<p>The aim of this study was to describe the demographic and socio-economic factors influencing infant feeding practices in the Amathola district, South Africa. A survey was chosen as the design method and a structured questionnaire was used to collect information regarding the socio-economic and demographic factors and related infant feeding choices. The study population consisted of 100 women with infants up to the age of 14 weeks, who brought their infant for immunization at the selected community health clinic (the largest clinic in the Mdantsane area). Infants up to the age of 14 weeks were used because all the visits up to 14 weeks coincide with the local immunization program, and according to WHO guidelines all infants should be exclusively breastfed until they reach the age of 6 months of age. The study found that there are many families in the Mdantsane area that suffer from poor conditions and inadequate services such as a lack of electricity, working taps or flush toilets within their dwelling, which in turn has an impact on infant feeding practices. It was found that even in poor demographic and socio-economic conditions, formula feeding is still the chosen feeding practice for the majority of mothers.</p>

In a Manila hospital, 204 mothers were randomized into three groups: two intervention groups receiving home-based counseling visits, one of them (n=68) by counselors trained to use a locally developed, two-tiered program of breastfeeding counseling, and the other by counselors trained in general childcare (n=67), were compared with a control group of mothers (n=69) who did not receive any counseling. All infants were scheduled for seven visits to the hospital for follow-up. During hospital visits, maternal and infant body measurements were made and an independent interviewer asked the mothers individually to recall how the infant had been fed. One study physician, blind to participant groups, was consulted at all scheduled and unscheduled infant visits. At six months, 44% of the breastfeeding-counseled mothers, 7% of the childcare-counseled mothers and none of the mothers in the control group were exclusively breastfeeding. Twenty- four mothers breastfed exclusively during the first six months, of whom 22 received breastfeeding counseling and 2 had no breastfeeding counseling. Among 24 infants who were exclusively breastfed from birth to six months there were no episodes of diarrhea. All infants had gained in weight, length and head circumference. Mean maternal weight loss at six months was similar whether her breastfeeding was exclusive or partial. The reasons why mothers without breastfeeding counseling introduced non-breast milk feeding before six months reflected lack of knowledge and support. Breastfeeding support during the first six months focusing on how to prevent and solve breastfeeding problems, particularly during the first two weeks, will enable mothers to choose to breastfeed exclusively up to six months. This study has provided fundamental evidence of successful intervention by breastfeeding counseling to achieve six months of exclusive breastfeeding among term, low-birthweight infants. The locally developed training program in breastfeeding counseling, which successfully prepared volunteers to counsel mothers at home, could be incorporated into primary health care in the Philippines. Mothers who received breastfeeding counseling appreciated how this helped them to achieve their breastfeeding goals for the first six months. Improved breastfeeding practices as a result of breastfeeding counseling provided infants with protection from diarrhea and respiratory infections, contributing to their health and development.

Despite global efforts, exclusive breastfeeding is rarely practiced in South Africa where infants are at risk of diarrheal infections, malnutrition and HIV transmission. The present study was conceptualized within the context of a multi-country, cluster randomized community-based behavioural intervention known as PROMISE-EBF in South Africa, Burkina Faso, Zambia and Uganda (www.clinicaltrials.gov, no: NCT00397150). The aim of this thesis was to identify and describe contextual factors that are important for the effectiveness of community-based peer counselling with a special focus on the promotion of exclusive breast and formula feeding. This thesis identifies the paradoxes and discrepancies embedded in the notion of community-based “peer” counselling approach, especially in the South African context of poverty, HIV and social distrust. Peer counselling, while perceived useful, was associated with social distrust which might have resulted in reduced effectiveness of the intervention. The thesis further illustrates that, while there is strong support for breast feeding, there was a general openness for early introduction of commercial foods and liquids. Mothers’ perceptions on infant feeding and peer counselling varied substantially according to HIV-status and geographical area. Nevertheless, the infant feeding peer counselling approach neither modified the mothers’ perceptions on feeding nor its associated barriers. Thus, several important barriers to exclusive breastfeeding including the risk for HIV stigmatization still remain. The results of this thesis highlight the need to rethink current approaches to the promotion of exclusive breastfeeding. It further draws attention to the gap between theoretical assumptions inherent in health interventions and the actual dynamic processes and realties of women in low-income high HIV settings.

