The debate that shouldn't be
Authors: Zoë Mullan
Journal: The Lancet Global Health (2015)

Some health-related topics are guaranteed to stir up heated debate in the general public whenever they crop up in the news. Publishing a research paper on chronic fatigue syndrome, homoeopathy, or mode of childbirth is a recipe for a media field day, a lively letters section, and a jammed inbox. The Lancet Global Health experienced its first taste of such events when we published Cesar Victora and colleagues' birth cohort study on breastfeeding and adult intelligence in March this year. Newspaper headlines proclaimed the “good news”, but many readers (notably in high-income countries) weren't so sure. “As if mothers don't feel enough pressure”, tweeted one. “What a load of rubbish…There may be health benefits in third world countries but this does not apply to the western world”, pronounced another by email. “Propaganda!” accused a Facebook follower. Some of the more scientific arguments are published in a series of Correspondence letters in this month's issue.That breastfeeding should be such a polarising social issue in high-income countries is deeply troubling for health professionals intent on making progress with reducing neonatal mortality worldwide. Lack of breastfeeding has been associated with a four-fold increased risk of dying from infectious causes in the first month of life in low-income and middle-income countries, and The Lancet's Series on maternal and child undernutrition found that suboptimum breastfeeding results in more than 800 000 child deaths annually. Only 38% of babies worldwide are exclusively breastfed. World Breastfeeding Week, celebrated Aug 1–7, aims to change that, citing goal 5 of WHO's global nutrition targets—to increase the rate of exclusive breastfeeding in the first 6 months to at least 50% by 2025. A policy brief published last year recommends a set of five key actions by which to achieve this target, the first of which is to “Provide hospital- and health facilities-based capacity to support exclusive breastfeeding, including revitalizing, expanding and institutionalizing the Baby-friendly Hospital Initiative in health systems”.The Baby-Friendly Hospital Initiative (BFHI) is a WHO/UNICEF programme to improve exclusive breastfeeding among new mothers in health facilities worldwide by training health workers to provide the optimum conditions for success. Since its launch in 1991, and subsequent updating to include care of women with HIV, 160 countries have implemented the initiative. At its heart are the Ten Steps to Successful Breastfeeding, which include informing all women of the benefits of breastfeeding, helping them to initiate breastfeeding within half an hour of birth, and allowing mothers to remain with their babies at all times. The final step involves fostering the establishment of breastfeeding support groups in the community and referring mothers to them on discharge from the hospital or clinic. Once all steps are in place, a health facility can apply for external accreditation as a Baby-Friendly Hospital.Despite the broad roll-out of the initiative globally, in east and southern Africa in 2009–10, only 26% of eligible health facilities had been accredited. One barrier to uptake could be the less than straightforward final step of fostering external support groups and the resource-intensive process of external accreditation. In this month's issue, Marcel Yotebieng and colleagues report the results of a cluster-randomised trial to assess whether a short-cut programme (steps 1–9 only) could improve early and exclusive breastfeeding in Kinshasa, Democratic Republic of Congo, compared with no BFHI training. They found that, although rates of early breastfeeding initiation remained high in both groups, the short-cut programme greatly improved rates of exclusive breastfeeding at 14 and 24 weeks. A third group that included a modified step 10, whereby training was extended to staff of well baby clinics outside the hospital setting and educational flyers were provided for family members, showed a lesser benefit and even evidence of a negative effect.The importance of very carefully designed training for breastfeeding support staff is clearly paramount in this setting and in fact every setting. Women should not feel bullied or emotionally blackmailed into breastfeeding by one over-zealous section of society any more than they should be made to feel ashamed for breastfeeding in public by another. Breastmilk provided exclusively for at least 6 months is unequivocally the best nutrition a baby can receive; women and their families need respectful advice to make the choice wherever that is possible. Some health-related topics are guaranteed to stir up heated debate in the general public whenever they crop up in the news. Publishing a research paper on chronic fatigue syndrome, homoeopathy, or mode of childbirth is a recipe for a media field day, a lively letters