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Evaluation of a breastfeeding-support programme with health promoters' participation

Reynaldo Alvarado M., Eduardo Atalah S., Soledad Diaz F., Soledad Rivero V., Maria Labbe D.. and Yolanda Escudero P.

Abstract

We assessed the effect of a programme promoting breastfeeding that included the participation of monitors chosen from the community and the combined follow-up of mother and child, in families of low socio-economic level. The results obtained in a non-governmental health centre (experimental group) were compared with those obtained in a health centre of the same geographic area (control group), in a cohort of 62 and 66 infants, respectively. The prevalence of exclusive breastfeeding was significantly greater in the experimental group during the entire period. At six months, 41.9% of the children in the experimental group and none of the children in the control group were exclusively breastfed (p <<.01), and the percentages of children weaned were 1.6% and 378%, respectively. Height and weight were significantly higher in the experimental group from the fourth to the sixth month, with a lower level of malnutrition (p < .05). We conclude that a programme with active community participation can be effective in promoting exclusive breastfeeding and improving infant growth.

Introduction

In recent decades the duration of breastfeeding has decreased in most Latin American countries. In Chile the rate of exclusive breastfeeding declined to less than 20% for infants age six months [1 3]. Many publications demonstrate the effect of breastfeeding in promoting children's growth and reducing morbidity, especially in families with low incomes and inadequate sanitary conditions. This is explained by the many nutritional and immunological benefits of mother's milk in diminishing the risks of infectious diseases and malnutrition. In addition, breastfeeding allows for better mother-child interaction, which represents a stimulus of the child's psychomotor development [4-9].

Chile has had success with several methods of promoting breastfeeding. In 1980 the Ministry of Health initiated an education campaign that produced a significant increase in breastfeeding in the clinics studied. Other analyses demonstrated the positive influence of health teams in this regard [10-15].

Years ago the Chilean Institute of Reproductive Medicine established a breastfeeding-promotion programme for middle-class women from Santiago. Among its achievements were a 60% rate of exclusive breastfeeding at six months and very low rates of infant malnutrition, morbidity, and mortality [16]. The criteria for this programme excluded an important portion of subjects: women younger than 18 or older than 35 years, infants born by Caesarean section, and infants with birthweight less than 2,500 or greater than 4,000 g. Although the outcomes were highly beneficial, it was considered important to evaluate the effectiveness of a similar programme in a population of women living in extreme poverty, and without the exclusion criteria. This can be done to advantage in a health structure that contemplates the active participation of the community.

For seven years the health project San Luis de Huechuraba, a non-governmental organization, has provided health care to a population living in extreme poverty in Conchali (in the northern area of Santiago), with the participation of the beneficiaries. The community is incorporated through community health groups and a strong educational component. The objective of this study was to evaluate a programme that promotes breastfeeding with care of the mother and child, and that actively incorporates health promoters with experience in disease prevention and participative educational techniques.

Materials and methods

A prospective design of analytical observation was used. The cohort was enrolled between September 1990 and March 1991 and was followed for six months. The size of the sample was calculated estimating a difference in the frequency of exclusive breastfeeding of 3:1 at six months of age (60:20%), with an a error of 5% and a testing power of 95%. According to this criterion, 55 persons were required in each group; considering a 15% loss during follow-up, it was decided to enter 65 people per group.

The study population were women of low income living in unsatisfactory sanitary conditions in the northern district of Santiago. The intervention (experimental) group consisted of pregnant women living in the area covered by the health project San Luis de Huechuraba. The nonintervention (control) group was chosen from women from a nearby area with similar socio-economic characteristics, covered by the public health centre Lucas Sierra.

Mothers in the intervention group were invited to participate in home visits from health promoters in the last three months of pregnancy. Ninety-two percent agreed to participate. The health promoters also visited the maternity ward in the immediate postpartum period to give support to the mothers and stimulate their commitment to the programme. Further follow-up was performed in the health centre. The control group received the type of health care established by the Ministry of Health.

