Counselling on breastfeeding: assessing knowledge and skills

Reported are the results of a randomized controlled trial to assess the effectiveness of the WHO/UNICEF 40-hour course ``Breastfeeding counselling: a training course''. The course was conducted in a maternity hospital which provides care to a low-income population in a metropolitan area in São Paulo, Brazil...

Childbirth practices in rural Rajasthan, India: implications for neonatal health and survival.

In a rural community of Rajasthan in north India, we explored family, community and provider practices during labor and childbirth, which are likely to influence newborn health outcomes. A range of qualitative data-gathering methods was applied in two rural clusters of Udaipur district. This paper reports on the key findings from eight direct observations of labor and childbirth at home and in primary health facilities, as well as 10 focus group discussions, 18 case interviews with recently delivered women and 39 key informant interviews carried out within the community. Although most families preferred home delivery, health-facility deliveries were preferred for first births, especially among adolescents. A team of birth attendants led by a traditional birth attendant or an elder female relative took decisions and performed key functions during home childbirth. Modern providers were commonly invited to administer intramuscular oxytocin injections to hasten home delivery, whereas health staff tended to do the same during facility deliveries. The practice of applying forceful fundal pressure, stemming from overriding concern about the woman's inability to deliver spontaneously, was near universal in both situations. In both facilities and homes, monitoring of labor was largely restricted to repeated unhygienic vaginal examinations with little or no monitoring of fetal or maternal well-being. Babies born at home remained lying on the wet floor till the placenta was delivered. The cord was usually tied using available twine or ceremonial thread and cut using a new blade. In facility settings, drying and wrapping of the baby after birth was delayed and preparedness for resuscitation was minimal. Families believed in delaying breast-feeding till 3 days after birth, when they believed breast milk became available. Even hospital staff discharged the mother and newborn without efforts to initiate breast-feeding. A combination of traditional and modern practices, rooted in the concept of inducing heat to facilitate labor, occurred in both home and facility delivery settings. Programs to improve neonatal survival in such rural settings will need to invest both in strengthening primary health services provided during labor and delivery through training and monitoring, and in community promotion of improved newborn care practices.

Care-seeking practices in rural Rajasthan: barriers and facilitating factors.

Poor care seeking contributes significantly to high neonatal mortality in developing countries. The study was conducted to identify care-seeking patterns for sick newborns in rural Rajasthan, India, and to understand family perceptions and circumstances that explain these patterns. Of the 290 mothers interviewed when the infant was 1 to 2 months of age, 202 (70%) reported at least one medical condition during the neonatal period that would have required medical care, and 106 (37%) reported a danger sign during the illness. However, only 63 (31%) newborns with any reported illness were taken to consult a care provider outside home, about half of these to an unqualified modern or traditional care provider. In response to hypothetical situations of neonatal illness, families preferred home treatment as the first course of action for almost all conditions, followed by modern treatment if the child did not get better. For babies born small and before time, however, the majority of families does not seem to have any preference for seeking modern treatment even as a secondary course of action. Perceptions of 'smallness', not appreciating the conditions as severe, ascribing the conditions to the goddess or to evil eye, and fatalism regarding surviving newborn period were the major reasons for the families' decision to seek care. Mothers were often not involved in taking this critical decision, especially first-time mothers. Decision to seek care outside home almost always involved the fathers or another male member. Primary care providers (qualified or unqualified) do not feel competent to deal with the newborns. The study findings provide important information on which to base newborn survival interventions in the study area: need to target the communication initiatives on mothers, fathers and grandmothers, need for tailor-made messages based on specific perceptions and barriers, and for building capacity of the primary care providers in managing sick newborns.

Construction of the World Health Organization child growth standards: selection of methods for attained growth curves.