section, and a jammed inbox. The Lancet Global Health experienced its first taste of such events when we published Cesar Victora and colleagues' birth cohort study on breastfeeding and adult intelligence in March this year. Newspaper headlines proclaimed the “good news”, but many readers (notably in high-income countries) weren't so sure. “As if mothers don't feel enough pressure”, tweeted one. “What a load of rubbish…There may be health benefits in third world countries but this does not apply to the western world”, pronounced another by email. “Propaganda!” accused a Facebook follower. Some of the more scientific arguments are published in a series of Correspondence letters in this month's issue. That breastfeeding should be such a polarising social issue in high-income countries is deeply troubling for health professionals intent on making progress with reducing neonatal mortality worldwide. Lack of breastfeeding has been associated with a four-fold increased risk of dying from infectious causes in the first month of life in low-income and middle-income countries, and The Lancet's Series on maternal and child undernutrition found that suboptimum breastfeeding results in more than 800 000 child deaths annually. Only 38% of babies worldwide are exclusively breastfed. World Breastfeeding Week, celebrated Aug 1–7, aims to change that, citing goal 5 of WHO's global nutrition targets—to increase the rate of exclusive breastfeeding in the first 6 months to at least 50% by 2025. A policy brief published last year recommends a set of five key actions by which to achieve this target, the first of which is to “Provide hospital- and health facilities-based capacity to support exclusive breastfeeding, including revitalizing, expanding and institutionalizing the Baby-friendly Hospital Initiative in health systems”. The Baby-Friendly Hospital Initiative (BFHI) is a WHO/UNICEF programme to improve exclusive breastfeeding among new mothers in health facilities worldwide by training health workers to provide the optimum conditions for success. Since its launch in 1991, and subsequent updating to include care of women with HIV, 160 countries have implemented the initiative. At its heart are the Ten Steps to Successful Breastfeeding, which include informing all women of the benefits of breastfeeding, helping them to initiate breastfeeding within half an hour of birth, and allowing mothers to remain with their babies at all times. The final step involves fostering the establishment of breastfeeding support groups in the community and referring mothers to them on discharge from the hospital or clinic. Once all steps are in place, a health facility can apply for external accreditation as a Baby-Friendly Hospital. Despite the broad roll-out of the initiative globally, in east and southern Africa in 2009–10, only 26% of eligible health facilities had been accredited. One barrier to uptake could be the less than straightforward final step of fostering external support groups and the resource-intensive process of external accreditation. In this month's issue, Marcel Yotebieng and colleagues report the results of a cluster-randomised trial to assess whether a short-cut programme (steps 1–9 only) could improve early and exclusive breastfeeding in Kinshasa, Democratic Republic of Congo, compared with no BFHI training. They found that, although rates of early breastfeeding initiation remained high in both groups, the short-cut programme greatly improved rates of exclusive breastfeeding at 14 and 24 weeks. A third group that included a modified step 10, whereby training was extended to staff of well baby clinics outside the hospital setting and educational flyers were provided for family members, showed a lesser benefit and even evidence of a negative effect. The importance of very carefully designed training for breastfeeding support staff is clearly paramount in this setting and in fact every setting. Women should not feel bullied or emotionally blackmailed into breastfeeding by one over-zealous section of society any more than they should be made to feel ashamed for breastfeeding in public by another. Breastmilk provided exclusively for at least 6 months is unequivocally the best nutrition a baby can receive; women and their families need respectful advice to make the choice wherever that is possible. Ten Steps to Successful Breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trialIn the setting of health-care clinics in DR Congo with a high proportion of mothers initiating breastfeeding, implementation of basic training in BFHI steps 1–9 had no additional effect on initiation of breastfeeding but significantly increased exclusive breastfeeding at 6 months of age. Additional support based on the same training materials and locally available breastfeeding support materials, offered during well-child visits (ie, step 10) did not enhance this effect, and might have actually lessened it. Full-Text PDF Open Access