Nutrition News for Africa
Abstract - August 2008
Mainstreaming nutrition into maternal and child health programmes:
scaling up of exclusive breastfeeding. Bhandari N, Kabir AK,
Salam MA. Maternal & Child Nutr 2008; 4 Suppl 1:5-23.
Introduction
The World Bank recently supported several teams of experts
to examine available evidence on selected nutrition-related
components of maternal and child health programs. In the current
edition of Nutrition News for Africa we summarize the results
of one of these previously published reviews, which examined
the results of large-scale programs that either promoted recommended
breastfeeding practices among women in the general population
(11 studies) or addressed breastfeeding issues specifically
among women with HIV infection (4 studies).
Findings and recommendations
Most of the studies reviewed, including 8 of the 11 studies
in the general population and all of the studies among women
with HIV, reported a positive impact on breastfeeding practices.
These positive outcomes included 1.2-11.7 fold increases in
the proportion of women exclusively breastfeeding at the time
of the analyses, and a 3.4-fold increase in the duration of
exclusive breastfeeding in one of the studies compared to
controls. The duration of the interventions was not always
reported, but significant differences were found as early
as 9-12 months after initiation.
No single approach was used to implement these successful
programs, but there were a number of similarities among the
eight successful interventions implemented in the general
population, such as:
1) the programs were based on internationally developed
training materials, namely the Baby Friendly Hospital Initiative
(BFHI) or the Integrated Management of Childhood Illness (IMCI)
training (8 of the 8 reports from the general population);
2) the programs were executed through existing health contacts,
such as at the time of vaccination campaigns, hospital deliveries,
and health clinic visits, or through mass media or other existing
community-based programs (8 of 8);
3) most of the programs included a community-based component
(7 of 8).
There were also a number of differences among these successful
programs, including:
1) the location of the intervention (hospitals, clinics,
community settings and/or homes)
2) the timing of the intervention (prenatally, at birth,
post-natally, during campaigns and/or special announcements
3) the use of single or multiple methods of contact
4) the use of single or multiple frequency of contact
The importance of using more than just one intervention was
highlighted in two studies, which found a positive dose-response
relationship between the number of contacts or the number
of different communication methods employed in disseminating
the message and the adoption of the recommended breastfeeding
techniques.
The authors concluded that the key processes required for
scaling up programs to promote exclusive breastfeeding are:
1) an evidence-based policy and science-driven technical guidelines,
and 2) an implementation plan for achieving high exclusive
breastfeeding rates in all strata of society, on a sustainable
basis. They also listed 13 key factors that contributed to
success in scaling-up breastfeeding programs:
1- Political will, advocacy and enabling policies
2- Leadership by health ministry at national, state and district
levels
3- Technical consensus on feeding guidelines
4- Program strategy and measurable short- and long-term goals
5- Long-term financial commitments
6- Partners with defined roles, assessment of their capacity
to deliver and plans to cover gaps in capacity
7- Emphasis on community-level interventions, and not just
facility-based programs
8- Formative research as the basis of effective scale-up
programs, particularly in the context of HIV
9- Communication strategy aided by formative research, pre-tested,
validated messages and tools
10- Careful selection of communication channels and the number
required to achieve timely coverage, consistency of messages
11- Quality trainers and training centers proportionate to
required scale
12- Monitoring and evaluation
13- Program redesign when relevant through research, analysis
and innovation
Program and policy implications
The authors noted that many different intervention strategies
are possible, depending on the local situation and available
resources. They emphasized the importance of monitoring and
evaluation and the need for cost-effectiveness studies to
convince policy makers to continue to finance these programs.
Most of the successful studies cited employed internationally
accepted training programs and used existing opportunities
to disseminate the breastfeeding messages.
Comments*
Because the methods used to promote breastfeeding varied
widely among the studies cited in this review, the authors
were not able to conduct a systematic meta-analysis of the
overall effectiveness of these programs. However, they were
able to demonstrate several important points: 1) various methods
can be used in developing successful breastfeeding programs,
as long as local needs and resources are considered; 2) the
success of breastfeeding programs may be improved by increasing
the number of intervention methods and contacts; 3) developing
programs with built-in evaluation strategies allows implementers
to document the success and cost-effectiveness of the program,
which is critical for the future continuation of these programs;
and 4) rigorous evaluations can be used to improve program
implementation strategies.
* The comments have been added by the editorial team and
are not part of the cited publication.
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