Health Canada recommends exclusive breastfeeding (EBF) until 6 months followed by introducing iron-rich complementary foods (CFs) such as iron-fortified cereal and meat to prevent iron deficiency (ID). There is a concern that consumption of CFs with high iron dose may predispose infants to inflammation through reactive oxygen species (ROS) generation in their intestinal tract. The nutrient intake from these recommended first CFs had not been assessed in terms of meeting the daily requirements. Therefore the aim of this study was to assess if the recommended CFs are safe from a free radical and inflammatory perspective and to assess these CFs in relation to socio-demographic characteristics, feeding patterns, nutrient intake, iron status and growth. Eighty-seven EBF infants were randomly assigned to receive one of the following: iron-fortified cereal (Cer), iron-fortified cereal with fruit (Cer+Fr), meat (M). Urine and stool samples were collected before and after introduction of CFs to assess the following markers: urinary F2-Isoprostanes, fecal ROS, fecal iron and fecal calprotectin. Blood was collected from 18 infants to measure iron parameters. Socio-demographic characteristics and feeding patterns were obtained using questionnaires. Nutrient intake was collected using 3-day dietary records. There are maternal factors that were associated with selected feeding patterns. Nutrient intake was only adequate when provided by both breast milk and CFs. Plasma ferritin decreased over time in all groups (p = 0.04). Infants in M group had lower fecal iron than infants in Cer and Cer+Fr groups (p < 0.001, p = 0.014, respectively). An increase in fecal ROS formation (p < 0.002) after the introduction of CFs was observed. There are maternal socio-demographic factors such as lower parity and lower BMI that need to be targeted in the future to optimize feeding time, type and frequency. Infants with EBF may be at risk of developing ID despite the provision of iron-rich CFs. Untargeted iron fortification may result in untoward effects including ROS generation in the infant’s intestinal tract. In future, if these findings are further confirmed in EBF and formula-fed infants, reconsidering the strategies of iron fortifications to both meet infants’ requirements and minimizing oxidative stress maybe warranted. / October 2015

<p>The aim of this study was to describe the demographic and socio-economic factors influencing infant feeding practices in the Amathola district, South Africa. A survey was chosen as the design method and a structured questionnaire was used to collect information regarding the socio-economic and demographic factors and related infant feeding choices. The study population consisted of 100 women with infants up to the age of 14 weeks, who brought their infant for immunization at the selected community health clinic (the largest clinic in the Mdantsane area). Infants up to the age of 14 weeks were used because all the visits up to 14 weeks coincide with the local immunization program, and according to WHO guidelines all infants should be exclusively breastfed until they reach the age of 6 months of age. The study found that there are many families in the Mdantsane area that suffer from poor conditions and inadequate services such as a lack of electricity, working taps or flush toilets within their dwelling, which in turn has an impact on infant feeding practices. It was found that even in poor demographic and socio-economic conditions, formula feeding is still the chosen feeding practice for the majority of mothers.</p>

Bakgrund: Hälsofördelarna med amning är välkända, och sedan 1992 försöker svenska sjukhus arbeta efter internationella amningsrekommendationer. Trots detta framkommer brister i vården och amningsstatistiken i Sverige sjunker. Syfte: Syftet med denna studie var att undersöka amningsdurationen hos förstföderskor, om den kunde associeras med vården de fått i samband med barnets födelse och första levnadsdygn, samt med mammornas skattning av amningsstöd vid amningsstart. Metod: Designen var en longitudinell kvantitativ tvärsnittsstudie och urvalet var icke slumpmässigt konsekutivt. I samband med utskrivning från BB, tillfrågades 63 mammor om att delta i en enkätstudie med frågor gällande vården de fått i relation till amning och 52 mammor besvarade enkäten. Efter nio till tolv månader blev de uppringda för en kortare uppföljning och 50 mammor valde att delta. Resultat: Medianen för durationen av exklusiv amning var tre månader och tre veckor och medianen för durationen av partiell amning var åtta månader. Amningsstödet på BB skattades högre vid det första mättillfället, men det påvisades inte ha något samband med amningsdurationen. Faktorer i vården såsom; hudnära vård, amning inom två timmar eller handgriplig amningshjälp, bidrog inte till någon skillnad i amningsduration. Däremot påverkades amningsdurationen negativt hos de barn som fått tillmatning på BB, med en kortare exklusiv amningsduration som följd, och de som fötts med kejsarsnitt, med kortare amningsduration såväl exklusivt som partiellt. Slutsats: Medianen för durationen av exklusiv amning var tre månader och tre veckor och medianen för durationen av partiell amning var åtta månader.  