Illustrative Example: Analyze the Situation (Step 2)

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Health and Breastfeeding Context [1]

Most of the information in this section is a global-level analysis for purposes of illustration. The country-specific situation analysis should focus on the local health and breastfeeding context.

Since 1990 there has been huge global progress in reducing child mortality. Five million fewer children died in 2011 than in 1990. It is starting to look like we can end preventable child deaths. But making that happen requires quite a bit more change.

Malnutrition still is a major factor in one-third of child deaths. This means we are not reducing malnutrition fast enough. Unless malnutrition is solved, it will continue to hold back progress in other areas of child health. Also, while overall child death rates are falling, more of those deaths now occur within the first month of life.

Breastfeeding saves lives. There is no doubt about it. One can argue that it is the single best way to reduce child malnutrition and save newborn lives. Breast milk contains all the food and water the baby needs in the first six months of life. Really. The first milk the mother produces is called colostrum. Colostrum is the most powerful natural immune system booster known to science.[2] It is so helpful to the newborn that some people call it “liquid gold”. Almost a million newborn deaths could be prevented every year if all infants were given breast milk in the first hour of life.

The benefits of breastfeeding for babies continue even after that critical first hour. Infants fed only breast milk for the first six months are protected against major childhood diseases. A child who is not breastfed is 15 times more likely to die from pneumonia and 11 times more likely to die from diarrhea.[3] Around one of every eight young child deaths could be prevented through breastfeeding.[4]

But breastfeeding is not valued nearly as much as it should be. Progress made in raising breastfeeding rates in the 1980s has slowed, stopped, or even reversed in some countries. Globally, only 43% of children are breastfed within the first hour of life and only 37% of children are exclusively breastfed for the first six months.[5] Progress is possible: 27 countries have increased their exclusive breastfeeding rates by more than 20 percentage points in 10 years.[6] Other countries are experiencing stagnation and even declines in exclusive breastfeeding are also taking place. According to recent national data, two-thirds of the 92 million children who are not exclusively breastfed are in just 10 countries, and seven of those countries (India, China, Nigeria, Indonesia, Philippines, Ethiopia and Vietnam) have very high child mortality rates.[7]

Common practices (to be discouraged) include:

  • Denying the newborn colostrum
  • Giving other foods or liquids before starting breastfeeding
  • Giving formula or milk instead of breastfeeding
  • Giving formula, water, teas, traditional mixtures or food in addition to breast milk within the first six months—in many cases, foods are given when the child is two or three months old.
  • Feeding under-two year olds food that is too difficult to digest or not nutritious enough.

Sub-optimal feeding practices are even common in many settings where breastfeeding for the first two years (or longer) is the norm.

Audience and Communication Analysis

Decisions affecting breastfeeding are made at various levels: the individual/family/community level, the health system level, and the society or policy level. It helps to look at the factors affecting breastfeeding behaviors at each of these levels separately. For example, FBOs tend to be particularly well-placed to act at the individual/family/community level. They can also be quite good at impacting the other levels as well, especially if the FBO operates health facilities or has a high-profile leader who is able to influence policy and business. Many sources were consulted to provide this global breastfeeding situation analysis.

Despite clear evidence that early and exclusive breastfeeding is the best way to care for newborns, many mothers are given bad advice, are pressured into harmful alternatives or do not have enough time to breastfeed exclusively because they have to return to work or household chores. Common reasons for sub-optimal breastfeeding practices are highlighted in the Table 6.

Table 6. Common reasons given for sub-optimal breastfeeding practices[8]

Harmful practice Common reasons for it
Pre-lacteal feed
  • To clean the newborn’s stomach/intestines
  • Belief that breast milk is not yet ready
  • Belief that there is not enough breast milk
  • To purge the first stool
  • Traditional or religious beliefs or practices
Withholding colostrum Religious or traditional beliefs; belief that colostrum is old, unhealthy, unclean, or hard to digest
Non-exclusive breastfeeding in the first 6 months (mixed feeding or artificial feeding)
  • Difficulty breastfeeding (Caesarean section, pain, not latching, cracked nipples, etc.)
  • Illness of mother or child
  • Lack of knowledge about how and how often to breastfeed
  • Lack of time due to chores or to work outside the home
  • Belief that the mother does not produce enough milk to satisfy the child
  • Belief that even infants need water in hot weather conditions
  • Belief that formula is better than breast milk
  • Shame of breastfeeding in public
  • Belief that child is ready for other foods and drinks because they think it will make them stronger than breastmilk alone
  • Belief that cow’s milk or various foods will help the child grow better
  • Lack of knowledge about or ability to safely express and store breast milk
  • Lack of knowledge of the benefits of breast milk – including the antibodies and other protective substances it contains
  • Fear that the child will become dependent on breast milk and not eat if the mother is away for any reason (for work, illness, death, other reasons.)
Inappropriate supplemental feeding in months 6-24
  • Lack of knowledge about what foods are appropriate at what ages
  • Belief that certain nutritious foods are harmful for the child
  • Lack of resources to get appropriate foods
  • Common practice for young children to eat what the rest of the family eats
  • Traditional practice for fathers to be given the most nutritious foods
Stopping breastfeeding before 24 months In addition to reasons already cited:

  • Many of the reasons mentioned above
  • Belief that breastfeeding cannot be re-established if stopped for health or other reasons
  • Taboos against sexual activity while breastfeeding
  • Taboos against breastfeeding while pregnant
  • Social status associated with infant formula
  • Return to work
Inadequate nutrition for breastfeeding mothers
  • Tradition of of limiting what breastfeeding mothers can eat
  • Lack of knowledge of importance of extra and more nutritious meals
  • Tradition of giving the most nutritious foods to the father
  • Belief that certain nutritious foods can harm the mother or breastfeeding child
  • Lack of resources to get more nutritious food

In addition, many women are not free to make their own decisions about whether they will breastfeed, or for how long. Instead, in some countries and communities, it is often husbands or mothers-in-law who decide. Fear of passing HIV to the newborn can also reduce breastfeeding, but studies show that breast milk remains the healthiest alternative even when the mother is HIV positive.

