Counselling on breastfeeding: assessing knowledge and skills

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

[Protection of mother's milk and ethics]. / Proteção do leite materno e ética.

INTRODUCTION: In 1981, the World Health Assembly created the International Code for the Marketing of Breast Milk Substitutes. The WHO standards have been effective in Brazil since 1988. The purpose of this study was to verify the companies' compliance with these standards, especially to what concern health care professionals. METHODS: An exploratory research was carried out in 32 cities, interviewing 95 health professional. RESULTS: Here we describe results of interviews with health professionals and their relationship with companies. Promotion of infant formula through pediatricians is common, showing evident conflict of interest: financial support they got for their benefits might link their names to the companies (and the products) that direct or indirectly funded them. There is a conflict of interest each time a secondary intention changes professional attitude (for example, changing methodology, analysis or type of results to be published) favoring this, instead of a scientific approach. CONCLUSIONS: Both the Code and the Resolution, gathering several ethical rules, are apparently not sufficient to assess the possible conflict of interest and to impose ethical limits in the relationship paediatrician-infant formula companies. Policies to protect breastfeeding practices of commercial interest must be reviewed to include ethics.

[Key aspects of sexual behavior and safer sex practice among men in the city of São Paulo]. / Alguns aspectos do comportamento sexual e prática de sexo seguro em homens do Município de São Paulo.

Heterosexual relations currently constitute the predominant route of HIV transmission to women in Brazil. Few studies have approached male sexual behavior taking women into account. This study included 597 men ages 21 to 50 in São Paulo city and explored several aspects pertaining to safer sex, such as sexual partners, knowledge of sexually transmitted diseases (STDs)/AIDS, risk perception, and protective practices aimed at AIDS prevention. The results showed that, similar to other countries, the proportion of men who have sex with men is low (5%), that younger men adopt more protective behavior than older men regarding multiple partners and condom use, that knowledge of AIDS is widespread (but that there is still a lack of knowledge concerning STDs in general), and that although risk perception increases protective behavior, presumption of the partner's behavior influences this perception, placing men and women in a vulnerable situation.

[Breastfeeding in two Brazilian State capitals: a comparative analysis]. / Situação do aleitamento materno em duas capitais brasileiras: uma análise comparada.

This paper describes rapid assessment of infant feeding practices based on surveys conducted on National Immunization Day in the cities of Florianópolis and João Pessoa, Brazil. Two different infant feeding patterns emerge clearly in the data analysis. Most infants begin breastfeeding, but exclusive breastfeeding (EBF) from 0-4 months (46.3% in Florianópolis and 23.9% in João Pessoa) and timely complementary feeding rates (32.2% in Florianópolis and 24.8% in João Pessoa) are below recommended standards. EBF and breastfeeding duration medians were 53 and 238 days, respectively, in Florianópolis and 16.5 and 195 days, respectively, in João Pessoa. The results pointed to increasing breastfeeding rates and duration medians in Florianópolis as compared to João Pessoa. Use of these data could improve planning and monitoring of breastfeeding activities and infant nutrition policies.

Determinants of the breastfeeding pattern among working women in São Paulo.

The needs of breastfeeding women who work away from home differ from those of other women, particularly those who breastfeed exclusively. Sixty-nine factory workers were interviewed in São Paulo, both during pregnancy and when they returned to work. Median durations of exclusive (EBF), predominant (PBF), and any breastfeeding (BF) were found to be 10 days, 70 days, and 150 days, respectively. Despite having used the 4-month leave to which they were entitled, by 1 month, 86% of the respondents had given tea, 50% water, and 42% artificial baby milk. Only 2 women were still exclusively breastfeeding when they returned to work. Various personal characteristics were associated with longer duration of breastfeeding. Maternity ward routines were generally not supportive, but duration of PBF was longer where better support was received. Duration of EBF was longer among women with support for breastfeeding at work, and shorter for those working on weekends or doing shift work. Thus, women may have adjusted their feeding patterns based on whether or not they anticipated workplace support. Only weekend work and socioeconomic status were linked to shorter duration of breastfeeding. Stronger social and health care support for EBF may be needed before the full impact of workplace support can be usefully studied in Brazil.

Counselling on breastfeeding: assessing knowledge and skills.

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

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

[Assessment of the Breastfeeding Counselling Course WHO/UNICEF] / Avaliação do curso de aconselhamento em amamentação.

OBJECTIVES: To assess the implementation and the impact of the Breastfeeding Counselling Course WHO/UNICEF on knowledge and skills of health workers. METHODOLOGY: The implementation of the course was assessed by participant observation; the impact on participants was assessed with an experimental controlled study where 20 health workers were randomly allocated as course participants (Exposed Group-EG) and 40 as non participants (Control Group -CG). Impact on knowledge was verified with pre and post evaluations, with multiple choice questions; clinical and counselling skills were assessed through pre and post tests, observing participants in clinical consults with mother and baby pairs in rooming-in before and after the course. Kruskal-Wallis test of variance of means was used in analysis. RESULTS: In the post test of knowledge, the mean of the EG was 8.35 and that of the CG was 5.54 (p=0,0000). In clinical and counselling skills, the means of the EG were higher when compared with the CG in all items observed (p < 0,05). Some difficulties were found in breastfeeding history and in breastfeeding observation. Counselling skills were the most incorporated aspects. CONCLUSION: The course may be implemented as proposed; participants acquired counselling skills, but clinical management should be reinforced; participants shoud have continued support to put what they learned in practice.

