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.     

The impact of knowledge and social influences on adolescents' breast-feeding beliefs and intentions

OBJECTIVES: Many health promotion educational interventions assume that increasing knowledge directly influences beliefs, intentions and behaviour, whereas research suggests that knowledge alone is insufficient for behavioural change. Social cognition frameworks such as the Theory of Reasoned Action propose a central role for beliefs and social normative influences. This Scottish study evaluates the role of knowledge and social influences (subjective norms, exposure to breast-feeding, social barriers) on beliefs and future intentions to breast-feed or bottle-feed. Social influences from family and peers are investigated.DESIGN: A cross-sectional between-subjects observational design was used. A questionnaire was administered to a sample of 229 (46%) male and 267 (54%) female adolescents aged 11-18 years.SETTING: Participants completed questionnaires during lessons at three secondary schools in Central Scotland.RESULTS: Knowledge about health benefits of breast-feeding was generally poor. Analyses found that perceived social barriers to breast-feeding moderated the relationship between knowledge and beliefs. More knowledge, positive beliefs and supportive subjective norms also predicted future intentions to breast-feed. Parental norms exerted greater influence than peer norms on adolescents' breast-feeding beliefs.CONCLUSIONS: Knowledge and social influences are important predictors of positive breast-feeding beliefs and future intentions to breast-feed in adolescents. This has important implications for breast-feeding health promotion interventions in young people.     

Breast-feeding initiation and exclusive breast-feeding in rural Vietnam

OBJECTIVE: To investigate the initiation of breast-feeding and exclusive breast-feeding within the first week after delivery for women in rural Vietnam. DESIGN: An interviewer-administered survey was conducted on a sample of rural women who gave birth during August-October 2002. SETTING: Quang Xuong District, Thanh Hoa Province of Vietnam. SUBJECTS: Four hundred and sixty-three women participated in the study, of whom 181 delivered at the district hospital (39.1%), 229 at a commune health centre (49.5%) and 53 at home attended by a traditional birth attendant (11.4%). RESULTS: Although the initiation and exclusive breast-feeding rates were relatively high at 98.3% and 83.6% respectively, the premature introduction of complementary food was a great concern. Logistic regression analysis showed that, together with socio-cultural determinants such as feeding preferences of the husband and maternal grandmother, feeding practices of friends, factors relating to delivery methods, delivery locations and health problems could influence the initiation rate and breast-feeding patterns. CONCLUSIONS: To promote breast-feeding practices of rural mothers, health education on breast-feeding should take into account local socio-cultural features in addition to improving the counselling skills of health workers.     

Factors associated with the initiation of breast-feeding by Aboriginal mothers in Perth

OBJECTIVES: To identify the prevalence of breast-feeding at discharge and the determinants of breast-feeding initiation amongst Aboriginal women. DESIGN: A prospective cohort study using a self-administered baseline questionnaire and telephone-administered follow-up interviews. SETTING: Six hospitals with maternity wards in Perth, Western Australia. SUBJECTS: Four hundred and twenty-five Aboriginal mothers of newborn infants. RESULTS: At discharge, 89.4% of Aboriginal mothers were breast-feeding. Breast-feeding at discharge was most positively associated with perceived paternal support of breast-feeding, with an adjusted odds ratio (OR) of 6.65 (95% confidence interval (CI) 2.81-15.74), and with maternal age (OR 1.12, 95% CI 1.03-1.22), but negatively associated with parity and having delivered vaginally. CONCLUSION: The factors independently associated with breast-feeding at discharge were similar to those previously identified for a group of non-Aboriginal Perth women, suggesting that separate breast-feeding interventions specially targeted at Aboriginal women are not warranted. The findings do, however, highlight the importance of including the father in the breast-feeding discussions.     