The World Health Organization (WHO), in collaboration with a number of research institutions worldwide, is developing new child growth standards. As part of a broad consultative process for selecting the best statistical methods, WHO convened a group of statisticians and child growth experts to review available methods, develop a strategy for assessing their strengths and weaknesses, and discuss methodological issues likely to be faced in the process of constructing the new growth curves. To select the method(s) to be used, the group proposed a two-stage decision-making process. First, to select a few relevant methods based on a list of set criteria and, second, to compare the methods using available tests or other established procedures. The group reviewed 30 methods for attained growth curves. Using the pre-defined criteria, a few were selected combining five distributions and two smoothing techniques. Because the number of selected methods was considered too large to be fully tested, a preliminary study was recommended to evaluate goodness of fit of the five distributions. Methods based on distributions with poor performance will be eliminated and the remaining methods fully tested and compared.

Nutrition counseling increases weight gain among Brazilian children.

To assess the impact on child growth of the nutrition-counseling component of the Integrated Management of Childhood Illnesses (IMCI) strategy, a randomized trial was implemented. All 28 government health centers in a Southern Brazil city were paired according to baseline nutritional indicators. One center from each pair was randomly selected and its doctors received 20-h training in nutrition counseling. Thirty-three doctors were included and 12-13 patients < 18 mo of age from each doctor were recruited. The study included testing the knowledge of doctors, observing consultations and visiting the children at home 8, 45 and 180 d after the initial consultation. Maternal knowledge, practices and adherence to nutritional recommendations were assessed, and anthropometric measurements were taken. Day-long dietary intake was evaluated on a subsample of children. Doctors in the intervention group had better knowledge of child nutrition and improved assessment and counseling practices. Maternal recall of recommendations was higher in the intervention than in the control group, as was satisfaction with the consultation. Reported use of recommended foods was also increased. Daily fat intake was higher in the intervention than in the control group; mean daily intakes of energy and zinc also tended to improve. Children 12 mo of age or older had improved weight gain and a positive but nonsignificant improvement in length. Nutrition-counseling training improved doctors' performances, maternal practices and the diets and weight gain of children. The randomized design with blind outcome evaluation strongly supports a causal link. These results should be replicated in other settings.

Care seeking in Sri Lanka: one possible explanation for low childhood mortality.

This paper examines care-seeking practices of mother caretakers with children less than five years of age in a rural district of Sri Lanka. The study was carried out from June to September 1998, documenting care-seeking practices of mother caretakers in a population of 2248 children in 60 villages. Of the five targeted diseases in the IMCI programme (Integrated Management of Childhood Illnesses) that were the focus of the study, acute respiratory infections (82.0%) and diarrhoea (14.8%) were predominant. Although malnutrition was highly prevalent it was not recognised by mother caretakers as an illness. Findings show that in 65.0% of illness episodes in children the mother caretakers sought outside care and treatment. Caretakers sought treatment from both private and public sectors with the majority seeking care in the private sector. Care seeking of mother caretakers was driven by symptomology. Young children with higher perceived severity and high-risk symptoms were brought to provider care more frequently, although a large percentage of episodes with low-risk symptoms were also brought for outside care. Care seeking was similar across socio-economic groups. The study points out that high care seeking of mother caretakers in Sri Lanka, particularly for illnesses with acute high-risk symptoms and signs, is a plausible explanation for the low level of childhood mortality despite the prevalence of a high rate of malnutrition.

Counselling on breastfeeding: assessing knowledge and skills.

Reported are the results of a randomized controlled trial to assess the effectiveness of the WHO/UNICEF 40-hour course "Breastfeeding counselling: a training course". The course was conducted in a maternity hospital which provides care to a low-income population in a metropolitan area in São Paulo, Brazil. Health workers from 60 health units were randomly assigned to be either participants (20) or controls (40), and their breastfeeding knowledge and skills were assessed before and immediately after the course, as well as 3 months later. Immediately after the course the participants' knowledge of breastfeeding had increased significantly compared to controls. Both their clinical and counselling skills also improved significantly. When assessed 3 months later, the scores remained high with only a small decrease. The implementation of the course was also evaluated. The methods used were participatory observation, key interviews and focus group discussion. In the 33 sessions of the course, the average score was 8.43 out of 10. Scores were highest for content and methodology of the theory sessions, and lowest for "use of time", "clinical management of lactation", and "discussion of clinical practice". "Breastfeeding counselling: a training course" therefore effectively increases health workers' knowledge and their clinical and counselling skills for the support of breastfeeding. The course can be conducted adequately using the material and methodology proposed, but could be more satisfactory if the time allocated to exercises and clinical practice sessions were increased.

