Rethinking research in breast-feeding: a critique of the evidence base identified in a systematic review of interventions to promote and support breast-feeding

OBJECTIVE: To appraise critically the relevance and value of the evidence base to promote and support the duration of breast-feeding, with a specific focus on disadvantaged groups. DESIGN: A systematic review was conducted of intervention studies relevant to enhancing the duration of breast-feeding; topics included public health, public policy, clinical issues, and education, training and practice change. A systematic search was conducted. Eighty studies met the inclusion criteria. Data were systematically extracted and analysed. Full results and recommendations are reported elsewhere. Here a critique of the evidence base--topics, quality and gaps--is reported. RESULTS: Many studies were substantially methodologically flawed, with problems including small sample sizes, inconsistent definitions of breast-feeding and lack of appropriate outcomes. Few were based on relevant theory. Only a small number of included studies (10%) were conducted in the UK. Very few targeted disadvantaged subgroups of women. No studies of policy initiatives or of community interventions were identified. There were virtually no robust studies of interventions to prevent and treat common clinical problems, or of strategies related to women's health issues. Studies of health professional education and practice change were limited. Cost-effectiveness studies were rare. CONCLUSIONS: Policy goals both in the UK and internationally support exclusive breast-feeding until 6 months of age. The evidence base to enable women to continue to breast-feed needs to be strengthened to include robust evaluations of policies and practices related to breast-feeding; a step change is needed in the quality and quantity of research funded.     

Do early infant feeding practices vary by maternal ethnic group?

OBJECTIVE: To examine UK country and ethnic variations in infant feeding practices. DESIGN: Cohort study. SETTING: Infants enrolled in the Millennium Cohort Study, born between September 2000 and January 2002. SUBJECTS: A total of 18 150 natural mothers (11 286 (8207 white) living in England) of singleton infants. OUTCOME MEASURES: Breast-feeding initiation, breast-feeding discontinuation and introduction of solid foods before 4 months. EXPLANATORY VARIABLES: Maternal ethnic group, education and social class. RESULTS: Seventy per cent of UK mothers started to breast-feed, of whom 62% stopped before 4 months. Median age at discontinuing breast-feeding was 14, 13, 10 and 6 weeks in Scotland, England, Wales and Northern Ireland, respectively. Thirty-six per cent of UK mothers (34% in England) introduced solids before 4 months. White mothers were more likely to discontinue breast-feeding (62%) and introduce solids early (37%) than most other ethnic minority groups; those stopping before 4 months were more likely to introduce solids early compared with those continuing to breast-feed beyond this age (adjusted rate ratio (95% confidence interval): 1.3 (1.1-1.2)). Educated mothers were less likely to stop breast-feeding before 4 months (white mothers, 0.8 (0.8-0.9); non-white mothers, 0.9 (0.8-1.0)) than those with no/minimal qualifications but, among ethnic minorities, were more likely to introduce solids early (1.3 (1.0-1.6)). Socio-economic status was positively associated with breast-feeding continuation among white women, and with age at introduction of solids among non-white women. CONCLUSIONS: We have identified important geographic, ethnic and social inequalities in breast-feeding continuation and introduction of solids within the UK, many of which have not been reported previously. The factors mediating these associations are complex and merit further study to ensure that interventions proposed to promote maternal adherence to current infant feeding recommendations are appropriate and effective.     

Motherhood meets epidemiology: measuring risk factors for breast-feeding cessation

OBJECTIVE: To examine statistical models that have been used to predict the cessation of breast-feeding. SETTING: In nutritional epidemiology, a knowledge of risk factors that lead to breast-feeding cessation is essential to promote optimal infant health by increasing or sustaining breast-feeding rates. However, a number of methodological issues complicate the measurement of such risk factors. It is important when building multivariate models that variables entered into the model are not intervening variables, factors on the causal pathway or surrogate outcomes. Inclusion of these types of variable can lead to inaccurate models and biased results. A factor often cited to predict breast-feeding is 'intention to breast-feed' prior to the birth of the infant, although this factor is directly on the causal decision-making pathway. Another factor often cited is the age of introduction of formula feeding, which is actually part of the outcome variable because formula feeding defines the difference between full, complementary and no breast-feeding. Rather than include these as risk factors in multivariate models, factors removed from the causal pathway such as influences of educational practices, including advice to complementary feed, and beliefs and attitudes of families and health-care practitioners should be measured. CONCLUSIONS: The accurate quantification of modifiable risk factors is essential for designing public health education campaigns that are effective in sustaining or increasing breast-feeding duration.     