Faktorer i vården som inverkade negativt på amningsdurationen var tillmatning på BB samt att barnet fötts med kejsarsnitt. Däremot fanns ingen association mellan amningsduration och amningsstöd, hudnära vård, amning inom två timmar eller handgriplig hjälp. / Background: The health benefits of breastfeeding are well known and since 1992, Swedish hospitals aim to provide care according to international guidelines of breastfeeding support. Despite this, there are inadequacies in the care provided, and the frequency of breastfeeding in Sweden is statistically decreasing. Aim: The aim of this study was to investigate the duration of breastfeeding among primiparas, if the duration was associated with the provided care and with how the mothers valued the help and support they received at the initiation of breastfeeding. Method: A quantitative longitudinal with consecutive sample was conducted. At discharge from hospital, 63 mothers were asked if they wanted to participate in a survey about breastfeeding and the related care, and 52 mothers filled in the questionnaire. After nine to twelve months the participants were contacted by phone for a short follow-up, and 50 mothers chose to participate. Results: The median duration of exclusive breastfeeding was three months and three weeks and the median duration of partial breastfeeding was eight months. The evaluation of the breastfeeding support was higher at the first data collection but did not appear to correlate with the duration of breastfeeding. Of the investigated factors; skin-to-skin contact immediately after birth, breastfeeding within two hours after birth and hands-on support, none of them led to differences in breastfeeding duration. Breastfeeding duration was adversely affected if the infant was given formula at the maternity ward and if the infant was born by Caesarean section. Feeding by infant formula led to a shorter duration of exclusive breastfeeding and birth by Caesarean section led to a shorter duration of both exclusive and partial breastfeeding. Conclusion: The median duration of exclusive breastfeeding was three months and three weeks and the median duration of partial breastfeeding was eight months. The infant being given formula at the maternity ward, and being born by Caesarean section were factors that adversely affected the duration of breastfeeding. However, there was no association between breastfeeding duration and; perceived breastfeeding support, skin-to-skin-care, breastfeeding within two hours or hands-on support.

South Africa recently changed infant feeding policy within Prevention of Mother to Child Transmission (PMTCT) of HIV from free formula to recommendation of breastfeeding for all. The country is evaluating the role of Community Health Workers (CHWs) in supporting mothers and newborns. The aim of this thesis is to explore perceptions of household members on the value given to and the social forces behind formula feeding in light of the recent policy change, and to assess the effect of a community-based package of maternal and newborn care delivered by CHWs on HIV-free survival and exclusive and appropriate infant feeding up to 12 weeks of age. Studies were conducted in a high HIV prevalence township. Focus group discussions were performed (grandmothers, fathers and teenage mothers) and in-depth interviews with HIV-positive and HIV-negative mothers. Perceptions of household members on the formula policy change were explored and the value household members place on formula feeding and circumstances that drive it. In a cluster-randomized trial (15 intervention, 15 control clusters) CHWs provided two antenatal and five post-natal home visits to support and promote PMTCT activities. There were misunderstandings by community members on the free formula policy change. Mothers transferred the motherhood role to their mothers while partners provided inadequate financial support, leading to risky mixed feeding. Teenage mothers rarely breastfed their infants due to perceived constraints including embarrassment, sagging breasts and loss of freedom and boyfriends. At 12 weeks of age the intervention had doubled exclusive breastfeeding (EBF) (28% vs. 14%) and slightly increased infant weight and length. No difference was seen between study arms in HIV-free survival. The effect on EBF at12 weeks did not differ with maternal education or wealth levels, but was higher among HIV-negative mothers.  Focusing on teenage mothers breastfeeding challenges, involvement of grandmothers and fathers in infant feeding decision-making, improving communication strategies on policy change and breastfeeding to the community and health workers and CHWs home visits supporting PMTCT activities are important for infant feeding and child health.