Use of folic acid supplements, particularly by low-income and young women: a series of systematic reviews to inform public health policy in the UK

OBJECTIVE: To provide a basis for making recommendations on the potential to improve use of folic acid supplements in the UK, particularly among low-income and young women. DESIGN: Systematic reviews of relevant research from 1989 to May 2006 in Europe, the USA, Canada, Australia and New Zealand. RESULTS: Twenty-six systematic reviews and/or meta-analyses were identified from the wider public health literature, and eighteen studies on the effectiveness of preconception interventions were included. Ninety studies were identified which were directly relevant to folic acid supplement intake. There were factors that are particularly associated with lower rates of use of folic acid supplements. One of the most important of these is the link with unintended pregnancy, followed by age, socio-economic and ethnic group. Integrated campaigns can increase the use of folic acid supplements to some extent. Research trials indicated that: (i) printed resources and the mass media used in isolation are not effective in the longer term; and (ii) health-care-based initiatives can be effective and are more likely to be successful if they include making supplements easily available. CONCLUSIONS: Campaigns and interventions have the potential to exacerbate socio-economic inequalities in folic acid use. One way of addressing this is to include elements that specifically target vulnerable women. To achieve and maintain an effect, they need to be based on good health promotion practice and to be sustained over a long period. However, even high-quality campaigns that increase use result in under half of women in the target group taking supplements.     

Breast-feeding in South Korea: factors influencing its initiation and duration

OBJECTIVE: To investigate factors influencing the practices of partial breast-feeding (PBF) and exclusive breast-feeding (EBF). DESIGN: A national, cross-sectional survey was conducted among married women aged 15-49 years from May to August 2003. SETTING: South Korea. SUBJECTS: A total of 865 mothers answered questions regarding the feeding practices of their youngest baby, born between January 2001 and May 2003. RESULTS: The initiation rates of PBF and EBF were 81% and 63%, respectively. However, the median durations of PBF and EBF were very short: 12 and 8 weeks, respectively. According to stepwise logistic and Cox regression analyses, the more prenatal care women received, the more likely they were to initiate PBF and EBF but the less likely to continue EBF. Delivery by Caesarean section decreased the initiation of PBF and EBF. The mother's education level and employment status before marriage, the amount of prenatal care, delivery method and baby's status at birth affected breast-feeding initiation, whereas the amount of prenatal care influenced breast-feeding duration. CONCLUSION: To promote breast-feeding, education and campaigning on the importance of continued breast-feeding should be provided to the general public, particularly to health workers in maternity units.     

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.     

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.     

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.     

Breast-feeding in a UK urban context: who breast-feeds, for how long and does it matter?

OBJECTIVE: To investigate what factors relate most strongly to breast-feeding duration in order to successfully support breast-feeding mothers. DESIGN: Prospective birth cohort study using questionnaires, routinely collected weights and health check at age 13 months. SETTING: Gateshead, UK. SUBJECTS: Parents of 923 term infants born in a defined geographical area and recruited shortly after birth, 50% of whom were breast-feeding initially. RESULTS: Only 225 (24%) infants were still breast-fed at 6 weeks, although 136 (15%) continued beyond 4 months. Infants in the most affluent quintile were three times more likely to be initially breast-fed (P < 0.001) and five times more likely to still be feeding at 4 months (P = 0.001) compared with infants in the most deprived quintile. A third of breast-fed infants were given supplementary feeds in the maternity unit and this was associated with a 10-fold increase in odds of giving up breast-feeding by discharge (P = 0.001). Frequent feeding was reported as a reason for giving up in 70% of mothers at 6 weeks and 55% at 4 months. Those infants who stopped breast-feeding earliest showed the most rapid weight gain and were tallest at age 13 months. Non-breast-fed infants had 50% more family doctor contacts up to age 4 months (P = 0.005). CONCLUSIONS: Initiation of breast-feeding in urban Britain remains strongly determined by socio-economic background and early cessation seems to be related to frequent feeding and rapid growth as well as a continuing failure to eradicate health practices that undermine breast-feeding. Those infants not receiving breast milk suffered increased morbidity, but the apparent association between breast-feeding duration and growth probably reflects reverse causation.     

