ABM Position Statement: Paid Maternity Leave-Importance to Society, Breastfeeding, and Sustainable Development.

Background: Paid maternity leave benefits all of society, reducing infant mortality and providing economic gains. It is endorsed by international treaties. Paid maternity leave is important for breastfeeding, bonding, and recovery from childbirth. Not all mothers have access to adequate paid maternity leave. Key Information: Paid leave helps meet several of the 17 United Nations' Sustainable Development Goals (2, 3, 4, 5, 8, and 10), including fostering economic growth. A family's expenses will rise with the arrival of an infant. Paid leave is often granted with partial pay. Many low-wage workers earn barely enough to meet their needs and are unable to take advantage of paid leave. Undocumented immigrants and self-employed persons, including those engaging in informal work, are often omitted from maternity leave programs. Recommendations: Six months of paid leave at 100% pay, or cash equivalent, should be available to mothers regardless of income, employment, or immigration status. At the very minimum, 18 weeks of fully paid leave should be granted. Partial pay for low-wage workers is insufficient. Leave and work arrangements should be flexible whenever possible. Longer flexible leave for parents of sick and preterm infants is essential. Providing adequate paid leave for partners has multiple benefits. Increasing minimum wages can help more families utilize paid leave. Cash benefits per birth can help informal workers and undocumented mothers afford to take leave. Equitable paid maternity leave must be primarily provided by governments and cannot be accomplished by employers alone.

Peer counselling as an approach to improve complementary feeding practices: a narrative review.

BACKGROUND: Appropriate complementary feeding can help reduce the risk of malnutrition and is especially important in Asian and African countries. Peer counselling has been used as an approach to improve complementary feeding practices and is often combined with other interventions, like food fortification or supplements, or as a part of broader nutrition education program. The aim of this narrative review is to assess the effectiveness of peer counselling on improving complementary feeding practices in Asian and African countries. METHODS: We searched through seven electronic databases: CINAHL, MEDLINE (OVID), PubMed, Embase, Web of Science, the Cochrane Library and WHO Global Health library from 2000 to April 2021, and had the following inclusion criteria. Studies were included if they were community- or hospital-based, had infants aged 5-24 months old, had individual or group peer counselling, and the effects of peer counselling on complementary feeding practices were measured. Methodological quality was assessed using the Joanna Briggs Institute's critical appraisal checklist for evidence studies. RESULTS: Out of 6 studies that met the above criteria, 3 studies were randomised controlled trials and 3 were quasi-experimental studies. In Bangladesh, India, Nepal and Somalia, peer counselling was found to be effective in improving timely initiation of complementary feeding, minimum meal frequency and minimum dietary diversity in all of our selected studies. In addition, improvement in breastfeeding practices, complementary foods preparation, hygiene, psychological stimulation for cognitive development of children and mothers' understanding of hunger cues were observed in some of our selected studies. CONCLUSIONS: This review evaluates the effectiveness of peer counselling to improve complementary feeding practices in Asian and African countries. Peer counselling improves timely complementary feeding and ensures the correct proportions and consistency of foods including adequate amounts of food is given. Other important complementary feeding indicators like minimum dietary diversity, minimum meal frequency and minimum acceptable diet can also be increased through peer-counselling interventions. Peer counselling is well known to enhance the rate of breastfeeding practices, but this review suggests it is also effective for complementary feeding and may inform future nutrition programs to extend the length of peer counselling for mothers.

Skin-to-skin contact after birth: Developing a research and practice guideline.

AIM: Skin-to-skin contact immediately after birth is recognised as an evidence-based best practice and an acknowledged contributor to improved short- and long-term health outcomes including decreased infant mortality. However, the implementation and definition of skin-to-skin contact is inconsistent in both practice and research studies. This project utilised the World Health Organization guideline process to clarify best practice and improve the consistency of application. METHODS: The rigorous guideline development process combines a systematic review with acumen and judgement of experts with a wide range of credentials and experience. RESULTS: The developed guideline received a strong recommendation from the Expert Panel. The result concluded that there was a high level of confidence in the evidence and that the practice is not resource intensive. Research gaps were identified and areas for continued work were delineated. CONCLUSION: The World Health Organization guideline development process reached the conclusion immediate, continuous, uninterrupted skin-to-skin contact should be the standard of care for all mothers and all babies (from 1000 g with experienced staff if assistance is needed), after all modes of birth. Delaying non-essential routine care in favour of uninterrupted skin-to-skin contact after birth has been shown to be safe and allows for the progression of newborns through their instinctive behaviours.

