BREASITFEEDING, WEANING & NUTRITION: THE BEHAVIORAL ISSUES -Is .!pd BEHAVIORAL ISSUES IN CHILD SURVIVAL PROGRAMS: Monograph Number Four Prepared for THE OFFICE OF HEALTH U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT By Ann Brownlee, Ph.D. Breastfeeding, Weaning and Nutrition: The Behavioral Issues Monograph Number Four Brownlee, Ann (author) U.S. Agency For Internatienal Development, Bureau for Science and Technology. Office of Health. (sponsor) International Health ay.d Development Associater. 18133 Coastline Drive, Suite 4A, Malibu, CA 90265 (sponsor) Behavioral Issues in Child Survival Programs; A Synthesis of the LVterature with Recommendations for Project Design & Implementation (six monograph series) *also available from- International Health and Development Associates. 18133 Coastline Drive, Suite 4A, Malibu, CA 90265 The impact of breastfeeding stretches across all child survival interventions. In addition to its direct impact on infants' health, it enhances each of the key child survival interventions -­ diarrheal disease control, immunization, nutrition, and child spacing, -- and benefits maternal health as well. UNICEF recently estimated that one million infant ).ives could be saved every year in developing colntries by promoting breastfeeding. This monograph on the behavioral aspects of breastfeeding, weaning and nutrition concentrates on several major issues, including: (1) beliefs, practices, and other important factors affecting feeding practices, nutrition and child survival; (2) health providers and institutions and their effects on feeding practicos; (3) infant and child nutrition interventions both at the community level and in health institutions; (4) the critical and often neglected issue of sustaining and expanding ntrition programs; and (5) qualitative research methods useful for examining behavioralaspects of infant and child feeding. As each of these issues is explored, important questions concerning project design and implementation are rirst outlined, significant findings are then reviewed, and finally recommendations and conclusions are presented for policy-makers Cind project and field personnel. This monograph is the fourth in the series which covers the behavioral issues of the following child survival interventions: Oral Rehydracion Therapy; Immunization; Breastfeeding, Weaning and Nutrition; and, Growth Monitoring and Pronmotion. Monograph Five, Breastfeedina, Weanin-f and Nutrition: ExpAnded Bibliograpny, a companion to this monograph, presents a more comprehensive bibliography on behavioral factors related to breastfeeding, weaning and nutrition. Pr\ -p , So BEHAVIORAL ISSUES IN CHILD SURVIVAL PROGRAMS: A Synthesis of the Literature with Recommendations for Project Design & Implementation Monograph Number Four BREASTFEEDI NG, WEANING & NUTRITION: THE BEHAVIORAL ISSUES By Ann Brownlee, Ph.D. Prepared for THE OFFICE OF HEALTH U. S. AGENCY FOR INTERNATIONAL DEVELOPMENT Washington D.C. INTERNATIONAL HEALTH & DEVELOPMENT ASSOCIATES July 1990 CONTENTS PREFACE: OVERVIEW OF THE SERIES .............................. v ACKNOW LEDGEMENTS ......................................... xi EXECUTIVE SUMMARY ......................................... xiii INTRODUCTIO N ................................................ 1 BEHAVIORAL ISSUES AND SIGNIFICANT FINDINGS .................... 3 I. Local Beliefs and Practices Related to Infant and Child Feeding ...... 3 Choice of Infant Feeding Method ............................. 3 Traditional Beliefs Concerning the Physiology of Breastfeeding ........ 4 Colostrum and Prelacteal Feeds .............................. 5 Frequency, Intensity and Duration of Suckling .................... 6 Restrictions, Taboos and Special Practices during Breastfeeding ...... 9 Using Breastmilk Substitutes ............................... 11 The W eaning Process .................................... 13 Terminating Breastfeeding ................................. 16 I1. Health Providers and Institutions - Their Effects on Feeding Practices ............................ 21 Knowledge and Practices of Health Providers ................... 22 Factors Affecting Health Providers' Knowledge and Practices ........ 23 Institutional Policies and Procedures .......................... 24 II1. Other Factors Affecting Feeding Practices, Nutrition and Child Survival ................................. 29 Social Networks and Support Systems ........................ 29 The Socio-Cultural Environment ............................. 30 Women's Work and Activity Patterns ......................... 32 Education and Income .................................... 34 Infants' Sex and Birth Order ................................ 35 The Physical Environment ................................. 