Mainstreaming nutrition into maternal and child health programmes: scaling up of exclusive breastfeeding

Mainstreaming nutrition into maternal and child healthprogrammes scaling up of exclusive breastfeedingNita Bhandari AKM Iqbal Kabirdagger and Mohammed Abdus Salamdagger

Society for Applied Studies New Delhi India and daggerInternational Centre for Diarrheal Disease Research Bangladesh Dhaka Bangladesh

Table of Contents

Summary 5Background 6Methods and search strategy 6The scale-up process 7Issues that need to be addressed while scaling up a programme for exclusive breastfeeding 7Conclusions 13Acknowledgements 14References 14Appendix 1 18Appendix 2 22

Summary

Interventions to promote exclusive breastfeeding have been estimated to have the potential toprevent 13 of all under-5 deaths in developing countries and are the single most importantpreventive intervention against child mortality According to World Health Organization andUnited Nations Children Funds (UNICEF) only 39 infants are exclusively breastfed for lessthan 4 months This review examines programme efforts to scale up exclusive breastfeeding indifferent countries and draws lesson for successful scale-up Opportunities and challenges inscaling up of exclusive breastfeeding into Maternal and Child Health programmes are identifiedThe key processes required for exclusive breastfeeding scale-up are (1) an evidence-basedpolicy and science-driven technical guidelines and (2) an implementation strategy and plan forachieving high exclusive breastfeeding rates in all strata of society on a sustainable basis Factorsrelated to success include political will strong advocacy enabling policies well-defined short-and long-term programme strategy sustained financial support clear definition of roles ofmultiple stakeholders and emphasis on delivery at the community level Effective use of ante-natal birth and post-natal contacts at homes and through community mobilization efforts isemphasized Formative research to ensure appropriate intervention design and delivery is criti-cal particularly in areas with high HIV prevalence Strong communication strategy and supportquality trainers and training contributed significantly to programme success Monitoring andevaluation with feedback systems that allow for periodic programme corrections and continuedinnovation are central to very high coverage Legal framework must make it possible for mothersto exclusively breastfeed for at least 4 months Sustained programme efforts are critical toachieve high coverage and this requires strong national- and state-level leadership

Keywords exclusive breastfeeding scale up breastfeeding promotion breastfeeding programs

Correspondence Nita Bhandari Society for Applied Studies 45 Kalu Sarai New Delhi ndash 110017 India E-mail communityresearch

cihuibno

Review Article

5copy 2008 The Authors Journal compilation copy 2008 Blackwell Publishing Ltd Maternal and Child Nutrition (2008) 4 pp 5ndash23

Background

The Lancet series on child survival identified breast-feeding interventions to have the potential to prevent13 of all under-5 deaths in developing areas of theworld ranking it as the most important preventiveapproach for saving child lives (Jones et al 2003)Exclusive breastfeeding that is administering onlybreastmilk and no other liquids or foods (WHO 2004)for the first 6 months of life confers important benefitsto the infant and the mother ndash it protects infantsagainst many common childhood diseases includingrepeated gastrointestinal infections and pneumoniaand thereby against some of the major causes of child-hood mortality (Feachem amp Koblinsky 1984 Jasonet al 1984 Habicht et al 1986 de Zoysa et al 1991WHO Collaborative Study Team on the Role ofBreastfeeding on the Prevention of Infant Mortality2000Arifeen et al 2001)A large volume of literatureexists regarding efficacy trials that have clearly dem-onstrated the beneficial impact of exclusive breast-feeding (Green 1999)

Unfortunately exclusive breastfeeding is not prac-tised universally Global monitoring indicates thatonly 39 of infants are exclusively breastfed forless than 4 months following birth (WHOUNICEF2003) Some reasons for failure to breastfeed exclu-sively for the recommended first 6 months of lifeinclude community beliefs that result in delay in ini-tiation of breastfeeding after birth giving other fluidsandor foods to breastfeeding infants the lack ofsocial support for women in resolving breastfeedingdifficulties and lack of health system support (Green1999)

The current international optimal feeding rec-ommendations include exclusive breastfeeding for6 months these are based on a review of scientificliterature to define the optimal duration of breast-feeding (Butte et al 2002 Kramer amp Kakuma 2002WHO 2002) These are also included in UnitedNations Children Fundsrsquo (UNICEFrsquos) Facts for Life

lsquoKey MessageWhat every family and community has a

right to know about breastfeedingrsquo (UNICEF 2002)In the early 1990s the World Health Organization

(WHO) and UNICEF launched the Baby-FriendlyHospital Initiative (BFHI) for strengthening mater-

nity services to support breastfeeding practices(WHOUNICEF 1992 table 3)

Although the BFHI includes a community compo-nent its implementation in developing countries isweak and support is only available in institutionsbefore and for a short period after delivery In severalregions a large proportion of deliveries occur athome Interventions at the community level aretherefore very important for supporting exclusivebreastfeeding

Identifying effective and sustainable means forscaling up of proven interventions into child healthprogrammes remains a major problem The purposeof this review is to define a process for scaling upexclusive breastfeeding based on experiences of pro-grammes or pilot projects for promotion of exclusivebreastfeeding implemented and evaluated in differentcountries The term lsquoscale uprsquo is commonly under-stood to mean reaching a larger number of beneficia-ries with a given intervention However apart fromcoverage maintaining quality as larger numbers arereached and effectively reaching out to those difficultto reach are also important considerations (The CoreGroup 2005) The issues addressed herein pertain topolicy programme design implementation strategyresources and costs management monitoring andevaluation and the possibility of continuing innova-tion and testing of novel approaches

Methods and search strategy

We conducted a systematic literature search with notime limits defined and used data from publishedliterature programme reports and monographsdescribing effectiveness or cluster randomized trialsor implementation programmes The databasessearched included PubMed the National Library ofMedicinersquos search service and Cochrane Library(Cochrane Controlled Trials Register) using the fol-lowing keywords breastfeeding or exclusive breast-feeding or breastfeeding promotion or breastfeedingintervention or breastfeeding programme or breast-feeding education or breastfeeding effect or impact orevaluation We also reviewed reference lists of iden-tified articles and hand searched reviews bibliogra-phies of books and abstracts and proceedings of

N Bhandari and AKMI Kabir6

copy 2008 The Authors Journal compilation copy 2008 Blackwell Publishing Ltd Maternal and Child Nutrition (2008) 4 pp 5ndash23

national and international conferences or meetingsAdditionally we contacted key researchers andorganizationsagencies for unpublished material ornarrowly disseminated reports

Consistent with the programmatic focus theexamples quoted in this review are demonstrationprojects that reached large populations or cluster ran-domized intervention trialsThe emphasis is on devel-oping countries and as some of these countries areburdened by HIVAIDS this review includes thiscontext as well

The scale-up process

The scale-up planning process must follow a logicalorder Several key issues that need attention are sum-marized in Table 1 It is apparent that many of thefeatures of the process are generic to neonatal andchild health programmes but there are issues in thearea of exclusive breastfeeding that requires addi-tional attention particularly in the HIV context

Issues that need to be addressedwhile scaling up a programme forexclusive breastfeeding

Policy framework

The Global Strategy on Infant and Young ChildFeeding was adopted by a World Health Assemblyresolution (5525 WHA 2002) The global strategybuilds on the BFHI (WHOUNICEF 1992) the

International Code of Marketing of Breastmilk Sub-stitutes (WHO 1981) and the Innocenti Declarationon the Protection (WHO 1989) Promotion andSupport of Breastfeeding in the overall context ofnational policies and programmes on nutrition andchild health The aim of the strategy is to improvethe feeding of infants and young children andincrease the commitment of governments societygroups and international organizations to promotethe health and nutrition of children The strategyemphasizes the need for comprehensive nationalpolicies on infant and young child feeding onan urgent basis including guidelines on ensuringoptimal feeding of infants and young children inexceptionally difficult circumstances and the need toensure that all health services protect promote andsupport infant and young child feeding (Gupta 2002WHOUNICEF 2003)

Once the decision to scale up a programme forexclusive breastfeeding is made in a region or stateor country the logical starting point is to review therelevant existing national policies and to assesswhether these address varying circumstances underwhich women deliver and live such as urban or ruralresidence working women and place of deliverySpecific features to note are the status of the imple-mentation of the BFHI in facilities where womendeliver access and support to mothers with younginfants by trained personnel during the post-natalperiod and beyond support for exclusive breastfeed-ing in community setting legislation for workingmothers that ensures leave of appropriate durationan enabling environment at the work place withingovernment and private settings and the policiesin place for discouraging promotion of breastmilksubstitutes

Existing policies are optimal in some countries(The Norwegian Government 1993 ILO 1998) butlacunae exists in others for example exclusive breast-feeding for 6 months is a policy in India but the dura-tion of maternity leave for government employees is135 days (Government of India 1997) In Norwayhowever a mother is entitled to over 6 months ofmaternity leave (The Norwegian Government 1993)Wherever weaknesses exist a decision needs to bemade on how these will be addressed during scale-up

Table 1 Steps in scaling up

Assess situation create a policy environment conducive toexclusive breastfeeding

Define roles relationships and responsibilities of all partnersestablish agreements

Review technical supportDefine programme strategyMobilize resourcesProvide training and technical assistanceDevelop and use monitoring and evaluation systemsMonitor coverage and qualityMeasure impact and costProvide for testing novel approaches and continuing innovation

Adapted from Knippenberg et al (2005) and Gonzales et al (1998)

Mainstreaming nutrition into MCH programs 7


Prior to scale-up a policy framework for implemen-tation needs to be developed This framework shouldinclude a vision consensus on technical issues onprogramme strategy roles relationships and respon-sibilities of implementing partners measurable goalswithin defined time lines and predictable adequatefunding to achieve these (The Core Group 2005) Itshould address the capacity of all implementing part-ners and the approach to fulfilling capacity gaps at alllevels particularly at the community level The policyframework should emphasize breastfeeding promo-tion through community-based programmes Politicalcommitment and ownership by relevant governmentdepartments at national state and district levels havealso been identified to be critical for effective scale-up(The Core Group 2005)

Technical and management support andother partnerships

Creating a policy framework designing a potentiallyeffective programme and an implementation strategyrequire multiple capacities which may not always beavailable within government departments or otherconcerned agencies

Technical and managerial support may need to bemobilized more so during the planning and earlyimplementation phase If this support is not availableinvolvement of external talent ndash national or eveninternational ndash may be required Once the pro-gramme is implemented the external support couldbe phased out gradually as local capacity is built

Forging partnerships between government minis-tries donors local non-governmental organizations(NGOs) and universities was a feature of many suc-cessful programmes (Appendix 1 Van Roekel et al

2002 Bhandari et al 2005 Quinn et al 2005) In theLINKAGES projects (Appendix 1) partnershipwith Programa de Coordinacion en Salud Integral(Collaborative Program for Integrated HealthPROCOSI) and NGOs in Bolivia UNICEF NGOsand the national government in Ghana and Intersec-toral Action Group for Nutrition and Jereo SalamaIsika in Madagascar added value and quality to pro-grammes resulted in effective pooling of resources

and expertise and improved programme design andmanagement (LINKAGES 2002 Van Roekel et al

2002 Quinn et al 2005)

Programme design and strategy

This requires a systematic description of steps andprocesses that help achieve high coverage qualityequity and sustainability capacity building and pro-gramme management are particularly important fea-tures (The Core Group 2005) Experience so farsuggests that for majority of developing countriesscale-up for exclusive breastfeeding will not be pos-sible unless intervention delivery at the communitylevel receives emphasis (Appendix 1) As an increas-ing number of mothers deliver in institutions mixedmodels will be required even in developing countries

An initial step is to carefully examine the existingopportunities as vehicles for promoting exclusivebreastfeeding If use of existing opportunities is insuf-ficient to achieve high coverage with good qualitythen additional approaches would need to be evolvedin a phased manner In Bangladesh the strategy ofpeer counsellors was used as the majority of deliveriesoccur at home and a community health worker is notroutinely available in that setting (Haider et al 2000)In India on the other hand village health workersalready exist so programmes are often designedaround them (Bhandari et al 2003 2004 2005)

Hospitalinstitution-based strategies

Efforts to scale up the BFHI in countries have shownmixed results (Table 2)

In regions where hospital deliveries are the normscale-up efforts through the BFHI (WHOUNICEF1992 Table 3 Perez-Escamilla 2007) have been suc-cessful and the strategy helped increase rates ofexclusive breastfeeding (Appendix 1) However inmany countries after initial years of enthusiasm thescale-up effort seems to have plateaued perhapsreflecting changing emphasis of donors and govern-ment The initial high rates of exclusive breastfeedingmay not be sustained after mothers are dischargedfrom facilities and return to their homes (Coutinhoet al 2005) The challenge therefore is to continue at



home the post-delivery support available in institu-tions through public and private providers to sustainexclusive breastfeeding or develop other mechanismsthat support recently delivered mothers to exclusivelybreastfeed once they are discharged from hospitals(de Oliveira et al 2006) Countries have addressedthis in different ways In Australia a cadre of breast-feeding counsellors exists (Australian BreastfeedingAssociation 2005) In pilot programmes in Indiaexclusive breastfeeding was promoted through healthworker home visits at immunization clinics growthmonitoring sessions and at sick-child contacts(Bhandari et al 2005) in addition to the BFHI Homevisits are particularly important in regions where cov-

erage through other channels is low or not feasibleand a cadre of community workers exists

Community-based strategies

Pilot efforts in countries or regions where home deliv-eries predominate have shown success through ver-tical as well as integrated approaches however pro-grammes integrated into ongoing activities are morelikely to be more sustainable (The Core Group 2005)In these programmes (Appendix 1) the messageswere delivered through either a single existing or newchannel or multiple delivery channels already inplace within the primary health-care systemThe deci-sion to use one or multiple channels was made basedon the ability to cover the target population In somecountries high coverage was feasible only with mul-tiple facility and community channels (Appendix 1)Multiple channels also help achieve consistency inadvice The credibility and acceptability of a givenchannel by the community was another factor in theirbeing used Routine activities of channels were modi-fied in some instances to incorporate exclusive breast-feeding counselling In India for instance it wasbelieved that immunization sessions could not beused as a counselling opportunity but better organi-zation and the presence of another available localworker during the session enabled the vaccinator tocounsel mothers (Bhandari et al 2005)Another illus-tration is the adaptation of the Integrated Manage-ment of Childhood Illness (IMCI) programme of theWHOUNICEF (2002) to the Integrated Manage-ment of Neonatal and Childhood Illness (IMNCIGovernment of India 2006) by India The IMNCIincludes three home visits for all births in the first 7days of life by an existing community worker theAnganwadi worker (ICDS 1982) to promote essentialnewborn care which includes exclusive breastfeedingIn other countries such as Bangladesh facility-basedIMCI was sought to be improved in its impact bygreater emphasis on community component of IMCIthat is C-IMCI (Gwatkin 2004)

Programme delivery

Recognizing that facility-based interventions areinsufficient countries have experimented with a

Table 2 Proportion of facilities with Baby-Friendly Hospital Initiative(WABA 2007)

Region Median (range)

West and Central Africa 013 (000ndash059)EasternSouthern Africa 023 (000ndash100)Middle East and North Africa 014 (000ndash100)South Asia 007 (001ndash100)East Asia and Pacific 0005 (000ndash087)Americas and the Caribbean 010 (000ndash100)Central and Eastern EuropeCommonwealth

of Independent States025 (004ndash093)

All Industrialized Countries 007 (000ndash097)

Table 3 The 10 steps to successful breastfeeding for hospitals andbirth centres

bull Maintain a written breastfeeding policy that is routinelycommunicated to all health-care staffbull Train all health-care staff in skills necessary to implement thispolicybull Inform all pregnant women about the benefits and managementof breastfeedingbull Help mothers initiate breastfeeding within 1 h of birthbull Show mothers how to breastfeed and how to maintain lactationeven if they are separated from their infantsbull Give infants no food or drink other than breastmilk unlessmedically indicatedbull Practise lsquorooming inrsquo ndash allow mothers and infants to remaintogether 24 hours a daybull Encourage unrestricted breastfeedingbull Give no pacifiers or artificial nipples to breastfeeding infantsbull Foster the establishment of breastfeeding support groups andrefer mothers to them on discharge from the hospital or clinic



variety of local workers such as peer counsellors inBangladesh (Haider et al 2000) lady health workersin Pakistan (Government of Pakistan 2003) and thelsquoAccredited Social Health Activistsrsquo (ASHA) workerin India (Government of India 2005) to promoteexclusive breastfeeding by itself or as a part of essen-tial newborn care Programmes that used peer coun-sellors as a single channel have been shown to beeffective in several efficacy (Green 1999 Lewin et al

2006) and effectiveness trials (Morrow et al 1999Haider et al 2000 Lewin et al 2006) However whilepeer or lay counsellors have been effective in theshort run long-term sustainability of this approach ona large scale is as yet not established

The possible reasons stated for the short-termsuccess of the lay health workers approach includepayment to the counsellors for performing a specificpiece of work the counsellorsrsquo own perception ofbenefits of their work and their recognition by thecommunity as being skilled These workers also feltthis opportunity to have the potential for opening upof further education and training (Haider et al 2002)An important issue would also be linking newworkers with the existing primary health system aspilot experience showed that these workers may notbe able to resolve complex breastfeeding problems(Haider et al 2002)

Recruitment of ASHA in India provides a uniqueopportunity to promote exclusive breastfeeding(Government of India 2005) Currently being re-cruited all over the country these workers will focuson essential newborn care including exclusive breast-feeding through home visitation in the first month oflife and community-based activities

While these efforts in different countries at improv-ing coverage of the target population through localworkers are of value the voluntary or semi-voluntarynature of the workers and ill-defined models of super-vision raise issues about sustainability and possiblyhigh attrition rates

Programmes that used multiple channels reportedbroader coverage (Bhandari et al 2005 Quinn et al

2005) In India formative research showed thatimmunization sessions and private providers werethe channels to which infants were most commonly(~80) exposed Following constitution of a

breastfeeding-promotion programme caregiversmost often received exclusive breastfeeding counsel-ling at immunization sessions (~40) weighing ses-sions (~25) and home visits (25ndash30) Governmentphysicians or private providers rarely (~2) coun-selled despite being trained (Bhandari et al 2005)When all the opportunities were considered together55ndash60 of caregivers had been counselled at leastonce by at least one of the channels in the last 3months indicating that multiple channels reachedmore families (Bhandari et al 2005)The frequency ofcontact with caregivers or the intensity of counsellinginfluences the cumulative benefit of the counsellingfor example six contacts with mothers resulted inhigher adoption rates for exclusive breastfeeding ascompared with three (Morrow et al 1999) In Indiathe number of channels at which caregivers werecounselled was positively associated with the rates ofexclusive breastfeeding at 3 months of age (Bhandariet al 2003) However the costs of training and theeffort will increase more than the number of channelsused and therefore this issue requires a balancedview

Another issue of interest is the value of counsellingfor the antenatal period itself Antenatal counsellinghas been used in several programmes but its effect isdifficult to delineate by itself as it was usually fol-lowed by post-natal counselling (Green 1999) In theHIV context however the importance of antenatalcounselling is obvious

Communications approach

An effective communications approach was a featureof most programmes and involvement of journalistsradio announcements and other mass media from theprogramme outset extended the reach of nutritionmessages even further (Appendix 1 Quinn et al

2005) Mass media were not used in some pro-grammes where a comparison group was present forrisk of contamination (Bhandari et al 2005) Utiliza-tion of existing or newly formed community groupsproduced the same effect (Bhandari et al 2005Quinn et al 2005) and community mobilization pro-grammes such as street plays rallies radio pro-grammes and songs helped disseminate messages



and increase community involvement (Bhandari et al

2005 Quinn et al 2005)Effective counselling requires assessment of

feeding practices recognition of problems and nego-tiation with the mother in choosing improved prac-tices that are feasible (WHOUNICEF 2002) thisrequires time and patience Programmes may chooseone-on-one counselling during opportunities in whichmore time is available such as home visits and groupcounselling for opportunities with lesser availabletime (Bhandari et al 2005) One of the reasons thatpeer counsellors may have been effective was thattheir sole responsibility was counselling mothersthrough home visits (Morrow et al 1999 Haider et al

2000) The more diverse the functions of the localworker the lesser will be the emphasis on a singlecomponent such as exclusive breastfeeding

Message development

The development of messages for interpersonal com-munication and for mass media needs careful atten-tion to design and content Successful programmesincluded an element of formative research to gain anin-depth understanding of the communities wherethese programmes were implemented with regard topractices pertaining to breastfeeding the reasons forthe current practices the common breastfeedingproblems and the barriers to adoption of ideal behav-iours in that cultural setting Formative research innorth India for instance showed general unwilling-ness to offer water to infants in summer months Thisbarrier was overcome by building specific explanatorymessages using local terms within the communicationstrategy (Bhandari et al 2003)

Once the design features and broad strategy are inplace attention must then shift to the operationaliza-tion of the strategy

Training and supervision

Prior to scale-up the training needs will need to bedefined Fortunately for promotion of exclusivebreastfeeding extensive experience is available ontraining of different cadres of health workers andeven for lay counsellors Most experiences used the

adapted versions of the UNICEFWHO Breastfeed-ing Counseling Course (WHOUNICEF 1993) or theIMCI module (WHOUNICEF 2002)

Training strategy and its quality merit attentionIn successful programmes the duration of trainingextended from 3 full days to 10 part days for differentworkers The training strategies as described werelsquoconcise action orientedrsquo and included modules thataimed to equip trainers with practical skills and con-fidence to counsel effectively (Appendix 1)

Training modules for areas with high HIV preva-lence also exist (WHO 2006)

While the training modules used in studies workedwell a gap remains for referralTrained workers at thecommunity level require that referral options avail-able are easily accessible prompt and preferablyavailable free of cost to mothers with complex breast-feeding problems

Another important issue to address is handlingtraining of new staff in most developing countriesstaff turnover and absenteeism rates are high

Monitoring and evaluation

The programme strategy will need to include systemsfor monitoring and evaluation of the programmePossible markers could include the rates of exclusivebreastfeeding worker performance referral andaction As for all other national programmes therewill be a need for periodic reviews and achievabletargets by time

Costs and resources

In all pilot programmes and projects services wereprovided to mothers free of cost In many developingcountries if the government cadre of health workers isused to promote exclusive breastfeeding as a part oftheir other responsibilities (eg the IMNCI) the basicservices will remain free However a system thatrequires setting up a cadre of trained lactation coun-sellors (eg in an urban setting or as referral sources forbreastfeeding problems in rural areas) will requireadditional resources A cost-effective analysis of theBFHI was conducted in three countriesBrazilMexicoand Honduras (Horton et al 1996) Savings on health



care resulting from reduction in diarrhoeal and respi-ratory morbidity were estimated as a result of theeffect of BFHI on breastfeeding The study showedthat breastfeeding promotion through a BFHI-likemodel is very cost-effective (1992 US$ 2ndash19 per dis-ability adjusted life years Horton et al 1996 Perez-Escamilla 2007) Examples of cost-effectivenessanalysis of community-based programmes using lay orprofessional support in different settings could not beidentified

Testing of novel approaches andcontinuing innovation

Scaled-up programmes must have inbuilt provision totest novel approaches and the ability for continuinginnovation

Scaling up of exclusive breastfeeding in thecontext of HIV

The policy and programme design and implemen-tation issues relevant to exclusive breastfeedingscale-up discussed above are relevant to HIV-prevalent areas but there are other unique featuresthat merit consideration

Creating policies for exclusive breastfeeding pro-motion in countries with high HIV prevalence is par-ticularly challenging The revised recommendationsencourage exclusive breastfeeding for the first 6months and continued breastfeeding for 2 years andbeyond for infants whose mothers are HIV negativeor whose HIV status is unknown For women who areknown to be HIV positive the most appropriateinfant feeding option for HIV-exposed infantsdepends on individual circumstances including con-sideration of health services counselling and supportExclusive breastfeeding is the better option for suchinfants unless replacement feeding is acceptable fea-sible affordable sustainable and safe for both themother and baby This recommendation is based onthe finding that exclusive breastfeeding for up to 6months in three large cohort studies is associated witha three- to fourfold decreased risk of transmission ofHIV compared with non-exclusive breastfeeding(WHO 2006) The recommendations may need

further revision if new findings demonstrate thatexclusive breastfeeding should be the feeding ofchoice for HIV-infected women (Iliff et al 2005)

Some pilot programmes for exclusive breastfeedingpromotion in high-HIV-prevalence countries aresummarized in Appendix 2

In general exclusive breastfeeding promotionformed a part of the prevention of mother-to-childtransmission programmes LINKAGESZambiaintegrated improved counselling on infant feedingmaternal nutrition and antiretroviral therapy duringprophylaxis in both health-care and community ser-vices to enable women to make and act on informedchoice to feed their infants optimally in the context ofhigh HIV prevalence