The effect of electronic job aid assisted one-to-one counselling to support exclusive breastfeeding among 0-5-month-old infants in rural Bangladesh.

Exclusive breastfeeding (EBF) for the first 6 months has established benefits, yet had slow improvements globally. Little is known about electronic job aid-assisted counselling to support EBF. As a secondary outcome of a cluster randomized controlled trial in Bangladesh, we assessed the effect of electronic job aid-supported nutrition counselling and practical demonstration on EBF. We randomized pregnant women to one of five study arms in the trial and followed mother-child dyads until 2 years of age. Community health workers (CHWs) provided breastfeeding counselling with or without prenatal and complementary nutrient supplements in all four intervention arms. The comparison arm continued with the usual practice where mothers could receive nutrition counselling at routine antenatal and postnatal care, and during careseeking for childhood illnesses. We assessed breastfeeding indicators at birth and monthly until the child was 6 months old, in both intervention and comparison arms. To evaluate the effect of nutrition counselling on breastfeeding, we combined all four intervention arms and compared them with the comparison arm. Intervention newborns had half the risk (relative risk [RR]: 0.54, 95% confidence interval [CI]: 0.39, 0.76) of receiving prelacteal feeds than those in the comparison arm. EBF declined steeply in the comparison arm after 3 months of age. EBF was 16% higher in the intervention than the comparison arm at 4 months (RR: 1.16, 95% CI: 1.08, 1.23) and 22% higher at 5 months of age (RR: 1.22, 95% CI: 1.12, 1.33). Maternal background and household characteristics did not modify the intervention effect, and we observed no difference in EBF among caesarean versus vaginal births. Breastfeeding counselling and practical demonstration using an electronic job aid by CHWs are promising interventions to improve EBF and are scalable into existing community-based programmes.

The Shishu Pushti Trial-Extended Peer Counseling for Improving Feeding Practices and Reducing Undernutrition in Children Aged 0-48 Months in Urban Bangladesh: Protocol for a Cluster-Randomized Controlled Trial.

BACKGROUND: The aim of this study is to assess if peer counseling of women improves breastfeeding, complementary feeding practices, and child growth, and thus reduces the prevalence of undernutrition in children up to 4 years of age. OBJECTIVE: Lack of exclusive breastfeeding and inappropriate complementary feeding are critical factors in reducing child undernutrition, morbidity, and mortality. There are reported trials of peer counseling to improve breastfeeding; however, they did not examine the efficacy of peer counseling to improve complementary feeding or the long-term impacts on child growth and development. METHODS: This study has used a community-based, cluster-randomized controlled trial with a superiority design and 2 parallel treatment arms. It is assessing the impact of peer counseling, starting in late pregnancy up to 1 year after delivery, on child feeding practices, growth, and development with follow-up until 48 months of age. The study site was Mirpur, a densely populated area in Dhaka. Using satellite maps and geographic information system mapping, we constructed 36 clusters with an average population of 5000 people. We recruited pregnant women in the third trimester aged 16-40 years, with no more than 3 living children. Trained peer counselors visited women at home twice before delivery, 4 times in the first month, monthly from 2 to 6 months, and again at 9 and 12 months. Trained research assistants collected anthropometric measurements. The primary outcome will be differences in child stunting and mean length for age at 6, 12, 15, and 18 months. Secondary outcomes will be differences in the percentage of women exclusively breastfeeding in the mean duration of any breastfeeding and in the percentage of children at 6 and 9 months of age who receive solid, semisolid, or soft foods; and the percentage of children consuming foods from 4 or more food groups at 9, 12, 15, and 18 months. We will assess the mean cognitive function scores from the Ages and Stages Questionnaire (9 and 18 months) and Bayley tests (24 and 36 months). RESULTS: We identified 65,535 people in mapped residences, from which we defined 36 clusters and randomly allocated them equally to intervention or control groups stratified by cluster socioeconomic status. From July 2011 to May 2013, we identified 1056 pregnant women and 993 births in the intervention group and 994 pregnancies and 890 births in the control group. At 18 months, 692 children remained in the intervention group and 551 in the control group. From January 2015 to February 2017, we conducted the long-term follow-up of the cohort. We have now completed the data collection and processing and have started analyses. CONCLUSIONS: This study will help fill the evidence gap about the short- and long-term impact of peer counseling on improving infant feeding, preventing childhood undernutrition, and enhancing child cognitive development. TRIAL REGISTRATION: ClinicalTrials.gov NCT01333995; https://clinicaltrials.gov/ct2/show/NCT01333995. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31475.