37 Women's Health and Nutrition .............................. 38 The Availability and Promotion of Breastmilk Substitutes ............ 40 IV. Infant and Child Nutrition Interventions Inthe Community .......... 45 Suppcrt Groups for Breastfeeding Mothers ..................... 45 Breafodeeding and Weaning Promotion and Education ............. 47 Effons to Improve and Introduce Weaning Foods ................ 49 Control of Infant Formula Advertising and Promotion .............. 51 Other Legislative Initiatives to Promote Infant Peeding ............. 52 V. Infant and Child Nutrition Interventions in Health Institutions ........ 55 Practices and Procedures that Promote and Protect Breastfeeding .... 55 Developing Training Programs for Health Personnel ............... 55 Changing Health Institution Policies and Procedures .............. 59 Controlling Infant Formula Promotion and Use .................. 63 Sharing Information and Promoting Utilization of Findings .......... 64 VI. Sustaining and Expanding Nutrition Programs ................... 69 Sustaining Nutrition Improvement Activities ..................... 69 Expanding Nutrition Improvement Programs .................... 70 VII. Methods for Studying Behavior Related to Breastfeeding, Weaning and Nutrition ................. 73 An Overview .......................................... 73 Guides for Community Nutrition Assessmel it and Diagnosis ......... 73 Use of Ethnographic Techniques to Explore Infant Feeding Practices .. 74 Use of Qualitative Research Tools in Nutrition Program Development .. 75 SELECTED BIBLIOGRAPHY ..................................... 79 ii LIST OF FIGURES Figure 1: Factors that decrease the influence of suckling ................... 7 Figure 2: Schema for breastfeeding definition ........................... 9 Figure 3: Marketing channels used by infant formula companies ............. 40 Figure 4: Steps to successful breastfeeding in maternity services ............ 56 Figure 5: Results of an intensified breastfeeding program at Dr. Kariadi Hospital, Semarang, Indonesia .................... 60 Figure 6: Decreased morbidity and mortality due to rooming-in at Sanglah Hospital, Denpasar, Indonesia ...................... 62 Figure 7: Cost savings from rooming-in at Jose Fabella Memorial Hospital, Manila, Philippines ........................ 63 iii PREFACE: OVERVIEW OF THE SERIES This monograph is the fourth in the series Behavioral Issues in Child Survival Programs: A Synthesis of the Literature with Recommendations for Project Design & Implementation. The series covers the major child survival interventions with the exception of birth spacing. It thus includes the following: Oral Rehydration Therapy; Immunization; Breastfeeding, Weaning and Nutrition; and Growth Monitoring and Promotion. This monograph, like others in Lhe series, sets forth the major behavioral issues related to the intervention, summarizes research findings on each issue, presents recommendations, and includes a bibliography. The fifth publication, Breastfeeding, Weaning and Nutrition: Expanded Biblioc1rgpbv, a companion to this monograph, presents a more comprehensive bibliography on behavioral factors related to this subject. Behavioral Factors in Child Survival Success in child survival projects and programs depends not only on technical interventions themselves but on their being accepted and used by the millions of mothers and other child caretakers who determine in developing countries whether a child lives or dies. This requires that project designers and implementors understand not only the technical but also the behavioral factors that influence child survival in developing countries. An enormous volume of research has been carried out during the 1980s on topics related to child survival. In addition to basic biomedical research, much of this has been qualitative research designed to provide answers on how to adapt technology, delivery systems, and promu-tional approaches to individual countries and cultures. Much of this research has been funded by the Agency for International Development (AID/Washington as well as by USAID bilateral projects). Additional research has been supported by UNICEF, WHO, and other organizations, public and private. Many social scientists have also conducted independent research that provides further valuable descriptive material about beliefs and practices of mothers and others that influence child survival. The findings and conclusions of this large body of qualitative research can be extremely valuable for improving the design, implementation, impact, and sustainability of donor-funded projects and host-country programs. These research results are not easily available, however, to either AID/Washington or mission personnel outside the countries where individual studies were