1. WHO and UNICEF developed the Global Strategy on Infant and Young Child Feeding
in 2002 to revitalize world attention to the substantial impact of feeding practices on
the growth and development, health, and survival of infants and young children.The
present review examines the evidence for the contribution that community-based
interventions can make to improve infant and young child feeding, and identifies
factors that are important to ensure that interventions are successful and sustainable.
The findings show that families and communities are more than simple beneficiaries
of interventions; they are also resources to shape the interventions and extend coverage
close to where mothers, other caregivers and young children live. It is intended that the
experiences presented here will help policy makers, programme planners, and health
professionals in the essential and challenging task of translating knowlege into action
at all levels: the health system, the community and civil society at large.

2. Selected WHO publications of related interest
WHO. Global Strategy for infant and young child feeding. Geneva: World Health
Organization, 2003
http://www.who.int/child-adolescent-health/publications/NUTRITION/IYCF_GS.htm
Pan American Health Organization. Guiding Principles for complementary feeding of the
breastfed child. Washington DC: Pan American Health Organization, World Health
Organization, 2003
http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/guiding_principles.pdf
WHO/UNAIDS/UNFPA/UNHCR/UNICEF/FAO/WFP/IAEA/World Bank. HIV and
infant feeding: framework for priority action. Geneva: World Health Organization, 2003
http://www.who.int/child-adolescent-health/publications/NUTRITION/HIV_IF_Framework.htm
WHO. Complementary feeding: family foods for breastfed children. WHO/NHD/001,
WHO/FCH/CAH/00.6. Geneva: World Health Organization, 2000
http://www.who.int/child-adolescent-health/publications/NUTRITION/WHO_FCH_CAH_00.6.htm
WHO. HIV and infant feeding counselling: a training course. WHO/FCH/CAH/002.6
Geneva: World Health Organization, 2000
http://www.who.int/child-adolescent-health/publications/NUTRITION/HIVC.htm
WHO. Evidence for the Ten Steps to Successful Breastfeeding. WHO/CHD/98.9. Geneva:
World Health Organization, 1999
http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/WHO_CHD_98.9.pdf
WHO. Improving family and community practices: a component of the IMCI strategy. WHO/
CHD/98.18 Geneva: World Health Organization, 1998
http://www.who.int/child-adolescent-health/publications/IMCI/WHO_CHD_98.18.htm
WHO/UNICEF. Breastfeeding counselling: a training course. WHO/CDR/93.3, UNICEF/
NUT/93.1 Geneva: World Health Organization, 1993
http://www.who.int/child-adolescent-health/publications/NUTRITION/BFC.htm
Other publications of interest can be consulted and ordered online at:
http://bookorders.who.int

3. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries
WORLD HEALTH ORGANIZATION
DEPARTMENT OF CHILD AND ADOLESCENT
HEALTH AND DEVELOPMENT
Stra
Community-based Strategies
Promotion
for Breastfeeding Promotion and
Developing
Support in Developing Countries
i

4. WHO Library Cataloguing-in-Publication Data
Community-based strategies for breastfeeding promotion and support in developing countries.
1.Breastfeeding 2.Community networks - utilization 3.Consumer participation
4.Strategic planning 5.Developing countries.
ISBN 92 4 159121 8 (NLM classification: WS 120)
© World Health Organization 2003
All rights reserved. Publications of the World Health Organization can be obtained from Marketing and
Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791
2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate
WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications,
at the above address (fax: +41 22 791 4806; email: permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply the expression
of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any
country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed
or recommended by the World Health Organization in preference to others of a similar nature that are not
mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial
capital letters.
The World Health Organization does not warrant that the information contained in this publication is complete
and correct and shall not be liable for any damages incurred as a result of its use.
Printed
ii

5. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries
Table of Contents
Acknowledgements v
Foreword vii
Introduction 1
Chapter 1. Background and Context 3
Breastfeeding practices in developing countries 3
Breastfeeding promotion and support: historical development 3
Evidence of effectiveness 4
Improving breastfeeding practices 5
Reducing morbidity and mortality 5
Framework and justification 6
Chapter 2. Approaches to Community-based Breastfeeding Promotion and Support 7
Foundation for community behaviour change 7
Partnerships 7
Formative research 7
Monitoring and evaluation 8
Training and supervision 8
Management and leadership 8
Community-level interventions 8
Behaviour change communication 8
Training community health-care providers 10
Lay counsellors 10
Women’s groups 11
Integration of breastfeeding with primary and preventive services 12
Integration of breastfeeding and early childhood development strategies 13
Chapter 3. Case Studies of Community-based Breastfeeding Promotion and Support 14
Madagascar 14
Honduras 16
India 17
Chapter 4. Application to Special Circumstances 20
Mothers’ return to work 20
Infants born to HIV-positive mothers 20
Emergency situations 21
Summary and conclusions 23
References 24
Annex 1. Issues in breastfeeding measurement 28
iii

6. Acknowledgements
Tables Table 1. Community-based breastfeeding support trials in developing countries
that include healthy newborn infants and mothers 4
Table 2. Infant mortality (0–6 months) in Dhaka, Bangladesh comparing
partial and no breastfeeding to exclusive breastfeeding 5
Figures Figure 1. Key messages: what every family and community has a right to
know about breastfeeding 1
Figure 2. Elements of a comprehensive breastfeeding programme 2
Figure 3. Trends in breastfeeding patterns in developing countries 1989–1999 3
Figure 4. Model of determinants of breastfeeding behaviour 6
Figure 5. Stages of change and communication approaches 9
Figure 6. Models of women’s groups in breastfeeding promotion and support 11
Figure 7. Breastfeeding promotion and support as an approach to integration
of primary health care services 14
Figure 8. Exclusive breastfeeding in the first 6 months of life, Madagascar 16
Figure 9. Initiation of breastfeeding within first hour, Madagascar 16
Figure 10. Exclusive breastfeeding in the first 4 and 6 months of life, Honduras 17
Figure 11. Prelacteal feedings and exclusive breastfeeding at 3 months
in intervention vs control communities, India 19
iv

7. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries
Acknowledgements
The primary author of this review was Dr. Ardythe Morrow (Cincinnati Children’s Research Foundation and the
LINKAGES Project, Academy for Educational Development [AED]). The primary editor was Ms. Luann Martin
(LINKAGES Project, AED). Contributions to the writing and/or review of this document were made by a number of
AED experts: Dr. Nancy Keith, for behaviour change communication; Dr. Ellen Piwoz and Dr. Jay Ross, for HIV
issues; Dr. Nadra Franklin, for evaluation issues; and Dr. Vicky Quinn and Dr. Agnès Guyon for the Madagascar
project description.
Valuable assistance in reviewing the paper was provided by Dr. Bernadette Daelmans, Dr. Jose Martines, Dr. Constanza
Vallenas, and Dr. Carmen Casanovas in the WHO Department of Child and Adolescent Health and Development;
Dr. Chessa Lutter (Pan American Health Organization, WHO/AMRO); Dr. Audrey Naylor (Wellstart, International);
Dr. Fran Butterfoss (Eastern Virginia Medical School), and Dr Nita Bhandari (All India Institute of Medical Sciences).
Funding for the development of this paper was provided by WHO and by USAID through the LINKAGES Project,
under Cooperative Agreement No. HRN-A-00-97-00007-00.
The material presented does not necessarily reflect the official position of either organization.
v

