Timely and Appropriate Breastfeeding
A primary goal of the USAID-funded LINKAGES Project (1996–2006) was to demonstrate in several countries an increase in optimal feeding practices among infants within a relatively short period of time (20–24 months) and at a scale that could achieve significant public health impact. AED supported the design and implementation ofnational-level advocacy, district-level programming, community-basedcounseling, and support groups to achieve measurable improvements in infant feeding behaviors.
Under LINKAGES AED supported long-term, large-scale country programs in Bolivia, Ethiopia, Ghana, Jordan, Madagascar, and Zambia. Using breastfeeding as its entry point, the project helped strengthen and expand the infant and young child feeding components of other programs such as child survival, reproductive health, nutrition, and prevention of mother-to-child transmission (PMTCT) of HIV.
In each country the program reached a sizeable population. To monitor program progress, AED used a common set of breastfeeding and infant feeding indicators based on WHO definitions (1991) and Wellstart International’s toolkit for monitoring and evaluating breastfeeding activities (1996). These standard indicators were all field tested prior to application. They were limited in number and fairly easy both to measure and interpret. This strong monitoring and evaluation base, with its clearly articulated indicators to measure progress in achieving results, set the direction for the project.
Timely initiation of breastfeeding (within one hour of birth)
Approximately one-fourth to one-half of infant deaths in developing countries occur in the first week of life. A recent study in Ghana found that timely initiation of breastfeeding—within the first hour of birth—could prevent up to 22 percent of neonatal deaths.[1] In many developing countries initiation of breastfeeding is delayed by hours if not days. Early initiation provides newborns with high levels of antibodies, vitamin A, and other protective factors through colostrum, the sticky, yellow-white early milk. Skin-to-skin contact during breastfeeding stabilizes the baby’s temperature, respiratory rate, and blood sugar level.
In LINKAGES’ five large-scale country programs, the timely initiation of breastfeeding rate[2] increased at statistically significant levels in all countries. With the exception of Ghana, the endline ranged from 68 percent to 77 percent. In most cases the largest gains in feeding practices were achieved for this indicator, perhaps because it is a one-time behavior. Based on annual monitoring data, there appears to be a positive correlation between intensity of the program at the community level and the rate of timely initiation of breastfeeding. Since program intensity was not formally quantified, the correlation could not be measured statistically.
Exclusive breastfeeding among infants less than six months old
Breastmilk provides all the energy, nutrients, and water that an infant needs during the first six months. Exclusive breastfeeding reduces infant deaths caused by common childhood illnesses such as diarrhea and pneumonia, hastens recovery during illness, and helps space births. Survey data in 1999 from 43 countries indicated that less than half (48 percent) of infants 0–<4 months of age were exclusively breastfed in the previous 24 hours. Increasing exclusive breastfeeding among infants in this age group as well as those 4–5 months of age is critical.
As with timely initiation of breastfeeding, the exclusive breastfeeding rate[3] increased at statistically significant levels in the five program countries. The baseline rates varied widely across countries, from 39 percent in the Oromia Region of Ethiopia to 68 percent in Ghana. In over 5 years in Madagascar, exclusive breastfeeding increased 28 percentage points. In 4 years in Zambia it increased 17 percentage points. And in 3 years in both Ghana and Bolivia, the rate increased by over 10 percentage points. In Ethiopia the rate increased over 20 percentage points in 2 years.
[1] Edmond et al, Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics 2006, 117:380-386
[2] The timely initiation of breastfeeding rate is the percentage of infants less than 12 months of age who are put to the breast within one hour of birth.
[3] The exclusive breastfeeding rate is the percentage of infants less than 6 months old who receive only breastmilk, and no other solids or liquids including water (based on 24-hour dietary recall), with the exception of drops or syrups consisting of vitamin or mineral supplements and medicines.
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