Breast-feeding initiation and exclusive duration at 6 months by social class--results from the Millennium Cohort Study

OBJECTIVES: To assess breast-feeding initiation and rates of exclusive breast-feeding for the first 6 months after birth, and to examine social class differences in breast-feeding rates. DESIGN: First sweep of a longitudinal population-based survey, the Millennium Cohort Study. SETTING: Four countries of the UK. SUBJECTS: Subjects were 18 125 singletons born over a 12-month period spanning 2000-01. Data were collected by parental interview on the initiation of breast-feeding and exclusivity at 1, 4 and 6 months after birth. RESULTS: Overall breast-feeding was initiated for 71% of babies, and by 1, 4 and 6 months of age the proportions being exclusively breast-fed were 34%, 3% and 0.3%, respectively. There were clear social class differences and mothers with routine jobs with the least favourable working conditions were more than four times less likely (odds ratio (OR) 0.22, 95% confidence interval (CI) 0.18-0.29) to initiate breast-feeding compared with women in higher managerial and professional occupations. Women in routine jobs were less likely to exclusively breast-feed their infants at 1 month (OR 0.42, 95% CI 0.36-0.50) and 4 months (OR 0.5, 95% CI 0.31-0.77) compared with women in higher managerial and professional occupations. CONCLUSIONS: Clear social class differences in breast-feeding initiation and exclusivity for the first 4 months were apparent in this large UK sample. By 6 months, less than 1% of babies were being exclusively breast-fed. A co-ordinated multi-faceted strategy is required to promote breast-feeding, particularly among lower-income women.     

Agricultural employers' hiring and safety practices for adolescent workers

The goal of the "Safety Training for Employers and Supervisors of Adolescent Farmworkers" initiative is to improve the occupational health and safety knowledge and practices of agricultural employers and supervisors responsible for employees, ages 14 to 17 years. Surveys were sent to members of the National Council of Agricultural Employers and the Washington Growers League to measure attitudes regarding adolescent employees, current hiring and training practices, and future intentions. More than half of the respondents hire adolescents. Two-thirds were male, nearly three-quarters of the respondents had college or post-graduate degrees, and more than half were 50 years or older. The majority of respondents had positive perceptions of adolescents in terms of dependability, helpfulness, and work ethic. Among those who currently hire young workers, the most common reasons were to provide a job for children of friends and family and because they can work part-time to fill a labor demand. Among those not hiring adolescents, the most common reason was concern about child labor regulations and associated tasks (e.g., paperwork, monitoring hours). Respondents use a variety of safety training resources, especially posters and safety meetings. For the future, they expect to need more handout materials and training videos. Study results provide insights into barriers to the employment of young workers and suggest methods by which agricultural safety specialists can best assist those employers and producers who are willing to hire adolescents into agricultural work settings.     

Increasing fruit and vegetable consumption: success of the Western Australian Go for 2&5 campaign

OBJECTIVE: The Western Australian Health Department's Go for 2&5 campaign aimed to increase adults' awareness of the need to eat more fruit and vegetables and encourage increased consumption of one serving over five years. DESIGN: The multi-strategy fruit and vegetable social marketing campaign, conducted from 2002 to 2005, included mass media advertising (television, radio, press and point-of-sale), public relations events, publications, a website (www.gofor2and5.com), and school and community activities. Campaign development and the evaluation framework were designed using health promotion theory, and assessed values, beliefs, knowledge and behaviour. Two independent telephone surveys evaluated the campaign: the Campaign Tracking Survey interviewed 5032 adults monitoring fruit and vegetable attitudes, beliefs and consumption prior to, during and 12 months after the campaign; and the Health & Wellbeing Surveillance System surveyed 17,993 adults between 2001 and 2006, continuously monitoring consumption. SETTING: Population public health intervention-social marketing campaign in Western Australia, population of 2,010,113 in 2005. SUBJECTS: Adults in the Perth metropolitan area. RESULTS: The campaign reached the target audience, increasing awareness of the recommended servings of fruit and vegetables. There was a population net increase of 0.8 in the mean number of servings of fruit and vegetables per day over three years (0.2 for fruit (1.6 in 2002 to 1.8 in 2005) and 0.6 for vegetables (2.6 in 2002 to 3.2 in 2005), significant at P < 0.05). CONCLUSION: Sustained, well-executed social marketing is effective in improving nutrition knowledge, attitudes and consumption behaviour. The Go for 2&5 campaign provides guidance to future nutrition promotion through social marketing.     