Introduction: Breast milk is the best way to feed all infants. It results in better nutrition for the infant and to reduced rates of chronic disease later in childhood and adulthood. Breastfed babies have lower rates of infectious diseases and will not be exposed to contaminated infant formula, such as the recent experience with melamine in China. The WHO Expert Consultation on Infant Feeding recommended exclusive breastfeeding for six months, with the introduction of complementary foods and continued breastfeeding thereafter. It was also recommended by the WHO that breastfeeding continue beyond six months for up to two years and beyond. Breastmilk can provide the majority of nutrients for the first 12 months of life. Complementary foods were given in the second half year gradually. / However with the rapid economic development, the traditional home based obstetric system in China has changed. Following the change in women’s living styles, traditional infant feeding perceptions and practices have changed. Women now have high rates of returning to work after delivering a baby, especially in the urban areas, and more infants are being given infant formula and other substitutes for breastfeeding. Zhejiang Province is the one of fastest developing economic regions located in the mid Eastern coast of China. The breastfeeding rate has dropped rapidly since the 1970’s. This has significant implications for the child health in this region. A longitudinal study of breastfeeding was needed to provide the data necessary to implement a comprehensive health promotion program. Efforts are needed to promote breastfeeding, which should be one of the highest health promotion priorities. / The aim of this study was to document the prevalence and duration of breastfeeding and exclusive breastfeeding in city, suburban and rural areas in Zhejiang Province; analyze the factors determining the initiation and the duration of breastfeeding; document mothers’ knowledge about the benefits of breastfeeding; identify the prevalence of problems associated with breastfeeding and constraints to exclusive breastfeeding up to six months of life; document the prevalence of prelacteal feeds and finally to describe differences in breastfeeding between city, suburb and rural area. / Method: In order to achieve these objectives a longitudinal cohort study was undertaken of infant feeding practices in three locations in Zhejiang Province which represent city and suburban and rural areas. Mothers who delivered babies during 2004 and 2005 were randomly selected from the obstetric wards while in hospital and invited to voluntarily participate in the study. The mothers were interviewed in hospital and after discharge, were contacted by telephone three more times at 1, 3 and 6 months. The few mothers who could not be reached by telephone were interviewed during the scheduled routine immunisation clinics at their local MCH clinic. On each of these follow up occasions they were interviewed using a structured questionnaire to obtain details of infant feeding practices. A total of 1520 mothers were recruited in 4 hospitals located in city, suburb and rural areas. Almost all mothers (98%) agreed to participate. All data analyses were carried out using the Statistical Package for Social Science (SPSS), release 14.0 (SPSS Inc., Chicago, IL, USA). Descriptive techniques and survival analysis were used to document breastfeeding rates and duration. Cox regression analysis was undertaken to explore factors affecting breastfeeding. / Results: Of the total 1520 mothers were recruited into the study, 628 were from the city, 347 from the suburb and 535 from the rural area. Breastfeeding