Formative research was critical to develop locallyappropriate and feasible infant feeding recommenda-tions for individual infants and their families based onHIV status In Zambia the research included focusedgroup discussions key information interviews obser-vations of household food preparation and feedingmarket survey of replacement foods and breastmilksubstitutes and household trials of improved feedingand caring practices (LINKAGES 2005)

High quality of health workers is another criticalfactor for sensitive and accurate individual counsel-ling Programmes incorporated behaviour changecommunication methodologies in training (LINK-AGES 2005) It is important to develop skills of com-munity members as well for improved servicesreferral outreach and follow-up care and support ofHIV-positive mothers and their infants

A comprehensive communications strategy tosupport scale-up was a notable feature of the LINK-AGES programme in Zambia In 2004 an intensiveeffort was launched using brochures posters radioand television spots billboards and reference guidesfor health providers (LINKAGES 2005) Messageswere targeted to relevant stakeholders ndash pregnantand lactating mothers health providers youth andcommunity leaders and all the materials were nation-ally disseminated

Monitoring and evaluation another importantfeature of effective scale-up was a feature of pilotprogrammes (Appendix 2 Ntabaye amp Lusiola 2004Rutenberg et al 2004) in Zambia and Tanzania Moni-



toring and evaluation not only provides a measure ofsuccess but identifies factors that may have contrib-uted to it and to lack of success to enable mid-coursecorrections The impact of some pilot programmes onexclusive breastfeeding is summarized in Appendix 2In most programmes exclusive breastfeeding ratesimproved In Zambia exclusive breastfeeding ratesincreased from 50 in 2002 to 64 in 2004 in Liv-ingstone from 57 in 2000 to 74 in 2004 in NdolaIn South Africa an antenatal clinic-based interven-tion led to 83 of infants born to HIV-infectedmother initiating exclusive breastfeeding InZimbabwe an intervention based on antenatal coun-selling resulted in a relatively lower exclusive breast-feeding rate of 246 at 3 months (Piwoz et al 2005)

Several barriers to success were identified Theseinclude inadequate skills of workers and non-integration of HIV counselling and tailoring into ante-natal care services (Ntabaye amp Lusiola 2004) which isthe backbone in which infant feeding counselling isbuiltWomen reported that mothers not breastfeedingtheir children were discriminated against by the com-munity and they faced the threat of domestic violenceProgramme managerrsquos understanding of barriersto effective programme implementation and impactwere emphasized as being important Governmentsupport partnerrsquos coordination increased humanresource and improving the supply system were iden-tified to be essential features to scale up programmesin the HIV context (Rutenberg et al 2004) Lowoverall exclusive breastfeeding rates prompted Piwozet al (2005) to conclude that women and their partnersshould have been reached more frequently during theantenatal and post-natal period

Conclusions

In a large number of programmes for improvingexclusive breastfeeding in developing countriesincluding in areas with high prevalence of HIV apositive impact on exclusive breastfeeding rates hasbeen achieved

Some of the factors that contributed to successfulscale-up are summarized in Table 4 Several limita-tions of the programmes reviewed merit attentionMost programmes involved special and generous

funding concentrated efforts and multiple contactsThese programmes were evaluated over relativelyshort periods of time usually 2ndash5 years and the long-term sustainability has not been really tested In theabsence of specific measures there is likely to be dilu-tion of quality as the programmes are scaled upfurther from their initial size The experience thus farleaves important questions to be addressed particu-larly on how programmes can be sustained over timeas they are scaled up at affordable costs

A key factor relevant to sustainability is to plan ona long-term basis a period of 10ndash20 years rather than5ndash10 years from the outset Experience with otherchild health programmes has shown that performancein immunization and oral rehydration therapy userates plateaued over time in many countries

Programme scale-up requires a programme man-agement capacity proportionate to the scale of opera-tions periodic assessment of barriers (Table 5) and anability to revise programme strategy to overcomethese Another key feature to sustainability ofscale-up is the extent to which capacity has been builtat the district block and community levels National-or state-level driven interventions begin with enor-mous enthusiasm which is difficult to sustain Thisfactor is particularly important as most developing

Table 4 Lessons learnt about scale-up key factors in success

bull Political will advocacy enabling policiesbull Championship by health ministries at national state and districtlevelbull Technical consensus on feeding guidelinesbull Programme strategy and measurable short- and long-term goalsbull Long-term financial commitmentbull Partners with defined roles assessment of their capacity todeliver and plans to cover gaps in capacitybull Emphasis on community-level interventions and not onlyfacility-based programmesbull Formative research as the backbone of effective scale-upprogrammes particularly in the context of HIVbull Careful selection of channels and the number required toachieve timely coverage consistency of messagesbull Communication strategy aided by formative research pre-testedvalidated messages and toolsbull Quality trainers and training centres proportionate to requiredscalebull Monitoring and evaluationbull Programme redesign when relevant through research analysisand innovation



countries are going through a process of decentrali-zation with increasing responsibility for planningimplementation and evaluation being delegated tolower levels of the health-care system Buildingcapacity at that level requires time resources andpatience and a longer-term perspective

Building capacity emerges to be a key factorTrainers and training centres vary in their qualitywhen training health workers and their supervisorsor programme managers As the burden of trainingincreases availability of good-quality trainersbecomes a limiting factor (WHOUNICEF 2002Government of India 2006) An effective strategymust plan for these incremental requirements includ-ing ensuring secure and sustained funding

Identifying barriers to success is a key actor Thebarriers to scaling up of health interventions havebeen elegantly described by Ranson et al (Table 5)Most of these are important for exclusive breastfeed-ing scale-up as well

Overall within the limitations discussed above anumber of programmes in countries with varying

HIV prevalence show that exclusive breastfeeding ona large scale is feasible and pilot programmes havegiven valuable guidance related to policies planningand implementation of large-scale programmes Thechallenge now is to build on these experiences whenplanning national programmes

Acknowledgements

We sincerely thank Dr MK Bhan for his constructivecriticism and sustained feedback at different stages ofdevelopment of this review

Conflicts of interest

The authors have declared no conflicts of interest

References

Arifeen S Black RE Antelman G Baqui A CaulfieldL amp Becker S (2001) Exclusive breastfeeding reducesacute respiratory infection and diarrhea deaths amonginfants in Dhaka slums Pediatrics 108 E67

Australian Breastfeeding Association (2005) Valuing Par-enthood Options for Paid Maternity Leave ndash InterimPaper 2002 Available at httpwwwbreastfeedingasnauadvocacymatleavehtml

Bhandari N Bahl R Mazumdar S Martines J BlackRE amp Bhan MK (2003) Effect of community basedpromotion of exclusive breastfeeding on diarrheal ill-nesses and growth a cluster randomized controlled trialLancet 361 1418ndash1423

Bhandari N Mazumder S Bahl R Martines J BlackRE amp Bhan MK (2004) An educational interventionto promote appropriate complementary feedingimproves child feeding practices and linear growth inrural Haryana India Journal of Nutrition 134 2342ndash2348

Bhandari N Mazumder S Bahl R Martines J BlackRE amp Bhan MK (2005) Use of multiple opportunitiesfor improving feeding practices in undertwos withinchild health programs Health Policy Plan 20 328ndash336

Bryce J Victora CG Habicht JP Vaughan JP ampBlack RE (2004) The multi-country evaluation of theintegrated management of childhood illness strategylessons for the evaluation of public health interventionsAmerican Journal of Public Health 94 406ndash415

Butte NF Lopez-Alarcon MG amp Garza C (2002) Nutri-ent Adequacy of Exclusive Breastfeeding for the TermInfant during the First Six Months of Life World HealthOrganization Geneva

Table 5 Barriers to scaling up of health interventions

Community and household levelsLack of information womenrsquos education physical financial

womenrsquos decision-making powerHealth services delivery levelShortage of qualified staff weak technical guidance programme

management and supervision inadequate supplies equipmentand infrastructure poor accessibility

Health sector policy and strategic management levelWeak and centralized system for planning and management weak

drug policies and supply system inadequate regulations lack ofintersectoral action and partnership weak incentives to useinputs efficiently and respond to user needs and preferencesreliance on donor funding

Public policies cutting across sectorsGovernment bureaucracy poor communication and transport

infrastructureEnvironmental characteristicsGovernance and overall policy frameworkCorruption weak government weak laws political instability and

insecurity low priority to social sectors weak structure for publicaccountability and opportunities for public opinions lack of freepress

Physical environmentClimatic and geographic predisposition physical environment

unfavourable to service delivery

Adapted from Ranson et al (2003)



Cohen J (2007) Retrovirus meeting Hope on new AIDSdrugs but breast-feeding strategy backfires Science 3151357

Coovadia HM Rollins NC Bland RM Little KCoutsoudis A Bennish ML et al (2007) Mother tochild transmission of HIV-1 infection during exclusivebreastfeeding in the first 6 months of life an interven-tion cohort study Lancet 369 1107ndash1116

Coutinho SB de Lira PI de Carvalho LM amp AshworthA (2005) Comparison of the effect of two systems forthe promotion of exclusive breastfeeding Lancet 3661094ndash1100

Feachem RG amp Koblinsky MA (1984) Interventions forthe control of diarrheal diseases among young childrenpromotion of breastfeeding Bulletin of the of the WorldHealth Organization 62 271ndash291

Gonzales A Arteaga E amp Howard-Grabman L (1998)Scaling Up the WARMI Project ndash Lessons LearnedMobilizing Bolivian Communities around ReproductiveHealth Save the Children Federation Inc Bolivia FieldOffice La Paz Available at httpwwwcoregrouporgresourcesSavebolipdf

Government of India (1997) Recommendations of the FifthCentral Pay Commission Relating to Enhancement ofQuantum of Maternity Leave and to Allow PaternityLeave in Respect of Central Government EmployeesDocument ref 13018197-Estt(L) Available at httppersminnicinesttleave2htm

Government of India (2005) National Rural HealthMission 2005ndash2012 Mission document Ministry ofHealth and Family Welfare New Delhi Government ofIndia Available at httpwwwmohfwnicinNRHM20Mission20Documentpdf

Government of India (2006) Operational Guidelines forImplementation of Integrated Management of Neonataland Childhood Illness (IMNCI) Ministry of HealthFamily Welfare New Delhi Available at httpmohfwnicindofw20websiteF20IMNCI20Operational20Plan201320june202006htm

Government of Pakistan (2003) National Programme forFamily Planning and Primary Health Care The LadyHealth Workers Programme 2003ndash2008 Ministry ofHealth Pakistan Available at httpwwwphcgovpkDownloadsPC-120augpdf

Green CP (1999) Improving Breastfeeding Behaviors Evi-dence from Two Decades of Intervention ResearchPublished for the US Agency for International Develop-ment (USAID) by the LINKAGES Project Academyfor Educational Development Washington DC

Gupta A (2002) National trends in breastfeeding andeffective strategies to improve breastfeeding ratesJournal of Neonatology 2002 4ndash14

Gwatkin DR (2004) Integrating the management of child-hood illness Lancet 364 1557ndash1558

Habicht JP DaVanzo J amp Butz WP (1986) Does breast-feeding really save lives or are apparent benefits due tobiases American Journal of Epidemiology 123279ndash290

Haider R Ashworth A Kabir I amp Huttly SR (2000)Effect of community based peer counsellors on exclusivebreastfeeding practices in Dhaka Bangladesh a ran-domized controlled trial Lancet 356 1643ndash1647

Haider R Kabir I Huttly SR amp Ashworth A (2002)Training peer counsellors to promote and support exclu-sive breastfeeding in Bangladesh Journal of HumanLactation 18 7ndash12

Horton S Sanghvi T Phillips M Fiedler J Perez-Escamilla R Lutter C et al (1996) Breastfeeding pro-motion and priority setting in health Health Policy andPlanning 11 156ndash168

ILO (1998) More than 120 Nations Provide Paid MaternityLeave Gap in Employment Treatment for Men andWomen Still Exists International Labour Office GenevaDocument ref ILO987 Available at httpwwwiloorgpublicenglishbureauinfpr19987htmr2

Iliff PJ Piwoz EG Tavengwa NV Zunguza CDMarinda ET Nathoo KJ et al (2005) Early exclusivebreastfeeding reduces the risk of postnatal HIV-1 trans-mission and increase HIV-free survival AIDS 19 699ndash708

Integrated Child Development Services Scheme (Revised)(ICDS) (1982) Ministry of Social Welfare Governmentof India New Delhi Available on URL httpwcdnicinudishahtmabouticdshtm

Jason JM Nieburg P amp Marks JS (1984) Mortality andinfectious disease associated with infant feeding prac-tices in developing countries Pediatrics 74 702ndash727

Jones G Steketee RW Black RE Bhutta ZA ampMorris SS Bellagio Child Survival Study Group (2003)How many child deaths can we prevent this yearLancet 362 65ndash71

Knippenberg R Lawn JE Darmstadt GL Begkayian GFogstad H Walelign N et al (2005) Systematic scalingup of neonatal care in countries Lancet 365 1087ndash1098

Kramer MS amp Kakuma R (2002) The optimal durationof exclusive breastfeeding a systematic reviewCochrane Database of Systematic Reviews 2002CD003517

Kramer MS Chalmers B Hodnett ED Sevkovskaya ZDzikovich I Shapiro S et al (2000) Promotion ofbreastfeeding intervention trial (PROBIT) a cluster ran-domized trial in the Republic of Belarus Design followup and data validation Advances in Experimental Medi-cine and Biology 478 327ndash345

Kramer MS Chalmers B Hodnett ED Sevkovskaya ZDzikovich I Shapiro S et al (2001) Promotion ofbreastfeeding intervention trial (PROBIT) a random-



ized trial in the Republic of Belarus Journal of theAmerican Medical Association 285 413ndash420

Lewin SA Dick J Pond P Zwarenstein M Aja Gvan Wyk B et al (2006) Lay health workers in primaryand community health care (Review) The CochraneLibrary 3 1ndash104

LINKAGES (2002) World LINKAGES MadagascarAcademy for Educational Development WashingtonDC

LINKAGES (2005) LINKAGES Zambia 1997ndash2005 FinalReport A Full Report on LINKAGES Infant Feedingand HIVAIDS Programs in Zambia Academy for Edu-cational Development Washington DC Available athttpwwwlinkagesprojectorgmediapublicationsFinal20draft20Zambia20final20report2012105pdf

Lutter CK Perez-Escamilla R Segall A Sanghvi TTeruya K amp Wickham C (1997) The effectiveness of ahospital based program to promote exclusive breastfeed-ing among low income women in Brazil AmericanJournal of Public Health 87 659ndash663

Morrow AL Guerrero ML Shults J Calva J Lutter CBravo J et al (1999) Efficacy of home based peer coun-selling to promote exclusive breastfeeding a randomizedcontrolled trial Lancet 353 1226ndash1231

Ntabaye MK amp Lusiola GJ (2004) Understanding barri-ers to PMTCT in Tanzania findings of a baseline surveyInternational Conference on AIDS 15 (B11396)

de Oliveira LD Giugliani ER do Espirito SLC FrancaMC Weigert EM Kohler CV et al (2006) Effect ofintervention to improve breastfeeding technique on thefrequency of exclusive breastfeeding and lactation-related problems Journal of Human Lactation 22 315ndash321

Perez-Escamilla R (2004) Effectiveness of MADLAC atImproving Breastfeeding Promotion and CounsellingIndicators in Maternity Wards in El Salvador Publishedfor the Basic Support for Institutionalizing Child Sur-vival Project (BASICS II) for the United States Agencyfor International Development Arlington VA Availableat httpwwwbasicsorgpdfFinal20MADLAC20Report20RPE20April207-2004pdf

Perez-Escamilla R (2007) Evidence based breast-feedingpromotion the Baby-Friendly Hospital InitiativeJournal of Nutrition 137 484ndash487

Piwoz EG Iliff PJ Tavengwa N Gavin L Marinda ELunney K et al (2005) An education and counselllingprogram for preventing breastfeeding associated HIVtransmission in Zimbabwe design and impact on mater-nal knowledge and behaviour Journal of Nutrition 135950ndash955

Quinn VJ Guyon AB Schubert JW Stone-Jimenez MHainsworth MD amp Martin LH (2005) Improvingbreastfeeding practices on a board scale at the commu-

nity level success stories from Africa and LatinAmerica Journal of Human Lactation 21 345ndash354

Ranson MK Hanson K Oliveira-Cruz V amp Mills A(2003) Constraints to expanding access to health inter-ventions an empirical analysis and country typologyJournal of International Development 15 15ndash40

Rea MF amp Berquo ES (1990) Impact of the Braziliannational breastfeeding programme on mothers inGreater Sao Paulo Bulletin of the of the World HealthOrganization 68 365ndash371

Rollins NC (2007) Infant feeding and HIV BritishMedical Journal 334 487ndash488

Rutenberg N Baek C Kalibala S Rosen J amp Mulenga D(2004) Evaluation of United Nations supported pilotprojects for the prevention of mother-to-child transmis-sion of HIV overview of findings International Confer-ence on AIDS 15 (WePeE6688)

The Core Group (2005) Scale and Scaling Up A COREGroup Background Paper on lsquoScaling-Uprsquo MaternalNewborn and Child Health Services CORE SpringMembership Meeting 2005 The Core Group Washing-ton DC Available at httpwwwcoregrouporgresourcesmeetingsapril05Scaling_Up_Background_Paper_7-13pdf

The Norwegian Government (1993) Women in PoliticsMinistry of Children and Equality Available at httpwwwregjeringennoendepbldRyddemappeSLA-AvdelingdoclegislationguidelinesWomen-in-Politicshtmlid=437166

Thior I Lockman S Smeaton LM Shapiro RL WesterC Heymann SJ et al (2006) Breastfeeding plus infantzidovudine prophylaxis for 6 months vs formula feedingplus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana a randomized trialthe Mashi Study Journal of the American Medical Asso-ciation 296 794ndash805

UNICEF (2002) Facts for Life lsquoKey Message What EveryFamily and Community Has a Right to Know aboutBreastfeedingrsquo Available at httpwwwuniceforgffl04key_messageshtm

Van Roekel K Plowman B Griffiths M de AlvaradoVV Matute J amp Calderon M (2002) BASICS IIMidterm Evaluation of the AIN Program in Honduras2000 Basic Support for Institutionalizing Child SurvivalProject (BASICS II) for the United States Agency forInternational Development Arlington VA

WABA (2007) UNICEF Records BHFI Record UpdateAvailable at httpwwwwabaorgmydocsBFHIjan07xls 2006 Regularly updated by Miriam HLabbok Center for Infant and Young ChildFeeding and Care Department of Maternaland Child Health School of Public Health The Univer-sity of North Carolina at Chapel Hill Chapel Hill NCUSA



WHA (2002) Infant and Young Child Nutrition Fifty-FifthWorld Health Assembly Agenda Item 1310 18 May2002 Available at httpwwwintgbebwhapdf_filesWHA55ewha5525pdf

WHO (1981) The International Code of Marketing ofBreastmilk Substitutes World Health OrganizationGeneva

WHO (1989) Protecting Promoting and Supporting Breast-feeding The Special Role of Maternity Services A JointWHOUNICEF Statement World Health OrganizationGeneva

WHO (2002) The Optimal Duration of Exclusive Breast-feeding Report of an Expert Consultation WHONHD0109 WHOFCHCAH0124 World HealthOrganization Geneva

WHO (2003a) Community Based Strategies for Breastfeed-ing Promotion and Support in Developing CountriesWorld Health Organization Geneva Document refISBN_92_4_159121_8 Available at httpwwwwhointchild-adolescent-healthNew_PublicationsNUTRITIONISBN_92_4_159121_8pdf

WHO (2003b) Multi-country Evaluation of IMCI Effective-ness Cost and Impact (MCE) Progress Report May2002ndashApril 2003 Document ref WHOFCHCAH035World Health Organization Geneva

WHO (2004) Promoting Proper Feeding for Infants andYoung Children World Health Organization GenevaAvailable at httpwwwwhointnutritiontopicsinfantfeedingen

WHO (2006) WHO HIV and Infant Feeding TechnicalConsultation-Consensus Statement World Health Orga-nization Geneva Available at httpwwwwhointhivmediacentreInfantfeedingconsensusstatementpfpdf

WHO Collaborative Study Team on the Role of Breast-feeding on the Prevention of Infant Mortality (2000)Effect of breastfeeding on infant and child mortality dueto infectious diseases in les developed countries apooled analysis Lancet 355 451ndash455

WHOUNICEF (1992) The global criteria for the WHOUNICEF Baby-Friendly Hospital Initiative In Baby-Friendly Hospital Initiative Part II Hospital LevelImplementation World Health Organization Geneva

WHOUNICEF (1993) Breastfeeding Counselling A Train-ing Course WHOCDR933 UNICEFNUT931 WorldHealth Organization Geneva

WHOUNICEF (2002) Protocol for Adapting the FeedingRecommendations Part III IMCI Adaptation GuideWorld Health Organization Geneva

WHOUNICEF (2003) Global Strategy for Infant andYoung Child Feeding World Health OrganizationGeneva Available at httpwwwwhointchild-adolescent-healthpublicationsNUTRITIONIYCF_GShtm

de Zoysa I Rea M amp Martines J (1991) Why promotebreastfeeding in diarrheal diseases control programmesHealth Policy and Planning 6 371ndash379



App

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x1

Cas

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udie

so

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stud

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pilo

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Stud

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Type

Inte

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Par

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Trai

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Rad

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68

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App

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nt

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larg

e

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lati

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rly

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9ndash12

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afte

rin

itia

tion

of

com

mun

ity

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viti

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Van

Roe

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2)W

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Ate

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ez(A

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Inte

grat

edC

hild

Car

e

Init

ially

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mar

ilya

grow

th

mon

itor

ing

prog

ram

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ulti

mat

ely

thro

ugh

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Pro

gram

me

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owth

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otio

nndash

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ssm

ent

of

mon

thly

wei

ght

gain

and

focu

son

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ssf

eedi

ng

prac

tice

san

dge

nera

lchi

ld

care

inin

fant

sun

der

2ye

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Impl

emen

ted

atgo

vern

men

t

faci

litie

san

dco

mm

unit

y

Star

ted

in19

92s

tren

gthe

ned

in19

95ndash1

997

wit

hgr

eate

r

focu

son

child

feed

ing

In

1997

pro

gram

me

intr

oduc

ed

wit

hIM

CI

(WH

OU

NIC

EF

2002

)

Maj

or

part

ners

UN

ICE

F

PAH

O

Am

eric

an

and

Hon

dura

n

Red

Cro

ss

CA

RE

Rad

io

broa

dcas

ts

relig

ious

lead

ers

IMC

IM

id-t

erm

eval

uati

on

show

ed39

of

mot

hers

inin

terv

enti

on

com

mun

itie

sex

clus

ivel

y

brea

stfe

dco

mpa

red

wit

h13

in

the

cont

rol

site

s



App

endi

x1

cont

inue

d

Stud

yde

scri

ptio

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tion

Type

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rven

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3)

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ster

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ial

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mun

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lati

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stfe

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Res

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Mas

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amin

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Mat

eria

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ng

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selli

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lusi

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stfe

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ths

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age

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8

The

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tive

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ct

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aine

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rict

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ram

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inde

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ping

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rate

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lopm

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and

mon

itor

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diti

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invo

lvem

ent

of

anN

GO

wer

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port

ant

feat

ures

that

cont

ribu

ted

to

the

succ

ess

ofth

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rven

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Mor

row

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9)

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ico

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ized

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ion

3000

0

Two

com

mun

itie

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the

inte

rven

tion

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com

pari

son

130

wom

en

Hom

e-ba

sed

peer

coun

selli

ng

Pee

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llors

mad

e3

or

6ho

me

visi

tsto

the

mot

her

Key

fam

ilym

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rsal

so

incl

uded

By

La

Lec

he

Lea

gue

of

Mex

ico

Exc

lusi

ve

brea

stfe

edin

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at3

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ths

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tum

67

(6vi

sits

)

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(3vi

sits

)12

(com

pari

son)

Firs

tcl

uste

rra

ndom

ized

com

mun

ity-

base

dtr

ialt

hat

used

peer

coun

sello

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prom

ote

excl

usiv

e

brea

stfe

edin

g

Hai

der

etal

2000

200

2

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ka

Low

mid

dle

and

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io-

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omic

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lati

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ster

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ial

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and

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rol

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mun

ity-

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selli

ngin

Dha

ka

15ho

me-

base

dco

unse

lling

visi

tsby

peer

coun

sello

rs

40h

(4h

yen10

days

)

WH

OU

NIC

EF

brea

stfe

edin

g

coun

selli

ngco

urse

(WH

OU

NIC

EF

1993

)