Breastfeeding practices after a counselling intervention for factory workers in Bangladesh.

Breastfeeding may be particularly challenging for female factory workers who have long working hours and inadequate access to health information and care. In Chattogram, Bangladesh, a peer counselling intervention was undertaken to improve infant feeding practices of factory workers. Counselling started during pregnancy and continued until children were 18 months old. This article presents the results of a cross-sectional survey undertaken during 2 weeks in March-April 2017, after the project's conclusion. The aim was to compare breastfeeding practices, specifically early breastfeeding initiation and exclusive breastfeeding (EBF), among factory workers who had received peer counselling in the intervention areas (IA) with those of non-counselled factory workers in the nearby comparison areas (CA). Six female interviewers, trained over 3 days, conducted interviews at the workers' homes. Data were analysed to assess the association of peer counselling with infant feeding practices. Factory workers (N = 382) with infants between 0 and 18 months of age participated in the survey, in IA (n = 188) and in CA (n = 194). Although there were more health facility deliveries among the CA workers, only 43 (22%) of those workers had initiated breastfeeding within 1 h of birth versus 166 (88%) of the IA workers (p < .001). EBF prevalence on 24-h recall in infants aged 0-6 months was only 7/83 (8%) for the CA workers versus 73/75 (97%) for IA workers (p < .001). The survey showed that breastfeeding practices of factory workers in the IA after the intervention were significantly better than those of factory workers in the CA.

Supporting Exclusive Breastfeeding Among Factory Workers and Their Unemployed Neighbors: Peer Counseling in Bangladesh.

BACKGROUND: Thirty-six percent of females are employed in Bangladesh, many in the readymade garments manufacturing industry. Inadequate access to health information, care, and long working hours makes exclusive breastfeeding particularly challenging for these employed mothers. RESEARCH AIM: To describe the influence of a breastfeeding education and support program on breastfeeding patterns of mothers working in garment and other factories in Bangladesh. METHODS: A descriptive two-group prospective, mixed methods, longitudinal prospective study was conducted from May 2015 to March 2017. Peer counselors were trained to provide home-based counseling from 6 months of pregnancy until infants completed 6 months for pregnant and lactating factory workers and neighboring unemployed women. The total evaluation sample (N = 304) consisted of participants still employed (n = 190) and unemployed (n = 144). Peer counselors recorded socioeconomic information, weights, and infant feeding patterns. Descriptive statistical analyses examined the peer counselors' influence on breastfeeding practices. RESULTS: Initiation of breastfeeding within 1 hr was high in both groups, 173 (91%) among the employed, and 101 (89%) among the unemployed participants. Exclusive breastfeeding at 6 months was reported by 107 out of 125 (86%) of the employed participants versus 72 out of 76 (95%) of those unemployed. CONCLUSIONS: Community-based peer counselors can help to inform, encourage, and support both factory workers and unemployed women with optimal breastfeeding patterns. Factories who have female workers should consider employing outreach peer counselors as part of their community social responsibility, and as a way to contribute to the sustainability of these programs.

Characteristics and experiences of peer counsellors in urban Dhaka: a structured interview study.