8. vi

9. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries
Foreword
The importance of appropriate infant and young child feeding for child survival, growth and development is well
known. Exclusive breastfeeding for the first six months of life confers important benefits on the infant and the
mother. It protects infants against common childhood diseases, including repeated gastrointestinal infections and
pneumonia, and hence against some of the major causes of childhood mortality. Timely introduction of adequate and
safe complementary foods at six months of age helps to fill the dietary gaps that cannot be met by breast milk alone.
Continued breastfeeding for two years or beyond confers major nutritional benefits and is an essential component of
appropriate complementary feeding.
Unfortunately, infant and young child feeding practices world-wide are not optimal. Global monitoring indicates that
only 39% of all infants world-wide are exclusively breastfed, even when the assessment is made in children less than
4 months of age. The timely complementary feeding rate is similarly low with a global average of 60% in 2002.
Much has been learned about effective interventions during the past decades. It is clear that mothers need support to
initiate and sustain optimal breastfeeding and complementary feeding practices – within the family, community,
workplace and health system. During the past decade, the Baby-friendly Hospital Initiative has been instrumental in
directing necessary resources to improve the quality of feeding care in maternity services. As a result, there is an
upwards trend in breastfeeding rates in various countries.
However, it is not enough to help a mother initiate exclusive breastfeeding. She needs to be able to go back to an
environment that is conducive to sustaining appropriate feeding practices and to access skilled support when she
needs it. This review examines the role of communities and community-based resource persons in providing this
support. Based on a review of the literature and an analysis of three projects, it assesses the impact of interventions,
the mechanisms through which behaviours can be changed, and the factors that are necessary to maximize and
sustain the benefits of interventions.
The findings confirm the expectations: communities can make a major difference in improving infant and young
child feeding. This is particularly so when community members participate in the design of interventions and, with
expert support, contribute to shaping the content and mode of delivery. Full engagement of health care providers and
supportive policies are other elements important for success.
Given the emphasis on breastfeeding as an issue of major public health importance over the past decades, experiences
are more abundant in this area. Nevertheless, evidence is accumulating rapidly that similar achievements are possible
for complementary feeding and one case study specifically reports on this.
WHO and UNICEF jointly developed the Global Strategy for Infant and Young Child Feeding to revitalize world
attention to the importance of infant and young child feeding for child survival, growth and development. The
strategy calls upon governments to ‘ensure that the health and other relevant sectors protect, promote and support
exclusive breastfeeding for six months and continued breastfeeding for two years or beyond …. and to promote
timely, adequate, safe and appropriate complementary feeding with continued breastfeeding’.
Families and communities can and should be partners in this endeavour. They are not only the beneficiaries but also
part of the plethora of resources that can be mobilized to reinstate infant and young child feeding as an area of public
health importance and concern. By adopting the Millennium Development Goals, the global community has committed
vii

10. to reducing childhood mortality by two-thirds and halving the proportion of people living with hunger by 2015.
Improving childhood nutrition is essential to achieve these goals. It can be done – what is needed is increased
commitment, investment, and innovation to engage all those who can help to make a difference. We hope that this
review will provide all readers with new ideas and motivation for moving forward.
Joy Phumaphi
Assistant Director-General
Family and Community Health
World Health Organization
viii

11. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries
“…the global strategy includes as a priority for all governments…to ensure that the
health and other relevant sectors protect, promote and support exclusive breastfeeding for six
months and continued breastfeeding up to two years of age or beyond, while providing women
access to the support they require – in the family, community and workplace – to achieve
this goal.”
Global Strategy for Infant and Young Child Feeding, May 2002
Introduction
Figure 1
B reastfeeding is an extension of maternal protection
that transitions the young infant from the shelter
of the in utero environment to life in the ex utero world
Key Messages: What every family and
community has a right to know about
breastfeeding
with its variety of potentially harmful exposures. The
promotion, protection, and support of breastfeeding is • Breastmilk alone is the only food and drink an infant
needs for the first six months. No other food or drink,
an exceptionally cost-effective strategy for improving
not even water, is usually needed during this period.
child survival and reducing the burden of childhood • There is a risk that a woman infected with HIV can pass
disease, particularly in developing countries (Horton et the disease on to her infant through breastfeeding.
Women who are infected or suspect that they may be
al., 1996; Morrow et al., 1999; Sikorski et al., 2002;
infected should consult a trained health worker for
Arifeen et al., 2001; Black et al., 2003; Jones et al., testing, counselling and advice on how to reduce the
2003). risk of infecting the child.
• Newborn babies should be kept close to their mothers
and begin breastfeeding within one hour of birth.
Scientific evidence has guided the development of • Frequent breastfeeding causes more milk to be
international recommendations for optimal infant produced. Almost every mother can breastfeed
feeding practices, which include exclusive breastfeeding successfully.
• Breastfeeding helps protect babies and young children
for 6 months (breast milk only with no other liquids
against dangerous illnesses. It also creates a special
or foods given) and continued breastfeeding up to 2 bond between mother and child.
years of age or beyond with timely addition of • Bottle-feeding can lead to illness and death. If a woman
cannot breastfeed her infant, the baby should be fed
appropriate complementar y foods. These
breastmilk or a breastmilk substitute from an ordinary
recommendations were adopted following a systematic clean cup.
review of current scientific evidence on the optimal • From the age of six months, babies need a variety of
additional foods, but breastfeeding should continue
duration of exclusive breastfeeding and an expert
through the child’s second year and beyond.
consultation on the subject (Butte et al., 2002; Kramer • A woman employed away from her home can continue
and Kakuma, 2002; WHO, 2002). They are also to breastfeed her child if she breastfeeds as often as
possible when she is with the infant.
included in UNICEF’s Facts for Life “Key Messages:
• Exclusive breastfeeding can give a woman more than
What every family and community has a right to know 98 percent protection against pregnancy for six months
about breastfeeding” (figure 1). after giving birth – but only if her menstrual periods
have not resumed, if her baby breastfeeds frequently
day and night, and if the baby is not given any other
Compliance with these recommendations has food or drinks, or a pacifier or dummy.
significant child health and nutritional benefits. The
(UNICEF, 2002)
Bellagio Child Survival Study Group has identified
optimal breastfeeding in the first year of life as one of
the most important strategies for improving child Jones et al., 2003). Improved breastfeeding practice
survival (Black et al., 2003; Jones et al., 2003). can also have a positive effect on birth-spacing, which
Increasing optimal breastfeeding practices could save contributes to child survival (Labbok et al., 1997; Jones
as many as 1.5 million infant lives every year, given et al., 2003). Further, population-based studies in a
the significant protection that breastfeeding provides number of developing countries have shown that the
infants against diarrhoeal disease, pneumonia, and greatest risk of nutritional deficiency and growth
neonatal sepsis (UNICEF, 2002; Black et al., 2003; retardation occurs in children between 3 and 15 months
1