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lusi

ve

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stfe

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at5

mon

ths

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in

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rven

tion

and

6in

the

cont

rol

Com

mun

ity-

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edin

gpr

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tegy

was

effe

ctiv

ein

Ban

glad

esh

whe

rem

ost

deliv

erie

soc

cur

atho

me



Bry

ceet

al

(200

4)W

HO

(200

3b)

Bra

zil

Per

u

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ania

Uga

nda

Mul

tico

untr

yev

alua

tion

of

IMC

Ith

atin

clud

ed

effe

ctiv

enes

sco

stan

d

impa

ct(B

ryce

etal

2004

)

Bre

astf

eedi

ngpr

omot

ion

asa

part

ofIM

CI

IMC

Iis

ast

rate

gyfo

r

impr

ovin

gch

ildhe

alth

and

deve

lopm

ent

thro

ugh

the

com

bine

d

deliv

ery

ofes

sent

ial

child

heal

th

inte

rven

tion

sIM

CI

bega

nw

ith

ase

tof

case

man

agem

ent

guid

elin

es

for

the

man

agem

ent

ofsi

ckch

ildre

nat

first

-lev

elhe

alth

faci

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s

and

the

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elin

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ere

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gned

for

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tati

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untr

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vela

nd

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wO

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eth

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tegy

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nded

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ude

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rven

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y

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rral

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ls

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odul

e(W

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F20

02)

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ults

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ive

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stfe

edin

g

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labl

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om

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ntim

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was

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pite

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ial

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ovem

ent

inth

equ

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y

ofca

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edby

IMC

Iat

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thfa

cilit

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key

fam

ily

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tice

ssu

chas

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usiv

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mm

unit

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had

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emen

ted

byth

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tim

e(W

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b)

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rife

en

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mun

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mun

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and

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ssan

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year

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eth

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App

endi

x2

Cas

est

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sin

scal

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effo

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IDS

Stud

yde

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Inte

rven

tion

Com

mun

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ion

stra

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Impa

cton

excl

usiv

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feed

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Com

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Pro

gram

me

thro

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and

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serv

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Rea

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60si

tes

in6

dist

rict

sby

2005

Inte

grat

ion

ofin

fant

feed

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coun

selli

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ater

naln

utri

tion

and

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retr

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aldr

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prop

hyla

xis

Trai

ning

ofhe

alth

wor

kers

and

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mun

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serv

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prov

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sto

coun

selw

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onsa

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opti

ons

for

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rsi

tuat

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Beh

avio

urch

ange

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mun

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ion

inte

rven

tion

sin

the

first

few

year

sM

ater

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evel

oped

lsquoAct

Now

rsquoM

edia

cam

paig

nsin

clud

edbr

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radi

oan

dte

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sion

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ean

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-up

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dan

dcl

inic

surv

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inse

lect

eddi

stri

cts

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lusi

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feed

ing

rate

incr

ease

dfr

om50

in

2002

to64

in

2004

inL

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gsto

nean

dfr

om57

in

2000

to74

in

2004

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Inte

grat

edde

mon

stra

tion

proj

ect

Had

seve

rals

tren

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rms

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prog

ram

me

man

ager

she

alth

-car

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and

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mun

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stro

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chan

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mm

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mun

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tner

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(20

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MB

Otr

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Har

are

Zim

babw

eE

duca

tion

and

coun

selli

ngpr

ogra

mm

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liver

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tena

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0m

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rndashba

bypa

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lled

from

14m

ater

nity

clin

ics

wit

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96h

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liver

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3m

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rval

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nega

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tive

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uped

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indi

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alco

unse

lling

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eos

broc

hure

sM

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rsw

hoen

rolle

dw

hen

prog

ram

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was

fully

impl

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ted

wer

e8

4ti

mes

mor

elik

ely

toex

clus

ivel

ybr

east

feed

than

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hers

who

enro

lled

befo

reth

epr

ogra

mm

ebe

gan

Ove

rall

excl

usiv

ebr

east

feed

ing

rate

sti

ll3

mon

ths

was

low

at24

6

Form

ativ

ere

sear

chus

edto

desi

gna

cult

ural

lyse

nsit

ive

educ

atio

nan

dco

unse

lling

prog

ram

me

Low

over

alle

xclu

sive

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gra

tes

prom

pted

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toco

nclu

deth

atw

omen

and

thei

rpa

rtne

rssh

ould

have

been

reac

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mor

efr

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ntly

duri

ngan

tena

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st-n

atal

peri

od



Thi

oret

al(

2006

)R

ollin

s(2

007)

C

ohen

(200

7)

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-inf

ecte

dpr

egna

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omen

atte

ndin

gan

tena

talc

linic

sin

sout

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ana

Inve

stig

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nuar

y-Fe

brua

ry20

06in

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epo

pula

tion

Mat

erna

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infa

ntan

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apy

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cton

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tran

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Ant

enat

alco

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lling

Cas

endashco

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iden

tify

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fact

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for

diar

rhoe

ano

tbr

east

feed

ing

was

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bigg

est

risk

fact

ora

djus

ted

odds

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o50

(95

confi

denc

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terv

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5ndash10

0)

Bot

swan

aha

sth

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stpr

imar

yhe

alth

-car

est

ruct

ure

wat

ersu

pply

and

sani

tati

onsy

stem

sin

Sout

hA

fric

aFo

rmul

apr

ovid

edfr

eeby

the

gove

rnm

ent

toin

fect

edm

othe

rsL

ower

mor

talit

yin

the

brea

stfe

edin

ggr

oup

at7

mon

ths

dem

onst

rate

sri

skof

form

ula

feed

ing

and

need

for

alte

rnat

est

rate

gies

(Thi

oret

al

2006

)A

utho

rsco

nclu

deth

athe

alth

syst

ems

inw

hich

thes

epr

ogra

mm

esar

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plem

ente

dsh

ould

beab

leto

cope

wit

hdi

arrh

oea

and

mal

nutr

itio

nth

atre

sult

sbe

caus

eof

form

ula

feed

ing

(Rol

lins

2007

)C

oova

dia

etal

(2

007)

Kw

aZul

uNat

al

Sout

hA

fric

a27

22H

IV-i

nfec

ted

and

unin

fect

edpr

egna

ntw

omen

enro

lled

into

ano

n-ra

ndom

ized

inte

rven

tion

coho

rtst

udy

from

ante

nata

lcl

inic

sIn

fant

feed

ing

data

obta

ined

wee

kly

bloo

dsa

mpl

esfr

omin

fant

sta

ken

mon

thly

83

of13

72in

fant

sbo

rnto

HIV

-inf

ecte

dm

othe

rsin

itia

ted

excl

usiv

ebr

east

feed

ing

from

birt

hB

reas

tfed

infa

nts

who

rece

ived

solid

sw

ere

sign

ifica

ntly

mor

elik

ely

toac

quir

ein

fect

ion

com

pare

dw

ith

excl

usiv

ely

brea

stfe

d(H

R10

87

151

ndash78

P=

001

8)as

wer

ein

fant

sw

hoat

12w

eeks

rece

ived

brea

stan

dfo

rmul

am

ilk(1

82

098

ndash33

6P

=0

57)

Cum

ulat

ive

3-m

onth

mor

talit

yin

excl

usiv

ely

brea

stfe

dw

as6

1(4

74ndash

792

)vs

15

1(7

63ndash

287

3)in

infa

nts

give

nre

plac

emen

tfe

eds

(HR

206

1

0ndash4

27P

=0

05)

The

stud

ysh

ows

that

excl

usiv

ebr

east

feed

ing

can

besu

cces

sful

lysu

ppor

ted

inH

IV-i

nfec

ted

wom

enT

heau

thor

sca

llfo

rfu

rthe

rre

visi

onof

UN

ICE

FW

HO

and

USA

IDin

fant

feed

ing

guid

elin

es

CD

CC

ente

rof

Dis

ease

Con

trol

HR

haz

ards

rati

oU

NIC

EF

Uni

ted

Nat

ions

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ldre

nF

unds

USA

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SA

genc

yfo

rIn

tern

atio

nalD

evel

opm

ent

WH

OW

orld

Hea

lth

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aniz

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nZ

VIT

AM

BO

Z

imba

bwe

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amin

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rM

othe

rsan

dB

abie

s



Background

The Lancet series on child survival identified breast-feeding interventions to have the potential to prevent13 of all under-5 deaths in developing areas of theworld ranking it as the most important preventiveapproach for saving child lives (Jones et al 2003)Exclusive breastfeeding that is administering onlybreastmilk and no other liquids or foods (WHO 2004)for the first 6 months of life confers important benefitsto the infant and the mother ndash it protects infantsagainst many common childhood diseases includingrepeated gastrointestinal infections and pneumoniaand thereby against some of the major causes of child-hood mortality (Feachem amp Koblinsky 1984 Jasonet al 1984 Habicht et al 1986 de Zoysa et al 1991WHO Collaborative Study Team on the Role ofBreastfeeding on the Prevention of Infant Mortality2000Arifeen et al 2001)A large volume of literatureexists regarding efficacy trials that have clearly dem-onstrated the beneficial impact of exclusive breast-feeding (Green 1999)

Unfortunately exclusive breastfeeding is not prac-tised universally Global monitoring indicates thatonly 39 of infants are exclusively breastfed forless than 4 months following birth (WHOUNICEF2003) Some reasons for failure to breastfeed exclu-sively for the recommended first 6 months of lifeinclude community beliefs that result in delay in ini-tiation of breastfeeding after birth giving other fluidsandor foods to breastfeeding infants the lack ofsocial support for women in resolving breastfeedingdifficulties and lack of health system support (Green1999)

The current international optimal feeding rec-ommendations include exclusive breastfeeding for6 months these are based on a review of scientificliterature to define the optimal duration of breast-feeding (Butte et al 2002 Kramer amp Kakuma 2002WHO 2002) These are also included in UnitedNations Children Fundsrsquo (UNICEFrsquos) Facts for Life

lsquoKey MessageWhat every family and community has a

right to know about breastfeedingrsquo (UNICEF 2002)In the early 1990s the World Health Organization

(WHO) and UNICEF launched the Baby-FriendlyHospital Initiative (BFHI) for strengthening mater-

nity services to support breastfeeding practices(WHOUNICEF 1992 table 3)

Although the BFHI includes a community compo-nent its implementation in developing countries isweak and support is only available in institutionsbefore and for a short period after delivery In severalregions a large proportion of deliveries occur athome Interventions at the community level aretherefore very important for supporting exclusivebreastfeeding

Identifying effective and sustainable means forscaling up of proven interventions into child healthprogrammes remains a major problem The purposeof this review is to define a process for scaling upexclusive breastfeeding based on experiences of pro-grammes or pilot projects for promotion of exclusivebreastfeeding implemented and evaluated in differentcountries The term lsquoscale uprsquo is commonly under-stood to mean reaching a larger number of beneficia-ries with a given intervention However apart fromcoverage maintaining quality as larger numbers arereached and effectively reaching out to those difficultto reach are also important considerations (The CoreGroup 2005) The issues addressed herein pertain topolicy programme design implementation strategyresources and costs management monitoring andevaluation and the possibility of continuing innova-tion and testing of novel approaches

Methods and search strategy

We conducted a systematic literature search with notime limits defined and used data from publishedliterature programme reports and monographsdescribing effectiveness or cluster randomized trialsor implementation programmes The databasessearched included PubMed the National Library ofMedicinersquos search service and Cochrane Library(Cochrane Controlled Trials Register) using the fol-lowing keywords breastfeeding or exclusive breast-feeding or breastfeeding promotion or breastfeedingintervention or breastfeeding programme or breast-feeding education or breastfeeding effect or impact orevaluation We also reviewed reference lists of iden-tified articles and hand searched reviews bibliogra-phies of books and abstracts and proceedings of








Policy framework
































Programme delivery





























Message development












Costs and resources





















Conclusions















Acknowledgements




References


























































































App

endi

x1

Cas

est

udie

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Inte

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and

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Trai

ning

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ICE

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vsr

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s

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ing

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(43

3vs

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)

and

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mon

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sign

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ntly

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er

Impl

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thro

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HI

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whe

reho

spit

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eco

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Per

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scam

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(200

4)

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SIC

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Bra

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MA

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low

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enro

lled

befo

reth

epr

ogra

mm

ebe

gan

Ove

rall

excl

usiv

ebr

east

feed

ing

rate

sti

ll3

mon

ths

was

low

at24

6

Form

ativ

ere

sear

chus

edto

desi

gna

cult

ural

lyse

nsit

ive

educ

atio

nan

dco

unse

lling

prog

ram

me

Low

over

alle

xclu

sive

brea

stfe

edin

gra

tes

prom

pted

auth

ors

toco

nclu

deth

atw

omen

and

thei

rpa

rtne

rssh

ould

have

been

reac

hed

mor

efr

eque

ntly

duri

ngan

tena

tala

ndpo

st-n

atal

peri

od



Thi

oret

al(

2006

)R

ollin

s(2

007)

C

ohen

(200

7)

HIV

-inf

ecte

dpr

egna

ntw

omen

atte

ndin

gan

tena

talc

linic

sin

sout

hB

otsw

ana

Inve

stig

atio

nsby

CD

Cof

adi

arrh

oea

outb

reak

inJa

nuar

y-Fe

brua

ry20

06in

the

sam

epo

pula

tion

Mat

erna

land

infa

ntan

tire

trov

iral

ther

apy

toas

cert

ain

impa

cton

HIV

tran

smis

sion

Ant

enat

alco

unse

lling

Cas

endashco

ntro

lstu

dyto

iden

tify

risk

fact

ors

for

diar

rhoe

ano

tbr

east

feed

ing

was

the

bigg

est

risk

fact

ora

djus

ted

odds

rati

o50

(95

confi

denc

ein

terv

al4

5ndash10

0)

Bot

swan

aha

sth

ebe

stpr

imar

yhe

alth

-car

est

ruct

ure

wat

ersu

pply

and

sani

tati

onsy

stem

sin

Sout

hA

fric

aFo

rmul

apr

ovid

edfr

eeby

the

gove

rnm

ent

toin

fect

edm

othe

rsL

ower

mor

talit

yin

the

brea

stfe

edin

ggr

oup

at7

mon

ths

dem

onst

rate

sri

skof

form

ula

feed

ing

and

need

for

alte

rnat

est

rate

gies

(Thi

oret

al

2006

)A

utho

rsco

nclu

deth

athe

alth

syst

ems

inw

hich

thes

epr

ogra

mm

esar

eim

plem

ente

dsh

ould

beab

leto

cope

wit

hdi

arrh

oea

and

mal

nutr

itio

nth

atre

sult

sbe

caus

eof

form

ula

feed

ing

(Rol

lins

2007

)C

oova

dia

etal

(2

007)

Kw

aZul

uNat

al

Sout

hA

fric

a27

22H

IV-i

nfec

ted

and

unin

fect

edpr

egna

ntw

omen

enro

lled

into

ano

n-ra

ndom

ized

inte

rven

tion

coho

rtst

udy

from

ante

nata

lcl

inic

sIn

fant

feed

ing

data

obta

ined

wee

kly

bloo

dsa

mpl

esfr

omin

fant

sta

ken

mon

thly

83

of13

72in

fant

sbo

rnto

HIV

-inf

ecte

dm

othe

rsin

itia

ted

excl

usiv

ebr

east

feed

ing

from

birt

hB

reas

tfed

infa

nts

who

rece

ived

solid

sw

ere

sign

ifica

ntly

mor

elik

ely

toac

quir

ein

fect

ion

com

pare

dw

ith

excl

usiv

ely

brea

stfe

d(H

R10

87

151

ndash78

P=

001

8)as

wer

ein

fant

sw

hoat

12w

eeks

rece

ived

brea

stan

dfo

rmul

am

ilk(1

82

098

ndash33

6P

=0

57)

Cum

ulat

ive

3-m

onth

mor

talit

yin

excl

usiv

ely

brea

stfe

dw

as6

1(4

74ndash

792

)vs

15

1(7

63ndash

287

3)in

infa

nts

give

nre

plac

emen

tfe

eds

(HR

206

1

0ndash4

27P

=0

05)

The

stud

ysh

ows

that

excl

usiv

ebr

east

feed

ing

can

besu

cces

sful

lysu

ppor

ted

inH

IV-i

nfec

ted

wom

enT

heau

thor

sca

llfo

rfu

rthe

rre

visi

onof

UN

ICE

FW

HO

and

USA

IDin

fant

feed

ing

guid

elin

es

CD

CC

ente

rof

Dis

ease

Con

trol

HR

haz

ards

rati

oU

NIC

EF

Uni

ted

Nat

ions

Chi

ldre

nF

unds

USA

IDU

SA

genc

yfo

rIn

tern

atio

nalD

evel

opm

ent

WH

OW

orld

Hea

lth

Org

aniz

atio

nZ

VIT

AM

BO

Z

imba

bwe

Vit

amin

Afo

rM

othe

rsan

dB

abie

s








Policy framework
































Programme delivery





























Message development












Costs and resources





















Conclusions















Acknowledgements




References


























































































App

endi

x1

Cas

est

udie

so

fef

fect

iven

ess

stud

ies

or

pilo

tpr

ogra

mm

es

Stud

yde

scri

ptio

nPo

pula

tion

Type

Inte

rven

tion

Par

tner

ship

sC

omm

unic

atio

n

stra

tegy

Trai

ning

Impa

cton

excl

usiv

e

brea

stfe

edin

g

Com

men

ts

Lut

ter

etal

(199

7)

Bra

zil

Low

-inc

ome

urba

nw

omen

deliv

erin

gin

hosp

ital

s

Bre

astf

eedi

ngpr

omot

ion

in

hosp

ital

sco

mpa

red

wit

h

nobr

east

feed

ing

prom

otio

n

Pro

mot

ion

ofbr

east

feed

ing

in

sele

cted

hosp

ital

s

Mea

nda

ysof

excl

usiv

e

brea

stfe

edin

g

75da

ysvs

22

days

(Plt

001

)

Rea

ampB

erqu

o

(199

0)

Wom

enw

ith

ach

ild

aged

lt2ye

ars

inSa

oP

aulo

Nat

iona

lbre

astf

eedi

ng

cam

paig

n19

81ndash1

986

BF

HI

Mas

sm

edia

cam

paig

n11

in

fant

s5ndash

6m

onth

s

excl

usiv

ely

brea

stfe

d

in19

88an

d37

in

1987

Con

foun

ding

fact

ors

over

the

6-ye

arpe

riod

not

mea

sure

d

Kra

mer

etal

(200

020

01)

PR

OB

ITtr

ial

Bel

arus

Clu

ster

rand

omiz

ed

34ho

spit

als

and

thei

rpo

lycl

inic

s

Trai

ning

inB

FH

I(W

HO

UN

ICE

F19

92)

vsr

outi

ne

prac

tice

san

dpo

licie

s

Exc

lusi

vebr

east

feed

ing

at3

(43

3vs

64

)

and

6(7

9

vs0

6

)

mon

ths

sign

ifica

ntly

high

er

Impl

emen

ted

thro

ugh

BF

HI

ina

sett

ing

whe

reho

spit

al

deliv

erie

sar

eco

mm

on

Per

ez-E

scam

illa

(200

4)

BA

SIC

SII

Mex

ico

Hon

dura

s

Bra

zil

MA

DL

AC

low

-cos

t

man

agem

ent

info

rmat

ion

syst

emto

use

an

evid

ence

-bas

edap

proa

chto

impr

ove

serv

ice

perf

orm

ance

Inte

rvie

win

gof

wom

enat

hosp

ital

disc

harg

epo

st

deliv

ery

usin

ga

ques

tion

nair

eth

atta

kes

5ndash7

min

toad

min

iste

ran

d

cont

ains

19br

east

feed

ing

prom

otio

nco

unse

lling

indi

cato

rs

Dat

aen

tere

dan

dre

sult

s

disc

usse

d3-

mon

thly

by

hosp

ital

com

mit

tee

Hos

pita

lim

plem

ents

chan

ges

in

brea

stfe

edin

g

supp

ort

base

don

anal

ysis

of

ques

tion

nair

es

Itis

aco

st-e

ffec

tive

inte

rven

tion

that

can

help

impr

ovem

ents

inth

eB

FH

I

and

isa

valu

able

tool

for

proc

ess

eval

uati

on



LIN

KA

GE

S

proj

ect

inA

fric

aan

d

Lat

inA

mer

ica

(Qui

nnet

al

2005

LIN

KA

GE

S

2002

WH

O20

03a)

Bol

ivia

(1

mill

ion)

Gha

na(3

5

mill

ion)

Mad

agas

car

(6m

illio

n)

Res

ourc

e-

poor

sett

ing

Pilo

tpr

ogra

mm

e

InB

oliv

iaan

d

Gha

napr

ogra

mm

e

focu

sed

on

brea

stfe

edin

gan

d

com

plem

enta

ry

feed

ing

InM

adag

asca

r

prog

ram

me

prom

oted

brea

stfe

edin

g

wit

hin

7es

sent

ial

nutr

itio

nac

tion

san

d

subs

eque

ntly

thro

ugh

IMC

I

Bui

lton

form

ativ

ere

sear

ch

and

sust

aine

dth

roug

h

prog

ram

me

acti

viti

esth

at

focu

sed

onbr

ingi

ngab

out

the

desi

red

beha

viou

r

chan

geM

ixof

inte

rven

tion

s

reac

hed

wom

enin

divi

dual

ly

orin

grou

psin

heal

th

faci

litie

sho

mes

or

com

mun

ity

sett

ings

Con

sist

ent

mes

sage

san

d

mat

eria

lacr

oss

all

prog

ram

me

chan

nels

Bol

ivi

PR

OC

OSI

NG

Os

Gha

na

UN

ICE

F

nati

onal

nutr

itio

n

offic

eN

GO

s

Mad

agas

car

Inte

rsec

tora

l

Act

ion

Gro

upfo

r

Nut

riti

on

Jere

o

Sala

ma

Isik

a

Pro

gram

desi

gned

wit

h

part

ners

Rad

ioin

all

thre

esi

tes

Mat

eria

ls

deve

lope

d

tosu

itne

eds

oflo

cal

heal

th

wor

kers

and

com

mun

ity

mem

bers

Gre

at

emph

asis

on

deve

lopm

ent

of coun

selli

ng

and

nego

tiat

ion

skill

s

prac

tica

l

sess

ions

Sign

ifica

ntin

crea

ses

inex

clus

ive

brea

stfe

edin

gra

tes

of

0ndash6-

mon

th-o

ld

infa

nts

from

54

to65

in

Bol

ivia

68

to79

in

Gha

naan

d46

to68

in

Mad

agas

car

In

Gha

naan

d

Mad

agas

car

sign

ifica

ntre

sult

s

obse

rved

wit

hin

aye

ar

ofin

itia

tion

of

com

mun

ity

inte

rven

tion

s

App

roac

hw

asef

fect

ive

and

achi

eved

sign

ifica

nt

incr

ease

sam

ong

larg

e

popu

lati

ons

asea

rly

as

9ndash12

mo

afte

rin

itia

tion

of

com

mun

ity

acti

viti

es

Van

Roe

kele

tal

(200

2)W

HO

(200

3a)

Hon

dura

sG

row

thm

onit

orin

gan

d

prom

otio

nkn

own

as

Ate

ncioacute

nIn

tegr

ala

la

Nintilde

ez(A

IN)

or

Inte

grat

edC

hild

Car

e

Init

ially

pri

mar

ilya

grow

th

mon

itor

ing

prog

ram

me

ulti

mat

ely

thro

ugh

IMC

I

Pro

gram

me

ongr

owth

prom

otio

nndash

asse

ssm

ent

of

mon

thly

wei

ght

gain

and

focu

son

illne

ssf

eedi

ng

prac

tice

san

dge

nera

lchi

ld

care

inin

fant

sun

der

2ye

ars

Impl

emen

ted

atgo

vern

men

t

faci

litie

san

dco

mm

unit

y

Star

ted

in19

92s

tren

gthe

ned

in19

95ndash1

997

wit

hgr

eate

r

focu

son

child

feed

ing

In

1997

pro

gram

me

intr

oduc

ed

wit

hIM

CI

(WH

OU

NIC

EF

2002

)

Maj

or

part

ners

UN

ICE

F

PAH

O

Am

eric

an

and

Hon

dura

n

Red

Cro

ss

CA

RE

Rad

io

broa

dcas

ts

relig

ious

lead

ers

IMC

IM

id-t

erm

eval

uati

on

show

ed39

of

mot

hers

inin

terv

enti

on

com

mun

itie

sex

clus

ivel

y

brea

stfe

dco

mpa

red

wit

h13

in

the

cont

rol

site

s



App

endi

x1

cont

inue

d

Stud

yde

scri

ptio

nPo

pula

tion

Type

Inte

rven

tion

Par

tner

ship

sC

omm

unic

atio

n

stra

tegy

Trai

ning

Impa

cton

excl

usiv

e

brea

stfe

edin

g

Com

men

ts

Bha

ndar

ieta

l

(200

3)

