Effect of breastfeeding education on the feeding pattern and health of infants in their first 4 months in the Islamic Republic of Iran.

Effect of breastfeeding education on the feeding pattern and health of infants in their first 4 months in the Islamic Republic of Iran M.D. Froozani,1 K. Permehzadeh,2 A.R. Dorosty Motlagh,2 & B. Golestan3 This quasi-experimental study was conducted in Shiraz, the Islamic Republic of Iran, on 120 pairs of mothers and infants in a maternity hospital that had a rooming-in programme. All 59 mothers in the study group received breastfeeding education, face-to-face, after delivery and during follow-up for 4 months in the mother and child health (MCH) centre or in their homes; the remaining 61 mothers comprised the control group. Exclusive breastfeeding rates were significantly higher in the study group (54%) than in the control group (6.5%), but 5% and 18% of infants, respectively, in the study and control groups had stopped breastfeeding by the age of 4 months. The mean number of days of diarrhoea experienced by infants in the study group were significantly lower (P4 0.004) than in the control group. At the end of 4 months, the mean weight and length of the infants were significantly higher (both P <0.05) in the study group than in the control group. The findings indicate that rooming-in is very important for promoting exclusive breastfeeding and that there is a need for continuous breastfeeding education of mothers. Voir page 389 le re´sume´ en franc¸ais. En la pa´gina 390 figura un resumen en espan˜ol. Introduction There is general agreement that breastfeeding is good for the growth and health of infants. In less developed countries it may be the only way to provide complete nutrition for sustaining neonates’ growth during the first 4–6 months of life, while at the same time reducing the incidence of infectious diseases such as diarrhoea and respiratory tract infections during the first year (1–4). In a developed country such as the USA, it has been estimated that, using illness as the sole indicator of costs, US$ 2160 million would be saved annually if mothers practised full breastfeeding for 12 weeks (5). Despite recognition of the numerous benefits of breastfeeding and of exclusive breastfeeding (in which water, milk, and other liquid or solid foods (except for vitamin drops and medicines) are not allowed), the duration of exclusive breastfeeding in the Islamic Republic of Iran, especially in the urban areas, is less than the 4–6 months recommended by WHO. The reasons for this may be lack of support for breastfeeding by social workers and health care providers, emotional stress in mothers and their perception of not having enough breast milk, and pressure from close relatives to introduce liquids or solid foods. The present study investigates the effect of breastfeeding education on the duration of exclusive breastfeeding and on the feeding pattern and health of infants in the first 4 months of life. Subjects and methods To investigate the effect of breastfeeding education, we carried out a cohort quasi-experimental study in Shiraz, capital of Fars Province, the Islamic Republic of Iran, from March to September 1994 in a public maternity hospital, which had a rooming-in pro- gramme. All subjects were selected, before delivery, from an urban population of low socioeconomic status according to the following criteria: mothers were primiparae or had previously been unsuccessful with breastfeeding, the pregnancy was normal and followed by vaginal delivery at term (38–42 weeks), and the mothers had no chronic disease and were not taking any medication. All those selected were willing to breastfeed and had no job outside the home. The neonates in the study were healthy singletons with a birth weight of at least 2500 g, which was considered appropriate for their gestational age (6). The mothers were randomly assigned, accord- ing to their delivery on odd or even days, to the study (S) or control (C) group, respectively. They were questioned before the intervention but were not told the group they had been assigned to. A total of 134 mothers were selected at the start of the study; frequency matching analysis (w2 test and t-test) showed no statistically significant differences be- tween the two groups. However, 8 pairs of mothers 1 Professor of Nutrition, Department of Nutrition, School of Public Health, Medical Sciences University of Teheran, Teheran, Islamic Republic of Iran. Requests for reprints should be sent to Dr M.D. Froozani, P.O. Box 14155/ 4487, Teheran, Iran. 2 School of Public Health, Medical Sciences University of Teheran, Teheran, Islamic Republic of Iran. 3 Department of Epidemiology and Biostatistics, School of Public Health, Medical Sciences University of Teheran, Teheran, Islamic Republic of Iran. Reprint No. 5802 381Bulletin of the World Health Organization, 1999, 77 (5) # World Health Organization 1999 and infants in the study group and 6 pairs