12. Introduction
of age, associated with poor breastfeeding and The first chapter of the paper places community-based
complementary feeding practices (Shrimpton et al., inter ventions in an historical and community
2001). development context and provides the scientific
rationale for this approach. The second chapter
The Global Strategy for Infant and Young Child Feeding describes key features of—and strategies for—
(2002), co-developed by WHO and UNICEF with community-based breastfeeding promotion and
broad participation of governments and other support, including integration with primar y and
stakeholders, is a blueprint for current and future public preventive health services. The third chapter presents
health action to improve infant feeding practices several countries’ experience implementing community-
worldwide. The World Health Assembly and UNICEF’s based strategies on a large population scale. The fourth
Executive Board adopted the strategy in 2002. The chapter addresses challenging circumstances to consider
foundation of this strategy is built on two decades of in implementing community-based breastfeeding
international and public health consensus and action, programmes around the world. The paper concludes
beginning with the Joint Meeting on Infant and Young with a summary of key issues regarding community-
Child Feeding (1979), the International Code of based breastfeeding promotion and support.
Marketing of Breast-milk Substitutes (1981), the
Innocenti Declaration (1990), and the Baby-friendly Figure 2
Hospital Initiative (1991). Elements of a comprehensive breastfeeding
programme
A novel contribution of the Global Strategy for Infant
and Young Child Feeding is its comprehensive approach. P OLICY
The Global Strategy gives heightened attention to
• National Breastfeeding Commission
breastfeeding and complementar y feeding in
• Health System Norms
exceptionally difficult circumstances, such as in HIV- • Code of Marketing of Breastmilk Substitutes
prevalent areas and emergency situations. The strategy • Worksite laws and regulations
also includes community-based interventions to • Information, education and communication
promote and support infant and young child feeding
as a new operational target. While significant progress H EALTH S ERVICES C OMMUNITY
in breastfeeding protection, promotion, and support
• Pre-service curriculum • Community
has been made through emphasis on policy and reform participation
maternity health services, experience suggests that • Baby-friendly Hospital • Training and
achieving optimal infant and young child feeding Initiative supervision of
requires an integrated, comprehensive strategy that
• In-service training counselling network
• Supportive supervision • Community
includes community-based interventions as well as education
policy and health services (figure 2).
• Information, education and communication
The purpose of this document is to provide the rationale • Monitoring, research and evaluation
and guideposts for community-based interventions to • Health information systems
promote and support breastfeeding. This document • Referral and counter referral
focuses on the growing evidence that community-based
approaches can significantly increase optimal (Wellstart International, 1996)
breastfeeding in diverse settings, summarizes the
lessons learnt from community-based breastfeeding
interventions in a number of developing countries, and
recommends approaches that can be applied by
programme planners and managers worldwide. Few
efforts to promote improved infant and young child
feeding have yet expanded to a large scale. The lessons
learnt from breastfeeding programmes should also be
applied in the future to promotion of and advocacy for
improved complementary feeding and to other aspects
of child health and development.
2

13. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries
Chapter 1
Background and Context
T hrough most of the twentieth century, initiation
and duration of breastfeeding declined worldwide Trends in breastfeeding patterns in
Figure 3
as a result of rapid social and economic change, developing countries, 1989–1999
including urbanization and marketing of breast milk 83
90%
substitutes. In recent years the global trend has shifted 77
80%
towards improved breastfeeding practices. However, the 70%
58
prevalence of exclusive breastfeeding and other optimal 60% 50 52
50% 46
infant feeding practices is still low in many countries. 39 41
40%
Continued attention to breastfeeding is therefore 30%
needed to achieve the sustained behaviour change that 20%
will lead to significant improvement in child survival 10%
%
and development.
Complementary
Breastfeeding
Breastfeeding
Breastfeeding
(12-15 mos)
(20-23 mos)
Feeding (6-9
(0-3 mos)
Continued
Continued
Exclusive
Breastfeeding practices in developing
mos)
countries
In the past two decades, breastfeeding initiation and Percent Change 1989-1999
duration began to increase in many developing +18% +22% +8% +12%
countries (Grummer-Strawn, 1996; Lutter, 2000;
UNICEF, 2001). Survey data from 43 countries (UNICEF, 2002)
indicate a significant increase in exclusive breastfeeding,
from 39% to 46% between 1989 and 1999, with wide
variations within and between geographic regions breastfeeding practices (Wellstart, 1996; Guerrero et
(figure 3). For example, DHS surveys indicate that al., 1999; Green, 1989; de Zoysa et al., 1998).
exclusive breastfeeding rates for infants 0–3 months of
age range from 25% (Dominican Republic, 1996) to Breastfeeding promotion and support:
78% (Peru, 2000) in Latin America, and from 4% (Côte historical development
d-Ivoire, 1998/99) to 63% (Malawi, 2000) in Africa.
In May 1980 the World Health Assembly adopted the
In countries and regions where breastfeeding promotion recommendations for promotion and support of
and support programmes have been well enacted, breastfeeding that were made the previous year at a
notably some Latin American countries, rates of WHO/UNICEF Meeting on Infant and Young Child
exclusive breastfeeding and other optimal breastfeeding Feeding (WHO, 1980). In the 1980s, workshops on
practices appear to be improving more dramatically. infant and young child feeding were organized in nearly
Nevertheless, in many developing countries certain 100 countries. National breastfeeding committees and
cultural beliefs continue to interfere with optimal national breastfeeding promotion programmes were
breastfeeding, especially feeding colostrum and established in various countries (Jelliffe and Jelliffe,
breastfeeding exclusively (Dimond and Ashworth, 1988). In 1990 policy-makers from 31 governments,
1987; Martines et al., 1989). In every culture, specific representatives of 8 UN agencies, and other participants
beliefs that impede optimal breastfeeding need to be at a WHO/UNICEF meeting in Italy produced and
identified through formative research and addressed adopted the Innocenti Declaration on the Protection,
through effective, well-designed behaviour change Promotion, and Support of Breastfeeding. The
communication to promote and support optimal Innocenti Declaration established operational targets
3