WH

O

(200

3a)

Rur

alco

mm

unit

ies

inH

arya

na

Indi

a

Clu

ster

rand

omiz

edtr

ial

8

com

mun

itie

s(t

otal

popu

lati

on~4

000

0)

Pro

mot

ion

ofex

clus

ive

brea

stfe

edin

gan

d

appr

opri

ate

com

plem

enta

ryfe

edin

g

Dev

elop

edth

roug

h

form

ativ

ere

sear

ch

ndashP

robl

emid

enti

ficat

ion

ndashP

arti

cipa

tory

desi

gnof

inte

rven

tion

impl

emen

tati

onan

d

eval

uati

on

Impl

emen

tati

onw

ithi

nan

exis

ting

prim

ary

heal

th-c

are

prog

ram

me

Opp

ortu

niti

esus

edto

deliv

erm

essa

ges

wer

e

imm

uniz

atio

ncl

inic

s

wei

ghin

gse

ssio

ns

sick

-chi

ldco

ntac

tsan

d

mon

thly

hom

evi

sits

Res

earc

hers

wit

hlo

cal

gove

rnm

ent

ICD

Ssy

stem

and

NG

O

The

atre

son

gs

Mas

sm

edia

not

used

for

risk

of

cont

amin

atio

n

Mat

eria

ls

deve

lope

d

for

heal

th

wor

kers

pos

ters

flip

book

sca

rds

Bre

astf

eedi

ng

coun

selli

ngse

ctio

n

ofth

eIM

CI

(WH

O

UN

ICE

F20

02)

Exc

lusi

ve

brea

stfe

edin

gin

the

prev

ious

24h

at3

mon

ths

of

age

79

vs4

8

The

posi

tive

effe

ct

rem

aine

dup

to

6m

onth

sof

age

(42

vs4

)

Tota

lpar

tici

pati

onof

the

dist

rict

heal

thsy

stem

from

ince

ptio

nof

the

prog

ram

me

inde

velo

ping

impl

emen

tati

onst

rate

gyt

ool

deve

lopm

ent

and

mon

itor

ing

inad

diti

onto

invo

lvem

ent

of

anN

GO

wer

eim

port

ant

feat

ures

that

cont

ribu

ted

to

the

succ

ess

ofth

e

inte

rven

tion

Mor

row

etal

(199

9)

Mex

ico

Cit

yC

lust

erra

ndom

ized

tria

l

Tota

lpop

ulat

ion

3000

0

Two

com

mun

itie

sin

the

inte

rven

tion

one

com

pari

son

130

wom

en

Hom

e-ba

sed

peer

coun

selli

ng

Pee

rco

unse

llors

mad

e3

or

6ho

me

visi

tsto

the

mot

her

Key

fam

ilym

embe

rsal

so

incl

uded

By

La

Lec

he

Lea

gue

of

Mex

ico

Exc

lusi

ve

brea

stfe

edin

g

at3

mon

ths

post

-par

tum

67

(6vi

sits

)

50

(3vi

sits

)12

(com

pari

son)

Firs

tcl

uste

rra

ndom

ized

com

mun

ity-

base

dtr

ialt

hat

used

peer

coun

sello

rsto

prom

ote

excl

usiv

e

brea

stfe

edin

g

Hai

der

etal

2000

200

2

Dha

ka

Low

mid

dle

and

low

-soc

io-

econ

omic

popu

lati

on

Clu

ster

rand

omiz

edtr

ial

20zo

nes

inin

terv

enti

on

and

20in

cont

rol

Com

mun

ity-

base

dpe

er

coun

selli

ngin

Dha

ka

15ho

me-

base

dco

unse

lling

visi

tsby

peer

coun

sello

rs

40h

(4h

yen10

days

)

WH

OU

NIC

EF

brea

stfe

edin

g

coun

selli

ngco

urse

(WH

OU

NIC

EF

1993

)

Exc

lusi

ve

brea

stfe

edin

g

at5

mon

ths

70

in

inte

rven

tion

and

6in

the

cont

rol

Com

mun

ity-

base

d

brea

stfe

edin

gpr

omot

ion

stra

tegy

was

effe

ctiv

ein

Ban

glad

esh

whe

rem

ost

deliv

erie

soc

cur

atho

me



Bry

ceet

al

(200

4)W

HO

(200

3b)

Bra

zil

Per

u

Tanz

ania

Uga

nda

Mul

tico

untr

yev

alua

tion

of

IMC

Ith

atin

clud

ed

effe

ctiv

enes

sco

stan

d

impa

ct(B

ryce

etal

2004

)

Bre

astf

eedi

ngpr

omot

ion

asa

part

ofIM

CI

IMC

Iis

ast

rate

gyfo

r

impr

ovin

gch

ildhe

alth

and

deve

lopm

ent

thro

ugh

the

com

bine

d

deliv

ery

ofes

sent

ial

child

heal

th

inte

rven

tion

sIM

CI

bega

nw

ith

ase

tof

case

man

agem

ent

guid

elin

es

for

the

man

agem

ent

ofsi

ckch

ildre

nat

first

-lev

elhe

alth

faci

litie

s

and

the

guid

elin

esw

ere

desi

gned

for

adap

tati

on

atco

untr

yle

vela

nd

belo

wO

ver

tim

eth

e

stra

tegy

expa

nded

to

incl

ude

ara

nge

of

guid

elin

esfo

rde

liver

ing

child

surv

ival

inte

rven

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at

hous

ehol

dco

mm

unit

y

and

refe

rral

leve

ls

IMC

Im

odul

e(W

HO

UN

ICE

F20

02)

Res

ults

onex

clus

ive

brea

stfe

edin

g

avai

labl

efr

om

Tanz

ania

whe

reno

sign

ifica

ntim

pact

was

seen

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pite

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ial

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ovem

ent

inth

equ

alit

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rede

liver

edby

IMC

Iat

heal

thfa

cilit

ies

key

fam

ily

prac

tice

ssu

chas

excl

usiv

e

brea

stfe

edin

gdi

dno

tch

ange

asco

mm

unit

yIM

CI

had

not

been

impl

emen

ted

byth

at

tim

e(W

HO

2003

b)

SA

rife

en

pers

onal

com

mun

icat

ion

Ban

glad

esh

Mat

lab

Com

mun

ity-

base

dcl

uste

r

desi

gn

Eva

luat

ion

offa

cilit

y-an

d

com

mun

ity-

base

dIM

CI

Inte

rven

tion

pack

age

incl

udes

feed

ing

asse

ssm

ent

and

coun

selli

ngon

mot

hers

ofyo

ung

child

ren

seek

ing

care

atfa

cilit

ies

for

illne

ssan

d

hom

e-ba

sed

coun

selli

ng

onim

prov

edfe

edin

gby

com

mun

ity-

base

dhe

alth

and

nutr

itio

nw

orke

rs

At

base

line

inth

e

year

2000

alit

tle

mor

eth

anha

lfth

e

0ndash5-

mon

th-o

ld

infa

nts

inth

est

udy

area

wer

ebe

ing

excl

usiv

ely

brea

stfe

dB

y20

05

this

incr

ease

dby

30

inth

eIM

CI

area

Dat

ano

t

avai

labl

efr

omth

e

com

pari

son

area

as

yet

Lac

kof

com

para

ble

data

from

the

com

pari

son

area

prev

ents

ade

finit

ive

conc

lusi

onas

tow

heth

erth

is

trul

yis

anim

pact

ofIM

CI

BA

SIC

SII

Bas

icSu

ppor

tfo

rIn

stit

utio

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Frie

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pita

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tegr

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Serv

ices

IM

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Inte

grat

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sM

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gram

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ions

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Org

aniz

atio

n



App

endi

x2

Cas

est

udie

sin

scal

e-up

effo

rts

inH

IVA

IDS

Stud

yde

scri

ptio

nPo

pula

tion

Inte

rven

tion

Com

mun

icat

ion

stra

tegy

Impa

cton

excl

usiv

ebr

east

feed

ing

Com

men

ts

LIN

KA

GE

S(2

005)

Zam

bia

Pro

gram

me

thro

ugh

heal

th-c

are

and

com

mun

ity

serv

ices

Rea

ched

60si

tes

in6

dist

rict

sby

2005

Inte

grat

ion

ofin

fant

feed

ing

coun

selli

ngm

ater

naln

utri

tion

and

anti

retr

ovir

aldr

ugs

prop

hyla

xis

Trai

ning

ofhe

alth

wor

kers

and

com

mun

ity

serv

ice

prov

ider

sto

coun

selw

omen

onsa

fety

opti

ons

for

thei

rsi

tuat

ion

Beh

avio

urch

ange

Com

mun

icat

ion

inte

rven

tion

sin

the

first

few

year

sM

ater

iald

evel

oped

lsquoAct

Now

rsquoM

edia

cam

paig

nsin

clud

edbr

ochu

res

post

ers

radi

oan

dte

levi

sion

Ass

esse

dth

roug

hba

selin

ean

dfo

llow

-up

hous

ehol

dan

dcl

inic

surv

eys

inse

lect

eddi

stri

cts

Exc

lusi

vebr

east

feed

ing

rate

incr

ease

dfr

om50

in

2002

to64

in

2004

inL

ivin

gsto

nean

dfr

om57

in

2000

to74

in

2004

inN

dola

Inte

grat

edde

mon

stra

tion

proj

ect

Had

seve

rals

tren

gths

inte

rms

ofth

eus

eof

form

ativ

ere

sear

chto

deve

lop

mes

sage

str

aini

ngan

dbu

ildin

gup

skill

sof

prog

ram

me

man

ager

she

alth

-car

epr

ovid

ers

and

com

mun

ity

wor

kers

adv

ocac

yfo

rna

tion

alpo

licy

stro

ngbe

havi

our

chan

geco

mm

unic

atio

nco

mpo

nent

st

reng

then

ing

com

mun

ity

capa

city

for

coun

selli

ngan

dre

ferr

als

and

mon

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ing

and

eval

uati

onw

ith

loca

lpar

tner

sP

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etal

(20

05)

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ITA

MB

Otr

ial

Har

are

Zim

babw

eE

duca

tion

and

coun

selli

ngpr

ogra

mm

ede

liver

edan

tena

tally

1411

0m

othe

rndashba

bypa

irs

enro

lled

from

14m

ater

nity

clin

ics

wit

hin

96h

ofde

liver

yan

dfo

llow

edup

at6

wee

ks

3m

onth

san

d3-

mon

thly

inte

rval

sIn

fant

-fee

ding

patt

erns

dete

rmin

edE

xclu

sive

brea

stfe

edin

gre

com

men

ded

for

HIV

nega

tive

un

know

nor

HIV

posi

tive

who

chos

eto

brea

stfe

ed

Gro

uped

ucat

ion

indi

vidu

alco

unse

lling

vid

eos

broc

hure

sM

othe

rsw

hoen

rolle

dw

hen

prog

ram

me

was

fully

impl

emen

ted

wer

e8

4ti

mes

mor

elik

ely

toex

clus

ivel

ybr

east

feed

than

mot

hers

who

enro

lled

befo

reth

epr

ogra

mm

ebe

gan

Ove

rall

excl

usiv

ebr

east

feed

ing

rate

sti

ll3

mon

ths

was

low

at24

6

Form

ativ

ere

sear

chus

edto

desi

gna

cult

ural

lyse

nsit

ive

educ

atio

nan

dco

unse

lling

prog

ram

me

Low

over

alle

xclu

sive

brea

stfe

edin

gra

tes

prom

pted

auth

ors

toco

nclu

deth

atw

omen

and

thei

rpa

rtne

rssh

ould

have

been

reac

hed

mor

efr

eque

ntly

duri

ngan

tena

tala

ndpo

st-n

atal

peri

od



Thi

oret

al(

2006

)R

ollin

s(2

007)

C

ohen

(200

7)

HIV

-inf

ecte

dpr

egna

ntw

omen

atte

ndin

gan

tena

talc

linic

sin

sout

hB

otsw

ana

Inve

stig

atio

nsby

CD

Cof

adi

arrh

oea

outb

reak

inJa

nuar

y-Fe

brua

ry20

06in

the

sam

epo

pula

tion

Mat

erna

land

infa

ntan

tire

trov

iral

ther

apy

toas

cert

ain

impa

cton

HIV

tran

smis

sion

Ant

enat

alco

unse

lling

Cas

endashco

ntro

lstu

dyto

iden

tify

risk

fact

ors

for

diar

rhoe

ano

tbr

east

feed

ing

was

the

bigg

est

risk

fact

ora

djus

ted

odds

rati

o50

(95

confi

denc

ein

terv

al4

5ndash10

0)

Bot

swan

aha

sth

ebe

stpr

imar

yhe

alth

-car

est

ruct

ure

wat

ersu

pply

and

sani

tati

onsy

stem

sin

Sout

hA

fric

aFo

rmul

apr

ovid

edfr

eeby

the

gove

rnm

ent

toin

fect

edm

othe

rsL

ower

mor

talit

yin

the

brea

stfe

edin

ggr

oup

at7

mon

ths

dem

onst

rate

sri

skof

form

ula

feed

ing

and

need

for

alte

rnat

est

rate

gies

(Thi

oret

al

2006

)A

utho

rsco

nclu

deth

athe

alth

syst

ems

inw

hich

thes

epr

ogra

mm

esar

eim

plem

ente

dsh

ould

beab

leto

cope

wit

hdi

arrh

oea

and

mal

nutr

itio

nth

atre

sult

sbe

caus

eof

form

ula

feed

ing

(Rol

lins

2007

)C

oova

dia

etal

(2

007)

Kw

aZul

uNat

al

Sout

hA

fric

a27

22H

IV-i

nfec

ted

and

unin

fect

edpr

egna

ntw

omen

enro

lled

into

ano

n-ra

ndom

ized

inte

rven

tion

coho

rtst

udy

from

ante

nata

lcl

inic

sIn

fant

feed

ing

data

obta

ined

wee

kly

bloo

dsa

mpl

esfr

omin

fant

sta

ken

mon

thly

83

of13

72in

fant

sbo

rnto

HIV

-inf

ecte

dm

othe

rsin

itia

ted

excl

usiv

ebr

east

feed

ing

from

birt

hB

reas

tfed

infa

nts

who

rece

ived

solid

sw

ere

sign

ifica

ntly

mor

elik

ely

toac

quir

ein

fect

ion

com

pare

dw

ith

excl

usiv

ely

brea

stfe

d(H

R10

87

151

ndash78

P=

001

8)as

wer

ein

fant

sw

hoat

12w

eeks

rece

ived

brea

stan

dfo

rmul

am

ilk(1

82

098

ndash33

6P

=0

57)

Cum

ulat

ive

3-m

onth

mor

talit

yin

excl

usiv

ely

brea

stfe

dw

as6

1(4

74ndash

792

)vs

15

1(7

63ndash

287

3)in

infa

nts

give

nre

plac

emen

tfe

eds

(HR

206

1

0ndash4

27P

=0

05)

The

stud

ysh

ows

that

excl

usiv

ebr

east

feed

ing

can

besu

cces

sful

lysu

ppor

ted

inH

IV-i

nfec

ted

wom

enT

heau

thor

sca

llfo

rfu

rthe

rre

visi

onof

UN

ICE

FW

HO

and

USA

IDin

fant

feed

ing

guid

elin

es

CD

CC

ente

rof

Dis

ease

Con

trol

HR

haz

ards

rati

oU

NIC

EF

Uni

ted

Nat

ions

Chi

ldre

nF

unds

USA

IDU

SA

genc

yfo

rIn

tern

atio

nalD

evel

opm

ent

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OW

orld

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lth

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aniz

atio

nZ

VIT

AM

BO

Z

imba

bwe

Vit

amin

Afo

rM

othe

rsan

dB

abie

s























Programme delivery





























Message development












Costs and resources





















Conclusions















Acknowledgements




References


























































































App

endi

x1

Cas

est

udie

so

fef

fect

iven

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stud

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Stud

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Inte

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inB

FH

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)

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low

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Inte

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kes

5ndash7

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Dat

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s

disc

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mit

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plem

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chan

ges

in

brea

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g

supp

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base

don

anal

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ques

tion

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Itis

aco

st-e

ffec

tive

inte

rven

tion

that

can

help

impr

ovem

ents

inth

eB

FH

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and

isa

valu

able

tool

for

proc

ess

eval

uati

on



LIN

KA

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S

proj

ect

inA

fric

aan

d

Lat

inA

mer

ica

(Qui

nnet

al

2005

LIN

KA

GE

S

2002

WH

O20

03a)

Bol

ivia

(1

mill

ion)

Gha

na(3

5

mill

ion)

Mad

agas

car

(6m

illio

n)

Res

ourc

e-

poor

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mm

e

InB

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mm

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on

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d

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ing

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adag

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prog

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g

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hin

7es

sent

ial

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d

subs

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thro

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form

ativ

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and

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aine

dth

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me

acti

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at

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part

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Rad

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all

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eria

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d

tosu

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cal

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com

mun

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mem

bers

Gre

at

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and

nego

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l

sess

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Sign

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ses

inex

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ive

brea

stfe

edin

gra

tes

of

0ndash6-

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th-o

ld

infa

nts

from

54

to65

in

Bol

ivia

68

to79

in

Gha

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toac

quir

ein

fect

ion

com

pare

dw

ith

excl

usiv

ely

brea

stfe

d(H

R10

87

151

ndash78

P=

001

8)as

wer

ein

fant

sw

hoat

12w

eeks

rece

ived

brea

stan

dfo

rmul

am

ilk(1

82

098

ndash33

6P

=0

57)

Cum

ulat

ive

3-m

onth

mor

talit

yin

excl

usiv

ely

brea

stfe

dw

as6

1(4

74ndash

792

)vs

15

1(7

63ndash

287

3)in

infa

nts

give

nre

plac

emen

tfe

eds

(HR

206

1

0ndash4

27P

=0

05)

The

stud

ysh

ows

that

excl

usiv

ebr

east

feed

ing

can

besu

cces

sful

lysu

ppor

ted

inH

IV-i

nfec

ted

wom

enT

heau

thor

sca

llfo

rfu

rthe

rre

visi

onof

UN

ICE

FW

HO

and

USA

IDin

fant

feed

ing

guid

elin

es

CD

CC

ente

rof

Dis

ease

Con

trol

HR

haz

ards

rati

oU

NIC

EF

Uni

ted

Nat

ions

Chi

ldre

nF

unds

USA

IDU

SA

genc

yfo

rIn

tern

atio

nalD

evel

opm

ent

WH

OW

orld

Hea

lth

Org

aniz

atio

nZ

VIT

AM

BO

Z

imba

bwe

Vit

amin

Afo

rM

othe

rsan

dB

abie

s







Programme delivery





























Message development












Costs and resources





















Conclusions















Acknowledgements




References


























































































App

endi

x1

Cas

est

udie

so

fef

fect

iven

ess

stud

ies

or

pilo

tpr

ogra

mm

es

Stud

yde

scri

ptio

nPo

pula

tion

Type

Inte

rven

tion

Par

tner

ship

sC

omm

unic

atio

n

stra

tegy

Trai

ning

Impa

cton

excl

usiv

e

brea

stfe

edin

g

Com

men

ts

Lut

ter

etal

(199

7)

Bra

zil

Low

-inc

ome

urba

nw

omen

deliv

erin

gin

hosp

ital

s

Bre

astf

eedi

ngpr

omot

ion

in

hosp

ital

sco

mpa

red

wit

h

nobr

east

feed

ing

prom

otio

n

Pro

mot

ion

ofbr

east

feed

ing

in

sele

cted

hosp

ital

s

Mea

nda

ysof

excl

usiv

e

brea

stfe

edin

g

75da

ysvs

22

days

(Plt

001

)

Rea

ampB

erqu

o

(199

0)

Wom

enw

ith

ach

ild

aged

lt2ye

ars

inSa

oP

aulo

Nat

iona

lbre

astf

eedi

ng

cam

paig

n19

81ndash1

986

BF

HI

Mas

sm

edia

cam

paig

n11

in

fant

s5ndash

6m

onth

s

excl

usiv

ely

brea

stfe

d

in19

88an

d37

in

1987

Con

foun

ding

fact

ors

over

the

6-ye

arpe

riod

not

mea

sure

d

Kra

mer

etal

(200

020

01)

PR

OB

ITtr

ial

Bel

arus

Clu

ster

rand

omiz

ed

34ho

spit

als

and

thei

rpo

lycl

inic

s

Trai

ning

inB

FH

I(W

HO

UN

ICE

F19

92)

vsr

outi

ne

prac

tice

san

dpo

licie

s

Exc

lusi

vebr

east

feed

ing

at3

(43

3vs

64

)

and

6(7

9

vs0

6

)

mon

ths

sign

ifica

ntly

high

er

Impl

emen

ted

thro

ugh

BF

HI

ina

sett

ing

whe

reho

spit

al

deliv

erie

sar

eco

mm

on

Per

ez-E

scam

illa

(200

4)

BA

SIC

SII

Mex

ico

Hon

dura

s

Bra

zil

MA

DL

AC

low

-cos

t

man

agem

ent

info

rmat

ion

syst

emto

use

an

evid

ence

-bas

edap

proa

chto

impr

ove

serv

ice

perf

orm

ance

Inte

rvie

win

gof

wom

enat

hosp

ital

disc

harg

epo

st

deliv

ery

usin

ga

ques

tion

nair

eth

atta

kes

5ndash7

min

toad

min

iste

ran

d

cont

ains

19br

east

feed

ing

prom

otio

nco

unse

lling

indi

cato

rs

Dat

aen

tere

dan

dre

sult

s

disc

usse

d3-

mon

thly

by

hosp

ital

com

mit

tee

Hos

pita

lim

plem

ents

chan

ges

in

brea

stfe

edin

g

supp

ort

base

don

anal

ysis

of

ques

tion

nair

es

Itis

aco

st-e

ffec

tive

inte

rven

tion

that

can

help

impr

ovem

ents

inth

eB

FH

I

and

isa

valu

able

tool

for

proc

ess

eval

uati

on



LIN

KA

GE

S

proj

ect

inA

fric

aan

d

Lat

inA

mer

ica

(Qui

nnet

al

2005

LIN

KA

GE

S

2002

WH

O20

03a)

Bol

ivia

(1

mill

ion)

Gha

na(3

5

mill

ion)

Mad

agas

car

(6m

illio

n)

Res

ourc

e-

poor

sett

ing

Pilo

tpr

ogra

mm

e

InB

oliv

iaan

d

Gha

napr

ogra

mm

e

focu

sed

on

brea

stfe

edin

gan

d

com

plem

enta

ry

feed

ing

InM

adag

asca

r

prog

ram

me

prom

oted

brea

stfe

edin

g

wit

hin

7es

sent

ial

nutr

itio

nac

tion

san

d

subs

eque

ntly

thro

ugh

IMC

I

Bui

lton

form

ativ

ere

sear

ch

and

sust

aine

dth

roug

h

prog

ram

me

acti

viti

esth

at

focu

sed

onbr

ingi

ngab

out

the

desi

red

beha

viou

r

chan

geM

ixof

inte

rven

tion

s

reac

hed

wom

enin

divi

dual

ly

orin

grou

psin

heal

th

faci

litie

sho

mes

or

com

mun

ity

sett

ings

Con

sist

ent

mes

sage

san

d

mat

eria

lacr

oss

all

prog

ram

me

chan

nels

Bol

ivi

PR

OC

OSI

NG

Os

Gha

na

UN

ICE

F

nati

onal

nutr

itio

n

offic

eN

GO

s

Mad

agas

car

Inte

rsec

tora

l

Act

ion

Gro

upfo

r

Nut

riti

on

Jere

o

Sala

ma

Isik

a

Pro

gram

desi

gned

wit

h

part

ners

Rad

ioin

all

thre

esi

tes

Mat

eria

ls

deve

lope

d

tosu

itne

eds

oflo

cal

heal

th

wor

kers

and

com

mun

ity

mem

bers

Gre

at

emph

asis

on

deve

lopm

ent

of coun

selli

ng

and

nego

tiat

ion

skill

s

prac

tica

l

sess

ions

Sign

ifica

ntin

crea

ses

inex

clus

ive

brea

stfe

edin

gra

tes

of

0ndash6-

mon

th-o

ld

infa

nts

from

54

to65

in

Bol

ivia

68

to79

in

Gha

naan

d46

to68

in

Mad

agas

car

In

Gha

naan

d

Mad

agas

car

sign

ifica

ntre

sult

s

obse

rved

wit

hin

aye

ar

ofin

itia

tion

of

com

mun

ity

inte

rven

tion

s

App

roac

hw

asef

fect

ive

and

achi

eved

sign

ifica

nt

incr

ease

sam

ong

larg

e

popu

lati

ons

asea

rly

as

9ndash12

mo

afte

rin

itia

tion

of

com

mun

ity

acti

viti

es

Van

Roe

kele

tal

(200

2)W

HO

(200

3a)

