Is being baby-friendly enough? Promoting breastfeeding in Brazil

The Baby-Friendly Hospital (BFH) Initiative is the most popular strategy for increasing the rate and duration of exclusive breastfeeding. Brazil has 289 BFH, more than any other country. But research in Pernambuco State suggests that the strategy has limited impact without additional community-based support for mothers.

If 90 percent of babies wereexclusively breastfed up to five months of age and continued to breastfeed fromsix to eleven months, there would be an estimated 13 percent reduction in childdeaths worldwide. But exclusive breastfeeding rates are much lower than this inmost countries, and the duration of breastfeeding is often short.

Researchers from the Federal Universityof Pernambuco and the London School of Hygiene andTropical Medicine compared two ways to promote exclusive breastfeeding based onthe BFH initiative. They worked in two hospitals where staff had received BFHtraining, and 175 mothers took part in the hospital-based system, while another175 received a combination of the hospital programme plus ten home visits oversix months. Mothers were allocated randomly to the two groups.

They found that:

• BFH trainingachieves a high rate (70 percent) of exclusive breastfeeding in the hospitals,but this falls once mothers get home. Only 30 percent are exclusivelybreastfeeding their babies at ten days of age.
• Health workerscompleted 99.6 percent of the four home visits planned for the first month andfive of the six (83 percent) later visits.
• The mean rate ofexclusive breastfeeding over the six month period is 45 percent among the groupgiven home visits, compared with 13 percent for the group that have none. Themean rate before the BFH training was seven percent.
• Fewer mothers inthe home visit group feed water, tea or other milks or give bottles orpacifiers to their babies in their first six months.
• With hospital-basedtraining, exclusive breastfeeding is more common among better-off andbetter-educated mothers. This inequity is not seen when mothers receive homevisits.

In Brazil, mothers stay inhospital only 24 to 36 hours after delivery or 48 hours after a Caesareansection. This early discharge reduces the chance for individual contact andsupport and may explain the stronger effect of home visits over thehospital-based system. However, a hospital can achieve Baby-Friendly statuseven if it offers only minimal post-natal support.

The researchers draw thefollowing conclusions for health policy:

• It may be unwiseto rely on the BFH initiative alone for breastfeeding promotion.
• A combination ofhospital and community based systems is needed so that mothers can receive ongoinghelp locally, especially in the early weeks after the birth when difficulties commonlyarise.
• Home support islikely to be especially important in countries where mothers stay in hospitalfor a short time.
• In differentcountries, home visits could involve traditional birth attendants,village-based workers, auxiliary nurse midwives, community health workers andother health care providers.
• Further researchis needed to work out the best number and timing of visits for success.