Elsevier

The Lancet

Volume 366, Issue 9491, 24–30 September 2005, Pages 1094-1100
The Lancet

Articles
Comparison of the effect of two systems for the promotion of exclusive breastfeeding

https://doi.org/10.1016/S0140-6736(05)67421-1Get rights and content

Summary

Background

Promotion of breastfeeding is an important child-survival intervention, yet little is known about which promotional strategies are the most effective. We aimed to compare the effects on rates of breastfeeding of two systems for promotion of breastfeeding in Brazil—a hospital-based system and the same system combined with a programme of home visits.

Methods

In February, 2001, maternity staff from two hospitals in Pernambuco, Brazil, were trained according to the Baby-Friendly Hospital Initiative (BFHI). In a randomised trial between March and August, 2001, 350 mothers giving birth at these hospitals were assigned ten postnatal home visits to promote and support breastfeeding (n=175) or no home visits (n=175). Breastfeeding practices were studied on days 1, 10, 30, 60, 90, 120, 150, and 180 by researchers unaware of group allocation. The primary outcome measure was the rate of exclusive breastfeeding from birth to 6 months. Analyses were by intention to treat.

Findings

The hospital-training intervention achieved a high rate (70%) of exclusive breastfeeding in the hospitals, but this rate was not sustained at home and at 10 days of age only 30% of infants were exclusively breastfed The patterns of exclusive breastfeeding in the two trial groups for days 10–180 differed significantly (p<0·0001), with a mean aggregated prevalence of 45% among the group assigned home visits compared with 13% for the group assigned none.

Interpretation

The BFHI achieves high rates of exclusive breastfeeding in hospital; however, in Brazil at least, the rates fall rapidly thereafter. Reliance on the BFHI as a strategy for breastfeeding promotion should be reassessed. A combination of promotional systems (hospital-based and in the community) is needed.

Introduction

The Lancet's Child Survival series1, 2, 3, 4, 5 drew attention to the unacceptably high rates of child mortality that continue in low-income countries and poor areas of middle-income countries. Most of the 10·8 million child deaths during the year 2000 were from preventable causes, especially neonatal disorders, pneumonia, and diarrhoea.1 If the few interventions for which there is sufficient evidence of effect (level 1)2 or limited evidence of effect (level 2) were fully implemented, 63% of deaths of children younger than 5 years could be prevented. If 90% of infants were exclusively breastfed at 0–5 months and continued to be breastfed from 6 months to 11 months, there would be an estimated 13% reduction in child deaths worldwide.2 This potential reduction in mortality is higher than for any other level-1 intervention. Current rates of exclusive breastfeeding are far below 90% in most countries, and in some, for example in Latin America, even the duration of breastfeeding is short.

The third paper in the Child Survival series highlighted the need to consider systems necessary to put an intervention in place.3 In relation to breastfeeding promotion, there is little information as to which strategies are the most effective in promoting exclusive breastfeeding and achieving high and equitable coverage.3 We report a randomised trial comparing the effect on rates of exclusive breastfeeding of two systems to promote breastfeeding in northeastern Brazil. The interventions were a hospital-based system, in which maternity staff were trained with the course content for the Baby-Friendly Hospital Initiative (BFHI), and a combination of this hospital-based system and a community-based system providing ten postnatal home visits. We also examined whether the effect applied equally among families below and above the poverty line and how it was related to maternal education, since the most disadvantaged infants are more likely to be exposed to health risks than those who are more affluent.4

Section snippets

Study site and participants

The study was done in the urban areas of Palmares and three neighbouring small towns (Catende, Água Preta, and Joaquim Nabuco) in the interior of the State of Pernambuco, northeastern Brazil. Their combined population is 135 000. The area is hilly and lies 130 km southwest of Recife, the State capital. The climate is hot and humid, and the economy of the region is mostly based on growing and processing sugar cane. Poverty is widespread. The adult female illiteracy rate is around 26%, and the

Results

In the preintervention study, 364 mother-infant pairs were recruited and 46 (13%) were lost to follow-up at 6 months (figure 1). In the trial, 350 mother-infant pairs were recruited and 20 (6%) were lost to follow-up (one sudden infant death; one congenital malformation diagnosed after recruitment; and 18 moved from the area, 13 in the non-visited group and five in the visited group). In both the preintervention study and the trial, the mother-infant pairs lost did not differ from those who

Discussion

The BFHI is the most widely promoted international programme to increase rates of exclusive breastfeeding and to extend breastfeeding duration. There are more than 18 000 baby-friendly hospitals worldwide, and Brazil has 289, more than any other country. The BFHI is based on Ten Steps to Successful Breastfeeding,11 and the evidence of effectiveness for each of the ten steps has been documented.13, 14 Although the maternity hospitals in our study did not attain baby-friendly certification, the

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