Background: Interventions to promote breastfeeding are the cornerstone of efforts to reduce childhood illness and death from undernutrition. Evidence suggests that one of the most effective strategies to increase breastfeeding is through peer counsellors. However, the experiences of peer counsellors has not been studied in depth. This study aimed to collect and report the experiences of peer counsellors participating in an intervention study to improve breastfeeding in urban Dhaka, Bangladesh. Methods: Peer counsellors underwent a 10 day training course in May 2013 which included practical sessions on position and attachment and common difficulties with breastfeeding. Home visits were conducted with new mothers and performance of peer counsellors was monitored by senior breastfeeding counsellors. The number of supervised home visits needed to achieve a satisfactory level of competency was recorded. Demographic data were collected and a structured interview was performed in the first six months of the project (May-September 2013). One structured interview per peer counsellor was conducted by the project manager at the project site office to gain understanding of their experiences in counselling mothers. The interview included some open-ended questions on specific aspects of the training that they found useful, challenges faced, and whether they developed close friendships with the mothers that they were counselling. Results: Seventeen peer counsellors with an average age of 31 years (SD 6.8) and at least six years of schooling participated in the study. All peer counsellors were satisfied with their role and with the training that they received, and most felt that they were able to deal with common breastfeeding problems. The peer counsellors reported that building a personal rapport and establishing a peer-to-peer relationship was most important in supporting mothers to breastfeed. Common challenges included interruption of sessions by relatives/children, as well as mothers being too busy for the visits. Conclusion: In future peer counselling for breastfeeding projects, more focus could be placed on the communications aspects of the training, especially in how to deal with non-supportive family members and managing interruptions effectively, as well as how to motivate and engage busy new mothers.

Breastfeeding and infant growth outcomes in the context of intensive peer counselling support in two communities in Bangladesh.

BACKGROUND: Exclusive breastfeeding and growth faltering during infancy remain challenges in Bangladesh. The Training & Assistance for Health & Nutrition Foundation has been working to address this gap through community-based peer counsellors since 2000. In this paper, we assessed the programme's progress, particularly with respect to early initiation of breastfeeding and exclusive breastfeeding for normal birth weight, as well as for low birth weight (LBW) infants. METHODS: The peer counselling programme is continuing in rural and urban areas of Bangladesh, but only data collected between January 2013 and June 2015 is presented in this descriptive study. Intensive breastfeeding counselling was provided to women during the third trimester of pregnancy and 6 months postpartum by well-trained peer counsellors. They recorded data on infants' birth weight, feeding practices and body weight every month and submitted these for computer entry. Weight measurements were converted to weight-for-age Z-scores (WAZ) and growth patterns assessed by comparing attained body weights with the World Health Organization (WHO) 2006 Child Growth Standards. RESULTS: A total of 994 infants were born during the study period; 94 % were normal birth weight and 6 % were LBW (<2.5 kg). Initiation of breastfeeding within one hour of birth was reported by 94 % of counselled mothers in both groups. The prevalence of exclusive breastfeeding at 6 months was 94 % in the normal birth weight infants and 92 % in the LBW infants, and their mean body weights were 7.5 ± 0.8 kg and 6.6 ± 0.7 kg respectively. There was no growth faltering in these infants during 6 months. Underweight rates in normal birth weight infants remained similar (2.2 % at 1 month and 2.5 % at 6 months), whereas underweight rates in LBW infants decreased from 42.1 % at 1 month to 21.1 % at 6 months. CONCLUSIONS: In the context of a well-structured programme setting, and under the described circumstances, it seems likely that the well-trained and supervised community-based peer counsellors could assist in encouraging and helping mothers of both normal birth weight and LBW infants to initiate breastfeeding within one hour and to continue exclusive breastfeeding until 6 months of age. Our data suggest that they may also have contributed towards prevention of growth faltering in these infants.

Management of acute malnutrition in infants aged under 6 months (MAMI): current issues and future directions in policy and research.