Pesticide knowledge and risk perception among adolescent Latino farmworkers

A substantial proportion of the agricultural production in the U.S. is dependent on the labor of Latino farmworkers. While exact figures are not known, it is estimated that adolescents make up 7% of this valuable workforce. These young workers may be at increased risk for the toxic effects of environmental exposures encountered during their work. Furthermore, language barriers and health beliefs may influence the risk perceptions of this population. We conducted a cross-sectional survey of migrant adolescent farmworkers in 1998 to investigate their work practices, health beliefs, and pesticide knowledge. The large majority of the adolescents in our sample were from Mexico, and 36.3% spoke primarily indigenous languages. Many of the adolescents (64.7%) were traveling and working in the U.S. independent of their parents. Few of the adolescents reported having received pesticide training; however, 21.6% of the sample reported that their current work involved mixing and/or applying agricultural chemicals. The scores on the pesticide knowledge questionnaire were found to significantly predict self-reported use of protection for adolescent farmworkers. The results of this study point to a need for improved pesticide training in youth agricultural workers and specialized education efforts directed toward minorities who speak indigenous dialects. Special attention is merited toward adolescent farmworkers who report that their work includes mixing or applying agricultural chemicals. As the number of adolescent farmworkers increases in the U.S. and the characteristics of the migrant stream continue to change, culturally and developmentally appropriate instruments are needed to adequately assess the health beliefs and protective practices of this population.     

Peer-led approaches to dietary change: report of the Food Standards Agency seminar held on 19 July 2006

OBJECTIVE: To summarise the discussions of a seminar on peer-led approaches to dietary change held at the Food Standards Agency (FSA) on 19 July 2006. DESIGN: Following presentations on three FSA-commissioned research projects involving peer-led dietary interventions, discussions in small workshop groups identified learning points for researchers, policy-makers and practitioners and considered how the findings of such studies can be effectively communicated to each of these groups. The target groups in the three separate projects were: older people living in sheltered accommodation; mothers and babies during the weaning period; and people with diabetes. RESULTS: The projects discussed here were quite different from one another, involving three separate populations, having different aims and approaches and different styles of peer leading. Their effectiveness in achieving quantitative dietary change was disappointing. However, results for some of the qualitative outcomes (social, psychological, behavioural) were more positive. Process evaluation, whether built in or post hoc, provided useful learning to inform future projects and potentially improve their effectiveness and usefulness for researchers, policy-makers and health promotion practitioners. CONCLUSIONS: The projects discussed here showed that peer-led interventions can achieve positive changes in outcomes such as knowledge, confidence and attitudes, as well as small improvements in diet. They also demonstrated that there is a need for a more sophisticated analysis of peer-led interventions that recognises the diversity of approaches and their suitability in different situations.     

The Public Health Nutrition workforce and its future challenges: the US experience

OBJECTIVES: To describe the US public health nutrition workforce and its future social, biological and fiscal challenges. DESIGN: Literature review primarily for the four workforce surveys conducted since 1985 by the Association of State and Territorial Public Health Nutrition Directors. SETTING: The United States. SUBJECTS: Nutrition personnel working in governmental health agencies. The 1985 and 1987 subjects were personnel in full-time budgeted positions employed in governmental health agencies providing predominantly population-based services. In 1994 and 1999 subjects were both full-time and part-time, employed in or funded by governmental health agencies, and provided both direct-care and population-based services. RESULTS: The workforce primarily focuses on direct-care services for pregnant and breast-feeding women, infants and children. The US Department of Agriculture funds 81.7 % of full-time equivalent positions, primarily through the WIC Program (Special Supplemental Nutrition Program for Women, Infants, and Children). Of those personnel working in WIC, 45 % have at least 10 years of experience compared to over 65 % of the non-WIC workforce. Continuing education needs of the WIC and non-WIC workforces differ. The workforce is increasingly more racially/ethnically diverse and with 18.2 % speaking Spanish as a second language. CONCLUSIONS: The future workforce will need to focus on increasing its diversity and cultural competence, and likely will need to address retirement within leadership positions. Little is known about the workforce's capacity to address the needs of the elderly, emergency preparedness and behavioural interventions. Fiscal challenges will require evidence-based practice demonstrating both costs and impact. Little is known about the broader public health nutrition workforce beyond governmental health agencies.     