14. Background and Context
for breastfeeding that focused primarily on policy and support by building on these past and continuing
health services (WHO, 1989). concepts and achievements. Over the past few years,
experience in enacting community-based strategies has
From that declaration emerged the Baby-friendly grown, along with a scientific evidence base to address
Hospital Initiative (BFHI), which has made a the efficacy and effectiveness of certain support
significant impact on breastfeeding practices globally strategies (Green, 1999). As a result of the confluence
through implementation of the “Ten Steps to Successful of policy development and the accumulation of
Breastfeeding,” focusing on maternity services and scientific evidence, the promotion and support of
newborn care (WHO, 1998). The tenth step, the optimal breastfeeding through community-based
establishment of breastfeeding support groups, initiatives is now more widely understood and accepted.
connects mothers to community support after discharge
from the hospital. Two other steps—antenatal care (step Evidence of effectiveness
3) and breastfeeding guidance (step 5)—also involve
maternal access to support and may reach beyond the This section describes 1) the evidence that community-
health facility to the community. based breastfeeding promotion and support can
improve breastfeeding practices in developing countries
The Global Strategy for Infant and Young Child Feeding and 2) the efficacy of such interventions to reduce
advances breastfeeding protection, promotion, and infant morbidity and mortality.
Table 1
Community-based breastfeeding support trials in developing countries that include healthy
newborn infants and mothers
Bre astfe e ding status
Study (de sign) Subje cts Inte rve ntion at last asse ssme nt,
<6 mo. RR (95%CI)
Barros et al 1994 U rban (Pelotas) Brazil, N=900 T hree hom e visits at 5, 10, 20 days A ny Breastfeeding
Enrollm ent site: Maternity unit postpartum by a social assistant or Intervention - 38%
(Random ized, controlled Inclusion criteria: Hospital stay 5 nutritionist experienced in Control - 35%
trial but m ethod of days or less, wanted to breastfeed, breastfeeding and trained in
random ization not stated) living in Pelotas, fam ily incom e breastfeeding counselling
< twice m inim um Brazilian wage
Froozani et al 1999 U rban Iran, N = 134 Contact by nutritionist in hospital A ny Breastfeeding
Enrollm ent site: Single hospital im m ediately after birth and at Intervention - 84%
(A lternating allocation to Inclusion criteria: Mothers without hom e or in clinic on days 10–15, Control - 75%
intervention vs. usual breastfeeding experience or chronic and m onthly thereafter to 4 Exclusive Breastfeeding*
care) disease giving birth to norm al m onths (5–6 visits) Intervention - 48%
birthweight, term infant Control - 6%
Haider et al 2000 Dhaka, Bangladesh, N=726 Peer counsellors, hom e visits up to Exclusive Breastfeeding*
Enrollm ent site: Com m unity 15 occasions including 2 in last Intervention - 56%
(Cluster random ized, Inclusion criteria: Wom en aged trim ester of pregnancy, 4 in m onth Control - 5%
controlled trial) 16–35 with 3 children or less and 1 and every two weeks thereafter
no serious illness, singleton birth, up to m onth 5.
with no congenital birth Visit duration 20–40 m inutes
abnorm alities, birth weight 1800 g
or m ore
Leite et al 1998 U rban Brazil, N = 1003 Peer counsellors m ade hom e visits A ny Breastfeeding*
Enrollm ent site: 8 public health up to 6 occasions, 5, 15, 30, 60, Intervention - 65%
(Random ized, controlled m aternity units 90 and 120 days, visits lasting Control - 53%
trial) Inclusion criteria: Newborns 30–40 m inutes. Counsellors had Exclusive Breastfeeding*
weighing < 3000 g, discharged personal experience with Intervention - 25%
< 5 days, singleton birth, no breastfeeding and had been Control - 20%
im portant health problem s in associated with m ilk bank for 5 or
m other or infant m ore years. Trained with adapted
WHO counselling course
Morrow et al 1999 Periurban, Mexico, N=130 Peer counsellors m ade 3 or 6 hom e A ny Breastfeeding
Enrollm ent site: Com m unity visits Intervention - 68%
(Cluster random ized, Inclusion criteria: A ll pregnant Group 1: 6 visits (2 in pregnancy, Control - 63%
controlled trial) m others wishing to be enrolled, and 1, 2, 4, 8 wks post-partum ) Exclusive Breastfeeding*
perinatal deaths excluded Group 2: 3 visits (1 late pregnancy, Intervention - 55%
and 1, 2 wks post-partum ) Control - 15%
* Significant at two-sided p<0.05 (abstracted from Sikorski et al, 2002)
4

15. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries
IMPROVING BREASTFEEDING PRACTICES. Sikorski et al. REDUCING MORBIDITY AND MORTALITY. The WHO
(2002) conducted a systematic review and meta-analysis Collaborative Study Team on the Role of Breastfeeding
of the efficacy of support for breastfeeding mothers. This on the Prevention of Infant Mortality found that in
study identified 20 randomized or quasi-randomized developing countries, any breastfeeding is associated
trials of breastfeeding support conducted in 10 countries. with more than two-fold protection against infant
Breastfeeding outcomes of interest were “any mortality compared with no breastfeeding in the first
breastfeeding” or “exclusive breastfeeding” for specific year of life (WHO, 2000). A cohort study of 1,677
age groups. Overall the meta-analysis revealed a infants living in the slums of Dhaka, Bangladesh, found
significant, beneficial effect of breastfeeding support on that the relative risk of mortality in the first 6 months
duration of any breastfeeding, with the greatest effect was more than two-fold lower in infants who were
on exclusive breastfeeding. Both lay and professional exclusively breastfed than in infants who were partially
support appeared to be effective, although in different or not breastfed (Arifeen et al., 2001) (table 2).
ways. Lay counsellors appeared to be most effective in Breastfeeding demonstrates a dose response
increasing the duration of exclusive breastfeeding, while relationship to infectious disease morbidity and
professional counsellors appeared to be most effective mortality in infancy, with exclusive breastfeeding
in extending the duration of any breastfeeding. offering the most protection and partial breastfeeding
intermediate protection when compared to no
Most of the studies cited were conducted in breastfeeding (Brown et al., 1989; Victora et al., 1989;
industrialized countries. Of the seven trials conducted Morrow et al., 1992). Thus, infants under 6 months
in developing countries (Bangladesh, Brazil, Iran, of age who are not breastfed are estimated to have a
Mexico, and Nigeria), five examined community-based greater than 5-fold increased risk of morbidity and
breastfeeding counselling to mothers of normal mortality from diarrhoea and pneumonia compared to
newborn infants (table 1). The sample size of each infants who are exclusively breastfed (Victora et al.,
individual study ranged from 130 to 1,003 (total for 1989; Black et al., 2003).
all five studies, n=2,893 mother-infant pairs). In four
of these five studies, the intervention involved home Table 2
visits by peer counsellors; the remaining study (Froozani Infant mortality (0-6 months) in Dhaka,
et al., 1999) involved maternal contact in a hospital Bangladesh comparing partial and no
by a trained nutritionist followed by home visits. The breastfeeding to exclusive breastfeeding
number of visits made to mothers by breastfeeding
RR (95% CI)
counsellors in these trials ranged from 3 to 12 or more
Causes of Infant Death Partial/no BF vs. EBF
(Haider et al., 2000). In most of the studies, counsellors
were trained using the WHO breastfeeding counselling All Causes 2.2 (1.4 – 3.4)
course in its original or adapted form; one study used Diarrhoea 3.9 (1.5 – 10.6)
a training course developed by La Leche League
Acute Respiratory Infection 2.4 (1.1 – 5.2)
(Morrow et al., 1999). Four of five trials examined
exclusive breastfeeding, and each of these demonstrated
(Arifeen et al, 2001)
significant impact of counselling on exclusive
breastfeeding. Only one of the four trials that examined
the duration of any breastfeeding as an outcome A randomized, controlled trial of healthy infants in
demonstrated a significant impact of counselling (Leite Mexico City found that home-based breastfeeding
et al., 1998). counselling was associated not only with a significant
increase in exclusive breastfeeding, but also with a
Two other trials in developing countries included in significant decrease in the percentage of infants who
the Cochrane Review (Haider et al., 1996, in experienced a physician-diagnosed episode of diarrhoea
Bangladesh and Davies-Adetugbo, 1997, in Nigeria) at any time during the first three months of life (one-
tested the effectiveness of breastfeeding counselling of tailed p<0.05 [Morrow et al., 1999]). The trial by
mothers whose infants were seen for diarrhoea in the Froozani et al. (1999) reported significantly fewer days
hospital or health care centre. In both studies, for the of diarrhoea among infants of mothers in the
2–3 weeks following counselling, exclusive breastfeeding breastfeeding counselling group (1.2 [SD 2.7])
was significantly increased, and infants experienced compared with those in the control group (4.0 [SD
fewer repeat cases of diarrhoea. 7.1] days, p<0.004). Similarly, a randomized,
controlled trial of community-based breastfeeding
support conducted in Haryana, India (see Chapter 3),
5