Follow-up at the health centre was done by a physician and a professional midwife three times in the first month and monthly thereafter until the child was six months of age. Both the child and the mother were examined on the same day, but separately. The children had periodic health monitoring and medical treatment of acute problems. The mothers received education, family planning counselling, and medical attention for acute illnesses. The control group infants received medical examinations and treatment for acute illnesses from a physician and subsequent health monitoring from a nurse at ages one, two, four, and six months.

Women living in the same geographic area, with experience in health-promotion activities, were trained as breastfeeding and general health-care promoters for mothers and children. They were important in enrolling, educating, and following the mothers. They received a monthly payment equivalent to US$80.

Exclusive breastfeeding until six months of age

was recommended to the experimental group, after which solid foods were introduced. Information about breastfeeding techniques and maternal nutrition was given. Also, instructions for non-maternal milk preparation were given if hypogalactorrhoea or other maternal limitation (work, illness) was confirmed. For the control group, traditional feeding practices in the northern area of Santiago were implemented. These norms introduce solid foods at age four months and do not give priority to exclusive breastfeeding. The attitudes of the health team varied in this respect, depending on personal experience and criteria.

Women in the intervention group received individual education at each follow-up visit and from the promoters at the second home visit. Group education was given with participation of the promoters in workshops lasting approximately two hours, twice during pregnancy and once a month until the infant was six months of age. The topics covered in the workshops included breastteeding techniques, solving breastfeeding problems, and general health care of the mother and the child. This material was reinforced with information on posters and in pamphlets.

Data were obtained by one of the authors (R. A.) from mothers' and children's records for both groups. Dietary information was obtained from a one-week dietary history. The variables analysed were the type of feeding at the first, second, fourth, and sixth months; the child's weight and length at the same periods; and the monthly weight gain. The percentage of infants with weight-for-age below minus 1 standard deviation of the WHO-National Center for Health Statistics (NCHS) standard and the proportion of infants with low weight gain were calculated for group comparisons.

The following definitions were used for the variables: exclusive breastfeeding-mother's breastmilk as the only source of food; partial breastfeeding- feeding with breastmilk and artificial milk; solid foods weaning-only artificial milk and solid foods given; underweight-weightfor-age below minus 1 standard deviation of the expected weight-for-age and sex according to the WHO-NCHS standard; and low weight gain-monthly weight gain less than 75% of the expected value for each infant's age according to the same growth standard, adapted by the Ministry of Health [17]. Statistical analysis used analysis of variance, X², and the two-tailed t test with or = .05.

Results

Sixty-five children were enrolled in the experimental group and 73 in the control group. During follow-up, three and seven children were lost from the groups, most due to change of address. Thus, the final analysis included 62 and 66 children in the experimental and control groups, respectively.

The initial characteristics of the mothers and children in the two groups were similar (table 1). In general, the women were young, of low socio-economic level, and with low parity, and the infants had birthweights and lengths similar to average national figures. Parity was significantly higher in the nonintervention group, given a lower percentage of primiparous and a greater number of multiparous women.

TABLE 1. Characteristics of mothers and newborns

TABLE 2. Type of feeding during the first six months of life

The distribution of children according to the type of feeding is shown in table 2. The prevalence of exclusive breastfeeding in the experimental group surpassed the frequencies usually found throughout the country. Compared with the control group, significant differences were observed throughout the entire study period (p <<.01). In the control group partial breastfeeding was most frequent at the age of four months. In the experimental group, exclusive or partial breastfeeding was practiced in 98.4% at six months. This figure is higher than the usual values in Chile. Solid foods were rarely given before the fourth month in both groups, demonstrating a positive change in relation to previous studies.

The average length and weight during the first six months are shown in table 3. In both groups, the averages were above the WHO-NCHS standard during the entire period. The average weight and length tended to be higher in the experimental group, with significant differences from the fourth month on. At age six months the differences between the groups were 380 g and 1.3 cm. The average monthly weight gain was also better in the experimental group, with significant differences in the first, fourth, fifth, and sixth months. The weight gain in both groups throughout the study was greater than expected according to the Ministry of Health norms, especially in the first month of life.