'The bigger the better'--mothers' social networks and child nutrition in Andhra Pradesh

OBJECTIVE: It is hypothesised that mothers' social networks can positively affect child nutrition through the sharing of health knowledge and other resources. The present study describes the composition of mothers' networks, examines their association with child nutrition, and assesses whether health knowledge is shared within networks. DESIGN AND SETTING: Cross-sectional data for mothers of young children from Andhra Pradesh (south India) were combined with existing data from the Young Lives study, in which the mothers were participating (n = 282). RESULTS: The composition of social networks varied between urban and rural areas, with urban networks being larger, more female, more literate and with a greater proportion of members living outside the household and being non-family. There was a positive association between child's height-for-age Z-score and mother's network size and network literacy rate. The association with network literacy was stronger among the poorest households. Women commonly reported seeking or receiving health advice from network members.CONCLUSION: Big and literate social networks are associated with better child nutrition, especially among the poor. The dissemination of health knowledge between network members is a plausible way in which social networks benefit child nutrition in India. Further research into the underlying mechanisms is necessary to inform the development of interventions that channel health information through word of mouth to the most excluded and vulnerable families.     

The impact of maternal employment on breast-feeding duration in the UK Millennium Cohort Study

OBJECTIVE: To examine the relationship of maternal employment characteristics, day care arrangements and the type of maternity leave pay to breast-feeding for at least 4 months. DESIGN: Cohort study. SETTING: Babies aged 9 months in the Millennium Cohort Study, born between September 2000 and January 2002. SUBJECTS: A total of 6917 British/Irish white employed mothers with singleton babies. RESULTS: Mothers employed part-time or self-employed were more likely to breast-feed for at least 4 months than those employed full-time (adjusted rate ratio (aRR) and 95% confidence interval (CI) 1.30 (1.17-1.44) and 1.74 (1.46-2.07), respectively). The longer a mother delayed her return to work postpartum, the more likely she was to breast-feed for at least 4 months (P for trend < 0.001). Mothers were less likely to breast-feed for at least 4 months if they returned to work for financial reasons (aRR 0.86, 95% CI 0.80-0.93) or used informal day care arrangements rather than care by themselves or their partner (aRR 0.81, 95% CI 0.71-0.91). Mothers were more likely to breastfeed for at least 4 months if their employer offered family-friendly (aRR 1.14, 95% CI 1.02-1.27) or flexible work arrangements (aRR 1.24, 95% CI 1.00-1.55), or they received Statutory Maternity Pay (SMP) plus additional pay during their maternity leave rather than SMP alone (aRR 1.13, 95% CI 1.02-1.26). These findings were independent of confounding factors, such as socio-economic status and maternal education. CONCLUSIONS: Current policies may encourage mothers to enter or return to employment postpartum, but this may result in widening inequalities in breast-feeding and persistence of low rates. Policies should aim to increase financial support and incentives for employers to offer supportive work arrangements.     

