providers do to support and enable women to breastfeed better? Key Points Carry out comprehensive strategies. Successful strategies to improve breastfeedinginclude health care services,communities andfamilies,and government.Health care servicesoffer a valuable point of contact for mothers-to-be and breastfeeding mothers.Mothers alsoneed information,support,and empowermentin the community and at home.Governmentefforts include enacting appropriate policies,such as supporting breastfeeding mothers inthe workplace.Changes can begin in any of these areas,but an effective strategy works inall three. Promote breastfeeding for birth spacing. Providers can advise women on appropriatecontraception during breastfeeding,particular-ly the lactational amenorrhea method (LAM).Amethod based on full or nearly full breastfeed-ing,LAM provides the best health benefits of breastfeeding for the infant and also postponesthe next pregnancy for up to six months.Thenit encourages switching to another family plan-ning method to space births. Address the challenges that HIV/AIDS posesfor breastfeeding.  The AIDS crisis has focusedconcern on HIV transmission through breast-milk,while drawing attention away from therisks to infant health of not breastfeeding.World Health Organization (WHO) and UnitedNations (UN) agencies recommend,particularlywhere safe alternatives to breastmilk are notavailable,that HIV-positive women breastfeedtheir infants exclusively for the first months of life before switching completely to replace-ment foods when possible.Exclusivebreastfeeding poses half the risk of HIV transmission as mixedbreastfeeding,while pre-venting deaths fromother illnesses. R  o g er L  em o  y n e /   U N I    C E F      S e e   C o  m  p  a  n  i o  n   I   N  F  O   R e  p o  r  t  o  n   B  r e  a  s  t  f e e  d  i  “  A   G  u  i  d e   f o  r   P  r o  v  i  d e  r  s  ”  CONTENTS 3691112 2 1723 Breastfeeding Gains and Goals Since the early 1990s,growing local and international efforts have helpedmothers gain both protection and support for breastfeeding.Recently,however,commitment to breastfeeding has faltered,largely due toconcerns over HIV transmission through breastmilk.Now the UN and WHOGlobal Strategy for Infant and Young Child Feeding calls on national govern-ments,health care services,communities,and international donors to re-vitalize breastfeeding efforts and apply lessons learned from past successes. Comprehensive Strategies Needed Countries can devise national strategies to inform and advise women aboutbreastfeeding,extend promotion into communities,and make changes ingovernment policies.Accurate,up-to-date medical advice and supportivehospital practices can encourage women to start breastfeeding as soon aspossible after birth.Support at home and in the community can helpwomen breastfeed better.Government policies can explicitly recognizethe public health benefits of optimal breastfeeding. Spotlight: Madagascar’s Comprehensive Approach ImprovesBreastfeeding In Madagascar,more women are breastfeeding immediately after child-birth,exclusively,and for up to six months of age.The Ministry of Health,in coordination with several partner organizations,launched a majorbreastfeeding program that combines improvements in health careservices with policy-level and community approaches. Breastfeeding Increases Women’s Contraceptive Options Mothers who breastfeed fully or nearly fully can rely on the lactationalamenorrhea method (LAM) to delay their next pregnancy.LAM takesadvantage of the natural infertility that results from frequent breastfeeding,which can last for six months postpartum,or longer,if a woman’s menseshave not resumed.Nonhormonal contraceptive methods and progestin-only hormonal methods also can be appropriate for nursing mothers anddo not affect breastmilk production or infant health. Centerspread: Breastfeeding Is Best Breastfeeding saves infants’lives by promoting healthy growth and devel-opment and protecting them from certain infectious and chronic diseases.Breastfeeding benefits women,too,immediately postpartum,throughoutbreastfeeding,and for the rest of their lives.It also helps women space births,and it saves families money that would be spent on breastmilk substitutes. Women with HIV Face Crucial Breastfeeding Decisions An HIV-positive mother faces a difficult decision—whether to breastfeed,inorder to give her infant important nutrients and protection from potentiallyfatal diseases,or not to breastfeed,in order to avoid the risk of transmittingHIV.Depending on her circumstances,a woman can rely on several saferbreastfeeding and nonbreastfeeding options to nourish her infant in theearly months.Health care providers can help an HIV-positive woman weighthe various risks in deciding whether to breastfeed. Bibliography Note:Italicized reference numbers in the text refer to citations printed onpage 23.These were the most helpful in preparing this report.Othercitations can be found online at http://www.populationreports.org/l14/. POPULATION REPORTS This report was prepared by VidyaSetty,MPH.Research assistance byFonda Kingsley,MHS. Bryant Robey,Editor;Richard Blackburn,EditorialSupervisor.Design by Mark Beisser,Fran Mueller,and Linda Sadler.Production by John Fiege,MónicaJiménez,and Catherine Richey. Populati   on Repor   t   s appreciates theassistance of the following reviewers:Marcos Arevalo,Jean Baker,BrunoBenavides,Jane Bertrand,AnnetteBongiovanni,Gloria Coe,Judy Levan Fram,John Howson,Monica Jasis,Mihira Karra,Miriam H.Labbok,Luann Martin,AnnePerrine,Ellen Piwoz,Malcolm Potts,TimothyC.Quick,Jay Ross,Pauline Russell-Brown,Stephen Settimi,James Shelton,BulbulSood,J.Joseph Speidel,Maryanne Stone-Jimenez,Youssef Tawfik,Melissa Vickers,Mary Beth Weinberger,and Kim Winnard.Suggested citation:Setty,V.