initiation rates were high in all three locations. Initially more than 95% of the mothers began breastfeeding, but only 50.3% babies averagely in three locations were being exclusively breastfed at discharge. The number of infants being exclusively breastfed prior to discharge was relatively low. Exclusive breastfeeding before discharge was positively related to delivery method, the first feed given to the baby, mother’s place of residence, mother’s age, mothers’ education level and family income. / ‘Any breastfeeding’ rates at discharge and at 1, 3 and 6 months were 96.9%, 96.0%, 89.7% and 76.7% respectively. ‘Exclusive breastfeeding’ rates at discharge, and at 1, 3, 6 months were 50.3%, 55.1%, 45.8% and 3.9% respectively. The average duration of ‘exclusive breastfeeding’ was 44.7 days (95% CI, 41.6-47.9). / Overall about half of mothers gave the babies prelacteal feeds before commencing breastfeeding. This situation was more common in city, compared with the suburban and rural mothers. The prelacteal feeding rates were 62.0%, 36.6% and 39.0% in city, suburb and rural area respectively. / The breastfeeding rates differed by location between the city, suburb and rural areas. ‘Any breastfeeding’ rates in the city, suburb and rural area at discharge were 96.5 %, 96.8 % and 97.4 % respectively, the ‘exclusive breastfeeding’ rates in city, suburb and rural area at discharge were 38.0%, 63.4 % and 61.0 % respectively. The rates of exclusive breastfeeding at six months were only 0.2%, 0.5 % and 7.2 % respectively, well below the Chinese and WHO targets. / The risk factors related to cessation of ‘any breastfeeding’ were ‘mother’s age’, ‘the time the decision to breastfeed was made’, ‘whether the infant was admitted to special care nursery’, ‘mother’s return to work within 6 months’, ‘the early feeding of water and /or other complementary foods, and location of mother’s usual residence. Factors negatively associated with ‘exclusive breastfeeding’ duration were early return to work and to place of residence, with the mothers living in the rural area exclusively breastfeeding for longer. / Delivery method was an important influence on breastfeeding. In this study the highest caesarean section rate was in the city (76%), with a similar rate in the suburbs (74%) and the lowest in the rural area (53%). Mothers who had a caesarean section were less likely to be exclusively breastfeeding on discharge (35.8% in city, 59.6% in the suburbs) compared to vaginal delivery where the rates were 45% and 74.4% respectively. The adjusted odds ratio for exclusive breastfeeding in caesarean section deliveries in the city and suburban mothers was 0.64 (95% CI 0.46, 0.88). / Conclusion: The study has descried the initiation and duration of breastfeeding (to six months) of babies in the different areas of Zhejiang Province. Separate information is provided on the prevalence of ‘any breastfeeding’ and ‘exclusive breastfeeding'. The factors that are associated with the initiation and duration of breastfeeding in Zhejiang Province are documented. Health promotion programs are needed to change some traditional inappropriate breastfeeding perceptions and to promote ‘exclusive breastfeeding’ in the first six months of life in Zhejiang. Education should be given and regulations should be introduced restricting hospital staff from recommending prelacteal and supplementary feeds unless warranted for medical reasons. The research also shows that there would be a benefit to breastfeeding if delivery and lactation leave were extended to six months and if the incidence of caesarean section could be reduced to levels more consistent with WHO expected levels.