Hon

dura

sG

row

thm

onit

orin

gan

d

prom

otio

nkn

own

as

Ate

ncioacute

nIn

tegr

ala

la

Nintilde

ez(A

IN)

or

Inte

grat

edC

hild

Car

e

Init

ially

pri

mar

ilya

grow

th

mon

itor

ing

prog

ram

me

ulti

mat

ely

thro

ugh

IMC

I

Pro

gram

me

ongr

owth

prom

otio

nndash

asse

ssm

ent

of

mon

thly

wei

ght

gain

and

focu

son

illne

ssf

eedi

ng

prac

tice

san

dge

nera

lchi

ld

care

inin

fant

sun

der

2ye

ars

Impl

emen

ted

atgo

vern

men

t

faci

litie

san

dco

mm

unit

y

Star

ted

in19

92s

tren

gthe

ned

in19

95ndash1

997

wit

hgr

eate

r

focu

son

child

feed

ing

In

1997

pro

gram

me

intr

oduc

ed

wit

hIM

CI

(WH

OU

NIC

EF

2002

)

Maj

or

part

ners

UN

ICE

F

PAH

O

Am

eric

an

and

Hon

dura

n

Red

Cro

ss

CA

RE

Rad

io

broa

dcas

ts

relig

ious

lead

ers

IMC

IM

id-t

erm

eval

uati

on

show

ed39

of

mot

hers

inin

terv

enti

on

com

mun

itie

sex

clus

ivel

y

brea

stfe

dco

mpa

red

wit

h13

in

the

cont

rol

site

s



App

endi

x1

cont

inue

d

Stud

yde

scri

ptio

nPo

pula

tion

Type

Inte

rven

tion

Par

tner

ship

sC

omm

unic

atio

n

stra

tegy

Trai

ning

Impa

cton

excl

usiv

e

brea

stfe

edin

g

Com

men

ts

Bha

ndar

ieta

l

(200

3)

WH

O

(200

3a)

Rur

alco

mm

unit

ies

inH

arya

na

Indi

a

Clu

ster

rand

omiz

edtr

ial

8

com

mun

itie

s(t

otal

popu

lati

on~4

000

0)

Pro

mot

ion

ofex

clus

ive

brea

stfe

edin

gan

d

appr

opri

ate

com

plem

enta

ryfe

edin

g

Dev

elop

edth

roug

h

form

ativ

ere

sear

ch

ndashP

robl

emid

enti

ficat

ion

ndashP

arti

cipa

tory

desi

gnof

inte

rven

tion

impl

emen

tati

onan

d

eval

uati

on

Impl

emen

tati

onw

ithi

nan

exis

ting

prim

ary

heal

th-c

are

prog

ram

me

Opp

ortu

niti

esus

edto

deliv

erm

essa

ges

wer

e

imm

uniz

atio

ncl

inic

s

wei

ghin

gse

ssio

ns

sick

-chi

ldco

ntac

tsan

d

mon

thly

hom

evi

sits

Res

earc

hers

wit

hlo

cal

gove

rnm

ent

ICD

Ssy

stem

and

NG

O

The

atre

son

gs

Mas

sm

edia

not

used

for

risk

of

cont

amin

atio

n

Mat

eria

ls

deve

lope

d

for

heal

th

wor

kers

pos

ters

flip

book

sca

rds

Bre

astf

eedi

ng

coun

selli

ngse

ctio

n

ofth

eIM

CI

(WH

O

UN

ICE

F20

02)

Exc

lusi

ve

brea

stfe

edin

gin

the

prev

ious

24h

at3

mon

ths

of

age

79

vs4

8

The

posi

tive

effe

ct

rem

aine

dup

to

6m

onth

sof

age

(42

vs4

)

Tota

lpar

tici

pati

onof

the

dist

rict

heal

thsy

stem

from

ince

ptio

nof

the

prog

ram

me

inde

velo

ping

impl

emen

tati

onst

rate

gyt

ool

deve

lopm

ent

and

mon

itor

ing

inad

diti

onto

invo

lvem

ent

of

anN

GO

wer

eim

port

ant

feat

ures

that

cont

ribu

ted

to

the

succ

ess

ofth

e

inte

rven

tion

Mor

row

etal

(199

9)

Mex

ico

Cit

yC

lust

erra

ndom

ized

tria

l

Tota

lpop

ulat

ion

3000

0

Two

com

mun

itie

sin

the

inte

rven

tion

one

com

pari

son

130

wom

en

Hom

e-ba

sed

peer

coun

selli

ng

Pee

rco

unse

llors

mad

e3

or

6ho

me

visi

tsto

the

mot

her

Key

fam

ilym

embe

rsal

so

incl

uded

By

La

Lec

he

Lea

gue

of

Mex

ico

Exc

lusi

ve

brea

stfe

edin

g

at3

mon

ths

post

-par

tum

67

(6vi

sits

)

50

(3vi

sits

)12

(com

pari

son)

Firs

tcl

uste

rra

ndom

ized

com

mun

ity-

base

dtr

ialt

hat

used

peer

coun

sello

rsto

prom

ote

excl

usiv

e

brea

stfe

edin

g

Hai

der

etal

2000

200

2

Dha

ka

Low

mid

dle

and

low

-soc

io-

econ

omic

popu

lati

on

Clu

ster

rand

omiz

edtr

ial

20zo

nes

inin

terv

enti

on

and

20in

cont

rol

Com

mun

ity-

base

dpe

er

coun

selli

ngin

Dha

ka

15ho

me-

base

dco

unse

lling

visi

tsby

peer

coun

sello

rs

40h

(4h

yen10

days

)

WH

OU

NIC

EF

brea

stfe

edin

g

coun

selli

ngco

urse

(WH

OU

NIC

EF

1993

)

Exc

lusi

ve

brea

stfe

edin

g

at5

mon

ths

70

in

inte

rven

tion

and

6in

the

cont

rol

Com

mun

ity-

base

d

brea

stfe

edin

gpr

omot

ion

stra

tegy

was

effe

ctiv

ein

Ban

glad

esh

whe

rem

ost

deliv

erie

soc

cur

atho

me



Bry

ceet

al

(200

4)W

HO

(200

3b)

Bra

zil

Per

u

Tanz

ania

Uga

nda

Mul

tico

untr

yev

alua

tion

of

IMC

Ith

atin

clud

ed

effe

ctiv

enes

sco

stan

d

impa

ct(B

ryce

etal

2004

)

Bre

astf

eedi

ngpr

omot

ion

asa

part

ofIM

CI

IMC

Iis

ast

rate

gyfo

r

impr

ovin

gch

ildhe

alth

and

deve

lopm

ent

thro

ugh

the

com

bine

d

deliv

ery

ofes

sent

ial

child

heal

th

inte

rven

tion

sIM

CI

bega

nw

ith

ase

tof

case

man

agem

ent

guid

elin

es

for

the

man

agem

ent

ofsi

ckch

ildre

nat

first

-lev

elhe

alth

faci

litie

s

and

the

guid

elin

esw

ere

desi

gned

for

adap

tati

on

atco

untr

yle

vela

nd

belo

wO

ver

tim

eth

e

stra

tegy

expa

nded

to

incl

ude

ara

nge

of

guid

elin

esfo

rde

liver

ing

child

surv

ival

inte

rven

tion

at

hous

ehol

dco

mm

unit

y

and

refe

rral

leve

ls

IMC

Im

odul

e(W

HO

UN

ICE

F20

02)

Res

ults

onex

clus

ive

brea

stfe

edin

g

avai

labl

efr

om

Tanz

ania

whe

reno

sign

ifica

ntim

pact

was

seen

Des

pite

subs

tant

ial

impr

ovem

ent

inth

equ

alit

y

ofca

rede

liver

edby

IMC

Iat

heal

thfa

cilit

ies

key

fam

ily

prac

tice

ssu

chas

excl

usiv

e

brea

stfe

edin

gdi

dno

tch

ange

asco

mm

unit

yIM

CI

had

not

been

impl

emen

ted

byth

at

tim

e(W

HO

2003

b)

SA

rife

en

pers

onal

com

mun

icat

ion

Ban

glad

esh

Mat

lab

Com

mun

ity-

base

dcl

uste

r

desi

gn

Eva

luat

ion

offa

cilit

y-an

d

com

mun

ity-

base

dIM

CI

Inte

rven

tion

pack

age

incl

udes

feed

ing

asse

ssm

ent

and

coun

selli

ngon

mot

hers

ofyo

ung

child

ren

seek

ing

care

atfa

cilit

ies

for

illne

ssan

d

hom

e-ba

sed

coun

selli

ng

onim

prov

edfe

edin

gby

com

mun

ity-

base

dhe

alth

and

nutr

itio

nw

orke

rs

At

base

line

inth

e

year

2000

alit

tle

mor

eth

anha

lfth

e

0ndash5-

mon

th-o

ld

infa

nts

inth

est

udy

area

wer

ebe

ing

excl

usiv

ely

brea

stfe

dB

y20

05

this

incr

ease

dby

30

inth

eIM

CI

area

Dat

ano

t

avai

labl

efr

omth

e

com

pari

son

area

as

yet

Lac

kof

com

para

ble

data

from

the

com

pari

son

area

prev

ents

ade

finit

ive

conc

lusi

onas

tow

heth

erth

is

trul

yis

anim

pact

ofIM

CI

BA

SIC

SII

Bas

icSu

ppor

tfo

rIn

stit

utio

naliz

ing

Chi

ldSu

rviv

alP

roje

ctB

FH

IB

aby-

Frie

ndly

Hos

pita

lIni

tiat

ive

ICD

SIn

tegr

ated

Chi

ldD

evel

opm

ent

Serv

ices

IM

CI

Inte

grat

edM

anag

emen

tof

Chi

ldho

odIl

lnes

sM

AD

LA

CM

onit

oreo

deA

poyo

Dir

ecto

con

laL

acat

anci

aM

ater

naN

GO

non

-gov

ernm

enta

lorg

aniz

atio

nPA

HO

Pan

Am

eric

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effo

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excl

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Pro

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me

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heal

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are

and

com

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ices

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60si

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dist

rict

sby

2005

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grat

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ofin

fant

feed

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coun

selli

ngm

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and

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prop

hyla

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Trai

ning

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alth

wor

kers

and

com

mun

ity

serv

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prov

ider

sto

coun

selw

omen

onsa

fety

opti

ons

for

thei

rsi

tuat

ion

Beh

avio

urch

ange

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mun

icat

ion

inte

rven

tion

sin

the

first

few

year

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evel

oped

lsquoAct

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cam

paig

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clud

edbr

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res

post

ers

radi

oan

dte

levi

sion

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esse

dth

roug

hba

selin

ean

dfo

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-up

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ehol

dan

dcl

inic

surv

eys

inse

lect

eddi

stri

cts

Exc

lusi

vebr

east

feed

ing

rate

incr

ease

dfr

om50

in

2002

to64

in

2004

inL

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gsto

nean

dfr

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in

2000

to74

in

2004

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dola

Inte

grat

edde

mon

stra

tion

proj

ect

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seve

rals

tren

gths

inte

rms

ofth

eus

eof

form

ativ

ere

sear

chto

deve

lop

mes

sage

str

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ngan

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gup

skill

sof

prog

ram

me

man

ager

she

alth

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epr

ovid

ers

and

com

mun

ity

wor

kers

adv

ocac

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tion

alpo

licy

stro

ngbe

havi

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mm

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reng

then

ing

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selli

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dre

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eval

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ith

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lpar

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and

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ics

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rval

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fant

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xclu

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com

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un

know

nor

HIV

posi

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stfe

ed

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uped

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ion

indi

vidu

alco

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lling

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hure

sM

othe

rsw

hoen

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prog

ram

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was

fully

impl

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e8

4ti

mes

mor

elik

ely

toex

clus

ivel

ybr

east

feed

than

mot

hers

who

enro

lled

befo

reth

epr

ogra

mm

ebe

gan

Ove

rall

excl

usiv

ebr

east

feed

ing

rate

sti

ll3

mon

ths

was

low

at24

6

Form

ativ

ere

sear

chus

edto

desi

gna

cult

ural

lyse

nsit

ive

educ

atio

nan

dco

unse

lling

prog

ram

me

Low

over

alle

xclu

sive

brea

stfe

edin

gra

tes

prom

pted

auth

ors

toco

nclu

deth

atw

omen

and

thei

rpa

rtne

rssh

ould

have

been

reac

hed

mor

efr

eque

ntly

duri

ngan

tena

tala

ndpo

st-n

atal

peri

od



Thi

oret

al(

2006

)R

ollin

s(2

007)

C

ohen

(200

7)

HIV

-inf

ecte

dpr

egna

ntw

omen

atte

ndin

gan

tena

talc

linic

sin

sout

hB

otsw

ana

Inve

stig

atio

nsby

CD

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adi

arrh

oea

outb

reak

inJa

nuar

y-Fe

brua

ry20

06in

the

sam

epo

pula

tion

Mat

erna

land

infa

ntan

tire

trov

iral

ther

apy

toas

cert

ain

impa

cton

HIV

tran

smis

sion

Ant

enat

alco

unse

lling

Cas

endashco

ntro

lstu

dyto

iden

tify

risk

fact

ors

for

diar

rhoe

ano

tbr

east

feed

ing

was

the

bigg

est

risk

fact

ora

djus

ted

odds

rati

o50

(95

confi

denc

ein

terv

al4

5ndash10

0)

Bot

swan

aha

sth

ebe

stpr

imar

yhe

alth

-car

est

ruct

ure

wat

ersu

pply

and

sani

tati

onsy

stem

sin

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fric

aFo

rmul

apr

ovid

edfr

eeby

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ent

toin

fect

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othe

rsL

ower

mor

talit

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stfe

edin

ggr

oup

at7

mon

ths

dem

onst

rate

sri

skof

form

ula

feed

ing

and

need

for

alte

rnat

est

rate

gies

(Thi

oret

al

2006

)A

utho

rsco

nclu

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athe

alth

syst

ems

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hich

thes

epr

ogra

mm

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ould

beab

leto

cope

wit

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and

mal

nutr

itio

nth

atre

sult

sbe

caus

eof

form

ula

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ing

(Rol

lins

2007

)C

oova

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etal

(2

007)

Kw

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uNat

al

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hA

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a27

22H

IV-i

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ted

and

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fect

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omen

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into

ano

n-ra

ndom

ized

inte

rven

tion

coho

rtst

udy

from

ante

nata

lcl

inic

sIn

fant

feed

ing

data

obta

ined

wee

kly

bloo

dsa

mpl

esfr

omin

fant

sta

ken

mon

thly

83

of13

72in

fant

sbo

rnto

HIV

-inf

ecte

dm

othe

rsin

itia

ted

excl

usiv

ebr

east

feed

ing

from

birt

hB

reas

tfed

infa

nts

who

rece

ived

solid

sw

ere

sign

ifica

ntly

mor

elik

ely

toac

quir

ein

fect

ion

com

pare

dw

ith

excl

usiv

ely

brea

stfe

d(H

R10

87

151

ndash78

P=

001

8)as

wer

ein

fant

sw

hoat

12w

eeks

rece

ived

brea

stan

dfo

rmul

am

ilk(1

82

098

ndash33

6P

=0

57)

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ulat

ive

3-m

onth

mor

talit

yin

excl

usiv

ely

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stfe

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as6

1(4

74ndash

792

)vs

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287

3)in

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give

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eds

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206

1

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=0

05)

The

stud

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ows

that

excl

usiv

ebr

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feed

ing

can

besu

cces

sful

lysu

ppor

ted

inH

IV-i

nfec

ted

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enT

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thor

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rthe

rre

visi

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ICE

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and

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ease

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trol

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ards

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ions

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ldre

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orld

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AM

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Z

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rM

othe

rsan

dB

abie

s





















Message development












Costs and resources





















Conclusions















Acknowledgements




References


























































































App

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inA

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aan

d

Lat

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2002

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in

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App

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imm

uniz

atio

ncl

inic

s

wei

ghin

gse

ssio

ns

sick

-chi

ldco

ntac

tsan

d

mon

thly

hom

evi

sits

Res

earc

hers

wit

hlo

cal

gove

rnm

ent

ICD

Ssy

stem

and

NG

O

The

atre

son

gs

Mas

sm

edia

not

used

for

risk

of

cont

amin

atio

n

Mat

eria

ls

deve

lope

d

for

heal

th

wor

kers

pos

ters

flip

book

sca

rds

Bre

astf

eedi

ng

coun

selli

ngse

ctio

n

ofth

eIM

CI

(WH

O

UN

ICE

F20

02)

Exc

lusi

ve

brea

stfe

edin

gin

the

prev

ious

24h

at3

mon

ths

of

age

79

vs4

8

The

posi

tive

effe

ct

rem

aine

dup

to

6m

onth

sof

age

(42

vs4

)

Tota

lpar

tici

pati

onof

the

dist

rict

heal

thsy

stem

from

ince

ptio

nof

the

prog

ram

me

inde

velo

ping

impl

emen

tati

onst

rate

gyt

ool

deve

lopm

ent

and

mon

itor

ing

inad

diti

onto

invo

lvem

ent

of

anN

GO

wer

eim

port

ant

feat

ures

that

cont

ribu

ted

to

the

succ

ess

ofth

e

inte

rven

tion

Mor

row

etal

(199

9)

Mex

ico

Cit

yC

lust

erra

ndom

ized

tria

l

Tota

lpop

ulat

ion

3000

0

Two

com

mun

itie

sin

the

inte

rven

tion

one

com

pari

son

130

wom

en

Hom

e-ba

sed

peer

coun

selli

ng

Pee

rco

unse

llors

mad

e3

or

6ho

me

visi

tsto

the

mot

her

Key

fam

ilym

embe

rsal

so

incl

uded

By

La

Lec

he

Lea

gue

of

Mex

ico

Exc

lusi

ve

brea

stfe

edin

g

at3

mon

ths

post

-par

tum

67

(6vi

sits

)

50

(3vi

sits

)12

(com

pari

son)

Firs

tcl

uste

rra

ndom

ized

com

mun

ity-

base

dtr

ialt

hat

used

peer

coun

sello

rsto

prom

ote

excl

usiv

e

brea

stfe

edin

g

Hai

der

etal

2000

200

2

Dha

ka

Low

mid

dle

and

low

-soc

io-

econ

omic

popu

lati

on

Clu

ster

rand

omiz

edtr

ial

20zo

nes

inin

terv

enti

on

and

20in

cont

rol

Com

mun

ity-

base

dpe

er

coun

selli

ngin

Dha

ka

15ho

me-

base

dco

unse

lling

visi

tsby

peer

coun

sello

rs

40h

(4h

yen10

days

)

WH

OU

NIC

EF

brea

stfe

edin

g

coun

selli

ngco

urse

(WH

OU

NIC

EF

1993

)

Exc

lusi

ve

brea

stfe

edin

g

at5

mon

ths

70

in

inte

rven

tion

and

6in

the

cont

rol

Com

mun

ity-

base

d

brea

stfe

edin

gpr

omot

ion

stra

tegy

was

effe

ctiv

ein

Ban

glad

esh

whe

rem

ost

deliv

erie

soc

cur

atho

me



Bry

ceet

al

(200

4)W

HO

(200

3b)

Bra

zil

Per

u

Tanz

ania

Uga

nda

Mul

tico

untr

yev

alua

tion

of

IMC

Ith

atin

clud

ed

effe

ctiv

enes

sco

stan

d

impa

ct(B

ryce

etal

2004

)

Bre

astf

eedi

ngpr

omot

ion

asa

part

ofIM

CI

IMC

Iis

ast

rate

gyfo

r

impr

ovin

gch

ildhe

alth

and

deve

lopm

ent

thro

ugh

the

com

bine

d

deliv

ery

ofes

sent

ial

child

heal

th

inte

rven

tion

sIM

CI

bega

nw

ith

ase

tof

case

man

agem

ent

guid

elin

es

for

the

man

agem

ent

ofsi

ckch

ildre

nat

first

-lev

elhe

alth

faci

litie

s

and

the

guid

elin

esw

ere

desi

gned

for

adap

tati

on

atco

untr

yle

vela

nd

belo

wO

ver

tim

eth

e

stra

tegy

expa

nded

to

incl

ude

ara

nge

of

guid

elin

esfo

rde

liver

ing

child

surv

ival

inte

rven

tion

at

hous

ehol

dco

mm

unit

y

and

refe

rral

leve

ls

IMC

Im

odul

e(W

HO

UN

ICE

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02)

Res

ults

onex

clus

ive

brea

stfe

edin

g

avai

labl

efr

om

Tanz

ania

whe

reno

sign

ifica

ntim

pact

was

seen

Des

pite

subs

tant

ial

impr

ovem

ent

inth

equ

alit

y

ofca

rede

liver

edby

IMC

Iat

heal

thfa

cilit

ies

key

fam

ily

prac

tice

ssu

chas

excl

usiv

e

brea

stfe

edin

gdi

dno

tch

ange

asco

mm

unit

yIM

CI

had

not

been

impl

emen

ted

byth

at

tim

e(W

HO

2003

b)

SA

rife

en

pers

onal

com

mun

icat

ion

Ban

glad

esh

Mat

lab

Com

mun

ity-

base

dcl

uste

r

desi

gn

Eva

luat

ion

offa

cilit

y-an

d

com

mun

ity-

base

dIM

CI

Inte

rven

tion

pack

age

incl

udes

feed

ing

asse

ssm

ent

and

coun

selli

ngon

mot

hers

ofyo

ung

child

ren

seek

ing

care

atfa

cilit

ies

for

illne

ssan

d

hom

e-ba

sed

coun

selli

ng

onim

prov

edfe

edin

gby

com

mun

ity-

base

dhe

alth

and

nutr

itio

nw

orke

rs

At

base

line

inth

e

year

2000

alit

tle

mor

eth

anha

lfth

e

0ndash5-

mon

th-o

ld

infa

nts

inth

est

udy

area

wer

ebe

ing

excl

usiv

ely

brea

stfe

dB

y20

05

this

incr

ease

dby

30

inth

eIM

CI

area

Dat

ano

t

avai

labl

efr

omth

e

com

pari

son

area

as

yet

Lac

kof

com

para

ble

data

from

the

com

pari

son

area

prev

ents

ade

finit

ive

conc

lusi

onas

tow

heth

erth

is

trul

yis

anim

pact

ofIM

CI

BA

SIC

SII

Bas

icSu

ppor

tfo

rIn

stit

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ing

Chi

ldSu

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alP

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ctB

FH

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aby-

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Hos

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ive

ICD

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tegr

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opm

ent

Serv

ices

IM

CI

Inte

grat

edM

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lnes

sM

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ater

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ernm

enta

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aniz

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PR

OB

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terv

enti

onTr

ial

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gram

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rdin

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nen

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tegr

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olla

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tive

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gram

for

Inte

grat

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NIC

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ted

Nat

ions

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ldre

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WH

OW

orld

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lth

Org

aniz

atio

n



App

endi

x2

Cas

est

udie

sin

scal

e-up

effo

rts

inH

IVA

IDS

Stud

yde

scri

ptio

nPo

pula

tion

Inte

rven

tion

Com

mun

icat

ion

stra

tegy

Impa

cton

excl

usiv

ebr

east

feed

ing

Com

men

ts

LIN

KA

GE

S(2

005)

Zam

bia

Pro

gram

me

thro

ugh

heal

th-c

are

and

com

mun

ity

serv

ices

Rea

ched

60si

tes

in6

dist

rict

sby

2005

Inte

grat

ion

ofin

fant

feed

ing

coun

selli

ngm

ater

naln

utri

tion

and

anti

retr

ovir

aldr

ugs

prop

hyla

xis

Trai

ning

ofhe

alth

wor

kers

and

com

mun

ity

serv

ice

prov

ider

sto

coun

selw

omen

onsa

fety

opti

ons

for

thei

rsi

tuat

ion

Beh

avio

urch

ange

Com

mun

icat

ion

inte

rven

tion

sin

the

first

few

year

sM

ater

iald

evel

oped

lsquoAct

Now

rsquoM

edia

cam

paig

nsin

clud

edbr

ochu

res

post

ers

radi

oan

dte

levi

sion

Ass

esse

dth

roug

hba

selin

ean

dfo

llow

-up

hous

ehol

dan

dcl

inic

surv

eys

inse

lect

eddi

stri

cts

Exc

lusi

vebr

east

feed

ing

rate

incr

ease

dfr

om50

in

2002

to64

in

2004

inL

ivin

gsto

nean

dfr

om57

in

2000

to74

in

2004

inN

dola

Inte

grat

edde

mon

stra

tion

proj

ect

Had

seve

rals

tren

gths

inte

rms

ofth

eus

eof

form

ativ

ere

sear

chto

deve

lop

mes

sage

str

aini

ngan

dbu

ildin

gup

skill

sof

prog

ram

me

man

ager

she

alth

-car

epr

ovid

ers

and

com

mun

ity

wor

kers

adv

ocac

yfo

rna

tion

alpo

licy

stro

ngbe

havi

our

chan

geco

mm

unic

atio

nco

mpo

nent

st

reng

then

ing

com

mun

ity

capa

city

for

coun

selli

ngan

dre

ferr

als

and

mon

itor

ing

and

eval

uati

onw

ith

loca

lpar

tner

sP

iwoz

etal

(20

05)

