|Food and Nutrition Bulletin Volume 17, Number 4, 1996 (UNU, 1996, 163 pages)|
|Social and demographic aspects|
Veronica Valdés and Janine Schooley
Many of the factors that have contributed to the decline in breastfeeding around the world can be overcome by education and support. Examples of successful approaches to education at different levels (mother, health professional, institution) that impact breastfeeding are discussed. For example, because breastfeeding is a learned behaviour for both mother and baby, providing the mother with information, skills, and support for the breastfeeding process is integral to her ability to breastfeed successfully. In addition, because the health professional plays a pivotal role in the success or failure of breastfeeding it is essential I that education and training of health professionals be adequately addressed. By using an approach to healthprofessional education that builds on a highly trained core and spreads to all levels through a built-in multiplier effect, improvement of breastfeeding practices can be assured. In order to sustain these results, however, health-professional school curricula must include adequate information on the science of lactation and the clinical management of breastfeeding The experience of Chile's National Breastfeeding Programme is used to illustrate the power of education at each of these levels in influencing the success of breastfeeding and the feasibility of using education of both mothers and health professionals as a way of preserving this incredible natural resource.
Breastfeeding is a learned behaviour
Why does breastfeeding, something so biological, natural, and part of the essence of being a mammal, need to be taught and learned? Lactation occurs in every female after delivery as a biological response to hormones present in that period, and yet 38,000 infants die every day because they are not breastfed . Clearly breastfeeding is a behaviour that needs to be learned for the survival of the species .
In nature, young females observe their elders caring for and breastfeeding their offspring. That experience will allow them to take care of their own when they reach reproductive age. A good example of the power of this experience is the case of a female gorilla named Dolly who had been raised at the San Diego Zoo. When she delivered her first offspring, she did not know what to do. She hugged the placenta and was afraid to touch the baby, whom she was not able to breastfeed. During her second pregnancy, the curators decided to teach her about mothering and breastfeeding. They showed her videos of mother gorillas in the wild nursing their infants and gave her a doll to teach her to be gentle in holding and nursing a baby. The teaching programme was a success, and she has been able to nurse and care for several other babies since then.
Something similar occurs with women in modern society . With urbanization and the lack of extended families, most first-time mothers have not seen their mothers or relatives breastfeeding. Even worse, from everywhere around them they have been receiving the message that what is normal and modern is bottle-feeding. As young girls, they are given a doll and bottle to play with, and their mothers also probably bottle-fed. Formula companies advertise their products to the public, and for many women, this is their only source of information regarding infant feeding . As more deliveries occur in hospitals, more women are influenced by hospital practices that often interfere with breastfeeding . There, they do not receive the necessary support from the health-care team, because health professionals generally lack the knowledge and skills for good clinical management of breastfeeding . In addition, an increasing number of women are working away from their homes and their infants.
Therefore, the natural behaviour of breastfeeding is subverted by a variety of forces, as reflected in the often abysmal rates of prevalence and duration of exclusive breastfeeding.
Educating women about breastfeeding has a positive effect on breastfeeding performance
One way to minimize this interference with breastfeeding is through the education and support of mothers. Several studies show that providing breastfeeding education for women has a positive impact on the success of breastfeeding [6-11]. This impact has been underscored by results achieved at the Hospital of the Pontifical Catholic University of Chile, which showed a significant increase in exclusive breastfeeding at six months post-partum among women who received prenatal group education . Eighty per cent of 59 women who received prenatal group education as part of a breastfeeding-promotion programme completed six months of exclusive breastfeeding versus 65% of the 363 who were part of the same study but did not receive prenatal group education (p < .003). This effect was even larger among primiparas, where only 57% of those who did not receive prenatal group education, versus 94% of those who did, were breastfeeding exclusively by the end of the sixth month (fig. 1).
These results were obtained in the context of a prospective study on the impact of a breastfeeding promotion programme on the duration of exclusive breastfeeding among lower-middle-class urban women. This study took place in the hospital and outpatient clinic of the Pontifical Catholic University in Santiago, Chile . The study included a control group of 313 mother-infant pairs and an intervention group of 422 mother-infant pairs. Both groups were followed monthly for six months. Thirty-two per cent of the control group were able to complete six months of exclusive breastfeeding. This was, in fact, a relatively high prevalence, because only 2% of infants that age were exclusively breastfed according to a national survey carried out by the Ministry of Health in 1986. The higher prevalence in this population was due to the fact that the hospital of the Pontifical Catholic University has always promoted breastfeeding and had rooming-in, and medical and nursing students are taught that breastfeeding is important.
Before recruiting the study population, there was a need to develop a comprehensive programme designed to promote exclusive breastfeeding. The breastfeedingpromotion programme involved educating all health-care providers at the institution who take care of mothers and infants; changing policies that interfere with breastfeeding to make them more supportive of optimal breastfeeding practices, such as immediate contact between mothers and infants; delaying supplements or solid foods until the end of the sixth month if the infant is growing well; creating a Lactation Clinic to prevent and solve breastfeeding problems; providing breastfeeding education for women during the prenatal and postnatal periods, including how to breastfeed and how to prevent problems; and emphasizing the effect of exclusive breastfeeding on delaying the return of fertility and the use of the lactation amenorrhoea method for child spacing.
After the implementation of the breastfeedingpromotion programme, 67% of the study population completed six months of exclusive breastfeeding (fig. 2). The prevalence has even improved in the broader population cared for at the hospital of the Pontifical Catholic University after the institution of the Lactation Clinic and the use of the lactation amenorrhoea method by an increasing number of women. Education and support activities were developed for women who work outside the home. When mothers were taught how to hand-express and store their own milk and were offered monthly clinical follow-up, 47% of the working mothers were able to feed their infants exclusively with their milk for six months, and fewer than 6% of the 170 motherinfant pairs who were followed weaned before six months (fig. 3). None of the women in the control group (those not receiving education and support) who continued to work completed six months of exclusive breastfeeding. All of this happened in an institution where the personnel thought they were already promoting breastfeeding, but the results show that much more could be done. What made the difference?