The World Health Organization recommends exclusive breastfeeding (EBF) until six months of age, and breastfeeding along with other foods up to two years of age or even longer. The importance of EBF until six months of age is well established, mainly because of the benefits for the child and for the mother such as a reduction in children's morbidity and mortality and also hospital admissions. Despite of the fact that breastfeeding is an effective and inexpensive way to improve child s health, unfortunately this practice is stopped long before the recommended period. Due to that, this study aimed at knowing EBF prevalence among children born at the University Hospital of Santa Maria as well as the reasons for the early weaning. Besides, it assessed the effect of a multiprofessional intervention to promote breastfeeding in the Hospital. The prevalence of EBF was assessed at four and six months postpartum in two groups: control group (whose mothers received the information usually provided by the staff) and intervention group (whose mothers received additional information about breastfeeding by a multiprofessional team). For this, a randomized trial was carried out, enrolling 379 dyads (mother-baby): 194 in the control group and 185 in the intervention group. The intervention consisted of meetings (as group dynamic) with the mothers. The results showed that EBF prevalence in the control group were 42.8% at four months, and 13.4% at six months age. On the other hand, in the intervention group the EBF prevalence was significantly higher: 57.8% at four months and 26.5% at six months age. In addition, the number of days of EBF in the intervention group was also significantly higher (median 150 days) compared to controls (median 113 days). The assessment of data at four and six months showed negative association with the variables "did not participate in the intervention" and "use of pacifiers" with the variable "duration of EBF". At six months it was further observed negative association between "duration of EBF" with mother coming back to work . The results of this study allowed us to prove the effectiveness of a multidisciplinary intervention carried out in the post-partum time in increasing EBF rates in children at the ages of four and six months. / A Organização Mundial de Saúde recomenda o aleitamento materno exclusivo (AME) até seis meses de idade e, após, que seja continuado com outros alimentos até dois anos ou mais. Apesar de já consagrada a importância do AME até os seis meses de idade, dos inúmeros benefícios comprovados para a criança e para a mãe, principalmente na redução significativa da morbimortalidade e hospitalizações infantis, essa prática é interrompida muito antes do período recomendado. A ciência de que o investimento na promoção do aleitamento materno é uma medida efetiva e de baixo custo para melhoria da saúde infantil motivou conhecer a prevalência do AME em crianças nascidas no Hospital Universitário de Santa Maria, os motivos que levam ao desmame precoce nessa população e avaliar o efeito de uma estratégia de intervenção multiprofissional, com vistas à promoção do aleitamento materno. Foram avaliadas as prevalências do AME aos quatro e seis meses pós-parto em dois grupos: grupo intervenção, cujas mães receberam, além das orientações da rotina do serviço, uma intervenção adicional, realizada por equipe multiprofissional; e grupo controle, cujas mães receberam apenas as orientações da rotina do serviço. Foi realizado um estudo analítico experimental, tipo ensaio de campo randomizado, no qual participaram 379 díades (mãe-bebê), sendo 194 no grupo controle e 185 no grupo intervenção. A intervenção constituiu-se de encontros em forma de dinâmica em grupo com as mães selecionadas. Os resultados demonstraram que as prevalências de AME no grupo controle foram de 42,8% aos quatro meses e de 13,4% aos seis meses. No grupo intervenção, as prevalências foram significativamente maiores: 57,8% aos 4 meses e de 26,5% aos 6 meses. Além disso, o número de dias de AME no grupo intervenção também foi significativamente maior (mediana de 150 dias) quando comparado ao controle (mediana de 113 dias). Aos quatro e seis meses foram observadas associações negativas entre as variáveis não participar da intervenção e uso de bico ou chupeta com a variável tempo de AME . Aos seis meses também foi observada associação negativa entre tempo de AME com o fato de a mãe trabalhar fora. Os resultados do presente estudo permitem comprovar a efetividade de uma intervenção multiprofissional realizada no pós-parto, em nível hospitalar, no aumento das taxas de AME em crianças tanto aos quatro como aos seis meses.

Magister Curationis - MCur / The aim of this study was to describe the demographic and socio-economic factors influencing infant feeding practices in the Amathola district, South Africa. A survey was chosen as the design method and a structured questionnaire was used to collect information regarding the socio-economic and demographic factors and related infant feeding choices. The study population consisted of 100 women with infants up to the age of 14 weeks, who brought their infant for immunization at the selected community health clinic (the largest clinic in the Mdantsane area). Infants up to the age of 14 weeks were used because all the visits up to 14 weeks coincide with the local immunization program, and according to WHO guidelines all infants should be exclusively breastfed until they reach the age of 6 months of age. The study found that there are many families in the Mdantsane area that suffer from poor conditions and inadequate services such as a lack of electricity, working taps or flush toilets within their dwelling, which in turn has an impact on infant feeding practices. It was found that even in poor demographic and socio-economic conditions, formula feeding is still the chosen feeding practice for the majority of mothers. / South Africa