[Possibilities and limitations of breast-feeding among formally employed women]. / Possibilidades e limitações da amamentação entre mulheres trabalhadoras formais.

INTRODUCTION: Studies carried out on breastfeeding and working women are difficult to compare. Breastfeeding practices among formally employed women in Brazil have not been much studied, despite important changes in public policies such as the extension of maternity leave to 120 days. OBJECTIVES: A description of breastfeeding patterns among women employed in factories and the constraints and opportunities involved in conciliating breastfeeding and work. MATERIAL AND METHOD: An exploratory study was carried out in 13 factories in S. Paulo city in 1994, where all women in the 3rd trimester of pregnancy were interviewed (76), and re-interviewed (69) when they went back to work (around 5,4 months after delivery). RESULTS: Breastfeeding initiation was found in 97% of women and the median duration was 150 days. The exclusive breastfeeding and predominant breastfeeding rates were, respectively, 10 and 70 days of median duration. Higher socio-economic status and nursery facilities and the existence of a place in which to extract and store the mother's milk at the workplace were factors associated with longer duration of breastfeeding. Other factors such as flex-time and work out of the production-line also showed a significant relation to longer duration of breastfeeding in the factories studied. CONCLUSION: Maternity leave is widely taken advantage of and highly beneficial for the majority of working women as regards breastfeeding, but other factors are important in maintaining lactation, such as circumstances which permit closer mother-child contact and/or the extraction of human milk during the working day.

[Evaluation of the differential practices of breast feeding: the ethnic question]. / Avaliação das práticas diferenciais de amamentação: a questão da etnia.

Breastfeeding practices in two Brazilian metropolitan areas (S. Paulo and Recife) are described, as part of a study carried out in 1987. In a random sample of healthy 0-8 month old infants, selected from all health care units, higher breastfeeding rates were found in S. Paulo (initiation, prevalence, median and average) than in Recife. The mean duration of breastfeeding, mixed and full, was of 127.5 and 66.6 days, respectively, for S. Paulo, and of 104.4 and 31.7 days for Recife. When data are analysed according to ethnic group, white S. Paulo women breastfeed more than white Recife women. Full breastfeeding rate is more prevalent among white and "mulato" S. Paulo women. However, when the data were analyzed for each city separately, it was found, remarkably, that the non-whites breastfeed more than the whites. In Recife, full breastfeeding is particularly low in whites (of 15.3 days median) and "mulatos" (of 16.7 days), but of 34.5 days in blacks. The study points out the need for greater in-depth investigation of the issue of ethnicity and infant feeding practices, still inadequately understood in world literature.

[Breast-milk substitutes: past and present]. / Substitutos do leite materno: passado e presente.

The historical development of industrialized products used as breast-milk, substitutes a process begun in the 18th century, is studied. The marketing strategy currently adopted infant formula companies is stressed and the different commercial practices used in the search for new markets in third world countries are described. A warning is given as to the precise instructions giver for the use of the so-called breast-milk substitutes, and the attention of health professionals and consumer groups is called to the low level of awareness regarding this subject, a factor which led the World Health Organization and United Nations Children's Fund to recommend the preparation of an appropriate marketing code and to its adoption by Brazil.

Impact of the Brazilian national breast-feeding programme on mothers in greater São Paulo.

A broad-based national breast-feeding programme was launched in Brazil in 1981 that was preceded by an evaluation of infant feeding habits in two metropolitan areas of the country. This paper reports the initial findings of an evaluation of the programme in Greater São Paulo that was carried out in 1987, 6 years after the programme started. The method employed was analogous to that used before the start of the programme in 1981. For this purpose, a representative sample of mothers who were attending child care services open to all income groups were interviewed, together with a number of health professionals. A total of 497 mothers with children aged 0-12 months were covered. A recall interview was also administered on the duration of breast-feeding for all children born to the mothers since 1981. As a result of the programme, the mean duration of breast-feeding rose from 89.4 days to 127.5 days and of feeding only breast-milk from 43.2 days to 66.6 days. The proportion of previous children who were breast-fed for more than 6 months rose from 18.9% for those born in 1981-82 to 37.7% for those born in 1984, when the programme activities were at their highest, and slipped back again to 27.6% in 1985-86.

The Brazilian National Breastfeeding Program: a success story.

The Brazilian National Breastfeeding Program launched in 1981, is remarkable for its broad scope, including activities aimed at protecting (employment legislation, control of marketing of substitutes for mother's milk), promoting (use of the media, professional training), and supporting breastfeeding (mothers' groups, information material, and direct counseling). The program was preceded by an assessment in the metropolitan areas of Recife and São Paulo. Evaluation of the program carried out in 1987-1988 shows that it has had an impact; the average duration of breastfeeding increased from 89 to 127 days in São Paulo and from 66 to 104 days in Recife. Exclusive breastfeeding, which averaged 43 days in São Paulo, increased by 1.5 times; while in Recife the increase was 2.2 times, leading to 32 days.