in the control group had moved to another city or were too busy to participate in the study. This left a total of 120 mother–infant pairs, 59 in the study group and 61 in the control group. The mothers in the study group participated in the breastfeeding education programme during their postpartum stay (usually for 24 hours) in the maternity ward of the hospital, with follow-ups in the hospital lactation clinic or at home. The instruction was given by a trained nutritionist in a 40-hour breastfeeding course (adapted from Breast- feeding counselling: a training course (unpublished docu- ment WHO/CDR/93.3-6)) in which each mother (after delivery) learned about the advantages of breastfeeding for herself and her child. The topics covered included the anatomy and physiology of the mammary gland, how to position the infant on the breast and prevent breastfeeding problems, rooming- in, breastfeeding on demand, and the importance of exclusive breastfeeding, i.e., using the breast as the only source of nutrients (except for vitamin drops) during the first 4 months of life. On the day of discharge, the baby’s position on the breast was observed and corrected (if necessary), and educa- tional materials on different aspects of breastfeeding were supplied to the mothers. Follow-up visits in the lactation clinic or at the patient’s home were conducted between day 10 and day 15 after delivery, after 30 days, and at monthly intervals until the end of the fourth month. Mothers were also encouraged to attend the clinic at any time if they were worried about the baby’s condition or their breastfeeding performance. The mothers in both groups were asked to record the number of suckling episodes (during the day and night) and the days when the infant had diarrhoea or a respiratory illness. At each visit, the breastfeeding pattern and the infant’s medical condition were noted. Measurements of the mother’s weight and height before delivery, and the infant’s weight, length and head circumference were recorded by the nutritionist after delivery and during each follow-up visit of all subjects in the study group. For the control group the infants were measured only at birth and at the end of 4 months. All measurements were carried out using standard procedures (7), equipment and methodology. The mechanical scale employed showed the child’s weight to within 10 g, a measuring board gave the child’s length to the nearest 0.5 cm, and a plastic tape was used to measure the head circumference to the nearest mm. The same persons recorded all the measurements to reduce inter- investigator errors (8). Data analysis Data were statistically analysed using EPI Info (9), PE2 (10), and Harvard Graphics software (11). The weight, length and head circumference of the neonates were compared using Z-scores, and the differences in the rate of exclusive breastfeeding at the end of each month were analysed using the log- rank test (12). The w2 test and Student’s t-test were used to determine the relationship between variables and to compare means, respectively. The infant’s weight and length were compared with data from the US National Center for Health Statistics (NCHS) (13) and the Darling study (14), while head circumferences were compared with reference data (15). Malnutrition was assessed by comparing the weight-for-age (W/A), height-for-age (H/A) and weight-for-height (W/H) measurements with NCHS reference data (16). Results Table 1 compares data from both groups concerning the infants (number of males and females, and measurements of their birth weight, length and head circumference) and their parents (age and weight of Table 1: Main characteristics of mothers and infants in the study and control groups Characteristic Study group Control group (n = 59) (n = 61) Mean maternal age (years) 23.0 (5.5)a 23.4 (6.4) Mean maternal weight before delivery (kg) 64.6 (9.0) 64.5 (9.5) Mean duration of mother’s education (years) 5.7 (2.5) 5.9 (2.5) Mean duration of father’s education (years) 5.9 (2.5) 6.6 (2.8) Mean family income (toman)b 14 745 (4474) 14 932 (4916) Infants: No. of males 30 29 No. of females 29 32 Mean birth weight (g) 3201.9 (386.0) 3183.3 (304.4) Mean birth length (cm) 50.0 (1.8) 50.0 (1.9) Mean head circumference (cm) 34.1 (1.3) 34.1 (1.1) a Figures in parentheses are standard deviations. b US$1 = 300 toman. Table 2: Feeding patterns 4 months after delivery in the study and control groups Feeding pattern Study group Control group (n = 59) (n = 61) No. on exclusive breastfeeding 32 (54.0)a, b 4 (6.5) No. on predominant breastfeeding 12 (20.5) 32 (52.5) No. on milk supplements and breastfeeding 12 (20.5)c 14 (23.0) No. who had stopped breastfeeding 3 (5.0)d 11 (18.9) a Figures in parentheses are percentages. b P <0.01. c Not significant. d P <0.05. Research 382 Bulletin of the World Health Organization, 1999, 77 (5) the mothers, monthly family income, and level of education). There were no significant differences between the