Are research priorities in Latin America in line with the nutritional problems of the population?

OBJECTIVE: Concordance of nutritional research priorities with the related burden of disease is essential to develop cost-effective interventions to address the nutritional problems of populations. The present study aimed to evaluate whether nutrition research priorities are in agreement with the population's nutritional problems in Latin America. DESIGN: The epidemiological profile was contrasted with the research priorities and research produced by academic institutions for each country. Qualitative analysis of research production by type of contribution to problem solving was also conducted. SETTINGS: Nine Latin American countries. RESULTS: Obesity (high body mass index (BMI)) and micronutrient deficiencies (anaemia) emerged as key problems, followed by stunting, breast-feeding/lactation and low birth weight. Wasting in children and women (low BMI) was uncommon. Concordance of ranked research priorities with the epidemiological profile of the country was generally good for nutrition-related chronic diseases, micronutrients and low birth weight, but not for undernutrition, stunting and breast-feeding. Studies on the efficacy and effectiveness of interventions were uncommon. CONCLUSIONS: The present research agenda insufficiently supports the goal of public health nutrition, which is to ensure the implementation of cost-effective nutrition programmes and policies. A more rational approach to define research priorities is needed.     

Deaths and years of life lost due to suboptimal breast-feeding among children in the developing world: a global ecological risk assessment

OBJECTIVE: We estimate attributable fractions, deaths and years of life lost among infants and children < or = 2 years of age due to suboptimal breast-feeding in developing countries. DESIGN: We compare actual practices to a minimum exposure pattern consisting of exclusive breast-feeding for infants < or = 6 months of age and continued breast-feeding for older infants and children < or = 2 years of age. For infants, we consider deaths due to diarrhoeal disease and lower respiratory tract infections, and deaths due to all causes are considered in the second year of life. Outcome measures are attributable fractions, deaths, years of life lost and offsetting deaths potentially caused by mother-to-child transmission of HIV through breast-feeding. SETTING: Developing countries. SUBJECTS: Infants and children < or = 2 years of age. RESULTS: Attributable fractions for deaths due to diarrhoeal disease and lower respiratory tract infections are 55% and 53%, respectively, for the first six months of infancy, 20% and 18% for the second six months, and are 20% for all-cause deaths in the second year of life. Globally, as many as 1.45 million lives (117 million years of life) are lost due to suboptimal breast-feeding in developing countries. Offsetting deaths caused by mother-to-child transmission of HIV through breast-feeding could be as high as 242,000 (18.8 million years of life lost) if relevant World Health Organization recommendations are not followed. CONCLUSIONS: The size of the gap between current practice and recommendations is striking when one considers breast-feeding involves no out-of-pocket costs, that there exists universal consensus on best practices, and that implementing current international recommendations could potentially save 1.45 million children's lives each year.     

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.     

Breast-feeding mothers can exercise: results of a cohort study

OBJECTIVES: To study the relationship between exercise by the mother and breast-feeding initiation and duration, and its effect on infant growth. DESIGN: A cohort study of mothers and infants, recruited at birth. Infant feeding methods were recorded in detail and breast-feeding was categorised as 'any' or 'full'. Exercise levels were categorised using the metabolic equivalent tasks approach based on details of physical activity recorded in questionnaires. SETTING: Perth, Western Australia. SUBJECTS: A total of 587 mothers were interviewed on seven occasions over a period of 12 months. RESULTS: There was no difference in the means of infant weight and length changes, indicating that exercise appeared to have no significant influence on infant growth up to 52 weeks after birth (P=0.236 and 0.974, respectively). The mother's level of exercise was not significantly associated with breast-feeding to 6 or 12 months. This applied to 'full' and 'any' categories of breast-feeding. CONCLUSION: Exercise does not affect breast-feeding outcomes at the usual levels of activity undertaken by mothers. Breast-feeding and exercise are important for maintaining and promoting health, and this study provides reassurance to health professionals wishing to encourage mothers to continue both behaviours.     