Breast-feeding Performance Index: a composite index to describe overall breast-feeding performance among infants under 6 months of age

OBJECTIVES: To develop a composite index to describe the overall breast-feeding performance of infants<6 months of age; and, using this index, to identify the factors associated with poor breast-feeding practices and the association between breast-feeding and infant morbidity. DESIGN, SETTING AND SUBJECTS: The 2003 Demographic and Health Survey was a multi-stage cluster sample survey of 4320 households in Timor-Leste which covered 573 infants aged<6 months. Breast-feeding Performance Index (BPI) was constructed by allocating one point for each of seven infant feeding practices: first suckling within an hour of birth; absence of prelacteals; non-use of feeding bottles; current breast-feeding; not receiving liquids; not receiving formula or other milk; and not receiving solids in the last 24 hours. BPI was treated as the dependent variable in univariate and multivariate analyses to identify the factors associated with poor breast-feeding. RESULTS: Exclusive breast-feeding rate was 29.9%. The BPI (mean 4.4, standard deviation 1.77) was categorised as low, average and high according to tertiles. Multivariate analysis indicated that infants from the richest households were 1.70 (95% confidence interval (CI) 1.04-2.77) times more likely to have 'low BPI' than the poorest. Maternal BMI<18.5 kg m(-2) was predictive of poor breast-feeding (odds ratio=1.79; 95% CI 1.27-2.52). In the 'low' BPI group, the incidence of diarrhoea (13.4%) and acute respiratory infections (20.7%) during the previous two weeks was significantly higher than in 'average' (4.3 and 9.3%) and 'high' BPI groups (4.6 and 5.5%). CONCLUSIONS: Creating a composite index to assess the overall breast-feeding performance among infants<6 months of age is feasible. BPI can be effectively used to identify target groups for breast-feeding promotion interventions.     

Why do adolescents eat what they eat? Personal and social environmental predictors of fruit, snack and breakfast consumption among 12-14-year-old Dutch students

OBJECTIVE: The aim of the study was to investigate the relative importance of personal and social environmental predictors of the consumption of fruit, high-fat snacks and breakfast. DESIGN: A school-based cross-sectional survey. Data were collected through written questionnaires. SETTING: Students from eight schools in the southern part of The Netherlands. SUBJECTS: Six hundred and one students from preparatory secondary vocational education schools. RESULTS: About a quarter of the variation in actual behaviours and intentions to change the behaviours could be explained. Stepwise multiple regression analysis revealed that, for all three behaviours, higher intention to change was especially associated with a more positive attitude and subjective norm, and higher intentions to increase fruit intake with more positive self-efficacy expectations. With regard to actual consumption, a more positive attitude towards eating fruit was the only significant correlate of a higher consumption of fruit. A more positive attitude towards eating high-fat snacks, perceived lower intake of the mother, and higher food availability and accessibility were associated with consumption of high-fat snacks, and a more positive attitude to breakfast more frequently was associated with more frequent breakfast consumption. CONCLUSION: The results indicate that adolescents' attitudes are the most important determinants of different health-related eating behaviours and intentions to change. Interventions promoting a healthy diet for adolescents should include creative strategies to achieve positive associations with healthy dietary changes.     

Socio-economic pathways to diet: modelling the association between socio-economic position and food purchasing behaviour

OBJECTIVES: To examine the association between education level and food purchasing behaviour and the contribution of dietary knowledge to this relationship; and the association between household income and purchasing behaviour and the contribution made by subjective perceptions about the cost of healthy food.DESIGN AND SETTING: The study was conducted in Brisbane City (Australia) in 2000. The sample was selected using a stratified two-stage cluster design. Data were collected by face-to-face interview from residents of private dwellings (n=1003), and the response rate was 66.4%. Dietary knowledge was measured using a 20-item index that assessed general knowledge about food, nutrition, health and their interrelationships. Food-cost concern was measured using a three-item scale derived from principal components analysis (alpha=0.647). Food purchasing was measured using a 16-item index that reflected a household's purchase of grocery items that were consistent (or otherwise) with dietary guideline recommendations. Associations among the variables were analysed using linear regression with adjustment for age and sex.RESULTS: Significant associations were found between education, household income and food purchasing behaviour. Food shoppers with low levels of education, and those residing in low-income households, were least likely to purchase foods that were comparatively high in fibre and low in fat, salt and sugar. Socio-economic differences in dietary knowledge represented part of the pathway through which educational attainment exerts an influence on diet; and food purchasing differences by household income were related to diet in part via food-cost concern.CONCLUSIONS: Our findings suggest that socio-economic differences in food purchasing behaviour may contribute to the relationship between socio-economic position and food and nutrient intakes, and, by extension, to socio-economic health inequalities for diet-related disease. Further, socio-economic differences in dietary knowledge and concerns about the cost of healthy food play an important role in these relationships and hence should form the focus of future health promotion efforts directed at reducing health inequalities and encouraging the general population to improve their diets.     