16. Background and Context
described significant increases in exclusive breastfeeding terms, these elements translate into providing mothers
and significant decreases in infant diarrhoea in with acceptance, encouragement, timely and salient
intervention communities (Bhandari et al., 2003). information regarding breastfeeding, and practical skills
These findings are consistent with a trial of the Baby- and strategies for overcoming socioeconomic, cultural,
friendly Hospital Initiative intervention in Belarus, or biomedical obstacles to optimal breastfeeding.
which reported that the rates of diarrhoea and of atopic
disease were significantly reduced among infants in the Involving community leaders, social support networks,
intervention group compared with controls (Kramer the health sector, and community members in
et al., 2001). Thus, observational and experimental data breastfeeding promotion and support provides a
provide compelling evidence that effective community- mechanism for shifting cultural knowledge, norms, and
based breastfeeding inter ventions can result in expectations (WHO, 2002). In short, community-based
significantly increased optimal breastfeeding and breastfeeding promotion and support can be justified
significantly lower infant morbidity and mortality. on grounds not only of effective breastfeeding
behaviour change leading to increased child survival,
Framework and justification but also of women’s empowerment and community
development. The following chapter addresses the
Optimal breastfeeding requires maternal choice concepts and strategies that underlie community-based
combined with the ability to implement that choice breastfeeding promotion and support.
(figure 4), which is in turn affected by social, physical,
and logistical factors that are immediate to the mother’s
experience. Influences that are a level removed from
the mother’s personal experience, such as cultural
attitudes and national policies, may or may not be
directly perceived as affecting her choice. Nevertheless,
they are powerful determinants that influence the
degree to which a mother experiences support or
barriers to optimal breastfeeding.
Figure 4
Model of determinants of breastfeeding
behaviour
Infant Feeding Behaviours
Proximate Opportunities to act
Maternal choices
determinants on these choices
Infant feeding information and physical
Intermediate and social support during pregnancy,
determinants childbirth and post-partum
• Familial, medical, and cultural attitudes
and norms
Underlying • Demographic and economic conditions
determinants • Commercial pressures
• National and international policies and
norms
(Lutter, 2000)
Social support for optimal breastfeeding can take many
forms. The elements of social support relevant to
breastfeeding are emotional, informational, and
instrumental (Raj and Plichta, 1998). In practical
6

17. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries
Chapter 2
Approaches to Community-based Breastfeeding
Promotion and Support
A n interagency working group including WHO,
UNICEF, USAID, the World Bank, the Department
individual mothers may not experience but that create
and sustain the community’s capacity for breastfeeding
for International Development (DFID) and the CORE promotion and support. These latter elements, which
consortium of nongovernmental organizations has can be considered the foundation for effective and
targeted the reduction of childhood morbidity and sustained action, include the development of
mortality using an approach that works with and through intersectoral partnerships or coalitions, formative
communities, and extends integrated facility-based care research, monitoring and evaluation, training and
for management of common childhood illnesses to super vision, strong management, and visionar y
support for prevention and good home care (WHO et leadership.
al, 2002). The working group advocates a community-
based approach that involves people from the P ARTNERSHIPS . The formation of intersectoral
community, adapts to community needs, builds on partnerships or coalitions increases the capacity for
existing resources and avoids duplication, strengthens effective and sustainable community-based behaviour
links and builds bridges between groups in the change (Butterfoss et al., 1993). At the community level
community and between those groups and the formal in developing countries, such partnerships may include
health system, focuses on outcomes, and is cost-effective the ministry of health, other ministries concerned with
and sustainable. At the heart of efforts is the promotion social welfare, community health centre staff, identified
and support of a set of key family behaviours to improve opinion leaders, nongovernmental agencies, and
child health and development. These behaviours include women’s groups.
optimal infant and young child feeding practices.
FORMATIVE RESEARCH . Formative research can be
Community-based breastfeeding promotion and support invaluable to guide effective action on breastfeeding as
is important insofar as this approach can achieve well as other public health concerns (Pelto et al., 1991;
sustained population-level breastfeeding behaviour Guerrero et al., 1999; Martines et al., 1989). The
change. This ambitious goal requires systematic purpose of such research is to clarify the values, beliefs,
application of behaviour change theory to strategies that and practices that most significantly affect breastfeeding
engage individuals and multiple levels of society. behaviour, and with that understanding to shape
Community-level change involves attention to messages and approaches that are likely to result in
community capacity (the foundation for change) as well positive breastfeeding behaviour change. For example,
as specific interventions intended to produce behaviour formative research conducted in Mexico indicated that
change (Wandersman et al., 1996). The section below mothers believed they should introduce another liquid
considers the foundation for community-level or food when the baby was “thirsty,” the baby or mother
breastfeeding behaviour change, describes specific was ill, or the mother was emotionally upset (Guerrero
interventions, discusses the integration of community- et al., 1999). These findings were used to develop
based breastfeeding initiatives with preventive and messages, materials, and training programmes for
primary health care services, and considers the argument physicians and lay counsellors to influence attitudes and
for integration of breastfeeding and early childhood behaviours that impeded exclusive breastfeeding in the
development initiatives. periurban Mexican setting. “Breast milk is sufficient to
quench a baby’s thirst, even in hot weather” was one of
Foundation for community behaviour the messages developed in response to the formative
change research. “Mother’s milk is better than any other method
of feeding a young infant, even when a mother is
Community-based intervention strategies include those emotionally upset (has coraje or susto)” was another key
that mothers experience directly, as well as elements that message. These specific messages helped to ensure that
7