ZV

ITA

MB

Otr

ial

Har

are

Zim

babw

eE

duca

tion

and

coun

selli

ngpr

ogra

mm

ede

liver

edan

tena

tally

1411

0m

othe

rndashba

bypa

irs

enro

lled

from

14m

ater

nity

clin

ics

wit

hin

96h

ofde

liver

yan

dfo

llow

edup

at6

wee

ks

3m

onth

san

d3-

mon

thly

inte

rval

sIn

fant

-fee

ding

patt

erns

dete

rmin

edE

xclu

sive

brea

stfe

edin

gre

com

men

ded

for

HIV

nega

tive

un

know

nor

HIV

posi

tive

who

chos

eto

brea

stfe

ed

Gro

uped

ucat

ion

indi

vidu

alco

unse

lling

vid

eos

broc

hure

sM

othe

rsw

hoen

rolle

dw

hen

prog

ram

me

was

fully

impl

emen

ted

wer

e8

4ti

mes

mor

elik

ely

toex

clus

ivel

ybr

east

feed

than

mot

hers

who

enro

lled

befo

reth

epr

ogra

mm

ebe

gan

Ove

rall

excl

usiv

ebr

east

feed

ing

rate

sti

ll3

mon

ths

was

low

at24

6

Form

ativ

ere

sear

chus

edto

desi

gna

cult

ural

lyse

nsit

ive

educ

atio

nan

dco

unse

lling

prog

ram

me

Low

over

alle

xclu

sive

brea

stfe

edin

gra

tes

prom

pted

auth

ors

toco

nclu

deth

atw

omen

and

thei

rpa

rtne

rssh

ould

have

been

reac

hed

mor

efr

eque

ntly

duri

ngan

tena

tala

ndpo

st-n

atal

peri

od



Thi

oret

al(

2006

)R

ollin

s(2

007)

C

ohen

(200

7)

HIV

-inf

ecte

dpr

egna

ntw

omen

atte

ndin

gan

tena

talc

linic

sin

sout

hB

otsw

ana

Inve

stig

atio

nsby

CD

Cof

adi

arrh

oea

outb

reak

inJa

nuar

y-Fe

brua

ry20

06in

the

sam

epo

pula

tion

Mat

erna

land

infa

ntan

tire

trov

iral

ther

apy

toas

cert

ain

impa

cton

HIV

tran

smis

sion

Ant

enat

alco

unse

lling

Cas

endashco

ntro

lstu

dyto

iden

tify

risk

fact

ors

for

diar

rhoe

ano

tbr

east

feed

ing

was

the

bigg

est

risk

fact

ora

djus

ted

odds

rati

o50

(95

confi

denc

ein

terv

al4

5ndash10

0)

Bot

swan

aha

sth

ebe

stpr

imar

yhe

alth

-car

est

ruct

ure

wat

ersu

pply

and

sani

tati

onsy

stem

sin

Sout

hA

fric

aFo

rmul

apr

ovid

edfr

eeby

the

gove

rnm

ent

toin

fect

edm

othe

rsL

ower

mor

talit

yin

the

brea

stfe

edin

ggr

oup

at7

mon

ths

dem

onst

rate

sri

skof

form

ula

feed

ing

and

need

for

alte

rnat

est

rate

gies

(Thi

oret

al

2006

)A

utho

rsco

nclu

deth

athe

alth

syst

ems

inw

hich

thes

epr

ogra

mm

esar

eim

plem

ente

dsh

ould

beab

leto

cope

wit

hdi

arrh

oea

and

mal

nutr

itio

nth

atre

sult

sbe

caus

eof

form

ula

feed

ing

(Rol

lins

2007

)C

oova

dia

etal

(2

007)

Kw

aZul

uNat

al

Sout

hA

fric

a27

22H

IV-i

nfec

ted

and

unin

fect

edpr

egna

ntw

omen

enro

lled

into

ano

n-ra

ndom

ized

inte

rven

tion

coho

rtst

udy

from

ante

nata

lcl

inic

sIn

fant

feed

ing

data

obta

ined

wee

kly

bloo

dsa

mpl

esfr

omin

fant

sta

ken

mon

thly

83

of13

72in

fant

sbo

rnto

HIV

-inf

ecte

dm

othe

rsin

itia

ted

excl

usiv

ebr

east

feed

ing

from

birt

hB

reas

tfed

infa

nts

who

rece

ived

solid

sw

ere

sign

ifica

ntly

mor

elik

ely

toac

quir

ein

fect

ion

com

pare

dw

ith

excl

usiv

ely

brea

stfe

d(H

R10

87

151

ndash78

P=

001

8)as

wer

ein

fant

sw

hoat

12w

eeks

rece

ived

brea

stan

dfo

rmul

am

ilk(1

82

098

ndash33

6P

=0

57)

Cum

ulat

ive

3-m

onth

mor

talit

yin

excl

usiv

ely

brea

stfe

dw

as6

1(4

74ndash

792

)vs

15

1(7

63ndash

287

3)in

infa

nts

give

nre

plac

emen

tfe

eds

(HR

206

1

0ndash4

27P

=0

05)

The

stud

ysh

ows

that

excl

usiv

ebr

east

feed

ing

can

besu

cces

sful

lysu

ppor

ted

inH

IV-i

nfec

ted

wom

enT

heau

thor

sca

llfo

rfu

rthe

rre

visi

onof

UN

ICE

FW

HO

and

USA

IDin

fant

feed

ing

guid

elin

es

CD

CC

ente

rof

Dis

ease

Con

trol

HR

haz

ards

rati

oU

NIC

EF

Uni

ted

Nat

ions

Chi

ldre

nF

unds

USA

IDU

SA

genc

yfo

rIn

tern

atio

nalD

evel

opm

ent

WH

OW

orld

Hea

lth

Org

aniz

atio

nZ

VIT

AM

BO

Z

imba

bwe

Vit

amin

Afo

rM

othe

rsan

dB

abie

s







Message development












Costs and resources





















Conclusions















Acknowledgements




References


























































































App

endi

x1

Cas

est

udie

so

fef

fect

iven

ess

stud

ies

or

pilo

tpr

ogra

mm

es

Stud

yde

scri

ptio

nPo

pula

tion

Type

Inte

rven

tion

Par

tner

ship

sC

omm

unic

atio

n

stra

tegy

Trai

ning

Impa

cton

excl

usiv

e

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stfe

edin

g

Com

men

ts

Lut

ter

etal

(199

7)

Bra

zil

Low

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erin

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s

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astf

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Pro

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ing

in

sele

cted

hosp

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s

Mea

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excl

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e

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stfe

edin

g

75da

ysvs

22

days

(Plt

001

)

Rea

ampB

erqu

o

(199

0)

Wom

enw

ith

ach

ild

aged

lt2ye

ars

inSa

oP

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Nat

iona

lbre

astf

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ng

cam

paig

n19

81ndash1

986

BF

HI

Mas

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cam

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n11

in

fant

s5ndash

6m

onth

s

excl

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ely

brea

stfe

d

in19

88an

d37

in

1987

Con

foun

ding

fact

ors

over

the

6-ye

arpe

riod

not

mea

sure

d

Kra

mer

etal

(200

020

01)

PR

OB

ITtr

ial

Bel

arus

Clu

ster

rand

omiz

ed

34ho

spit

als

and

thei

rpo

lycl

inic

s

Trai

ning

inB

FH

I(W

HO

UN

ICE

F19

92)

vsr

outi

ne

prac

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OU

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erns

dete

rmin

edE

xclu

sive

brea

stfe

edin

gre

com

men

ded

for

HIV

nega

tive

un

know

nor

HIV

posi

tive

who

chos

eto

brea

stfe

ed

Gro

uped

ucat

ion

indi

vidu

alco

unse

lling

vid

eos

broc

hure

sM

othe

rsw

hoen

rolle

dw

hen

prog

ram

me

was

fully

impl

emen

ted

wer

e8

4ti

mes

mor

elik

ely

toex

clus

ivel

ybr

east

feed

than

mot

hers

who

enro

lled

befo

reth

epr

ogra

mm

ebe

gan

Ove

rall

excl

usiv

ebr

east

feed

ing

rate

sti

ll3

mon

ths

was

low

at24

6

Form

ativ

ere

sear

chus

edto

desi

gna

cult

ural

lyse

nsit

ive

educ

atio

nan

dco

unse

lling

prog

ram

me

Low

over

alle

xclu

sive

brea

stfe

edin

gra

tes

prom

pted

auth

ors

toco

nclu

deth

atw

omen

and

thei

rpa

rtne

rssh

ould

have

been

reac

hed

mor

efr

eque

ntly

duri

ngan

tena

tala

ndpo

st-n

atal

peri

od



Thi

oret

al(

2006

)R

ollin

s(2

007)

C

ohen

(200

7)

HIV

-inf

ecte

dpr

egna

ntw

omen

atte

ndin

gan

tena

talc

linic

sin

sout

hB

otsw

ana

Inve

stig

atio

nsby

CD

Cof

adi

arrh

oea

outb

reak

inJa

nuar

y-Fe

brua

ry20

06in

the

sam

epo

pula

tion

Mat

erna

land

infa

ntan

tire

trov

iral

ther

apy

toas

cert

ain

impa

cton

HIV

tran

smis

sion

Ant

enat

alco

unse

lling

Cas

endashco

ntro

lstu

dyto

iden

tify

risk

fact

ors

for

diar

rhoe

ano

tbr

east

feed

ing

was

the

bigg

est

risk

fact

ora

djus

ted

odds

rati

o50

(95

confi

denc

ein

terv

al4

5ndash10

0)

Bot

swan

aha

sth

ebe

stpr

imar

yhe

alth

-car

est

ruct

ure

wat

ersu

pply

and

sani

tati

onsy

stem

sin

Sout

hA

fric

aFo

rmul

apr

ovid

edfr

eeby

the

gove

rnm

ent

toin

fect

edm

othe

rsL

ower

mor

talit

yin

the

brea

stfe

edin

ggr

oup

at7

mon

ths

dem

onst

rate

sri

skof

form

ula

feed

ing

and

need

for

alte

rnat

est

rate

gies

(Thi

oret

al

2006

)A

utho

rsco

nclu

deth

athe

alth

syst

ems

inw

hich

thes

epr

ogra

mm

esar

eim

plem

ente

dsh

ould

beab

leto

cope

wit

hdi

arrh

oea

and

mal

nutr

itio

nth

atre

sult

sbe

caus

eof

form

ula

feed

ing

(Rol

lins

2007

)C

oova

dia

etal

(2

007)

Kw

aZul

uNat

al

Sout

hA

fric

a27

22H

IV-i

nfec

ted

and

unin

fect

edpr

egna

ntw

omen

enro

lled

into

ano

n-ra

ndom

ized

inte

rven

tion

coho

rtst

udy

from

ante

nata

lcl

inic

sIn

fant

feed

ing

data

obta

ined

wee

kly

bloo

dsa

mpl

esfr

omin

fant

sta

ken

mon

thly

83

of13

72in

fant

sbo

rnto

HIV

-inf

ecte

dm

othe

rsin

itia

ted

excl

usiv

ebr

east

feed

ing

from

birt

hB

reas

tfed

infa

nts

who

rece

ived

solid

sw

ere

sign

ifica

ntly

mor

elik

ely

toac

quir

ein

fect

ion

com

pare

dw

ith

excl

usiv

ely

brea

stfe

d(H

R10

87

151

ndash78

P=

001

8)as

wer

ein

fant

sw

hoat

12w

eeks

rece

ived

brea

stan

dfo

rmul

am

ilk(1

82

098

ndash33

6P

=0

57)

Cum

ulat

ive

3-m

onth

mor

talit

yin

excl

usiv

ely

brea

stfe

dw

as6

1(4

74ndash

792

)vs

15

1(7

63ndash

287

3)in

infa

nts

give

nre

plac

emen

tfe

eds

(HR

206

1

0ndash4

27P

=0

05)

The

stud

ysh

ows

that

excl

usiv

ebr

east

feed

ing

can

besu

cces

sful

lysu

ppor

ted

inH

IV-i

nfec

ted

wom

enT

heau

thor

sca

llfo

rfu

rthe

rre

visi

onof

UN

ICE

FW

HO

and

USA

IDin

fant

feed

ing

guid

elin

es

CD

CC

ente

rof

Dis

ease

Con

trol

HR

haz

ards

rati

oU

NIC

EF

Uni

ted

Nat

ions

Chi

ldre

nF

unds

USA

IDU

SA

genc

yfo

rIn

tern

atio

nalD

evel

opm

ent

WH

OW

orld

Hea

lth

Org

aniz

atio

nZ

VIT

AM

BO

Z

imba

bwe

Vit

amin

Afo

rM

othe

rsan

dB

abie

s




















Conclusions















Acknowledgements




References


























































































App

endi

x1

Cas

est

udie

so

fef

fect

iven

ess

stud

ies

or

pilo

tpr

ogra

mm

es

Stud

yde

scri

ptio

nPo

pula

tion

Type

Inte

rven

tion

Par

tner

ship

sC

omm

unic

atio

n

stra

tegy

Trai

ning

Impa

cton

excl

usiv

e

brea

stfe

edin

g

Com

men

ts

Lut

ter

etal

(199

7)

Bra

zil

Low

-inc

ome

urba

nw

omen

deliv

erin

gin

hosp

ital

s

Bre

astf

eedi

ngpr

omot

ion

in

hosp

ital

sco

mpa

red

wit

h

nobr

east

feed

ing

prom

otio

n

Pro

mot

ion

ofbr

east

feed

ing

in

sele

cted

hosp

ital

s

Mea

nda

ysof

excl

usiv

e

brea

stfe

edin

g

75da

ysvs

22

days

(Plt

001

)

Rea

ampB

erqu

o

(199

0)

Wom

enw

ith

ach

ild

aged

lt2ye

ars

inSa

oP

aulo

Nat

iona

lbre

astf

eedi

ng

cam

paig

n19

81ndash1

986

BF

HI

Mas

sm

edia

cam

paig

n11

in

fant

s5ndash

6m

onth

s

excl

usiv

ely

brea

stfe

d

in19

88an

d37

in

1987

Con

foun

ding

fact

ors

over

the

6-ye

arpe

riod

not

mea

sure

d

Kra

mer

etal

(200

020

01)

PR

OB

ITtr

ial

Bel

arus

Clu

ster

rand

omiz

ed

34ho

spit

als

and

thei

rpo

lycl

inic

s

Trai

ning

inB

FH

I(W

HO

UN

ICE

F19

92)

vsr

outi

ne

prac

tice

san

dpo

licie

s

Exc

lusi

vebr

east

feed

ing

at3

(43

3vs

64

)

and

6(7

9

vs0

6

)

mon

ths

sign

ifica

ntly

high

er

Impl

emen

ted

thro

ugh

BF

HI

ina

sett

ing

whe

reho

spit

al

deliv

erie

sar

eco

mm

on

Per

ez-E

scam

illa

(200

4)

BA

SIC

SII

Mex

ico

Hon

dura

s

Bra

zil

MA

DL

AC

low

-cos

t

man

agem

ent

info

rmat

ion

syst

emto

use

an

evid

ence

-bas

edap

proa

chto

impr

ove

serv

ice

perf

orm

ance

Inte

rvie

win

gof

wom

enat

hosp

ital

disc

harg

epo

st

deliv

ery

usin

ga

ques

tion

nair

eth

atta

kes

5ndash7

min

toad

min

iste

ran

d

cont

ains

19br

east

feed

ing

prom

otio

nco

unse

lling

indi

cato

rs

Dat

aen

tere

dan

dre

sult

s

disc

usse

d3-

mon

thly

by

hosp

ital

com

mit

tee

Hos

pita

lim

plem

ents

chan

ges

in

brea

stfe

edin

g

supp

ort

base

don

anal

ysis

of

ques

tion

nair

es

Itis

aco

st-e

ffec

tive

inte

rven

tion

that

can

help

impr

ovem

ents

inth

eB

FH

I

and

isa

valu

able

tool

for

proc

ess

eval

uati

on



LIN

KA

GE

S

proj

ect

inA

fric

aan

d

Lat

inA

mer

ica

(Qui

nnet

al

2005

LIN

KA

GE

S

2002

WH

O20

03a)

Bol

ivia

(1

mill

ion)

Gha

na(3

5

mill

ion)

Mad

agas

car

(6m

illio

n)

Res

ourc

e-

poor

sett

ing

Pilo

tpr

ogra

mm

e

InB

oliv

iaan

d

Gha

napr

ogra

mm

e

focu

sed

on

brea

stfe

edin

gan

d

com

plem

enta

ry

feed

ing

InM

adag

asca

r

prog

ram

me

prom

oted

brea

stfe

edin

g

wit

hin

7es

sent

ial

nutr

itio

nac

tion

san

d

subs

eque

ntly

thro

ugh

IMC

I

Bui

lton

form

ativ

ere

sear

ch

and

sust

aine

dth

roug

h

prog

ram

me

acti

viti

esth

at

focu

sed

onbr

ingi

ngab

out

the

desi

red

beha

viou

r

chan

geM

ixof

inte

rven

tion

s

reac

hed

wom

enin

divi

dual

ly

orin

grou

psin

heal

th

faci

litie

sho

mes

or

com

mun

ity

sett

ings

Con

sist

ent

mes

sage

san

d

mat

eria

lacr

oss

all

prog

ram

me

chan

nels

Bol

ivi

PR

OC

OSI

NG

Os

Gha

na

UN

ICE

F

nati

onal

nutr

itio

n

offic

eN

GO

s

Mad

agas

car

Inte

rsec

tora

l

Act

ion

Gro

upfo

r

Nut

riti

on

Jere

o

Sala

ma

Isik

a

Pro

gram

desi

gned

wit

h

part

ners

Rad

ioin

all

thre

esi

tes

Mat

eria

ls

deve

lope

d

tosu

itne

eds

oflo

cal

heal

th

wor

kers

and

com

mun

ity

mem

bers

Gre

at

emph

asis

on

deve

lopm

ent

of coun

selli

ng

and

nego

tiat

ion

skill

s

prac

tica

l

sess

ions

Sign

ifica

ntin

crea

ses

inex

clus

ive

brea

stfe

edin

gra

tes

of

0ndash6-

mon

th-o

ld

infa

nts

from

54

to65

in

Bol

ivia

68

to79

in

Gha

naan

d46

to68

in

Mad

agas

car

In

Gha

naan

d

Mad

agas

car

sign

ifica

ntre

sult

s

obse

rved

wit

hin

aye

ar

ofin

itia

tion

of

com

mun

ity

inte

rven

tion

s

App

roac

hw

asef

fect

ive

and

achi

eved

sign

ifica

nt

incr

ease

sam

ong

larg

e

popu

lati

ons

asea

rly

as

9ndash12

mo

afte

rin

itia

tion

of

com

mun

ity

acti

viti

es

Van

Roe

kele

tal

(200

2)W

HO

(200

3a)

Hon

dura

sG

row

thm

onit

orin

gan

d

prom

otio

nkn

own

as

Ate

ncioacute

nIn

tegr

ala

la

Nintilde

ez(A

IN)

or

Inte

grat

edC

hild

Car

e

Init

ially

pri

mar

ilya

grow

th

mon

itor

ing

prog

ram

me

ulti

mat

ely

thro

ugh

IMC

I

Pro

gram

me

ongr

owth

prom

otio

nndash

asse

ssm

ent

of

mon

thly

wei

ght

gain

and

focu

son

illne

ssf

eedi

ng

prac

tice

san

dge

nera

lchi

ld

care

inin

fant

sun

der

2ye

ars

Impl

emen

ted

atgo

vern

men

t

faci

litie

san

dco

mm

unit

y

Star

ted

in19

92s

tren

gthe

ned

in19

95ndash1

997

wit

hgr

eate

r

focu

son

child

feed

ing

In

1997

pro

gram

me

intr

oduc

ed

wit

hIM

CI

(WH

OU

NIC

EF

2002

)

Maj

or

part

ners

UN

ICE

F

PAH

O

Am

eric

an

and

Hon

dura

n

Red

Cro

ss

CA

RE

Rad

io

broa

dcas

ts

relig

ious

lead

ers

IMC

IM

id-t

erm

eval

uati

on

show

ed39

of

mot

hers

inin

terv

enti

on

com

mun

itie

sex

clus

ivel

y

brea

stfe

dco

mpa

red

wit

h13

in

the

cont

rol

site

s



App

endi

x1

cont

inue

d

Stud

yde

scri

ptio

nPo

pula

tion

Type

Inte

rven

tion

Par

tner

ship

sC

omm

unic

atio

n

stra

tegy

Trai

ning

Impa

cton

excl

usiv

e

brea

stfe

edin

g

Com

men

ts

Bha

ndar

ieta

l

(200

3)

WH

O

(200

3a)

Rur

alco

mm

unit

ies

inH

arya

na

Indi

a

Clu

ster

rand

omiz

edtr

ial

8

com

mun

itie

s(t

otal

popu

lati

on~4

000

0)

Pro

mot

ion

ofex

clus

ive

brea

stfe

edin

gan

d

appr

opri

ate

com

plem

enta

ryfe

edin

g

Dev

elop

edth

roug

h

form

ativ

ere

sear

ch

ndashP

robl

emid

enti

ficat

ion

ndashP

arti

cipa

tory

desi

gnof

inte

rven

tion

impl

emen

tati

onan

d

eval

uati

on

Impl

emen

tati

onw

ithi

nan

exis

ting

prim

ary

heal

th-c

are

prog

ram

me

Opp

ortu

niti

esus

edto

deliv

erm

essa

ges

wer

e

imm

uniz

atio

ncl

inic

s

wei

ghin

gse

ssio

ns

sick

-chi

ldco

ntac

tsan

d

mon

thly

hom

evi

sits

Res

earc

hers

wit

hlo

cal

gove

rnm

ent

ICD

Ssy

stem

and

NG

O

The

atre

son

gs

Mas

sm

edia

not

used

for

risk

of

cont

amin

atio

n

Mat

eria

ls

deve

lope

d

for

heal

th

wor

kers

pos

ters

flip

book

sca

rds

Bre

astf

eedi

ng

coun

selli

ngse

ctio

n

ofth

eIM

CI

(WH

O

UN

ICE

F20

02)

Exc

lusi

ve

brea

stfe

edin

gin

the

prev

ious

24h

at3

mon

ths

of

age

79

vs4

8

The

posi

tive

effe

ct

rem

aine

dup

to

6m

onth

sof

age

(42

vs4

)

Tota

lpar

tici

pati

onof

the

dist

rict

heal

thsy

stem

from

ince

ptio

nof

the

prog

ram

me

inde

velo

ping

impl

emen

tati

onst

rate

gyt

ool

deve

lopm

ent

and

mon

itor

ing

inad

diti

onto

invo

lvem

ent

of

anN

GO

wer

eim

port

ant

feat

ures

that

cont

ribu

ted

to

the

succ

ess

ofth

e

inte

rven

tion

Mor

row

etal

(199

9)

Mex

ico

Cit

yC

lust

erra

ndom

ized

tria

l

Tota

lpop

ulat

ion

3000

0

Two

com

mun

itie

sin

the

inte

rven

tion

one

com

pari

son

130

wom

en

Hom

e-ba

sed

peer

coun

selli

ng

Pee

rco

unse

llors

mad

e3

or

6ho

me

visi

tsto

the

mot

her

Key

fam

ilym

embe

rsal

so

incl

uded

By

La

Lec

he

Lea

gue

of

Mex

ico

Exc

lusi

ve

brea

stfe

edin

g

at3

mon

ths

post

-par

tum

67

(6vi

sits

)

50

(3vi

sits

)12

(com

pari

son)

Firs

tcl

uste

rra

ndom

ized

com

mun

ity-

base

dtr

ialt

hat

used

peer

coun

sello

rsto

prom

ote

excl

usiv

e

brea

stfe

edin

g

Hai

der

etal

2000

200

2

Dha

ka

Low

mid

dle

and

low

-soc

io-

econ

omic

popu

lati

on

Clu

ster

rand

omiz

edtr

ial

20zo

nes

inin

terv

enti

on

and

20in

cont

rol

Com

mun

ity-

base

dpe

er

coun

selli

ngin

Dha

ka

15ho

me-

base

dco

unse

lling

visi

tsby

peer

coun

sello

rs

40h

(4h

yen10

days

)