The proportion of children with a deficit in the weight-for-age index is shown in figure 1. The prevalence fence was relatively low in the experimental group, and was remarkably lower by six months of age(p <.01).

TABLE 3. Average weight and length in the first six months of life

FIG 1. Percentage of children with low weight-for-age (below minus 1 standard deviation of the expected weight-for-age according to the WHO-NCHS standard) according to age and health centre (San Luis: experimental; L. Sierra: control)

Discussion

The study population consisted of approximately 20% of the newborns admitted to the control clinic between September 1990 and March 1991. The average birthweight in this group was similar to that in another study performed in the same clinic, suggesting that this was a representative sample. The mothers in both groups were young, in agreement with the age distribution in the population of the area. The average parity in both groups was low, which is explained by the age of the mothers and the effect of family planning programmes. The parity was significantly higher in the control group, even when greatly multiparous women were excluded.

Overall, the high frequency of breastfeeding in the experimental group was especially relevant; its prevalence was even higher than in other successful breastfeeding-promotion programmes [12-14]. It is important to point out that four mothers achieved relactation [18], and therefore the percentage of children who were exclusively breastfed was greater in the first month than would be expected based on figures found on leaving the maternity ward.

The success achieved with this programme may have several explanations. It is most likely that the attitude of the health team was a fundamental element. They provided motivation and incentive, answered questions, and promoted breastteeding. They were able to train the mothers about the advantages of successful breastfeeding in such a way that the mothers considered themselves of primary importance in raising their children. The contact with the mothers since pregnancy through home visits could have favoured confidence in and commitment to the programme, thus enhancing mothers' participation in all the activities. The greater opportunities of the mothers to enquire about feeding or health problems for themselves or their children could also have been important.

The participation of the monitors (mothers from the same area) should have had a positive influence on the mothers' acceptance of, and integration and participation in, the programme's activities. In the opinion of the health team, the educational workshops, led primarily by monitors, solidified the understanding between them and the participants. In addition to attaining specific training objectives, they created an atmosphere that facilitated interpersonal relationships. This contributed to the exchange of experiences and particular situations in each family group, giving the health team a living experience in relation to raising children.

Another key element was the concern of the health team that follow-up of mothers and children was carried out according to a fixed schedule of appointments. This was highly appreciated by the mothers, because it represented an important time saving, an element that usually affects the use of health services [19].

Non-milk foods were introduced after the fourth month in both study groups, which is in agreement with actual recommendations but differs from what was reported in previous studies [12, 13]. This indicates that the change in the age for introducing solid foods was incorporated into the practice of the health team. The instructions given at the clinic assumed exclusive breastfeeding until six months of age, but some of the mothers decided to give non-milk products to their children before then.

The weight change of the children during the first semester in both groups was greater than the 50th percentile in the WHO-NCHS tables, suggesting that this standard is applicable to the low-income national population. It is important to point out that weight gain during the first month was higher than the Ministry of Health norm and the reference table. This finding agrees with other authors who suggested the need to define curves of growth for healthy breastfed children [16, 19, 20]. The weight gain was significantly better in the experimental group, with an accumulated difference at six months of 380 g (5% total weight), which can make a difference between a child's being classified as healthy or malnourished. In addition, it can have a protective effect to counteract the negative impact of an eventual digestive or respiratory disease.

Our results reinforce the importance of breastfeeding in the growth of the infant during the first few months of life, and reaffirm the importance of the attitude of the health team in a health-promotion programme. With relatively limited resources, good results can be obtained in a short period of time, allowing a significant improvement in the health conditions of children from low-income families.

Acknowledgements

We acknowledge the contributions made by Judith Frikker and Erik Diaz. This project was partially funded by the Population Council.

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