18. Approaches to Community-based Breastfeeding Promotion and Support
the lay counselling intervention achieved significant quench thirst. If giving only breast milk to her three-
change in exclusive breastfeeding behaviour (Morrow month-old baby will result in the disapproval of her
et al., 1999). mother-in-law and potentially her community, the
woman may decide that the risk of adopting the
MONITORING AND EVALUATION. Another way to tie data recommended practice is too great. Communication
to action is through monitoring and evaluation. Data strategies must therefore address not only individual
can provide potent motivation for action when specific behaviour change of the mother, but also the beliefs of
behaviour change goals are identified, measured as those who influence her at all levels: health workers,
indicators, and used for local ongoing evaluation of family members, elders, and community members.
effectiveness. The development of a monitoring system
that allows local and routine use of data builds capacity Two broad paradigms are currently used for improving
for community-level change and creates a needed health behaviours: 1) the behaviour change approach,
evidence base for effective pubic health action (De Zoysa with its roots in individual psychology and
et al., 1998; Morrow, 2000). behaviourism and 2) community-based participatory
approaches to empower people to improve their
TRAINING AND SUPERVISION. Training and supervision communities in a sustainable way. Successful
of health-care providers and lay volunteers for breastfeeding programmes have employed both of these
breastfeeding counselling and community outreach are approaches. The Transtheoretical (Prochaska, 1982)
also important elements of the foundation for change or Stages of Change Model is a useful tool for looking
and an effective community-based breastfeeding at the process of individual change. In this model the
behaviour strategy. Providers and volunteers need individual moves from pre-awareness of the
accurate information and mastery of skills in counselling recommended practice to awareness, contemplation of
and communication to support and motivate community trying the new practice, trial of the practice, adoption
members. of the practice, maintenance, and finally advocacy of
the new practice. This model enables practitioners first
MANAGEMENT AND LEADERSHIP. Finally, the foundation to identify the stage of the target audience and then to
for change requires vision and managerial and leadership structure interventions to move individuals along the
skills. Implementation falters in the absence of these process of change.
elements. Managers’ failure to adjust programmes to
new realities jeopardizes programme sustainability. In the past health communicators often focused entirely
or disproportionately on one or more stages, such as
Community-level interventions providing information to increase knowledge, only to
find themselves frustrated when practices did not
With the elements outlined above in place, the specific change. The Stages of Change Model indicates that
community-based interventions are more likely to “knowledge” is not enough. A woman may be able to
succeed. An effective community-based breastfeeding recite messages about exclusive breastfeeding
behaviour change strategy is multifaceted, with attention (“knowledge”) but may not think that they apply to
to behaviour change communication, partnership with her. If health workers ask the woman to try a new
the health sector, and involvement or mobilization of practice such as not giving water to her baby for a week,
the community through engaged opinion leaders, the woman and her family will immediately see for
women’s support groups, and trained health-care workers themselves the advantages of exclusive breastfeeding
and lay counsellors. and may be convinced to adopt it. Thus, the individual
is persuaded through negotiation to move along the
B EHAVIOUR CHANGE COMMUNICATION . Improved change process from “knowledge” to “trial,” increasing
breastfeeding practices are more likely to occur if the chances of adoption. Figure 5 shows specific
women perceive them as beneficial, feasible, and interventions that can be used to promote change in
socially acceptable. Improving practices at the individual behaviour or community norms at various
community level requires behaviour change strategies stages.
that lead to changes in community norms, including
individual and group approaches. A breastfeeding To maintain the new practice, a woman needs support
woman typically does not make decisions alone. For from her family and community. Successful
example, a woman may hear about exclusive breastfeeding programmes have used group approaches
breastfeeding at the health facility but then be told by that address special audiences or the collective
her mother-in-law that babies need additional water to community while strengthening the capacity of
8

19. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries
Figure 5
Stages of change and communication approaches
Movement from one stage of change to another requires a mix of appropriate communication interventions from the following
categories:
• Mass, electronic, and print media (e.g., radio, TV, newspaper, flyers)
• Community advocacy and events (e.g., theatre, fairs, community gatherings)
• Interpersonal communication (community groups, individual counselling, mother-to-mother support groups, home visits)
These approaches help change individual behaviours and social norms and are directed to mothers as well as to family members,
community leaders, and other social, religious, and political influentials.
Stage s of Change Le ve l of knowle dge and attitude P urpose of appropriate communication inte rve ntions
toward or e xpe rie nce with the to move individual to ne xt stage
ne w practice
Pre-awareness Has not heard of new practice Provide inform ation
A wareness Has heard of new practice Provide m ore inform ation and begin to focus on persuasion
Contem plation Considers the resources and tasks Provide encouragem ent that practice is "do-able" and
needed to actually perform the introduce role playing, role m odeling
practice
Intention Intends to try new practice Focus on appreciating benefits and overcom ing obstacles;
introduce negotiation of trying new practice; hom e visits are
very appropriate
Trial of new practice Tries new practice to experience Reinforce benefits and overcom ing of obstacles with fam ily
benefits and overcom e obstacles and com m unity influentials; provide additional support to
m other through hom e visits and support groups
A doption of new A ppreciates benefits and has Continue to reinforce and support practice, including praise
practice overcom e obstacles during trial of from influentials
new practice; adopts practice
Maintenance Decides to continue new practice Continue to reinforce and support practice, including praise
from influentials
Telling others Believes in new practice and wants to Provide opportunities for practitioners to com m unicate their
tell others m essages to other wom en widely (m ass electronic and print
m edia) or within the com m unity (com m unity events and
advocacy; interpersonal com m unication)
(LINKAGES Project)
community organizations. Encouraging community occurs when a critical mass of community members
groups to identify and solve problems increases support have tried the innovation and begun to see its benefits.
for the mother’s decision and increases the likelihood Communication strategies can hasten this process
that she will maintain the new behaviour. through the use of lay counsellors to facilitate
discussions in mother support groups, community
The Diffusion of Innovation Theory (Rogers, 1983) is development groups, credit associations, or religious
useful for examining how innovative ideas are groups for men or women.
introduced and adopted in a community. “Early
adopters” are the risk takers; “late adopters” are the Formative research can help target clear and effective
ones who wait to see how well the innovation works. messages to specific populations or community groups.
Innovations are more easily adopted when they have Such tailored messages can help reduce the perceived
certain characteristics, such as ease of adoption, risk of trying the new behaviour and enable people to
similarity to current practice, low level of risk in trying understand how adopting the new practice brings
out the practice, and benefits that outweigh the benefits to them and to the community. Strengthening
disadvantages. When an innovation is introduced to a community organizations can increase the community’s
community by a risk-taking early adopter, others capacity to change norms and improve infant feeding
observe the results and gradually adopt the practice behaviours.
themselves. Long-term change of a community norm
9

20. Approaches to Community-based Breastfeeding Promotion and Support
TRAINING COMMUNITY HEALTH - CARE PROVIDERS . L AY C O U N S E L L O R S . Even community health
Mothers in many countries cite the advice of health- professionals who are well trained in breastfeeding and
care providers as the reason for their making specific lactation management typically lack sufficient time to
infant feeding decisions. Unfortunately, advice from promote and support breastfeeding. As a result, lay
health-care providers is too often uninformed, counsellors have become critical to providing accessible
undermining efforts to support mothers who elect to breastfeeding counselling in many communities. When
breastfeed. Breastfeeding has been neglected in pre- lay breastfeeding counsellors, who are not professional
service and in-service training of most health workers, health-care workers, are trained to provide breastfeeding
leaving a serious gap in their knowledge and skills. As counselling to mothers of their communities, they can
a result WHO, UNICEF, and others have placed a major be highly effective in increasing exclusive breastfeeding
emphasis on training health-care workers in the and, potentially, early initiation and longer duration of
fundamentals of lactation and breastfeeding counselling breastfeeding (see Evidence of effectiveness, Chapter 1).
(Rea et al., 1999; Cattaneo et al., 2001). WHO and
UNICEF have created several standardized The terms “lay counsellor” or “peer counsellor” are often
breastfeeding courses. These include an 18-hour course used interchangeably. More precisely, however, peer
designed to help staff of maternity facilities make counsellors are typically women who have given birth
maternity care “baby-friendly” (UNICEF, 1993) and a to at least one child and have breastfed successfully. Peer
40-hour course to develop clinical skills in breastfeeding counsellors have a background similar to that of the
counselling for health-care workers in all parts of the people they are counselling. Some propose that to be
health system (WHO, 1993). Basic knowledge and credible, lay counsellors should be peers. However,
skills promoted in these tools are also applied in case experience in many circumstances suggests that
management guidelines and an 11-day training course committed and well-trained lay counsellors, like health
for first-level health workers developed as part of the professionals, can be successful even when they
Integrated Management of Childhood Illness (IMCI) themselves have not had personal breastfeeding
strategy (see discussion on integration of breastfeeding experience. Indeed, La Leche League International,
with primary and preventive health services – page12). which has been training breastfeeding peer counsellors
since 1987, notes that the demand for peer counsellors
A randomized controlled trial of the effectiveness of the is so great that many such counsellors are now women
40-hour WHO training course was conducted in Brazil and men who do not meet the traditional concept of
with health workers from 60 health units. This study peers.
found that participants’ knowledge and skills in
breastfeeding counselling improved significantly, both Haider and others (2002) recommend systematic and
immediately after the course and three months later (Rea well-supervised training, recruitment, and deployment
et al., 1999). The responses of participants and of lay breastfeeding counsellors. Lay counsellors also
observation, however, suggested that the skills involved need ongoing connection to an organization that can
in clinical practice and management of lactation needed sustain their efforts. Such a connection could be to a
more time for development and reinforcement. nongovernmental organization such as La Leche League
or through the community outreach activities of the
Although increasing the breastfeeding knowledge and health system. Depending on the community and
skills of health-care providers has been an important circumstances, lay counsellors may serve entirely as
and necessar y element to promote and sustain volunteers or receive stipends to help support their
breastfeeding behaviour change, this training is not activities. Some organizations have reported a high
readily available to all health-care workers and tends to turnover rate among volunteer counsellors and have
be expensive and hard to sustain. To address the training found that some form of stipend helps volunteers to
gap, some countries are undertaking a systematic review continue in this role. Others have retained volunteers
of their pre-service curricula for training doctors, nurses, primarily through personal connection, praise,
and midwives and are strengthening the lactation recognition, and continuing education (Green, 1998).
management and infant feeding components of those
curricula so that providers do not need to be retrained Studies of the effectiveness of lay counsellors in
after they have started practice. Use of the 40-hour and increasing breastfeeding have examined their role in
18-hour breastfeeding courses continues to be home visitation. The specific activities of lay counsellors
recommended for health-care providers who typically can vary substantially. Depending on circumstances,
lack appropriate pre-service education in this arena. lay counsellors may work alongside community health
workers in clinic settings or may focus on making
10

21. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries
routine visits to the homes of pregnant or breastfeeding Figure 6
mothers. Lay counsellors may provide individual-level Models of women’s groups in
counselling to mothers, lead breastfeeding support breastfeeding promotion and support
groups, or give talks to community groups about
Model 1a. Breastfeeding Support Group
breastfeeding. The 40-hour WHO/UNICEF course on
breastfeeding counselling, originally developed for • Convened specifically to support breastfeeding mothers.
health-care professionals, has been successfully used • Interested women attend meetings held in health centres,
as the basis for training lay and peer counsellors. La homes, or other accessible locations. Meetings are often
led by trained volunteer leaders who invite and encourage
Leche League International also offers a peer counsellor participants.
training programme. • La Leche League is the prototype for this approach.
Model 1b. Mother’s Support Group with a broader
WOMEN’S GROUPS . Community-based support for purpose
breastfeeding mothers often focuses on breastfeeding
support groups. The first formal recognition of a • Convened to further a maternal and child health
behaviour and/or nutrition agenda inclusive of, and
breastfeeding support group might be the 1956 compatible with, breastfeeding.
formation of La Leche League, which provides the
Model 2. Community mobilization that engages
prototype for such groups. The purpose of a existing social groups
breastfeeding support group is to provide “mother-to-
mother” encouragement and assistance to initiate and • Groups convened for purposes other than breastfeeding,
such as social, economic, educational, or religious
sustain breastfeeding. Trained volunteers lead group
purpose.
meetings. The focus of the meetings is almost entirely • Groups provide volunteer base for peer counsellors and
on breastfeeding, with consideration of related topics. a channel for behaviour change communication (social
marketing).
The atmosphere of breastfeeding support groups is one
• Groups provide support and encouragement to the peer
of acceptance and equal participation. In this volunteers.
atmosphere mothers feel comfortable sharing
experiences, asking questions, and obtaining answers
regarding their experience with breastfeeding. This in a low-income, periurban area. On follow-up, mothers
model is now being used in many countries. of infants under 6 months of age who had contact with
the peer counsellors practiced exclusive breastfeeding
In addition to women’s groups focused primarily on for an average of 10 weeks compared with 4 weeks for
breastfeeding, other forms of women’s groups have mothers in the control group (Rivera et al., 1993). In
become involved in breastfeeding promotion and another study La Leche League of Honduras trained
support (figure 6). Some women’s groups address peer counsellors in 20 rural communities to lead
breastfeeding as part of their discussion of parenting monthly breastfeeding support meetings and visit 1–2
or nutrition and health topics. Other women’s groups, mothers each at home. Mothers who had contact with
founded for economic development, community the peer counsellors were three times more likely than
service, or social, political, or religious reasons, have other mothers to practice exclusive breastfeeding at
also participated in breastfeeding promotion and three months postpartum (AHLACMA et al., 1993).
support. These groups may include breastfeeding- In Guatemala, La Leche League trained peer counsellors
related topics as part of their programmes to educate and formed breastfeeding support groups in about 10
and support members or attendees and may provide periurban communities. A study conducted more than
volunteers for breastfeeding education support as part three years after the end of funding found that the
of their community service and outreach. Available data programme had been sustained: one-quarter of women
suggest that participants in women’s support groups in the community had contact with a breastfeeding peer
improve their breastfeeding behaviour, but questions counsellor either through support groups, home visits,
remain whether volunteer groups alone are sufficient or other contacts (de Maza et al., 1997).
to affect and sustain population-level behaviour change.
A community inter vention trial undertaken in
Despite their growing popularity for breastfeeding periurban Guatemala as a collaboration of La Leche
promotion and support, women’s groups have not been League and the LINKAGES Project found that after
studied extensively (Green, 1998). La Leche League’s one year the rate of exclusive breastfeeding in
model, however, has been evaluated in Honduras and intervention areas with peer counsellors did not
Guatemala, which have had exceptional programmes. significantly increase compared with the control
In Honduras La Leche League trained peer counsellors communities (Dearden et al., 2002a). However, only
11