two groups, although educational level and income were slightly higher in the control group. Table 2 compares the breastfeeding pattern (exclusive breastfeeding, predominant breastfeeding (i.e. breast milk as the main food, but allowing some non-food fluids such as water, tea, sugar water, vitamin drops and medicines), and breastfeeding plus milk supplements) in the two groups. The rate of exclusive breastfeeding was significantly higher (P <0.01) in the study group (54%) than the control group (6.5%), while predominant breastfeeding was significantly lower (P <0.01) in the study group. During the 4 months of study, 5% and 18% of infants in the study and control groups, respectively, had completely stopped breastfeeding. Table 3 presents the rate of exclusive breast- feeding among infants in both groups at the end of each month. The rates in the study group were significantly higher (P < 0.000001, using log-rank tests) in the study group. The mean duration of exclusive breastfeeding was higher (P < 0.05) in the study group (2.96+1.36 months) than in the control group (1.05+1.34 months). Milk supplements, other liquids and food supplements were introduced earlier by mothers in the control group (Table 4). The usual reason for the early introduction of milk supplements was the mother’s perception that she did not have enough breast milk. The mean number of days of diarrhoeal illness during the 4-month study period was significantly lower in the study group (P <0.004) than in the control group (Table 5). Respiratory illness was also lower in the study group, but this was not significant. The mean weight and length of the infants in the two groups did not differ significantly at birth (Table l), but there was a significant difference between the two groups in both these measurements at the end of 4 months (Table 6). Discussion Several groups have reported on how breastfeeding education has changed the knowledge of mothers about various aspects of breastfeeding (17–20) and how it increased the duration of exclusive breastfeed- ing in infants aged 4–6 months (21–24). In the present study there was a significant difference in the breastfeeding pattern between the study and control groups. The decrease in exclusive breastfeeding in the control group could have been due to a mis- conception among mothers and their families about the early introduction of water and other liquids (e.g. for treating colic) and of food supplements to their infants. Continuous breastfeeding education of mothers and their close relatives, with special emphasis on the advantages of exclusive breastfeed- ing during the first 4 months of life, would therefore Table 3. Number of mothers exclusively breastfeeding during the first 4 months in the study and control groups Exclusive breastfeeding Study group Control group (n = 59) (n = 61) At the end of: 1st month 55 (93)a 28 (46) 2nd month 46 (78) 20 (33) 3rd month 42 (71) 12 (20) 4th month 32 (54) 4 (6.5) a Figures in parentheses are percentages. Table 4: Age of introduction of milk and other liquid and food supplements in the study (n = 59) and control (n = 61) groups Supplements Milk Liquids and food Study Control Study Control group group group group No. who received no supplements 44 (74.5)a 36 (59.0) 38 (64.5) 6 (9.8) No. who received supplements in the: 1st month 1 (1.7) 5 (8.2) 3 (5.0) 32 (52.5) 2nd month 4 (6.8) 6 (9.8) 7 (11.9) 4 (6.6) 3rd month 4 (6.8) 8 (13.2) 3 (5.0) 8 (13.1) 4th month 6 (10.0) 6 (9.8) 8 (13.6) 11 (18.0) a Figures in parentheses are percentages. Table 5: Number of days of diarrhoea or respiratory illness per child during the first 4 months in the study and control groups Study group Control group (n = 59) (n = 61) Mean number of days of illness per child with: Diarrhoea 1.2 (2.7)a, b 4.0 (7.1 )a, b Respiratory illness 3.2 (5.0) 3.7 (8.8) a Figures in parentheses are standard deviations. b P <0.004. Table 6: Weight, length and head circumference of infants at 4 months of age in the study and control groups Measurement Study group Control group P-value (n = 59) (n = 61) Mean weight (g) 6335.4 (740.0)a 6054.8 (752.7) < 0.05 Mean length (cm) 63.2 (2.3) 62.4 (1.9) < 0.05 Mean head circumference (cm) 41.0 (1.4) 40.7 (1.1) Not significant a Figures in parentheses are standard deviations. Effect of breastfeeding education in the Islamic Republic of Iran 383Bulletin of the World Health Organization, 1999, 77 (5) help to improve their knowledge and lead to the adoption of healthy practices. At the end of the first month, the rates of exclusive breastfeeding were 93% and 46%, respec- tively, in the study and control groups; by the end of the fourth month the rates had decreased to 54% and 6.5%, respectively (Table 3). This difference was very significant (P <0.000001). The reduction in the rate of exclusive breastfeeding in the study group was from 93% to 71% between the first and third months, and from 71% to 54% during the fourth month (Table 3). The reasons