PIP: This document presents a report which assesses the effectiveness of the WHO/UNICEF 40-hour course "Breastfeeding counseling: a training course" (BFC). The course was conducted in a maternity hospital which provides services to a low-income population in Sao Paulo, Brazil. The randomized controlled trial was composed of 60 health professionals divided into an "exposed" group (20) and a control group (40). The participants' breastfeeding knowledge and skills were assessed before, immediately after, and 3 months after the course. Results showed that the participants' knowledge of breastfeeding together with their clinical and counseling skills had markedly improved by the period immediately after the course. Three months after the course, their knowledge skills remained high with only a slight decrease. Participatory observation, key interviews and focus group discussions were used in evaluating the course implementation. The content and methodology of the theory sessions received the highest scores whereas "use of time", "clinical management of lactation", and "discussion of clinical practice" got the lowest scores. In general, BFC was effective in increasing the health workers' clinical and counseling skills for the support of breastfeeding. The course, however, does need to be improved with regard to the time allocated for exercises and clinical practice sessions.

Research steps in the development and evaluation of public health interventions.

Presented is a conceptual framework for planning intervention-related research. Altogether, nine steps in the process of developing and evaluating public health interventions are specified. This process is dynamic and iterative, and all steps are not always required, or need follow in sequence. The framework can be used to set research priorities by verifying where there is sufficient knowledge to move forward and by identifying critical information gaps. It can also help select appropriate research designs, as each step is characterized by certain types of studies. Greater effort is required to move beyond descriptive epidemiological and behavioural studies, to intervention studies. Field trials of public health interventions require particular attention as they are often neglected, despite their significance for public health policy and practice.

Case-control study of risk of dehydrating diarrhoea in infants in vulnerable period after full weaning.

OBJECTIVES: To investigate risk factors for dehydrating diarrhoea in infants, with special interest in the weaning period. DESIGN: Case-control study. SETTING: Metropolitan area of Porto Alegre, Brazil. SUBJECTS: Cases were 192 children aged 0-23 months hospitalised with acute diarrhoea and moderate to severe dehydration. Controls were 192 children matched for age and neighbourhood who did not have diarrhoea in the previous week. MAIN OUTCOME MEASURES: Associations between dehydrating diarrhoea and child's age, type of milk consumed, time since breast feeding stopped, and breast feeding status. RESULTS: In infants aged < 12 months the risk of dehydrating diarrhoea was significantly higher in the first 9 months of life (P < 0.001), and in those aged 12-23 months the risk was again greater in younger children (12-17 months) (P = 0.03). The type of milk consumed before start of diarrhoea episode was strongly associated with dehydration independent of socioeconomic, environmental, maternal reproductive, demographic, and health services factors. Compared with infants exclusively breast fed, bottle fed infants were at higher risk (odds ratio (95% confidence interval) for cow's milk 6.0 (1.8 to 19.8), for formula milk 6.9 (1.4 to 33.3)). Compared with those still breast feeding, children who stopped in the previous two months were more likely to develop dehydrating diarrhoea (odds ratio 8.4 (2.4 to 29.6)). This risk decreased with time since breast feeding stopped. CONCLUSION: These results confirm the protective effect of breast feeding and suggest there is a vulnerable period soon after breast feeding is stopped, which may be of relevance for developing preventive strategies.