Are infant feeding options that are recommended for mothers with HIV acceptable, feasible, affordable, sustainable and safe? Pregnant women's perspectives

OBJECTIVE: To investigate pregnant women's views on infant feeding options recommended for HIV-infected women. DESIGN: A structured interview survey complemented with focus group discussions. SETTING: Antenatal clinics in Moshi urban and rural districts of Tanzania. SUBJECTS: Five hundred pregnant women participated in the interview survey and 46 pregnant women participated in six focus group discussions. RESULTS: Participating women reported that they would change to an alternative infant feeding method if they were found to be HIV-infected and were advised to do so. Cow's milk was regarded as the most feasible infant feeding method for local HIV-infected mothers. Infant feeding formula was regarded as too costly, but if recommended by health workers and distributed free of charge, the majority of the women (82%) were confident that they would then choose this option. In the focus group discussions, women were less optimistic and expressed great concern for the social consequences of not breast-feeding. The safety of exclusive breast-feeding was questioned. Less common infant feeding methods, such as expressed heat-treated breast milk and wet-nursing, were not regarded as viable options. Several social barriers to replacement feeding were identified in the focus group discussions, including possible lack of support from partner and potential negative reactions from the community. CONCLUSION: Future research on infant feeding options should include the broader cultural context and the psychological stress that HIV-infected women face when choosing infant feeding methods.     

The theory of planned behavior: use and application in targeting agricultural safety and health interventions

Traditional farm safety programs rely mostly on iterations of knowledge-based components, typically lack local input into identification of issues and concerns, and are difficult to evaluate. Psychological models have been looked at as tools to address these problems. The Theory of Planned Behavior (ToPB) is a psychological model that has been used to understand behavioral beliefs and to provide a framework for using those beliefs as intervention targets. The fundamental characteristics of ToPB are reviewed. Examples of specifically stated behavioral questions are provided from ToPB application in field settings. Pertinent findings from an example study on personal protective equipment use and beliefs are summarized to illustrate advantages and disadvantages of using ToPB. ToPB can provide information useful in targeting interventions aimed at locally identified safety and health concerns. The use of beliefs identified using ToPB as intervention targets can increase the use of personal protective equipment beyond levels used prior to the intervention. And, ToPB has shown multiple correlations of 0.28 (up to 0.35 in other examples not reported) between intentions and self-reported behaviors, indicating that other contributory factors are present and need to be studied.     

Breast-feeding at 12 months of age and dietary habits among breast-fed and non-breast-fed infants

OBJECTIVE: To analyse factors associated with breast-feeding and use of sweetened drinks at 12 months, and to compare dietary habits among breast-fed and non-breast-fed infants. DESIGN: Data were collected by a semi-quantitative food-frequency questionnaire filled in by the parents. SETTING: National dietary survey in Norway. SUBJECTS: In total, 1932 12-month-old infants were included. RESULTS: At 12 months, 36% of the infants were breast-fed. The odds of breast-feeding at this age were more than doubled both for mothers > or =35 years compared with mothers <25 years and for mothers in the highest educational group compared with mothers in the lowest. A negative association was found for maternal smoking, and the odds of breast-feeding were 40% lower for mothers who smoked than for non-smokers. Some dietary differences were observed between breast-fed and non-breast-fed infants apart from intake of milk. In particular, breast-fed infants had a significantly lower daily intake of sweetened drinks than non-breast-fed infants and a 16% lower mean daily intake of added sugars (P<0.001). Furthermore, breast-fed infants had 30% higher odds of not receiving sweetened drinks daily, compared with non-breast-fed infants. CONCLUSIONS: Maternal age, education and smoking status were important factors for breast-feeding at 12 months. Breast-fed infants had lower intakes of sweetened drinks and added sugars than non-breast-fed infants. From a public health perspective, continued promotion of breast-feeding is needed to reduce inequalities in breast-feeding. Moreover, prevention of high intakes of sweetened drinks and added sugars should start in infancy.     