Health-professional education is the cornerstone of improvement in breastfeeding practices
The difference was due to the intensive education of a core team of health professionals in the science of lactation and the clinical management of breastfeeding, and the resulting multiplier effect . Before implementing the breastfeedingpromotion programme, a multidisciplinary team composed of a paediatrician and an obstetrician participated in Wellstart International's lactation management education programme. During their trip to San Diego for the course that would initiate their participation in the lactation management education programme, these professionals, like the hundreds of others throughout the world who have participated in the programme, asked themselves, "What can we learn that is new about breastfeeding and lactation during a whole month?" At the end of the four-week course, like all the others who have participated in the programme, they had acquired new knowledge and skills, shared experiences, and realized that lactation was such a broad topic that they had only just begun to learn. Wellstart's lactation management education programme is designed to develop core resources of expertise that can form the basis of teaching and promotion programmes at the institutional, national, and regional levels, using the following approach:
The lactation management education programme has had an impact throughout the world, not so much because of what it has done, but because of the galvanizing effect its approach has had on others. By putting essential tools and resources into the hands of teachers and decision makers, the programme has served as a catalyst for a powerful multiplier effect in a number of countries. More than 550 associates from over 50 countries have participated in the lactation management education programme. In part because of their participation, National Breastfeeding Programmes are developing in more than 20 countries, National Training Centres in 13 countries, and Regional Training Centres in 5 countries. The impact is particularly great in countries where the UNICEF/WHO Baby-Friendly Hospital Initiative is under way, and many positive influences are at work. Chile provides an excellent example of the effect of health-professional education on breastfeeding. In October 1990 the results of the research project "The effect of a breastfeeding promotion program on the fertility of urban women in Santiago, Chile"  were presented in a three-day breastfeeding course for health professionals. The course was designed to offer participants basic knowledge on the anatomy and physiology of the mammary gland, clinical management of breastfeeding, updated benefits of breastmilk and breastfeeding, and the relation between fertility and breastfeeding, along with the results of the above-mentioned project and several others. Two years later, a questionnaire was sent to the participants to see if the course had had an impact on their actual practices and recommendations regarding breastfeeding. The results showed there were significant increases in clinical practices supporting breastfeeding, which included teaching the mothers and supervising breastfeeding techniques. The weaning recommendations given to mothers, including when to begin weaning foods and milk supplements and when to complete weaning, reflected a postponement of over two months compared with earlier practices (fig. 4) .
This course was also the beginning of a process of creating a critical mass of people with knowledge and interest in promoting and supporting breastfeeding throughout the country. By adopting many of the approaches used in the lactation management education programme, Chile developed its own cascade effect. In 1992, after the Innocenti Declaration and the World Summit for Children, the Chilean government created a National Breastfeeding Commission to develop a National Breastfeeding Programme. As part of that programme, the Baby-Friendly Hospital Initiative was launched in Chile with the support of UNICEF. The main emphasis and activities of the National Breastfeeding Programme, with the participation of the six Wellstart associates, have been educating health-professional teams on breastfeeding and developing teaching materials to help them disseminate that training. In 1992, 34 professionals, including teams from three hospitals, participated in the first Baby-Friendly Hospital Initiative Training for Trainers Workshop. These teams received teaching materials such as slides, videos, books, and syllabi to replicate the teaching at their institutions.. Since then two new workshops have been developed, attended by 142 new trainers who are now teaching the health teams in their own and neighbouring institutions.. By the end of 1994, more than 4,500 health workers had been trained throughout the country in replicated, 18-hour courses (fig. 5). Eleven hospitals have been designated as Baby-Friendly owing to their supportive practices for breastfeeding. In 1994 approximately 290,000 infants were born in Chile, with 52,000 of these births occurring in Baby-Friendly Hospitals.
A national survey carried out at the end of 1993 showed that the prevalence of exclusive breastfeeding at six months had increased from 2% in 1985 to 25% in 1993 (fig. 6). In areas of the country where health workers in hospitals and community clinics have been trained, the percentage of exclusive breastfeeding at six months is more than 60%. These results show that there actually was a lack of knowledge among health workers on how to promote and support breastfeeding [17, 18], and that when they learn, they change their practices, which then have an impact on the prevalence and duration of breastfeeding in the community.
The next step is to make this effort sustainable and costeffective. The only way to do this is to change what is taught at the university level and to include the scientific basis and clinical management of breastfeeding in the curricula of health-professional schools [19, 20]. This effort has already begun in many countries. A curriculum guide for medical, nursing, and nutrition training programmes has been developed by Wellstart and is beginning to be used in several universities in the United States, Latin America, and Africa. In Latin America two subregional workshops were hod for this purpose, one in Guatemala and another in Paraguay. A national pre-service curriculum workshop was held in the Pontifical Catholic University in Chile as the first activity of the National Breastfeeding Training Centre. The participants included representatives from schools of medicine, nursing, midwifery, nutrition, pharmacy, and dentistry from all the Chilean universities. In Africa a similar process is under way with the participation of 10 countries in east, central, and southern Africa.
Heal to-professional education is critical to making any kind of long-term-change in the way breastfeeding is promoted, supported, and protected. When health professionals are convinced that a breastfed child has the best start in life and really understand how breastfeeding works, they will send the right messages and give the needed support. Only then will the impact on the community be sustainable and something as natural as breastfeeding be preserved.
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