PIP: Researchers conducted a case control study in Porto Alegre, Brazil, to examine risk factors for dehydrating diarrhea in children 0-23 months old, particularly during the weaning period. There were 192 cases hospitalized with dehydrating diarrhea and 192 age- and neighborhood-matched controls who had no diarrhea in the previous 7 days. Among infants, the risk of developing dehydrating diarrhea was highest during the first 9 months of life, especially at 2-3 months (odds ratio [OR] = 7.1) (p 0.001). For toddlers (12-23 months), the risk was greatest at 12-17 months (OR = 3.7; p = 0.03). Only 8% of cases and 23% of controls were completely breast fed. Children who had not been breast fed faced a higher risk of dehydration than those who had been exclusively breast feed (p = 0.006). The degree of risk depended on the type of breast milk substitute used. Children who consumed cow's milk only and formula only faced the greatest risk of developing dehydrating diarrhea even when adjusted for age and other factors (OR = 6 and 6.9, respectively). Partially breast fed children had intermediate levels of risk (OR = 1.3-2.2). Children who had never breast fed were at low risk of developing dehydrating diarrhea (OR = 0.7), while those who had stopped were at high risk (OR = 6.4) (p 0.001). This increased risk was greatest in the first 2 months after stopping breast feeding (OR = 8.4) and decreased thereafter. These findings support the protective effect of breast feeding. They also point to a vulnerable period soon after termination of breast feeding. Thus, health workers need to pay closer attention to recently weaned children.

Weaning in southern Brazil: is there a "weanling's dilemma"?

In Pelotas, Brazil, 400 newborns from low income families were followed-up until 26 wk of life to study the relationship between their feeding patterns and growth as modified by access to water and by diarrhea. Effects of access to water were the strongest among non-breastfed infants. In houses without indoor water taps, the weight gain of non-breastfed infants during the first 3 mo was approximately half that of partially or predominantly breastfed infants (P < 0.001). In houses with indoor water taps, non-breastfed infants' growth was similar to or exceeded that of predominantly breastfed infants from 2 mo. Predominantly breastfed infants' growth was similar in houses with and without water taps. Breastfed infants had less weight loss per day of diarrhea than non-breastfed infants during the first 4 mo and less diarrhea through 6 mo of life, particularly in houses without taps, in which diarrhea was most prevalent. The existence of a "weanling's dilemma" was approached by comparing the duration of the detrimental effects of not breastfeeding (i.e., 0-3 mo in this study) with the age at which breast milk alone becomes less than optimal for growth (i.e., at 5 mo). Because these two points did not coincide, we conclude that there is no "weaning's dilemma" in this population.

Magnitud del problema global de las enfermedades diarreicas: actualización decenal / The magnitude of the global problem of diarrhoeal disease: a ten-year update

Con el fin de actualizar las estimaciones globales de morbilidad y mortalidad por enfermedades diarreicas en los países en desarrollo, hemos revisado varios artículos publicados desde 1980 hasta la fecha y estimado la tasa mediana de incidencia y la mortalidad por diarrea en niños menores de 5 años. Nuestra incidencia estimada de diarrea (2,6 episodios anuales por niño) fue casi igual a la de Snyder y Merson en 1982, pero la de mortalidad global fue menor (3,3 millones de defunciones anuales, con una variación de 1,5 a 5,1 millones). La estimación de la mortalidad se basa en un pequeño número de estudios prospectivos y de vigilancia activa y, por lo tanto, encierra mucha incertidumbre como consecuencia de la debilidad de la base global de datos. Sin embargo, numerosas encuestas que han revelado disminuciones de la mortalidad en distintos lugares son compatibles con una estimación más baja. Es necesario emplear con más precisión los métodos de encuesta de la OMS- entre ellos el muestreo poblacional en lugares representativos- y repetir las encuestas cada 5 años para observar los logros alcanzados por los programas de control de las enfermedades diarreicas y las tendencias de la morbilidad y mortalidad por diarrea a lo largo del tiempo