BACKGROUND: Globally, some 4.7 million infants aged under 6 months are moderately wasted and 3.8 million are severely wasted. Traditionally, they have been over-looked by clinicians, nutritionists, and policy makers. OBJECTIVE: To present evidence and arguments for why treating acute malnutrition in infants under 6 months of age is important and outline some of the key debates and research questions needed to advance their care. METHODS: Narrative review. RESULTS AND CONCLUSIONS: Treating malnourished infants under 6 months of age is important to avoid malnutrition-associated mortality in the short-term and adverse health and development outcomes in the long-term. Physiological and pathological differences demand a different approach from that in older children; key among these is a focus on exclusive breastfeeding wherever possible. New World Health Organization guidelines for the management of severe acute malnutrition (SAM) include this age group for the first time and are also applicable to management of moderate acute malnutrition (MAM). Community-based breastfeeding support is the core, but not the sole, treatment. The mother-infant dyad is at the heart of approaches, but wider family and community relationships are also important. An urgent priority is to develop better case definitions; criteria based on mid-upper-arm circumference (MUAC) are promising but need further research. To effectively move forward, clinical trials of assessment and treatment are needed to bolster the currently sparse evidence base. In the meantime, nutrition surveys and screening at health facilities should routinely include infants under 6 months of age in order to better define the burden and outcomes of acute malnutrition in this age group.

The principles and practices of nutrition advocacy: evidence, experience and the way forward for stunting reduction.

Advocacy represents an intervention into complex, dynamic and highly contextual socio-political systems, in which strategies and tactics must be adjusted on a continual basis in light of rapidly changing conditions, reactions from actors and feedback. For this reason, the practice of advocacy is often considered more art than science. However, capacities and practices for advocacy can be strengthened by sharing and analysing experiences in varying contexts, deriving general principles and learning to adapt these principles to new contexts. Nutrition is a particular context for advocacy, but to date, there has been little systematic analysis of experiences. The purpose of this paper is to illustrate and draw lessons from the practice of nutrition advocacy, especially in relation to stunting and complementary feeding, and suggest ways to strengthen capacities and practices in the future. The strategies and tactics, achievements and lessons learnt are described for three case studies: Uganda, Vietnam and Bangladesh. These cases, and experience from elsewhere, demonstrate that concerted, well-planned and well-implemented advocacy can bring significant achievements, even in short period of time. In light of the global and national attention being given to stunting reduction through the SUN (Scaling Up Nutrition) movement and other initiatives, there is now a need for much stronger investments in strategic and operational capacities for advocacy, including the human, organisational and financial resources for the advocacy and strategic communication themselves, as well as for monitoring and evaluation, supportive research and institutional capacity-building.

Key principles to improve programmes and interventions in complementary feeding.

Although there are some examples of successful complementary feeding programmes to promote healthy growth and prevent stunting at the community level, to date there are few, if any, examples of successful programmes at scale. A lack of systematic process and impact evaluations on pilot projects to generate lessons learned has precluded scaling up of effective programmes. Programmes to effect positive change in nutrition rarely follow systematic planning, implementation, and evaluation (PIE) processes to enhance effectiveness over the long term. As a result a set of programme-oriented key principles to promote healthy growth remains elusive. The purpose of this paper is to fill this gap by proposing a set of principles to improve programmes and interventions to promote healthy growth and development. Identifying such principles for programme success has three requirements: rethinking traditional paradigms used to promote improved infant and young child feeding; ensuring better linkages to delivery platforms; and, improving programming. Following the PIE model for programmes and learning from experiences from four relatively large-scale programmes described in this paper, 10 key principles are identified in the areas of programme planning, programme implementation, programme evaluation, and dissemination, replication, and scaling up. Nonetheless, numerous operational research questions remain, some of which are highlighted in this paper.

Why does nutrition deteriorate rapidly among children under 2 years of age? Using qualitative methods to understand community perspectives on complementary feeding practices in Bangladesh.