22. Approaches to Community-based Breastfeeding Promotion and Support
31% of mothers in the intervention communities with and through the media and other channels of
infants under 6 months of age had any contact with a communication. Reproductive health services, including
peer breastfeeding counsellor. As in previous studies, maternity care and family planning services, are critical
exclusive breastfeeding was higher among women in avenues for breastfeeding promotion and support. Many
intervention communities who were exposed to La studies have shown that early initiation of breastfeeding
Leche League support groups and home visits than and later breastfeeding practices are strongly associated
among women who were not exposed (Dearden et al., with the support or the barriers experienced with
2002a). maternity services. The Baby-friendly Hospital Initiative
was designed to address this issue, although the concept
Microenterprise programmes represent another model should be extended to perinatal care delivered in homes
of women’s groups. An evaluation of Freedom from and clinics.
Hunger’s Credit with Education Programme, managed
by the Lower Pra Rural Bank in Ghana, found major A natural point of integration between reproductive
improvements in breastfeeding practices among health services and breastfeeding is education and
programme participants between the 1993 baseline and support of mothers regarding use of the lactational
1996 follow-up surveys. Women not involved in the amenorrhoea method (LAM), a well-documented
programme did not show improved practices: 98% of method of contraception. This method has been shown
programme participants gave colostrum, compared with to have 98% efficacy for the first 6 months postpartum
only 71% of non-participants and 78% of women in (Labbok et al., 1997). Use of LAM requires that
control communities. Further, programme participants mothers practice full or nearly full breastfeeding1, do
delayed introduction of water to their infants until an not experience return of their menses, and have not
average of 125 days of age, compared with 63 days for passed the first six months postpartum. Mothers who
non-participants and 51 days for women in control practice this method are also encouraged to switch to
communities (McNelly, 1997; Green, 1998). other family planning methods when any of one of these
criteria is no longer met.
As experience with community-based breastfeeding
promotion and support deepens, diverse approaches are Breastfeeding promotion and support is also a key
being used for forming and involving women’s groups. intervention in the IMCI strategy (WHO, 1999). This
In some regions existing women’s groups provide strategy is championed by WHO and health agencies
volunteers to work with the breastfeeding initiatives of worldwide as the foundation for pediatric primary care
the health sector. In other regions new support groups and improved child health outcomes in developing
are formed focused on the breastfeeding experiences of countries. The strategy involves strengthening the
the women who attend. More rapid change may be quality and accessibility of primary care by addressing
achieved by using existing women’s groups for outreach three major dimensions of the care delivery process—
purposes than by establishing new groups focused on the health system, the skills of health staff, and family
breastfeeding support. However, experience suggests that and community practices. Based on this comprehensive
either approach may be effective for breastfeeding approach, IMCI encompasses a range of specific
promotion and support, depending on the aims, time interventions to prevent and manage the major causes
frame, culture, and circumstances. of childhood morbidity and mortality, integrating
feeding counselling as an essential aspect of clinical
Integration of breastfeeding with primary care. At this stage of implementation, substantial
and preventive health services integration of IMCI with other breastfeeding promotion
and support initiatives has been achieved in only a few
Community-based approaches to breastfeeding are places in the world, but emphasis has been given to
unlikely to succeed or to be sustained without the creating more effective approaches to outreach and
involvement of the health sector. Breastfeeding developing community-based breastfeeding support
counselling should be supported within the health care that is well integrated with IMCI. There is a need for
system at a number of contact points that correspond additional well-designed trials to examine the impact
to time points along the maternal-child life course,
including antenatal, postnatal, well-baby, sick-baby, and
1
Full breastfeeding is the term applied to both exclusive
immunization health service visits. In other words, breastfeeding (no other liquid or solid given to infant) and
support for breastfeeding should be interwoven with almost exclusive breastfeeding (vitamins, water, juice, or
reproductive health, primary care, and maternal and ritualistic feeds given infrequently in addition to
breastfeeds). Nearly full breastfeeding means that the vast
child nutrition messages delivered in clinical settings majority of feeds are breastfeeds.
12

23. Community-based Strategies for Breastfeeding Promotion and Support in Developing Countries
of breastfeeding support in the primary care setting
(Guise et al., 2003).
Integration of breastfeeding and early
childhood development strategies
To maximize resources and population coverage,
breastfeeding promotion and support should, to the
extent possible, be effectively integrated with all
initiatives and services that affect infant and young
child health and development. UNICEF encourages
countries to integrate breastfeeding promotion and
support in their early childhood development
initiatives. A number of studies have reported
breastfeeding to be associated significantly with
measures of psychological development (de Andraca
et al., 1998; Lucas et al., 1992; WHO, 1999).
Mechanisms for the psychoneurologic impact of
breastfeeding may include improved mother-infant
bonding and communication and the presence of long-
chain polyunsaturated fatty acids in human milk that
have been shown to be important to infant neurologic
development (Lanting et al., 1994; Innis et al., 2001).
The beneficial effects of feeding human milk to infants
is best evidenced in preterm infants. Lucas et al. (1992)
examined the effects of tube feeding of preterm infants
(<1,850 grams) using human milk vs formula feedings.
Infants fed human milk had higher cognitive scores at
18 months and at 7–8 years of age compared with those
who did not receive their own mothers’ milk. This study
controlled for potential confounding factors but may
not have fully controlled for differences in parenting
and genetic capacity. While randomized trials have not
been conducted to address the impact of breastfeeding
promotion on psychological development of infants in
developing countries, evidence suggests that
breastfeeding has a modest but significant impact on
both physical and psychological development in the
infant. Thus, breastfeeding should be considered the
foundation for effective early childhood development
programmes in developing countries.
13

24. Case Studies of Community-based Breastfeeding Promotion
Chapter 3
Case Studies of Community-based
Breastfeeding Promotion
T his section provides case studies of community-
based breastfeeding promotion and support in
nutrition advocates at the national level; the
harmonization of nutrition messages by this group; and
three developing countries: Madagascar, Honduras, and the group’s development and use of the same
India. The Madagascar and Honduras case studies communication materials, nutrition guidelines, and
represent large-scale projects that involve major regions protocols helped create a favorable environment for
of each country. The case study in Haryana, India, was behaviour change (LINKAGES, 2002).
a large randomized, controlled trial. The Haryana study
is included because it was designed to provide a pilot In 1999 LINKAGES, in partnership with Jereo Salama
for sustainable ser vices at scale through the Isika (JSI), initiated district and community activities
mobilization of existing community resources. It also in 10 districts in 2 of the country’s 6 provinces and in
provides evidence that it is possible to improve 2001 expanded to 13 more districts. These activities
complementary feeding practices through well-targeted now reach about 6 million people. Grassroots
community interventions. organizations and district and local “champions of
change” implement the vast majority of the activities,
Each case study builds on intersectoral partnerships with LINKAGES providing technical assistance,
and uses community-based approaches to increase training modules, and materials to help them succeed
exclusive breastfeeding. Core elements of successful in their efforts. By integrating behaviour change
community-based breastfeeding promotion and support interventions with existing community programmes,
are evident in these three examples, but each has unique LINKAGES was able to expand its reach and coverage
elements and strategies. Different approaches used in and “fast track” the programme.
these programmes in measuring breastfeeding status
are discussed in the annex to this paper. The community approach in Madagascar builds on the
IMCI strategy adopted by the Ministry of Health and
Madagascar: Integrated child survival, supported by other donors and organizations. Elements
family planning, and nutrition of reproductive health related to breastfeeding, such
as LAM, are incorporated in the approach. As illustrated
In Madagascar the Ministr y of Health and the in Figure 7, breastfeeding serves as an entry point to
LINKAGES Project developed a programme to improve the community to address nutrition, child health, and
breastfeeding practices at a scale that would achieve family planning issues.
significant public health impact. LINKAGES is a global Figure 7
project funded by the United States Agency for
Breastfeeding promotion and support as an
International Development (USAID) and managed by approach to integration of primary health
the Academy for Educational Development. The care services
project’s goal is to improve breastfeeding and related
complementary feeding and maternal dietary practices
and to increase the offering of the lactational R EPRODUCTIVE
IMCI H EALTH
amenorrhea method of family planning.
During the first two years of the programme (1997– B REASTFEEDING
1999), LINKAGES provided support to the Ministry
N UTRITION
of Health for national policy activities, particularly the
E SSENTIALS
establishment and coordination of an intersectoral
nutrition action group representing approximately 50
(LINKAGES Project, Madagascar)
organizations. The mobilization of a critical mass of
14