WH

OU

NIC

EF

brea

stfe

edin

g

coun

selli

ngco

urse

(WH

OU

NIC

EF

1993

)

Exc

lusi

ve

brea

stfe

edin

g

at5

mon

ths

70

in

inte

rven

tion

and

6in

the

cont

rol

Com

mun

ity-

base

d

brea

stfe

edin

gpr

omot

ion

stra

tegy

was

effe

ctiv

ein

Ban

glad

esh

whe

rem

ost

deliv

erie

soc

cur

atho

me



Bry

ceet

al

(200

4)W

HO

(200

3b)

Bra

zil

Per

u

Tanz

ania

Uga

nda

Mul

tico

untr

yev

alua

tion

of

IMC

Ith

atin

clud

ed

effe

ctiv

enes

sco

stan

d

impa

ct(B

ryce

etal

2004

)

Bre

astf

eedi

ngpr

omot

ion

asa

part

ofIM

CI

IMC

Iis

ast

rate

gyfo

r

impr

ovin

gch

ildhe

alth

and

deve

lopm

ent

thro

ugh

the

com

bine

d

deliv

ery

ofes

sent

ial

child

heal

th

inte

rven

tion

sIM

CI

bega

nw

ith

ase

tof

case

man

agem

ent

guid

elin

es

for

the

man

agem

ent

ofsi

ckch

ildre

nat

first

-lev

elhe

alth

faci

litie

s

and

the

guid

elin

esw

ere

desi

gned

for

adap

tati

on

atco

untr

yle

vela

nd

belo

wO

ver

tim

eth

e

stra

tegy

expa

nded

to

incl

ude

ara

nge

of

guid

elin

esfo

rde

liver

ing

child

surv

ival

inte

rven

tion

at

hous

ehol

dco

mm

unit

y

and

refe

rral

leve

ls

IMC

Im

odul

e(W

HO

UN

ICE

F20

02)

Res

ults

onex

clus

ive

brea

stfe

edin

g

avai

labl

efr

om

Tanz

ania

whe

reno

sign

ifica

ntim

pact

was

seen

Des

pite

subs

tant

ial

impr

ovem

ent

inth

equ

alit

y

ofca

rede

liver

edby

IMC

Iat

heal

thfa

cilit

ies

key

fam

ily

prac

tice

ssu

chas

excl

usiv

e

brea

stfe

edin

gdi

dno

tch

ange

asco

mm

unit

yIM

CI

had

not

been

impl

emen

ted

byth

at

tim

e(W

HO

2003

b)

SA

rife

en

pers

onal

com

mun

icat

ion

Ban

glad

esh

Mat

lab

Com

mun

ity-

base

dcl

uste

r

desi

gn

Eva

luat

ion

offa

cilit

y-an

d

com

mun

ity-

base

dIM

CI

Inte

rven

tion

pack

age

incl

udes

feed

ing

asse

ssm

ent

and

coun

selli

ngon

mot

hers

ofyo

ung

child

ren

seek

ing

care

atfa

cilit

ies

for

illne

ssan

d

hom

e-ba

sed

coun

selli

ng

onim

prov

edfe

edin

gby

com

mun

ity-

base

dhe

alth

and

nutr

itio

nw

orke

rs

At

base

line

inth

e

year

2000

alit

tle

mor

eth

anha

lfth

e

0ndash5-

mon

th-o

ld

infa

nts

inth

est

udy

area

wer

ebe

ing

excl

usiv

ely

brea

stfe

dB

y20

05

this

incr

ease

dby

30

inth

eIM

CI

area

Dat

ano

t

avai

labl

efr

omth

e

com

pari

son

area

as

yet

Lac

kof

com

para

ble

data

from

the

com

pari

son

area

prev

ents

ade

finit

ive

conc

lusi

onas

tow

heth

erth

is

trul

yis

anim

pact

ofIM

CI

BA

SIC

SII

Bas

icSu

ppor

tfo

rIn

stit

utio

naliz

ing

Chi

ldSu

rviv

alP

roje

ctB

FH

IB

aby-

Frie

ndly

Hos

pita

lIni

tiat

ive

ICD

SIn

tegr

ated

Chi

ldD

evel

opm

ent

Serv

ices

IM

CI

Inte

grat

edM

anag

emen

tof

Chi

ldho

odIl

lnes

sM

AD

LA

CM

onit

oreo

deA

poyo

Dir

ecto

con

laL

acat

anci

aM

ater

naN

GO

non

-gov

ernm

enta

lorg

aniz

atio

nPA

HO

Pan

Am

eric

anH

ealt

hO

rgan

izat

ion

PR

OB

ITP

rom

otio

nof

Bre

astf

eedi

ngIn

terv

enti

onTr

ial

PR

OC

OSI

Pro

gram

ade

Coo

rdin

acio

nen

Salu

dIn

tegr

al(C

olla

bora

tive

Pro

gram

for

Inte

grat

edH

ealt

h)U

NIC

EF

Uni

ted

Nat

ions

Chi

ldre

nF

unds

WH

OW

orld

Hea

lth

Org

aniz

atio

n



App

endi

x2

Cas

est

udie

sin

scal

e-up

effo

rts

inH

IVA

IDS

Stud

yde

scri

ptio

nPo

pula

tion

Inte

rven

tion

Com

mun

icat

ion

stra

tegy

Impa

cton

excl

usiv

ebr

east

feed

ing

Com

men

ts

LIN

KA

GE

S(2

005)

Zam

bia

Pro

gram

me

thro

ugh

heal

th-c

are

and

com

mun

ity

serv

ices

Rea

ched

60si

tes

in6

dist

rict

sby

2005

Inte

grat

ion

ofin

fant

feed

ing

coun

selli

ngm

ater

naln

utri

tion

and

anti

retr

ovir

aldr

ugs

prop

hyla

xis

Trai

ning

ofhe

alth

wor

kers

and

com

mun

ity

serv

ice

prov

ider

sto

coun

selw

omen

onsa

fety

opti

ons

for

thei

rsi

tuat

ion

Beh

avio

urch

ange

Com

mun

icat

ion

inte

rven

tion

sin

the

first

few

year

sM

ater

iald

evel

oped

lsquoAct

Now

rsquoM

edia

cam

paig

nsin

clud

edbr

ochu

res

post

ers

radi

oan

dte

levi

sion

Ass

esse

dth

roug

hba

selin

ean

dfo

llow

-up

hous

ehol

dan

dcl

inic

surv

eys

inse

lect

eddi

stri

cts

Exc

lusi

vebr

east

feed

ing

rate

incr

ease

dfr

om50

in

2002

to64

in

2004

inL

ivin

gsto

nean

dfr

om57

in

2000

to74

in

2004

inN

dola

Inte

grat

edde

mon

stra

tion

proj

ect

Had

seve

rals

tren

gths

inte

rms

ofth

eus

eof

form

ativ

ere

sear

chto

deve

lop

mes

sage

str

aini

ngan

dbu

ildin

gup

skill

sof

prog

ram

me

man

ager

she

alth

-car

epr

ovid

ers

and

com

mun

ity

wor

kers

adv

ocac

yfo

rna

tion

alpo

licy

stro

ngbe

havi

our

chan

geco

mm

unic

atio

nco

mpo

nent

st

reng

then

ing

com

mun

ity

capa

city

for

coun

selli

ngan

dre

ferr

als

and

mon

itor

ing

and

eval

uati

onw

ith

loca

lpar

tner

sP

iwoz

etal

(20

05)

ZV

ITA

MB

Otr

ial

Har

are

Zim

babw

eE

duca

tion

and

coun

selli

ngpr

ogra

mm

ede

liver

edan

tena

tally

1411

0m

othe

rndashba

bypa

irs

enro

lled

from

14m

ater

nity

clin

ics

wit

hin

96h

ofde

liver

yan

dfo

llow

edup

at6

wee

ks

3m

onth

san

d3-

mon

thly

inte

rval

sIn

fant

-fee

ding

patt

erns

dete

rmin

edE

xclu

sive

brea

stfe

edin

gre

com

men

ded

for

HIV

nega

tive

un

know

nor

HIV

posi

tive

who

chos

eto

brea

stfe

ed

Gro

uped

ucat

ion

indi

vidu

alco

unse

lling

vid

eos

broc

hure

sM

othe

rsw

hoen

rolle

dw

hen

prog

ram

me

was

fully

impl

emen

ted

wer

e8

4ti

mes

mor

elik

ely

toex

clus

ivel

ybr

east

feed

than

mot

hers

who

enro

lled

befo

reth

epr

ogra

mm

ebe

gan

Ove

rall

excl

usiv

ebr

east

feed

ing

rate

sti

ll3

mon

ths

was

low

at24

6

Form

ativ

ere

sear

chus

edto

desi

gna

cult

ural

lyse

nsit

ive

educ

atio

nan

dco

unse

lling

prog

ram

me

Low

over

alle

xclu

sive

brea

stfe

edin

gra

tes

prom

pted

auth

ors

toco

nclu

deth

atw

omen

and

thei

rpa

rtne

rssh

ould

have

been

reac

hed

mor

efr

eque

ntly

duri

ngan

tena

tala

ndpo

st-n

atal

peri

od



Thi

oret

al(

2006

)R

ollin

s(2

007)

C

ohen

(200

7)

HIV

-inf

ecte

dpr

egna

ntw

omen

atte

ndin

gan

tena

talc

linic

sin

sout

hB

otsw

ana

Inve

stig

atio

nsby

CD

Cof

adi

arrh

oea

outb

reak

inJa

nuar

y-Fe

brua

ry20

06in

the

sam

epo

pula

tion

Mat

erna

land

infa

ntan

tire

trov

iral

ther

apy

toas

cert

ain

impa

cton

HIV

tran

smis

sion

Ant

enat

alco

unse

lling

Cas

endashco

ntro

lstu

dyto

iden

tify

risk

fact

ors

for

diar

rhoe

ano

tbr

east

feed

ing

was

the

bigg

est

risk

fact

ora

djus

ted

odds

rati

o50

(95

confi

denc

ein

terv

al4

5ndash10

0)

Bot

swan

aha

sth

ebe

stpr

imar

yhe

alth

-car

est

ruct

ure

wat

ersu

pply

and

sani

tati

onsy

stem

sin

Sout

hA

fric

aFo

rmul

apr

ovid

edfr

eeby

the

gove

rnm

ent

toin

fect

edm

othe

rsL

ower

mor

talit

yin

the

brea

stfe

edin

ggr

oup

at7

mon

ths

dem

onst

rate

sri

skof

form

ula

feed

ing

and

need

for

alte

rnat

est

rate

gies

(Thi

oret

al

2006

)A

utho

rsco

nclu

deth

athe

alth

syst

ems

inw

hich

thes

epr

ogra

mm

esar

eim

plem

ente

dsh

ould

beab

leto

cope

wit

hdi

arrh

oea

and

mal

nutr

itio

nth

atre

sult

sbe

caus

eof

form

ula

feed

ing

(Rol

lins

2007

)C

oova

dia

etal

(2

007)

Kw

aZul

uNat

al

Sout

hA

fric

a27

22H

IV-i

nfec

ted

and

unin

fect

edpr

egna

ntw

omen

enro

lled

into

ano

n-ra

ndom

ized

inte

rven

tion

coho

rtst

udy

from

ante

nata

lcl

inic

sIn

fant

feed

ing

data

obta

ined

wee

kly

bloo

dsa

mpl

esfr

omin

fant

sta

ken

mon

thly

83

of13

72in

fant

sbo

rnto

HIV

-inf

ecte

dm

othe

rsin

itia

ted

excl

usiv

ebr

east

feed

ing

from

birt

hB

reas

tfed

infa

nts

who

rece

ived

solid

sw

ere

sign

ifica

ntly

mor

elik

ely

toac

quir

ein

fect

ion

com

pare

dw

ith

excl

usiv

ely

brea

stfe

d(H

R10

87

151

ndash78

P=

001

8)as

wer

ein

fant

sw

hoat

12w

eeks

rece

ived

brea

stan

dfo

rmul

am

ilk(1

82

098

ndash33

6P

=0

57)

Cum

ulat

ive

3-m

onth

mor

talit

yin

excl

usiv

ely

brea

stfe

dw

as6

1(4

74ndash

792

)vs

15

1(7

63ndash

287

3)in

infa

nts

give

nre

plac

emen

tfe

eds

(HR

206

1

0ndash4

27P

=0

05)

The

stud

ysh

ows

that

excl

usiv

ebr

east

feed

ing

can

besu

cces

sful

lysu

ppor

ted

inH

IV-i

nfec

ted

wom

enT

heau

thor

sca

llfo

rfu

rthe

rre

visi

onof

UN

ICE

FW

HO

and

USA

IDin

fant

feed

ing

guid

elin

es

CD

CC

ente

rof

Dis

ease

Con

trol

HR

haz

ards

rati

oU

NIC

EF

Uni

ted

Nat

ions

Chi

ldre

nF

unds

USA

IDU

SA

genc

yfo

rIn

tern

atio

nalD

evel

opm

ent

WH

OW

orld

Hea

lth

Org

aniz

atio

nZ

VIT

AM

BO

Z

imba

bwe

Vit

amin

Afo

rM

othe

rsan

dB

abie

s





Conclusions















Acknowledgements




References


























































































App

endi

x1

Cas

est

udie

so

fef

fect

iven

ess

stud

ies

or

pilo

tpr

ogra

mm

es

Stud

yde

scri

ptio

nPo

pula

tion

Type

Inte

rven

tion

Par

tner

ship

sC

omm

unic

atio

n

stra

tegy

Trai

ning

Impa

cton

excl

usiv

e

brea

stfe

edin

g

Com

men

ts

Lut

ter

etal

(199

7)

Bra

zil

Low

-inc

ome

urba

nw

omen

deliv

erin

gin

hosp

ital

s

Bre

astf

eedi

ngpr

omot

ion

in

hosp

ital

sco

mpa

red

wit

h

nobr

east

feed

ing

prom

otio

n

Pro

mot

ion

ofbr

east

feed

ing

in

sele

cted

hosp

ital

s

Mea

nda

ysof

excl

usiv

e

brea

stfe

edin

g

75da

ysvs

22

days

(Plt

001

)

Rea

ampB

erqu

o

(199

0)

Wom

enw

ith

ach

ild

aged

lt2ye

ars

inSa

oP

aulo

Nat

iona

lbre

astf

eedi

ng

cam

paig

n19

81ndash1

986

BF

HI

Mas

sm

edia

cam

paig

n11

in

fant

s5ndash

6m

onth

s

excl

usiv

ely

brea

stfe

d

in19

88an

d37

in

1987

Con

foun

ding

fact

ors

over

the

6-ye

arpe

riod

not

mea

sure

d

Kra

mer

etal

(200

020

01)

PR

OB

ITtr

ial

Bel

arus

Clu

ster

rand

omiz

ed

34ho

spit

als

and

thei

rpo

lycl

inic

s

Trai

ning

inB

FH

I(W

HO

UN

ICE

F19

92)

vsr

outi

ne

prac

tice

san

dpo

licie

s

Exc

lusi

vebr

east

feed

ing

at3

(43

3vs

64

)

and

6(7

9

vs0

6

)

mon

ths

sign

ifica

ntly

high

er

Impl

emen

ted

thro

ugh

BF

HI

ina

sett

ing

whe

reho

spit

al

deliv

erie

sar

eco

mm

on

Per

ez-E

scam

illa

(200

4)

BA

SIC

SII

Mex

ico

Hon

dura

s

Bra

zil

MA

DL

AC

low

-cos

t

man

agem

ent

info

rmat

ion

syst

emto

use

an

evid

ence

-bas

edap

proa

chto

impr

ove

serv

ice

perf

orm

ance

Inte

rvie

win

gof

wom

enat

hosp

ital

disc

harg

epo

st

deliv

ery

usin

ga

ques

tion

nair

eth

atta

kes

5ndash7

min

toad

min

iste

ran

d

cont

ains

19br

east

feed

ing

prom

otio

nco

unse

lling

indi

cato

rs

Dat

aen

tere

dan

dre

sult

s

disc

usse

d3-

mon

thly

by

hosp

ital

com

mit

tee

Hos

pita

lim

plem

ents

chan

ges

in

brea

stfe

edin

g

supp

ort

base

don

anal

ysis

of

ques

tion

nair

es

Itis

aco

st-e

ffec

tive

inte

rven

tion

that

can

help

impr

ovem

ents

inth

eB

FH

I

and

isa

valu

able

tool

for

proc

ess

eval

uati

on



LIN

KA

GE

S

proj

ect

inA

fric

aan

d

Lat

inA

mer

ica

(Qui

nnet

al

2005

LIN

KA

GE

S

2002

WH

O20

03a)

Bol

ivia

(1

mill

ion)

Gha

na(3

5

mill

ion)

Mad

agas

car

(6m

illio

n)

Res

ourc

e-

poor

sett

ing

Pilo

tpr

ogra

mm

e

InB

oliv

iaan

d

Gha

napr

ogra

mm

e

focu

sed

on

brea

stfe

edin

gan

d

com

plem

enta

ry

feed

ing

InM

adag

asca

r

prog

ram

me

prom

oted

brea

stfe

edin

g

wit

hin

7es

sent

ial

nutr

itio

nac

tion

san

d

subs

eque

ntly

thro

ugh

IMC

I

Bui

lton

form

ativ

ere

sear

ch

and

sust

aine

dth

roug

h

prog

ram

me

acti

viti

esth

at

focu

sed

onbr

ingi

ngab

out

the

desi

red

beha

viou

r

chan

geM

ixof

inte

rven

tion

s

reac

hed

wom

enin

divi

dual

ly

orin

grou

psin

heal

th

faci

litie

sho

mes

or

com

mun

ity

sett

ings

Con

sist

ent

mes

sage

san

d

mat

eria

lacr

oss

all

prog

ram

me

chan

nels

Bol

ivi

PR

OC

OSI

NG

Os

Gha

na

UN

ICE

F

nati

onal

nutr

itio

n

offic

eN

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s

Mad

agas

car

Inte

rsec

tora

l

Act

ion

Gro

upfo

r

Nut

riti

on

Jere

o

Sala

ma

Isik

a

Pro

gram

desi

gned

wit

h

part

ners

Rad

ioin

all

thre

esi

tes

Mat

eria

ls

deve

lope

d

tosu

itne

eds

oflo

cal

heal

th

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inic

sIn

fant

feed

ing

data

obta

ined

wee

kly

bloo

dsa

mpl

esfr

omin

fant

sta

ken

mon

thly

83

of13

72in

fant

sbo

rnto

HIV

-inf

ecte

dm

othe

rsin

itia

ted

excl

usiv

ebr

east

feed

ing

from

birt

hB

reas

tfed

infa

nts

who

rece

ived

solid

sw

ere

sign

ifica

ntly

mor

elik

ely

toac

quir

ein

fect

ion

com

pare

dw

ith

excl

usiv

ely

brea

stfe

d(H

R10

87

151

ndash78

P=

001

8)as

wer

ein

fant

sw

hoat

12w

eeks

rece

ived

brea

stan

dfo

rmul

am

ilk(1

82

098

ndash33

6P

=0

57)

Cum

ulat

ive

3-m

onth

mor

talit

yin

excl

usiv

ely

brea

stfe

dw

as6

1(4

74ndash

792

)vs

15

1(7

63ndash

287

3)in

infa

nts

give

nre

plac

emen

tfe

eds

(HR

206

1

0ndash4

27P

=0

05)

The

stud

ysh

ows

that

excl

usiv

ebr

east

feed

ing

can

besu

cces

sful

lysu

ppor

ted

inH

IV-i

nfec

ted

wom

enT

heau

thor

sca

llfo

rfu

rthe

rre

visi

onof

UN

ICE

FW

HO

and

USA

IDin

fant

feed

ing

guid

elin

es

CD

CC

ente

rof

Dis

ease

Con

trol

HR

haz

ards

rati

oU

NIC

EF

Uni

ted

Nat

ions

Chi

ldre

nF

unds

USA

IDU

SA

genc

yfo

rIn

tern

atio

nalD

evel

opm

ent

WH

OW

orld

Hea

lth

Org

aniz

atio

nZ

VIT

AM

BO

Z

imba

bwe

Vit

amin

Afo

rM

othe

rsan

dB

abie

s








Acknowledgements




References


























































































App

endi

x1

Cas

est

udie

so

fef

fect

iven

ess

stud

ies

or

pilo

tpr

ogra

mm

es

Stud

yde

scri

ptio

nPo

pula

tion

Type

Inte

rven

tion

Par

tner

ship

sC

omm

unic

atio

n

stra

tegy

Trai

ning

Impa

cton

excl

usiv

e

brea

stfe

edin

g

Com

men

ts

Lut

ter

etal

(199

7)

Bra

zil

Low

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ome

urba

nw

omen

deliv

erin

gin

hosp

ital

s

Bre

astf

eedi

ngpr

omot

ion

in

hosp

ital

sco

mpa

red

wit

h

nobr

east

feed

ing

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otio

n

Pro

mot

ion

ofbr

east

feed

ing

in

sele

cted

hosp

ital

s

Mea

nda

ysof

excl

usiv

e

brea

stfe

edin

g

75da

ysvs

22

days

(Plt

001

)

Rea

ampB

erqu

o

(199

0)

Wom

enw

ith

ach

ild

aged

lt2ye

ars

inSa

oP

aulo

Nat

iona

lbre

astf

eedi

ng

cam

paig

n19

81ndash1

986

BF

HI

Mas

sm

edia

cam

paig

n11

in

fant

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6m

onth

s

excl

usiv

ely

brea

stfe

d

in19

88an

d37

in

1987

Con

foun

ding

fact

ors

over

the

6-ye

arpe

riod

not

mea

sure

d

Kra

mer

etal

(200

020

01)

PR

OB

ITtr

ial

Bel

arus

Clu

ster

rand

omiz

ed

34ho

spit

als

and

thei

rpo

lycl

inic

s

Trai

ning

inB

FH

I(W

HO

UN

ICE

F19

92)

vsr

outi

ne

prac

tice

san

dpo

licie

s

Exc

lusi

vebr

east

feed

ing

at3

(43

3vs

64

)

and

6(7

9

vs0

6

)

mon

ths

sign

ifica

ntly

high

er

Impl

emen

ted

thro

ugh

BF

HI

ina

sett

ing

whe

reho

spit

al

deliv

erie

sar

eco

mm

on

Per

ez-E

scam

illa

(200

4)

BA

SIC

SII

Mex

ico

Hon

dura

s

Bra

zil

MA

DL

AC

low

-cos

t

man

agem

ent

info

rmat

ion

syst

emto

use

an

evid

ence

-bas

edap

proa

chto

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ove

serv

ice

perf

orm

ance

Inte

rvie

win

gof

wom

enat

hosp

ital

disc

harg

epo

st

deliv

ery

usin

ga

ques

tion

nair

eth

atta

kes

5ndash7

min

toad

min

iste

ran

d

cont

ains

19br

east

feed

ing

prom

otio

nco

unse

lling

indi

cato

rs

Dat

aen

tere

dan

dre

sult

s

disc

usse

d3-

mon

thly

by

hosp

ital

com

mit

tee

Hos

pita

lim

plem

ents

chan

ges

in

brea

stfe

edin

g

supp

ort

base

don

anal

ysis

of

ques

tion

nair

es

Itis

aco

st-e

ffec

tive

inte

rven

tion

that

can

help

impr

ovem

ents

inth

eB

FH

I

and

isa

valu

able

tool

for

proc

ess

eval

uati

on



LIN

KA

GE

S

proj

ect

inA

fric

aan

d

Lat

inA

mer

ica

(Qui

nnet

al

2005

LIN

KA

GE

S

2002

WH

O20

03a)

Bol

ivia

(1

mill

ion)

Gha

na(3

5

mill

ion)

Mad

agas

car

(6m

illio

n)