Are review articles a reliable source of evidence to support conservation and environmental management? A comparison with medicine

Review articles are important sources of information and often the only source of evidence used by decision makers in conservation and environmental management to assess effectiveness and impact of interventions and other actions. Recent developments in the field of medicine and public health have established ‘systematic review’ guidelines to minimise bias and explicitly document methodology, allowing replication and updating in light of further advances. The aim of this article was to assess the methodological and reporting rigour of reviews from the disciplines of conservation, ecology and environmental management (referred to as “ecological reviews”). This was achieved by comparing them to medical systematic reviews, using 27 detailed criteria well established in medicine. When compared with medical systematic reviews, ecological reviews were more likely to be prone to bias, lacking details in the methods used to search for studies, and were less likely to assess the relevance of studies, quality of the original experiments and to quantitatively synthesise the evidence. Overall, ecological reviews show lower quality and greater variation in reporting style and review methods. To address this, reviewers could use a systematic review approach and journals could provide more explicit guidelines for the preparation and production of review articles.     

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.     

Public health nutrition practice in Canada: a situational assessment

OBJECTIVE: Renewed focus on public health has brought about considerable interest in workforce development among public health nutrition professionals in Canada. The present article describes a situational assessment of public health nutrition practice in Canada that will be used to guide future workforce development efforts. METHODS: A situational assessment is a planning approach that considers strengths and opportunities as well as needs and challenges, and emphasizes stakeholder participation. This situational assessment consisted of four components: a systematic review of literature on public health nutrition workforce issues; key informant interviews; a PEEST (political, economic, environmental, social, technological) factor analysis; and a consensus meeting. FINDINGS:Information gathered from these sources identified key nutrition and health concerns of the population; the need to define public health nutrition practice, roles and functions; demand for increased training, education and leadership opportunities; inconsistent qualification requirements across the country; and the desire for a common vision among practitioners. CONCLUSIONS: Findings of the situational assessment were used to create a three-year public health nutrition workforce development strategy. Specific objectives of the strategy are to define public health nutrition practice in Canada, develop competencies, collaborate with other disciplines, and begin to establish a new professional group or leadership structure to promote and enhance public health nutrition practice. The process of conducting the situational assessment not only provided valuable information for planning purposes, but also served as an effective mechanism for engaging stakeholders and building consensus.     

Exclusive and any breast-feeding rates of Pacific infants in Auckland: data from the Pacific Islands Families First Two Years of Life Study

OBJECTIVES: To present current breast-feeding rates for Pacific infants resident in New Zealand. Reasons for the introduction of complementary liquid foods were also explored. DESIGN: A longitudinal study using hospital discharge summary records and maternal home interviews undertaken at 6 weeks, 12 and 24 months postpartum. Turnbull's non-parametric survival analysis was used to model exclusive breast-feeding rates. SETTING: Auckland, New Zealand. RESULTS: The cohort comprised 1376 infants at 6 weeks, 1223 infants at 12 months and 1142 infants at 24 months. Exclusive breast-feeding rates at hospital discharge, 6 weeks, 3 and 6 months postpartum were 84% (95% confidence interval (CI): 80-88%), 49% (95% CI: 43-55%), 37% (95% CI: 32-42%) and 9% (95% CI: 7-11%), respectively. Significant ethnic difference existed, with Samoan mothers having higher exclusive breast-feeding rates than Tongan mothers (P = 0.002). The percentage of infants receiving any breast milk at hospital discharge, 6 weeks, 12 and 24 months was 96% (95% CI: 94-97%), 95% (95% CI: 94-96%), 31% (95% CI: 28-34%) and 15% (95% CI: 13-17%), respectively. Again ethnic differences emerged. Common reasons cited for discontinuation of exclusive breast-feeding included uncertainty of breast milk supply (56%), problems with breasts (30%) and difficulties breast-feeding in work or educational environments (26%). However, 691 (50%) mothers sought no advice about their breast-feeding concerns within the first six weeks of life. CONCLUSIONS: Exclusive breast-feeding rates for Pacific infants are ethnically heterogeneous, have declined since the 1990s and fall short of the World Health Organization recommendations. The principal reasons cited for exclusive breast-feeding discontinuation echo those reported over a decade ago.     