“BetterBreastfeeding,Healthier Lives.” PopulationReports ,Series L,No.14.Baltimore,JohnsHopkins Bloomberg School of PublicHealth,The INFO Project,March 2006.Available online:http://www.populationreports.org/l14/Volume XXXIII,Number 3 The INFO ProjectCenter for Communication ProgramsThe Johns Hopkins BloombergSchool of Public Health Jane T.Bertrand,PhD,MBA,Professor andDirector,Center for CommunicationPrograms and Principal Investigator, The INFO ProjectEarle Lawrence,Project DirectorStephen Goldstein,Chief,PublicationsDivision Populati   on Repor   t   s is published at 111Market Place,Suite 310,Baltimore,Maryland 21202,USA,by the INFO Projectof the Johns Hopkins Bloomberg School of Public Health/Center for CommunicationPrograms Populati   on Repor   t   s is designed to providean accurate and authoritative overview of important developments in family plan-ning and related health issues.The opinionsexpressed herein are those of the authorsand do not necessarily reflect the views of the US Agency for International Develop-ment or The Johns Hopkins University. Published with support from the United States Agency forInternational Development (USAID),Global,GH/POP/PEC,under theterms of Grant No.GPH-A-00-02-00003-00. ã Counseling Aid: When Cana Woman Use LAM?,p.14ã Counseling Aid: HIV andInfant Feeding CounselingFlow Chart,p.19ã Box:  Taking Ten Steps toSuccessful Breastfeeding,p.7ã Table: When BreastfeedingMothers Can Begin a FamilyPlanning Method,p.16  Breastfeeding saves infants’lives,provides the best nutri-tion for infants and young children,and benefits mothers’health.Breastfeeding provides the best health benefitswhen started immediately after an infant’s birth,continuedexclusively (without introducing other foods,liquids,orwater) for the first six months of life,and then continuedalong with suitable complementary feeding through agetwo or longer (see box,p.5).Frequent and intense breastfeeding can reliably delaypregnancy for up to six months after childbirth.The lacta-tional amenorrhea method (LAM),as this form of contra-ception is known,is effective when a woman’s menstrualperiods have not yet returned and the infant receives nofood but breastmilk for the first six months.Breastfeeding choices are ultimately a mother’s individualdecision.Women can make informed decisions when healthcare providers offer information about breastfeeding andsupport for it.As more women breastfeed,more childrensurvive their first years and grow up healthy.Gains in thepractice of any breastfeeding reduce levels of malnutritionand prevent child deaths from diarrhea and pneumonia.Gains in optimal breastfeeding practices reduce risks of illnesses,malnutrition,and early death the most.A growing percentage of infants are breastfed,accordingto findings from countries surveyed more than once since1986 by the Demographic and Health Surveys (DHS) andReproductive Health Surveys (RHS) programs (see Table 1).Comparable data show that in all but 4 of 65 countriessurveyed at least 90% of children are breastfed.Yet onlya minority of infants are breastfed in optimal ways (seeTable 2,next page).For instance,in most countries lessthan half of infants are breastfed within one hour of birth.Also,less than half are exclusively breastfed for the first sixmonths of life.Breastfeeding practices fall short of the optimal for manyreasons.An estimated 60% of births in developing coun-tries are not attended by trained health care workers.Inaddition to facing greater risk because they lack access toadequate health care,these mothers and babies rarelyreceive antenatal or extended postpartum health careservices that support optimal breastfeeding (251).Women increasingly work in jobs outside of the home.When women resume full-time employment after child-birth,the separation from their infants makes it difficult tomaintain exclusive breastfeeding for the full first sixmonths of the child’s life.Also,many women hold incorrect views about breastfeed-ing or do not recognize its health benefits (6,83,118,166,209).Women and their family members may believe incor-rectly that breastmilk is not enough to satisfy or nourishtheir infants.In fact,breastmilk is a complete food andcontains all the water and nutrients an infant needs.Others mistakenly believe that breastfeeding too often,orfeeding from both breasts,will deplete