Res

ourc

e-

poor

sett

ing

Pilo

tpr

ogra

mm

e

InB

oliv

iaan

d

Gha

napr

ogra

mm

e

focu

sed

on

brea

stfe

edin

gan

d

com

plem

enta

ry

feed

ing

InM

adag

asca

r

prog

ram

me

prom

oted

brea

stfe

edin

g

wit

hin

7es

sent

ial

nutr

itio

nac

tion

san

d

subs

eque

ntly

thro

ugh

IMC

I

Bui

lton

form

ativ

ere

sear

ch

and

sust

aine

dth

roug

h

prog

ram

me

acti

viti

esth

at

focu

sed

onbr

ingi

ngab

out

the

desi

red

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viou

r

chan

geM

ixof

inte

rven

tion

s

reac

hed

wom

enin

divi

dual

ly

orin

grou

psin

heal

th

faci

litie

sho

mes

or

com

mun

ity

sett

ings

Con

sist

ent

mes

sage

san

d

mat

eria

lacr

oss

all

prog

ram

me

chan

nels

Bol

ivi

PR

OC

OSI

NG

Os

Gha

na

UN

ICE

F

nati

onal

nutr

itio

n

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eN

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s

Mad

agas

car

Inte

rsec

tora

l

Act

ion

Gro

upfo

r

Nut

riti

on

Jere

o

Sala

ma

Isik

a

Pro

gram

desi

gned

wit

h

part

ners

Rad

ioin

all

thre

esi

tes

Mat

eria

ls

deve

lope

d

tosu

itne

eds

oflo

cal

heal

th

wor

kers

and

com

mun

ity

mem

bers

Gre

at

emph

asis

on

deve

lopm

ent

of coun

selli

ng

and

nego

tiat

ion

skill

s

prac

tica

l

sess

ions

Sign

ifica

ntin

crea

ses

inex

clus

ive

brea

stfe

edin

gra

tes

of

0ndash6-

mon

th-o

ld

infa

nts

from

54

to65

in

Bol

ivia

68

to79

in

Gha

naan

d46

to68

in

Mad

agas

car

In

Gha

naan

d

Mad

agas

car

sign

ifica

ntre

sult

s

obse

rved

wit

hin

aye

ar

ofin

itia

tion

of

com

mun

ity

inte

rven

tion

s

App

roac

hw

asef

fect

ive

and

achi

eved

sign

ifica

nt

incr

ease

sam

ong

larg

e

popu

lati

ons

asea

rly

as

9ndash12

mo

afte

rin

itia

tion

of

com

mun

ity

acti

viti

es

Van

Roe

kele

tal

(200

2)W

HO

(200

3a)

Hon

dura

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row

thm

onit

orin

gan

d

prom

otio

nkn

own

as

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ncioacute

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tegr

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ez(A

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or

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grat

edC

hild

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e

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ially

pri

mar

ilya

grow

th

mon

itor

ing

prog

ram

me

ulti

mat

ely

thro

ugh

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gram

me

ongr

owth

prom

otio

nndash

asse

ssm

ent

of

mon

thly

wei

ght

gain

and

focu

son

illne

ssf

eedi

ng

prac

tice

san

dge

nera

lchi

ld

care

inin

fant

sun

der

2ye

ars

Impl

emen

ted

atgo

vern

men

t

faci

litie

san

dco

mm

unit

y

Star

ted

in19

92s

tren

gthe

ned

in19

95ndash1

997

wit

hgr

eate

r

focu

son

child

feed

ing

In

1997

pro

gram

me

intr

oduc

ed

wit

hIM

CI

(WH

OU

NIC

EF

2002

)

Maj

or

part

ners

UN

ICE

F

PAH

O

Am

eric

an

and

Hon

dura

n

Red

Cro

ss

CA

RE

Rad

io

broa

dcas

ts

relig

ious

lead

ers

IMC

IM

id-t

erm

eval

uati

on

show

ed39

of

mot

hers

inin

terv

enti

on

com

mun

itie

sex

clus

ivel

y

brea

stfe

dco

mpa

red

wit

h13

in

the

cont

rol

site

s



App

endi

x1

cont

inue

d

Stud

yde

scri

ptio

nPo

pula

tion

Type

Inte

rven

tion

Par

tner

ship

sC

omm

unic

atio

n

stra

tegy

Trai

ning

Impa

cton

excl

usiv

e

brea

stfe

edin

g

Com

men

ts

Bha

ndar

ieta

l

(200

3)

WH

O

(200

3a)

Rur

alco

mm

unit

ies

inH

arya

na

Indi

a

Clu

ster

rand

omiz

edtr

ial

8

com

mun

itie

s(t

otal

popu

lati

on~4

000

0)

Pro

mot

ion

ofex

clus

ive

brea

stfe

edin

gan

d

appr

opri

ate

com

plem

enta

ryfe

edin

g

Dev

elop

edth

roug

h

form

ativ

ere

sear

ch

ndashP

robl

emid

enti

ficat

ion

ndashP

arti

cipa

tory

desi

gnof

inte

rven

tion

impl

emen

tati

onan

d

eval

uati

on

Impl

emen

tati

onw

ithi

nan

exis

ting

prim

ary

heal

th-c

are

prog

ram

me

Opp

ortu

niti

esus

edto

deliv

erm

essa

ges

wer

e

imm

uniz

atio

ncl

inic

s

wei

ghin

gse

ssio

ns

sick

-chi

ldco

ntac

tsan

d

mon

thly

hom

evi

sits

Res

earc

hers

wit

hlo

cal

gove

rnm

ent

ICD

Ssy

stem

and

NG

O

The

atre

son

gs

Mas

sm

edia

not

used

for

risk

of

cont

amin

atio

n

Mat

eria

ls

deve

lope

d

for

heal

th

wor

kers

pos

ters

flip

book

sca

rds

Bre

astf

eedi

ng

coun

selli

ngse

ctio

n

ofth

eIM

CI

(WH

O

UN

ICE

F20

02)

Exc

lusi

ve

brea

stfe

edin

gin

the

prev

ious

24h

at3

mon

ths

of

age

79

vs4

8

The

posi

tive

effe

ct

rem

aine

dup

to

6m

onth

sof

age

(42

vs4

)

Tota

lpar

tici

pati

onof

the

dist

rict

heal

thsy

stem

from

ince

ptio

nof

the

prog

ram

me

inde

velo

ping

impl

emen

tati

onst

rate

gyt

ool

deve

lopm

ent

and

mon

itor

ing

inad

diti

onto

invo

lvem

ent

of

anN

GO

wer

eim

port

ant

feat

ures

that

cont

ribu

ted

to

the

succ

ess

ofth

e

inte

rven

tion

Mor

row

etal

(199

9)

Mex

ico

Cit

yC

lust

erra

ndom

ized

tria

l

Tota

lpop

ulat

ion

3000

0

Two

com

mun

itie

sin

the

inte

rven

tion

one

com

pari

son

130

wom

en

Hom

e-ba

sed

peer

coun

selli

ng

Pee

rco

unse

llors

mad

e3

or

6ho

me

visi

tsto

the

mot

her

Key

fam

ilym

embe

rsal

so

incl

uded

By

La

Lec

he

Lea

gue

of

Mex

ico

Exc

lusi

ve

brea

stfe

edin

g

at3

mon

ths

post

-par

tum

67

(6vi

sits

)

50

(3vi

sits

)12

(com

pari

son)

Firs

tcl

uste

rra

ndom

ized

com

mun

ity-

base

dtr

ialt

hat

used

peer

coun

sello

rsto

prom

ote

excl

usiv

e

brea

stfe

edin

g

Hai

der

etal

2000

200

2

Dha

ka

Low

mid

dle

and

low

-soc

io-

econ

omic

popu

lati

on

Clu

ster

rand

omiz

edtr

ial

20zo

nes

inin

terv

enti

on

and

20in

cont

rol

Com

mun

ity-

base

dpe

er

coun

selli

ngin

Dha

ka

15ho

me-

base

dco

unse

lling

visi

tsby

peer

coun

sello

rs

40h

(4h

yen10

days

)

WH

OU

NIC

EF

brea

stfe

edin

g

coun

selli

ngco

urse

(WH

OU

NIC

EF

1993

)

Exc

lusi

ve

brea

stfe

edin

g

at5

mon

ths

70

in

inte

rven

tion

and

6in

the

cont

rol

Com

mun

ity-

base

d

brea

stfe

edin

gpr

omot

ion

stra

tegy

was

effe

ctiv

ein

Ban

glad

esh

whe

rem

ost

deliv

erie

soc

cur

atho

me



Bry

ceet

al

(200

4)W

HO

(200

3b)

Bra

zil

Per

u

Tanz

ania

Uga

nda

Mul

tico

untr

yev

alua

tion

of

IMC

Ith

atin

clud

ed

effe

ctiv

enes

sco

stan

d

impa

ct(B

ryce

etal

2004

)

Bre

astf

eedi

ngpr

omot

ion

asa

part

ofIM

CI

IMC

Iis

ast

rate

gyfo

r

impr

ovin

gch

ildhe

alth

and

deve

lopm

ent

thro

ugh

the

com

bine

d

deliv

ery

ofes

sent

ial

child

heal

th

inte

rven

tion

sIM

CI

bega

nw

ith

ase

tof

case

man

agem

ent

guid

elin

es

for

the

man

agem

ent

ofsi

ckch

ildre

nat

first

-lev

elhe

alth

faci

litie

s

and

the

guid

elin

esw

ere

desi

gned

for

adap

tati

on

atco

untr

yle

vela

nd

belo

wO

ver

tim

eth

e

stra

tegy

expa

nded

to

incl

ude

ara

nge

of

guid

elin

esfo

rde

liver

ing

child

surv

ival

inte

rven

tion

at

hous

ehol

dco

mm

unit

y

and

refe

rral

leve

ls

IMC

Im

odul

e(W

HO

UN

ICE

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02)

Res

ults

onex

clus

ive

brea

stfe

edin

g

avai

labl

efr

om

Tanz

ania

whe

reno

sign

ifica

ntim

pact

was

seen

Des

pite

subs

tant

ial

impr

ovem

ent

inth

equ

alit

y

ofca

rede

liver

edby

IMC

Iat

heal

thfa

cilit

ies

key

fam

ily

prac

tice

ssu

chas

excl

usiv

e

brea

stfe

edin

gdi

dno

tch

ange

asco

mm

unit

yIM

CI

had

not

been

impl

emen

ted

byth

at

tim

e(W

HO

2003

b)

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rife

en

pers

onal

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mun

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ion

Ban

glad

esh

Mat

lab

Com

mun

ity-

base

dcl

uste

r

desi

gn

Eva

luat

ion

offa

cilit

y-an

d

com

mun

ity-

base

dIM

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Inte

rven

tion

pack

age

incl

udes

feed

ing

asse

ssm

ent

and

coun

selli

ngon

mot

hers

ofyo

ung

child

ren

seek

ing

care

atfa

cilit

ies

for

illne

ssan

d

hom

e-ba

sed

coun

selli

ng

onim

prov

edfe

edin

gby

com

mun

ity-

base

dhe

alth

and

nutr

itio

nw

orke

rs

At

base

line

inth

e

year

2000

alit

tle

mor

eth

anha

lfth

e

0ndash5-

mon

th-o

ld

infa

nts

inth

est

udy

area

wer

ebe

ing

excl

usiv

ely

brea

stfe

dB

y20

05

this

incr

ease

dby

30

inth

eIM

CI

area

Dat

ano

t

avai

labl

efr

omth

e

com

pari

son

area

as

yet

Lac

kof

com

para

ble

data

from

the

com

pari

son

area

prev

ents

ade

finit

ive

conc

lusi

onas

tow

heth

erth

is

trul

yis

anim

pact

ofIM

CI

BA

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Bas

icSu

ppor

tfo

rIn

stit

utio

naliz

ing

Chi

ldSu

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alP

roje

ctB

FH

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aby-

Frie

ndly

Hos

pita

lIni

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ive

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emen

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on

Impl

emen

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ting

prim

ary

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ges

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e

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uniz

atio

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inic

s

wei

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gse

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d

mon

thly

hom

evi

sits

Res

earc

hers

wit

hlo

cal

gove

rnm

ent

ICD

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stem

and

NG

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atre

son

gs

Mas

sm

edia

not

used

for

risk

of

cont

amin

atio

n

Mat

eria

ls

deve

lope

d

for

heal

th

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kers

pos

ters

flip

book

sca

rds

Bre

astf

eedi

ng

coun

selli

ngse

ctio

n

ofth

eIM

CI

(WH

O

UN

ICE

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02)

Exc

lusi

ve

brea

stfe

edin

gin

the

prev

ious

24h

at3

mon

ths

of

age

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vs4

8

The

posi

tive

effe

ct

rem

aine

dup

to

6m

onth

sof

age

(42

vs4

)

Tota

lpar

tici

pati

onof

the

dist

rict

heal

thsy

stem

from

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ptio

nof

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prog

ram

me

inde

velo

ping

impl

emen

tati

onst

rate

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ent

and

mon

itor

ing

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diti

onto

invo

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of

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port

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that

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ted

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row

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9)

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ized

tria

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3000

0

Two

com

mun

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sin

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com

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130

wom

en

Hom

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peer

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mot

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so

incl

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gue

of

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ico

Exc

lusi

ve

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g

at3

mon

ths

post

-par

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)

50

(3vi

sits

)12

(com

pari

son)

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tcl

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ized

com

mun

ity-

base

dtr

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hat

used

peer

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sello

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prom

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usiv

e

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stfe

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g

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der

etal

2000

200

2

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ka

Low

mid

dle

and

low

-soc

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econ

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popu

lati

on

Clu

ster

rand

omiz

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nes

inin

terv

enti

on

and

20in

cont

rol

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mun

ity-

base

dpe

er

coun

selli

ngin

Dha

ka

15ho

me-

base

dco

unse

lling

visi

tsby

peer

coun

sello

rs

40h

(4h

yen10

days

)

WH

OU

NIC

EF

brea

stfe

edin

g

coun

selli

ngco

urse

(WH

OU

NIC

EF

1993

)

Exc

lusi

ve

brea

stfe

edin

g

at5

mon

ths

70

in

inte

rven

tion

and

6in

the

cont

rol

Com

mun

ity-

base

d

brea

stfe

edin

gpr

omot

ion

stra

tegy

was

effe

ctiv

ein

Ban

glad

esh

whe

rem

ost

deliv

erie

soc

cur

atho

me



Bry

ceet

al

(200

4)W

HO

(200

3b)

Bra

zil

Per

u

Tanz

ania

Uga

nda

Mul

tico

untr

yev

alua

tion

of

IMC

Ith

atin

clud

ed

effe

ctiv

enes

sco

stan

d

impa

ct(B

ryce

etal

2004

)

Bre

astf

eedi

ngpr

omot

ion

asa

part

ofIM

CI

IMC

Iis

ast

rate

gyfo

r

impr

ovin

gch

ildhe

alth

and

deve

lopm

ent

thro

ugh

the

com

bine

d

deliv

ery

ofes

sent

ial

child

heal

th

inte

rven

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sIM

CI

bega

nw

ith

ase

tof

case

man

agem

ent

guid

elin

es

for

the

man

agem

ent

ofsi

ckch

ildre

nat

first

-lev

elhe

alth

faci

litie

s

and

the

guid

elin

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ere

desi

gned

for

adap

tati

on

atco

untr

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vela

nd

belo

wO

ver

tim

eth

e

stra

tegy

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incl

ude

ara

nge

of

guid

elin

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liver

ing

child

surv

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rven

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at

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ehol

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y

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odul

e(W

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Res

ults

onex

clus

ive

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whe

reno

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edby

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key

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ssu

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excl

usiv

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asco

mm

unit

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had

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impl

emen

ted

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tim

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HO

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b)

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rife

en

pers

onal

com

mun

icat

ion

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glad

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lab

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mun

ity-

base

dcl

uste

r

desi

gn

Eva

luat

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offa

cilit

y-an

d

com

mun

ity-

base

dIM

CI

Inte

rven

tion

pack

age

incl

udes

feed

ing

asse

ssm

ent

and

coun

selli

ngon

mot

hers

ofyo

ung

child

ren

seek

ing

care

atfa

cilit

ies

for

illne

ssan

d

hom

e-ba

sed

coun

selli

ng

onim

prov

edfe

edin

gby

com

mun

ity-

base

dhe

alth

and

nutr

itio

nw

orke

rs

At

base

line

inth

e

year

2000

alit

tle

mor

eth

anha

lfth

e

0ndash5-

mon

th-o

ld

infa

nts

inth

est

udy

area

wer

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ing

excl

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ely

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stfe

dB

y20

05

this

incr

ease

dby

30

inth

eIM

CI

area

Dat

ano

t

avai

labl

efr

omth

e

com

pari

son

area

as

yet

Lac

kof

com

para

ble

data

from

the

com

pari

son

area

prev

ents

ade

finit

ive

conc

lusi

onas

tow

heth

erth

is

trul

yis

anim

pact

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App

endi

x2

Cas

est

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sin

scal

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effo

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inH

IVA

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Stud

yde

scri

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pula

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Inte

rven

tion

Com

mun

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Impa

cton

excl

usiv

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feed

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005)

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Pro

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thro

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are

and

com

mun

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60si

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dist

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sby

2005

Inte

grat

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ofin

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and

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Trai

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kers

and

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mun

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prov

ider

sto

coun

selw

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onsa

fety

opti

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for

thei

rsi

tuat

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Beh

avio

urch

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mun

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inte

rven

tion

sin

the

first

few

year

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ater

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evel

oped

lsquoAct

Now

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edia

cam

paig

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clud

edbr

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res

post

ers

radi

oan

dte

levi

sion

Ass

esse

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hba

selin

ean

dfo

llow

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dcl

inic

surv

eys

inse

lect

eddi

stri

cts

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lusi

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feed

ing

rate

incr

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dfr

om50

in

2002

to64

in

2004

inL

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gsto

nean

dfr

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in

2000

to74

in

2004

inN

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Inte

grat

edde

mon

stra

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proj

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seve

rals

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gths

inte

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form

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deve

lop

mes

sage

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gup

skill

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prog

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and

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mun

ity

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kers

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ocac

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stro

ngbe

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chan

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unic

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then

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and

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clin

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96h

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ks

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edE

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com

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know

nor

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east

feed

than

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gan

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rall

excl

usiv

ebr

east

feed

ing

rate

sti

ll3

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ths

was

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6

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ativ

ere

sear

chus

edto

desi

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cult

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atio

nan

dco

unse

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prog

ram

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over

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xclu

sive

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tes

prom

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atw

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and

thei

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have

been

reac

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mor

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Thi

oret

al(

2006

)R

ollin

s(2

007)

C

ohen

(200

7)

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ecte

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ndin

gan

tena

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sin

sout

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ana

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stig

atio

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nuar

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brua

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sam

epo

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erna

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infa

ntan

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ther

apy

toas

cert

ain

impa

cton

HIV

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smis

sion

Ant

enat

alco

unse

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Cas

endashco

ntro

lstu

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iden

tify

risk

fact

ors

for

diar

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ano

tbr

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feed

ing

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bigg

est

risk

fact

ora

djus

ted

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o50

(95

confi

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terv

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5ndash10

0)

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yhe

alth

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ula

feed

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and

need

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est

rate

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(Thi

oret

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2006

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nclu

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alth

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atre

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inte

rven

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sta

ken

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thly

83

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HIV

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othe

rsin

itia

ted

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usiv

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ing

from

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ifica

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ely

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fect

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pare

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ith

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Stud

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in

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onth

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excl

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in19

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1987

Con

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on



LIN

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proj

ect

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2005

LIN

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2002

WH

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Bol

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(4h

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days

)

WH

OU

NIC

EF

brea

stfe

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g

coun

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ngco

urse

(WH

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NIC

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stfe

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mon

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70

in

inte

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u

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fant

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xclu

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stfe

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gre

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men

ded

for

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nega

tive

un

know

nor

HIV

posi

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uped

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gan

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feed

ing

rate

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ths

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6

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ativ

ere

sear

chus

edto

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ive

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Thi

oret

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s(2

007)

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(200

7)

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ecte

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erna

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apy

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cert

ain

impa

cton

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sion

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enat

alco

unse

lling

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endashco

ntro

lstu

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iden

tify

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fact

ors

for

diar

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ano

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ing

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ths

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ula

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atre

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ula

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lins

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rven

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mpl

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thly

83

of13

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fant

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rnto

HIV

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ecte

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othe

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itia

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excl

usiv

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who

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ived

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ifica

ntly

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elik

ely

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fect

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pare

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ith

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wer

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ive

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in

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whe

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(200

4)W

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u

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tion

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clud

ed

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)

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sent

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ano

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as

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data

from

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com

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prev

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ade

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sin

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eval

uati

onw

ith

loca

lpar

tner

sP

iwoz

etal

(20

05)

ZV

ITA

MB

Otr

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Har

are

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babw

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and

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1411

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othe

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14m

ater

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clin

ics

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hin

96h

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ks

3m

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san

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thly

inte

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fant

-fee

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erns

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edE

xclu

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brea

stfe

edin

gre

com

men

ded

for

HIV

nega

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un

know

nor

HIV

posi

tive

who

chos

eto

brea

stfe

ed

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uped

ucat

ion

indi

vidu

alco

unse

lling

vid

eos

broc

hure

sM

othe

rsw

hoen

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hen

prog

ram

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was

fully

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elik

ely

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clus

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ybr

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hers

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enro

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gan

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rall

excl

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feed

ing

rate

sti

ll3

mon

ths

was

low

at24

6

Form

ativ

ere

sear

chus

edto

desi

gna

cult

ural

lyse

nsit

ive

educ

atio

nan

dco

unse

lling

prog

ram

me

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over

alle

xclu

sive

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stfe

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gra

tes

prom

pted

auth

ors

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nclu

deth

atw

omen

and

thei

rpa

rtne

rssh

ould

have

been

reac

hed

mor

efr

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ntly

duri

ngan

tena

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peri

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Thi

oret

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2006

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s(2

007)

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(200

7)

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tena

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ana

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stig

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CD

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arrh

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nuar

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brua

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the

sam

epo

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erna

land

infa

ntan

tire

trov

iral

ther

apy

toas

cert

ain

impa

cton

HIV

tran

smis

sion

Ant

enat

alco

unse

lling

Cas

endashco

ntro

lstu

dyto

iden

tify

risk

fact

ors

for

diar

rhoe

ano

tbr

east

feed

ing

was

the

bigg

est

risk

fact

ora

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ted

odds

rati

o50

(95

confi

denc

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terv

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0)

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fect

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rsL

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talit

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ths

dem

onst

rate

sri

skof

form

ula

feed

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and

need

for

alte

rnat

est

rate

gies

(Thi

oret

al

2006

)A

utho

rsco

nclu

deth

athe

alth

syst

ems

inw

hich

thes

epr

ogra

mm

esar

eim

plem

ente

dsh

ould

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leto

cope

wit

hdi

arrh

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and

mal

nutr

itio

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atre

sult

sbe

caus

eof

form

ula

feed

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(Rol

lins

2007

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oova

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etal

(2

007)

Kw

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al

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ted

and

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enro

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into

ano

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inte

rven

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coho

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from

ante

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fant

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sta

ken

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thly

83

of13

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rnto

HIV

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dm

othe

rsin

itia

ted

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usiv

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feed

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from

birt

hB

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infa

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who

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ifica

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elik

ely

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pare

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ith

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usiv

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151

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001

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wer

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ilk(1

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3-m

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usiv

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as6

1(4

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ions

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evi

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earc

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eria

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posi

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ct

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aine

dup

to

6m

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(42

vs4

)

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tici

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the

dist

rict

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stem

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ptio

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prog

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peer

coun

sello

rs

40h

(4h

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days

)

WH

OU

NIC

EF

brea

stfe

edin

g

coun

selli

ngco

urse

(WH

OU

NIC

EF

1993

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at5

mon

ths

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in

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d

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was

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glad

esh

whe

rem

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deliv

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cur

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me



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4)W

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3b)

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zil

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u

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of

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effe

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sco

stan

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etal

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astf

eedi

ngpr

omot

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part

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and

the

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Trai

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few

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2004

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1411

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14m

ater

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clin

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96h

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erna

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apy

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endashco

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tify

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for

diar

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atre

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ndom

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rven

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coho

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udy

from

ante

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fant

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data

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wee

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mpl

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sta

ken

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83

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rsin

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hB

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ifica

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ith

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erna

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iral

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apy

toas

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ain

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cton

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sion

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enat

alco

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lling

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endashco

ntro

lstu

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tify

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ors

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fact

ora

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ted

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ths

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rven

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ined

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dsa

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esfr

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sta

ken

mon

thly

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of13

72in

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dm

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ted

excl

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ebr

east

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tfed

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ived

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ifica

ntly

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ely

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quir

ein

fect

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ith

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ely

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R10

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ein

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ived

brea

stan

dfo

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=0

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excl

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stfe

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as6

1(4

74ndash

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1(7

63ndash

287

3)in

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nts

give

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plac

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tfe

eds

(HR

206

1

0ndash4

27P

=0

05)

The

stud

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ows

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usiv

ebr

east

feed

ing

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besu

cces

sful

lysu

ppor

ted

inH

IV-i

nfec

ted

wom

enT

heau

thor

sca

llfo

rfu

rthe

rre

visi

onof

UN

ICE

FW

HO

and

USA

IDin

fant

feed

ing

guid

elin

es

CD

CC

ente

rof

Dis

ease

Con

trol

HR

haz

ards

rati

oU

NIC

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Uni

ted

Nat

ions

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ldre

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unds

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atio

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orld

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Mainstreaming nutrition into maternal and child health programmes: scaling up of exclusive breastfeeding

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