Protection, promotion and support of breast-feeding in Europe: current situation

OBJECTIVE: To describe the current situation regarding protection, promotion and support of breast-feeding in Europe, as a first step towards the development of a blueprint for action. DESIGN AND SETTING: A questionnaire was completed by 29 key informants and 128 other informants in the EU, including member states, accession and candidate countries. RESULTS: EU countries do not fully comply with the policies and recommendations of the Global Strategy on Infant and Young Child Feeding that they endorsed during the 55th World Health Assembly in 2002. Some countries do not even comply with the targets of the Innocenti Declaration (1990). Pre-service training on breast-feeding practice is inadequate and in-service training achieves only low to medium coverage. The Baby Friendly Hospital Initiative is well developed only in three countries; in 19 countries, less than 15% of births occur in baby-friendly hospitals. The International Code of Marketing of Breastmilk Substitutes, endorsed in 1981 by all countries, is not fully applied and submitted to independent monitoring. The legislation for working mothers meets on average the International Labour Organization standards, but covers only women with full formal employment. Voluntary mother-to-mother support groups and trained peer counsellors are present in 27 and 13 countries, respectively. Breast-feeding rates span over a wide range; comparisons are difficult due to use of non-standard methods. The rate of exclusive breast-feeding at 6 months is low everywhere, even in countries with high initiation rates. CONCLUSIONS: EU countries need to revise their policies and practices to meet the principles inscribed in the Global Strategy on Infant and Young Child Feeding in order to better protect, promote and support breast-feeding.     

Breast-feeding and feeding practices of infants in a developing country: a national survey in Lebanon

OBJECTIVE: Breast-feeding (BF) provides the ideal food for the healthy growth and development of infants. The prevalence of BF in Lebanon shows mixed results. The present study was the first large-scale, extensive survey on BF parameters in Lebanon that aimed to explore demographic, socio-economic and other fundamental issues associated with the initiation and duration of BF by Lebanese mothers.DESIGN: The survey was cross-sectional in design and administered over 10 months.SETTING: Information on all variables was collected from mothers at health centres.SUBJECTS: Two-stage sampling was conducted to select participants. A total of 1,000 participants were randomly selected. A consent form was provided to each participant. Data were collected from 830 of these.RESULTS: Almost all mothers were Lebanese, married and had given birth in a hospital. About a third stated that breast milk was the first food introduced after birth. Although 55.9% started breast-feeding their newborns within a few hours after birth, and 18.3% within half an hour, 21.2% replied that they initiated BF a few days after birth. Only 4.6% of the mothers replied that they never breast-fed their infant. Timing of initiation of BF was associated with the type of delivery (vaginal/Caesarean section) and hospital-related factors (rooming-in, night feedings and frequency of mother-infant interaction). Of the mothers who breast-fed exclusively beyond 6 months, 86.7% had initiated BF a few hours following delivery, while only 13.3% had initiated BF a few days later. Compared with the exceptionally high proportion of BF initiation, exclusivity of BF was low, dropping to 52.4% at 1 month. Exclusivity of BF was also associated with place of residence (urban/rural) and negatively associated with educational level of the mother. Duration of BF was inversely associated with the use of pain killers during delivery and maternal education. Rural mothers and those who practised exclusive BF maintained BF for a longer duration.CONCLUSION: Initiation rates of BF are very high in Lebanon but rates of exclusive BF are low and duration of BF is short. Future research targeting the factors associated with BF, with particular emphasis on exclusivity, is needed. For the 95.4% of mothers who initiated BF, an ecological perspective on intervention aimed at women and their social support system is required to improve duration and exclusivity.