the supply of breastmilk.In fact,these practices lead to more productionof breastmilk.Still others may think that their child is stillhungry when the child cries or reaches out and thus givefoods other than breastmilk,instead of continuing tobreastfeed.Such misperceptions and social pressuresabout breastfeeding often reflect accepted communitywisdom and long-held beliefs. POPULATION REPORTS 3 Breastfeeding Gains and Goals  Table 1. Breastfeeding Practices Improving Breastfeeding Trends in Countries with Multiple Surveys Since 1986, by Number of Countries   % BreastfedWithin 1 HourAfter Birth% Exclusively orFully BreastfedThrough 6 Months% BreastfedWithin 1 DayAfter Birth% ExclusivelyBreastfedThrough 6 Months% Breastfed AtLeast 2 Years Decreased in…Increased in…Unchanged* in… 36 countries37 countries30 countries32 countries27 countriesNone3 countries3 countries1 country2 countries8 countries4 countries9 countries9 countries9 countries *No change or change was less than 1%For trends by country, see Web tables 1, 2, and 3 at www.populationreports.org/l14/webtables.shtmlExclusive breastfeeding refers to feeding infants only breastmilk and no other solids or liquids. Full breastfeeding refers to feeding infants water, water-baseddrinks and fruit juices (but no other food-based fluid) in addition to breastmilk. Programs in many countries report that extending health services into communities helps more women breastfeed exclusively and for longer durations.  A Call to Action In 1990 the World Health Organization (WHO) and theUnited Nations Children’s Fund (UNICEF) called on govern-ments,donors,and international organizations to “protect,promote,and support”breastfeeding to improve infantnutrition and survival (269).This call to action,known asthe Innocenti Declaration,led to a number of positivesteps during the 1990s: ã In 1991 WHO and UNICEF establishedthe Baby-Friendly™ Hospital Initiative to help ensurethat maternity clinics encourage optimalbreastfeeding practices. ã Many countries appointed national breastfeedingcoordinators and developed national breastfeedingpolicies. ã Countries did more to enforce the 1981 InternationalCode of Marketing of Breastmilk Substitutes,whichlimits unethical marketing by manufacturers of breastmilk substitutes.In recent years,however,government and donor supportfor optimal breastfeeding has declined.Perhaps the mainreason is that the AIDS crisis has focused attention on HIVtransmission through breastmilk,while drawing attentionaway from the risks to children’s health of not breastfeed-ing.The mistaken belief that all HIV-positive mothers willpass HIV to their infants through breastfeeding hasovershadowed the health and life-saving benefits of breastfeeding ( 129 ) (see p.10).At the same time,somemanufacturers of infant formula have continued unethicalpromotion that may discourage breastfeeding.Concerned about declining national and international com-mitment to breastfeeding,WHO and UNICEF in 2000–2002developed the Global Strategy for Infant and Young ChildFeeding ( 258 ).The strategy calls on national governments,health care services,communities,and internationaldonors to apply lessons learned about breastfeeding tobetter enable and support women to breastfeed optimally. POPULATION REPORTS Table 2. Breastfeeding Common but Not Usually Optimal Breastfeeding Levels, Most Recent Available Surveys, 1994–2005   Percentage of Infants Breastfed…Exclusively or fully up to 6 monthsUnweightedAverageAmongCountriesRangeAmongCountriesNumber of Countrieswith DataEverWithin 1 hour after birthWithin 1 day after birthExclusively up to 3 monthsExclusively up to 6 monthsExclusively or fully up to 3 monthsAt least 2 years 96%86%-99%41%653%-81%71%25%-97%656538%1%-79%4731%<1%-90%5762%19%-90%4754%13%-91%5740%5%-89%42 The data presented in Tables 1 and 2 come principally from online DHS STATcompiler <www.measuredhs.com/statcompiler/> tabulations aswell as from RHS country final reports. Final DHS country report data have been used in cases where data were not available from STATcompiler.Not all surveys include questions on all the indicators presented in the tables, nor are the respondents defined the same way in all surveys. As aresult, the number of countries reported in different sections varies.For region- and country-specific data, see Web figures 1 and 2 at www. populationreports.org/l14/webtables.shtml 4 How To Use This Report   With the help of this issue of  Population Reports  governments,programs, and health care providers can:ã Encourage and support better breastfeeding by carrying outcomprehensive strategies involving governments, health careservices, and families and their communities (see p. 6).ã Counsel women on how breastfeeding can help space birthsup to six months postpartum and encourage switching toanother contraceptive method thereafter (see p. 11).ã Inform and advise women on HIV and breastfeeding andon weighing the risks of breastfeeding and replacementfeeding for HIV-positive mothers (see p. 17).
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