for the early introduction of milk supplements were, as reported in other studies (25– 30), the mother’s perception of not having enough milk (54% in the control group and 36% in the study group) and crying by the infant (26% and 28% in the control and study groups, respectively). The sig- nificant difference in the number of days of diarrhoea between the two groups is probably due to the higher rate of exclusive breastfeeding in the study group. Other studies have also reported a lower incidence of diarrhoeal illness among breast-fed infants (18, 31, 32). The number of days with respiratory illness was less in the study group than the control group, but this difference was not significant. Two infants in the control group, one male and one female, were malnourished (as indicated by weight-for-age and length-for-age) at the end of the fourth month. The differences between the two groups in terms of the weight, length and head circumference of infants were not significant at birth (Table l), but became so at the end of the fourth month with regard to the infants’ weight and length (Table 6). The latter finding is probably due to the longer duration of exclusive breastfeeding and the fewer days with diarrhoea and respiratory illnesses among infants in the study group. In conclusion, the results of the present study show that breastfeeding education of mothers after delivery and during the first 4 months of lactation increased the rate of exclusive breastfeeding and improved the nutritional and health status of the infants. The education of the mothers’ close relatives may also be important for promoting breast- feeding. n Re´sume´ Effet de l’enseignement de l’allaitement au sein sur les modalite´s d’alimentation et la sante´ des nourrissons au cours des 4 premiers mois en Re´publique islamique d’Iran Cette e´tude quasi-expe´rimentale a e´te´ mene´e a` Chiraz (Re´publique islamique d’Iran) sur 120 couples me`re- enfant (re´partis en un groupe expe´rimental et un groupe te´moin) d’une maternite´ pratiquant la pre´sence du nourrisson aupre`s de sa me`re. Les 59 me`res du groupe expe´rimental ont rec¸u un enseignement de l’allaitement au sein, dispense´ en teˆte-a`-teˆte apre`s l’accouchement et au cours d’un suivi de 4 mois dans un centre de sante´ maternelle et infantile ou a` leur domicile; les 61 autres me`res constituaient le groupe te´moin. Le taux d’allaitement exclusif au sein e´tait sensiblement plus e´leve´ dans le groupe expe´rimental (54 %) que dans le groupe te´moin (6,5%), mais 5% et 18% des nourrissons appartenant respectivement au groupe expe´rimental et au groupe te´moin n’avaient plus e´te´ nourris au sein a` partir de 4 mois. Le nombre moyen de jours de diarrhe´e e´tait sensiblement plus faible (P 4 0,004) chez les nourrissons du groupe expe´ri- mental que chez ceux du groupe te´moin. Au bout des 4 mois, la taille et le poids moyens des nourrissons e´taient sensiblement plus e´leve´s chez les enfants du groupe expe´rimental (P < 0,05) que chez ceux du groupe te´moin. Ces re´sultats montrent que la pre´sence de l’enfant aupre`s de sa me`re est tre`s importante pour encourager celle-ci a` allaiter exclusivement au sein et qu’en Iran, il faut assurer un enseignement permanent de cette pratique aux me`res. Resumen Efectos de la educacio´n sobre lactancia natural en las pautas de alimentacio´n y la salud de los lactantes en sus primeros cuatro meses de vida en la Repu´blica Isla´mica del Ira´n Este estudio cuasiexperimental se llevo´ a cabo en Shiraz (Repu´blica Isla´mica del Ira´n) entre 120 pares de madres y lactantes en un hospital de maternidad en el que funcionaba un programa de alojamiento conjunto madre-bebe´. Las 59 madres del grupo estudiado recibieron educacio´n sobre lactancia natural, de forma personal e individualizada, despue´s del parto y durante los cuatro meses de seguimiento posteriores en el centro de salud maternoinfantil o en su hogar; las otras 61 madres constituyeron el grupo testigo. Las tasas de lactancia natural exclusiva fueron significativamente mayores en el grupo estudiado (54%) que en el grupo testigo (6,5%), pero a la edad de cuatro meses el 5% y el 18% de los lactantes de los grupos estudiado y testigo, respectivamente, habı´an dejado de ser alimentados al pecho. El nu´mero medio de dı´as de diarrea entre los lactantes del grupo estudiado fue significativamente menor (P 4 0,004) que en el grupo testigo. Al te´rmino de los cuatro meses, el peso y talla medios de los lactantes fueron significativamente mayores (en los dos casos P < 0,05) en el grupo estudiado que en el grupo testigo. Los resultados indican que el alojamiento conjunto madre-bebe´ es muy importante para promover la lactancia materna exclusiva, y que es necesario que las madres del Ira´n reciban educacio´n continua sobre lactancia natural. Research 384 Bulletin of the World Health Organization, 1999, 77 (5) References 1. Victora CG et al. 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