At the individual, family and community level, several factors have been shown to improve breastfeeding practices[9] :

  • Social, community and family support
  • Positive social norms around breastfeeding
  • Correct information
  • Practical support from a knowledgeable and experienced person – relative, neighbor, health worker, religious institution member.
  • Maternities and workplaces with baby-friendly policies

One-third of infants are born without a skilled birth attendant present.[10] As a result, the opportunity to support mothers to breastfeed in the first few hours can be lost. An analysis of data from 44 countries7 found that women who had a skilled attendant present at birth were twice as likely to breastfeed within the first hour. However, it has also been found that many skilled birth attendants are unaware of the importance of breastfeeding within the first hour, give in to pressure from families to withhold breast milk, or actually discourage women from starting breastfeeding early (for example, because they feel the mother is too weak)[11] .

Delivery room set-up and procedures, such as removing the infant from the mother right after birth for more than an hour, can discourage or prevent early breastfeeding. In addition, mothers having trouble breastfeeding before leaving the health facility might not get the support they need from overwhelmed nurses. Health systems have improved breastfeeding practices by:

  1. Having medical personnel, including community health workers and birth attendants, provide skilled support and correct advice
  2. Having a companion (e.g., supportive family member) in the delivery room with the mother
  3. Having maternities with “baby-friendly” policies such as the Baby-Friendly Hospital and Community Initiative, launched in 1991 by WHO and UNICEF
  4. Helping parents decide before delivery to exclusively breastfeed and create a plan to do so

Returning to work after the birth of a child is difficult for any mother. Continuing to breastfeed can be very challenging for working mothers—even those who work at home or on the family farm.

For mothers who work outside the home, three areas of national policy play a key role in a woman’s ability to breastfeed:

  • Maternity leave,
  • Financial protection to help maintain the family’s income while the mother is not working, and
  • Workplace provisions to allow breastfeeding to continue once a mother returns to work.

To promote exclusive breastfeeding, women must receive enough paid maternity leave. Ideally this would be 14-18 weeks’ leave with at least two-thirds pay. Most less-developed countries do not meet this standard. Back at work, there must be policies in place that require employers to provide paid breaks and private places where women can breastfeed or express milk so that they are able to continue breastfeeding.

Women in informal jobs also face problems in continuing to breastfeed when they return to work. They are often unable to take their children with them farm or to do household chores such as collecting firewood and water. For these women, state grants and social protection (such as social security payments or cash benefits) that do not depend on formal maternity leave are even more important.

FBOs can play a key role by:

  • Organizing household and community savings plans that families can access in the months when the mother is working less in order to breastfeed more,
  • Assisting with household costs or chores, or
  • Providing childcare that encourages women to express milk for feeding during the day.

It is true that certain infants need to be formula-fed. However, it seems that formula is marketed in a way that encourages mothers to prefer it even though their babies do not need it. Marketing images and mixed messages might not make it clear that formula can actually put children at risk.

Factors at the socio-political level that limit optimal breastfeeding practices include:

  • Widespread promotion of breast milk substitutes
  • No commercial advocate for breast milk, unlike infant formula
  • Limiting promotion of infant formula

Table 7 combines Tables 1 and 2, above, so programs can see how the situation analysis findings drive the choice of interventions.

Table 7. Strategic prioritization of situation analysis findings

Audience Current Behaviors Factors associated with suboptimal breastfeeding practices Factors associated with optimal breastfeeding practices So what Now what
Primary Audience
Influencing Audience
FB leaders and communities
Policy makers?
Community health workers?

[Download this table as a Word document.]

References for Table 6

Qiu, L., Zhao, Y., Binns, C. W., Lee, A. H., & Xie, X. (2009). Initiation of breastfeeding and prevalence of exclusive breastfeeding at hospital discharge in urban, suburban and rural areas of Zhejiang China. Int Breastfeed J, 4(1), 1746-53.
Yotebieng, M., Chalachala, J. L., Labbok, M., & Behets, F. (2013). Infant feeding practices and determinants of poor breastfeeding behavior in Kinshasa, Democratic Republic of Congo: a descriptive study. International breastfeeding journal, 8(1), 11.
Setegn, T., Belachew, T., Gerbaba, M., Deribe, K., Deribew, A., & Biadgilign, S. (2012). Factors associated with exclusive breastfeeding practices among mothers in Goba district, south east Ethiopia: a cross-sectional study. Int Breastfeed J, 7(1), 17.

Egata, G., Berhane, Y., & Worku, A. (2013). Predictors of non-exclusive breastfeeding at 6 months among rural mothers in east Ethiopia: a community-based analytical cross-sectional study. Int Breastfeed J, 8(8).

Inayati, D. A., Scherbaum, V., Purwestri, R. C., Hormann, E., Wirawan, N. N., Suryantan, J., ... & Bellows, A. C. (2012). Infant feeding practices among mildly wasted children: a retrospective study on Nias Island, Indonesia. International breastfeeding journal, 7(3), 1-9.