BACKGROUND: Child undernutrition remains high in South Asian and sub-Saharan African countries. Rapid declines in nutritional status occur before the age of 2 years, particularly during the period of complementary feeding. Improving complementary feeding practices is a neglected area in nutrition programs. OBJECTIVE: To understand community perspectives on complementary feeding practices in order to inform the design of future interventions for improved complementary feeding. METHODS: From May through August 2009, data were collected in two rural locations and one urban location in Bangladesh through semistructured interviews, food attributes exercises, 24-hour dietary recalls, opportunistic observations, and trials of improved practices (TIPs). Key informant interviews and focus group discussions were also carried out among family members and community opinion leaders. RESULTS: Lay perceptions about complementary feeding differ substantially from international complementary feeding recommendations. A large proportion of children do not consume sufficient amounts of complementary foods to meet their energy and micronutrient needs. There was a gap in knowledge about appropriate complementary foods in terms of quality and quantity and strategies to convert family foods to make them suitable for children. Complementary feeding advice from family members, peers, and health workers, the importance given to feeding young children, and time spent by caregivers in feeding influenced the timing, frequency, types of food given, and ways in which complementary feeding occurred. CONCLUSIONS: Perceptions and practices related to complementary feeding need to be effectively addressed to improve the levels of child undernutrition. Lack of understanding of children's nutritional needs and insufficient time for feeding children are key barriers to complementary feeding.

Breastfeeding in infancy: identifying the program-relevant issues in Bangladesh.

BACKGROUND: In Bangladesh, many programs and projects have been promoting breastfeeding since the late 1980 s. Breastfeeding practices, however, have not improved accordingly. METHODS: For identifying program-relevant issues to improve breastfeeding in infancy, quantitative data were collected through visits to households (n = 356) in rural Chittagong and urban slums in Dhaka, and qualitative data from sub-samples by applying semi-structured in-depth interviews (n = 42), focus group discussions (n = 28), and opportunistic observations (n = 21). Trials of Improved Practices (TIPs) (n = 26) were conducted in the above sites and rural Sylhet to determine how best to design further interventions. Our analysis focused on five breastfeeding practices recommended by the World Health Organization: putting baby to the breast within the first hour of birth, feeding colostrum and not giving fluids, food or other substances in the first days of life, breastfeeding on demand, not feeding anything by bottle, and exclusive breastfeeding for the first six months. RESULTS: The biggest gaps were found to be in putting baby to the breast within the first hour of birth (76% gap), feeding colostrum and not giving other fluids, foods or substances within the first three days (54% gap), and exclusive breastfeeding from birth through 180 days (90% gap). Lack of knowledge about dangers of delaying initiation beyond the first hour and giving other fluids, foods or substances, and the common perception of "insufficient milk" were main reasons given by mothers for these practices. Health workers had talked to only 8% of mothers about infant feeding during antenatal and immunization visits, and to 34% of mothers during sick child visits. The major providers of infant feeding information were grandmothers (28%). CONCLUSIONS: The findings showed that huge gaps continue to exist in breastfeeding behaviors, mostly due to lack of awareness as to why the recommended breastfeeding practices are beneficial, the risks of not practicing them, as well as how to practice them. Health workers' interactions for promoting and supporting optimal breastfeeding are extremely low. Counseling techniques should be used to reinforce specific, priority messages by health facility staff and community-based workers at all contact points with mothers of young infants.

Panel 2.1 1: food security and nutrition.

This is a summary of the presentations and discussion of Panel 2.11, Food Security and Nutrition of the Conference, Health Aspects of the Tsunami Disaster in Asia, convened by the World Health Organization (WHO) in Phuket, Thailand, 04-06 May 2005. The topics discussed included issues related to food security and nutrition as pertain to the responses to the damage created by the Tsunami. It is presented in the following major sections: (1) findings; (2) key questions; (3) discussion; and (4) recommendations.

Training peer counselors to promote and support exclusive breastfeeding in Bangladesh.

Exclusive breastfeeding is rare in Bangladesh. About 90% of women have home deliveries, so the Baby-Friendly Hospital Initiative has no mechanism to reach them. Mother support groups do not exist, and community health workers do not have time to promote and support exclusive breastfeeding. To provide this kind of support at the community level, an area in Dhaka was selected for a peer-counseling intervention program. Using certain selection criteria, 1 woman from each community was trained as a peer counselor. The training was based on the World Health Organization/United Nations International Children's Emergency Fund 40-hour breastfeeding counseling course and related books. Counseling skills were taught using demonstrations and role play, followed by practical training in the project area. The intervention was very successful, as 70% of the mothers in the project area breastfed their infants exclusively for 5 months compared to only 6% in the control area. The authors describe the peer counseling training, strategies used for peer counseling visits, and lessons learned.