Breast-feeding initiation and determinants of exclusive breast-feeding - a questionnaire survey in an urban population of western Nepal

OBJECTIVE: To assess rates of initiation of breast-feeding and exclusive breast-feeding within 2 months after delivery and to determine the factors influencing exclusive breast-feeding. DESIGN: A health worker-administered questionnaire survey was carried out during the time period 1 August-30 September 2005. SETTING: Immunisation clinics of Pokhara, a submetropolitan city in western Nepal. SUBJECTS: Three hundred and eighty-five mothers who had delivered a child within the previous 2 months. RESULTS: The rates of initiation within 1 h and within 24 h of delivery were 72.7 and 84.4%, respectively. Within 2 months after delivery, exclusive breast-feeding was practised by 82.3% of the mothers. Breast milk/colostrum was given as the first feed to 332 (86.2%) babies but 17.2% of them were either given expressed breast milk or were put to the breast of another lactating mother. Pre-lacteal feeds were given to 14% of the babies. The common pre-lacteal feeds given were formula feeds (6.2%), sugar water (5.9%) and cow's milk (2.8%). Complementary feeds were introduced by 12.7% of the mothers. By logistic regression analysis, friends' feeding practices, type of delivery and baby's first feed were the factors influencing exclusive breast-feeding practice of the mothers. CONCLUSIONS: Despite the higher rates of initiation and exclusive breast-feeding, practices such as pre-lacteal feeds and premature introduction of complementary feeds are of great concern in this urban population. There is a need for promotion of good breast-feeding practices among expectant mothers and also the community, especially the families, taking into account the local traditions and customs.     

Factors that affect the adoption and maintenance of weekly vitamin A supplementation among women in Ghana

OBJECTIVE: To identify regimen, individual, community and cultural factors that affect adoption and adherence to weekly vitamin A supplementation in Ghana. DESIGN: Fifty semi-structured interviews were conducted with women who would be eligible for vitamin A supplementation, 30 with husbands, and 13 with drug sellers, birth attendants and health workers. Six focus group discussions were also conducted with women. These interviews were followed by a 4-month capsule trial with 60 women. Data from a previously conducted communication channel survey of 332 women were also reviewed. SETTING: The study was conducted in Kintampo District in central Ghana. SUBJECTS: Participants for the semi-structured interviews and focus groups were selected from four villages and the district capital, and women in the capsule trial were selected at random from two villages. RESULTS: Knowledge of vitamins was low and taking 'medicines' for long periods and when healthy is a new concept. In spite of this, long-term supplementation will be accepted if motives are explained, specific questions answered and clear instructions are given. Potential barriers included the idea of 'doctor' medicines as curative, false expectations of the supplement, forgetting to take the supplement, losing the supplement, travelling, lack of motivation, perceived side-effects, concerns that the supplement is really family planning or will make delivery difficult, and concerns about taking the supplement with other 'doctor' or herbal medicine, or when pregnant or breast-feeding, or if childless. CONCLUSION: Successful supplementation programmes require appropriately designed information, education and communication strategies. Designing such strategies requires pre-programme formative research to uncover barriers and facilitators for supplementation.     

Unintended pregnancies are associated with less likelihood of prolonged breast-feeding: an analysis of 18 Demographic and Health Surveys

OBJECTIVE: To examine the relationship between unintended pregnancies and prolonged breast-feeding among 18 countries on an individual and aggregated level.DESIGN AND SETTING: Regional multivariate logistic regression analyses were conducted to examine this association based on 18 Demographic and Health Surveys conducted between 1995 and 2000.SUBJECTS: Women who had a live child between 13 and 36 months old were included in these analyses (n=41 353).RESULTS: Regression models were adjusted for 10 covariates including child age, maternal age, pregnancy status of mother at the time of interview and parity. In 11 out of the 18 countries the odds ratio (OR) of the association between unintended pregnancies and prolonged breast-feeding was <1.0, reaching statistical significance in three countries. Pooled analyses of all 18 countries detected a significant association between unintended pregnancies and less likelihood of prolonged breast-feeding (OR=0.90, 95% confidence interval=0.85-0.96).CONCLUSIONS: Prospective studies are needed to further understand if and how pregnancy intentions influence breast-feeding outcomes in different settings.