Magnitud del problema global de las enfermedades diarreicas: actualización decenal / The magnitude of the global problem of diarrhoeal disease: a ten-year update

Con el fin de actualizar las estimaciones globales de morbilidad y mortalidad por enfermedades diarreicas en los países en desarrollo, hemos revisado varios artículos publicados desde 1980 hasta la fecha y estimado la tasa mediana de incidencia y la mortalidad por diarrea en niños menores de 5 años. Nuestra incidencia estimada de diarrea (2,6 episodios anuales por niño) fue casi igual a la de Snyder y Merson en 1982, pero la de mortalidad global fue menor (3,3 millones de defunciones anuales, con una variación de 1,5 a 5,1 millones). La estimación de la mortalidad se basa en un pequeño número de estudios prospectivos y de vigilancia activa y, por lo tanto, encierra mucha incertidumbre como consecuencia de la debilidad de la base global de datos. Sin embargo, numerosas encuestas que han revelado disminuciones de la mortalidad en distintos lugares son compatibles con una estimación más baja. Es necesario emplear con más precisión los métodos de encuesta de la OMS- entre ellos el muestreo poblacional en lugares representativos- y repetir las encuestas cada 5 años para observar los logros alcanzados por los programas de control de las enfermedades diarreicas y las tendencias de la morbilidad y mortalidad por diarrea a lo largo del tiempo

Se publica en inglés en el Bull. WHO, Vol. 70(6), 1992

Breast feeding in the first six months.

PIP: Virtually all mothers in developing countries tend to supplement breast milk with water or teas, often during the infant's 1st week, thinking that these fluids have therapeutic effects. Moreover many physicians encourage this practice. It is unnecessary and could adversely affect infant health. Exclusively breast fed infants are less likely to suffer from diarrhea. For example, studies in the Philippines and Peru show that 6 month old breast fed infants who also received other fluids suffered from diarrhea at twice the rate of those who were exclusively breast fed. Further a study in Brazil reveals that these infants were more likely to die than those who only received breast milk. Moreover infants who received fluids other than breast milk consume less breast milk and breast feed for shorter duration than exclusively breast fed infants. In Brazil, breast fed infants who received supplements in the 1st days of life were 2 times as likely to not breast feed after 3 months than exclusively breast fed infants. Thus growth in infants who receive water or teas will not be optimal. Another benefit of breast feeding that supplements erode include increased birth intervals. Moreover research consistently shows that healthy infants who receive enough breast milk to meet their energy needs also receive enough fluid to meet their requirements, even in hot and dry environments. Improved maternity services following delivery increases exclusive breast feeding rates during the 1st few weeks of life. These services include telling all pregnant women how and why to breast feed, helping mothers start breast feeding soon after delivery, rooming in 24 hours/day, encouraging breast feeding on demand, and giving no other fluids, except for required medications. Further working mothers should have the right to breast feed. Support groups and health workers should encourage mothers to exclusively breast feed for the 1st 6 months.^ieng

The magnitude of the global problem of diarrhoeal disease: a ten-year update.

In order to update global estimates of diarrhoeal morbidity and mortality in developing countries, we carried out a review of articles published from 1980 to the present and calculated median estimates for the incidence of diarrhoea and diarrhoeal mortality among under-5-year-olds. The incidence of diarrhoea obtained (2.6 episodes per child per year) was virtually the same as that estimated by Snyder & Merson in 1982, while the global mortality estimate was lower (3.3 million deaths per year; range, 1.5-5.1 million). The mortality estimate is based on a small number of active surveillance and prospective studies, and thus associated with a large degree of uncertainty, reflecting the weakness of the global database. However, many surveys reporting reductions in mortality in several locations are consistent with a decreased estimate for mortality. More accurate execution of WHO survey methods, including population-based sampling in representative locations, and repeat surveys every 5 years, are needed to monitor the progress of diarrhoeal disease control programmes and trends in diarrhoeal morbidity and mortality over time.