Behavior Profile: Early Initiation of Breastfeeding
Goal has not been set
Mother initiates breastfeeding within first hour of baby’s life
Percentage of new-borns put to the breast within an hour of birth

Behavior Analysis

Strategy

BEHAVIOR AND STEPS

What steps are needed to practice this behavior?

Mother initiates breastfeeding within first hour of baby’s life

  1. Provider or birth attendant facilitates early and uninterrupted skin-to-skin contact (SSC)
  2. Provider or birth attendant supports all mothers to initiate breastfeeding (BF) as soon as possible after birth
  3. Mother allows newborn to suckle immediately even if milk does not appear to be presenting
  4. All caregivers refrain from offering pre-lacteal feeding, providing breastmilk substitute, and offering pacifiers or dummies
  5. Providers offer mother practical support to initiate and establish BF, and manage common BF problems, starting during antenatal care (ANC)
  6. Providers give mothers coaching and support to express milk in the event that they are separated from baby
  7. Providers keep mothers and newborns together at all times from birth to discharge, unless medically necessary due to complications requiring specialized medical care, in which case, see Step #4 above
  8. Providers support mothers to practice responsive feeding

FACTORS

What factors may prevent or support practice of this behavior?
Structural
Accessibility: Breastmilk substitutes are often widely available in health facilities
Service Provider Competencies: Facilities that include specific standards for immediate initiation of breastfeeding see higher rates of success
Service Provider Competencies: Essential newborn care (ENC) protocols are not always followed: practices often still include immediate washing and wrapping of baby instead of putting baby to chest immediately
Service Provider Competencies: Although national guidelines for breastfeeding by HIV-positive women exist, understanding and practice of protocol at facility level is often confused or out-of-date
Service Provider Competencies: Provider Capacity and Commitment: Providers sometimes believe breastmilk substitute is easier or more nutritious
Service Provider Competencies: Provider Capacity and Commitment: Providers sometimes believe babies need milk immediately and turn to breastmilk substitutes before the mother’s milk has come in
Service Provider Competencies: Provider Capacity and Commitment: Providers trained on breastfeeding are more likely to actively support immediate initiation
Service Provider Competencies: Provider Capacity and Commitment: Although women are more likely to request immediate initiation if they have discussed it (including importance of colostrum) during ANC or as part of birth preparation, providers do not always have time or willingness to provide such counseling
Service Provider Competencies: Provider Capacity and Commitment: For women who had obstetric complications or cesarean sections, providers do not always believe the woman will be able to breastfeed immediately and therefore do not assess the possibility
Service Experience: Clinic protocol often dictates that newborn and mother are often separated immediately after birth
Social
Family and Community Support: Some mothers and family members do not understand the importance of immediate suckling and colostrum, even without milk presenting
Family and Community Support: Families often believe breastmilk substitutes to be more nutritious because they see more affluent families using them
Norms: In some cultures, colostrum is considered inappropriate for the baby
Norms: In some places, babies, especially those born at home, are given pre-lacteal feeds with cultural importance
Internal
Attitudes and Beliefs: Some mothers believe their babies need milk immediately and turn to breastmilk substitute or other substances if they are not producing milk immediately at birth

SUPPORTING ACTORS AND ACTIONS

Who must support the practice of this behavior, and what actions must they take?
Institutional
Policymakers: Review clinical protocols for ENC to ensure that guidance for immediate breastfeeding is clear
Policymakers: Clarify baby-friendly hospital policy, including prevention of routine use of breastmilk substitutes and keeping the mother-baby dyad together throughout the facility stay
Managers: Control local environment within a facility for breastmilk substitutes, ensuring their dissemination is not standard practice
Managers: Remind providers that ENC includes putting baby to breast and SSC
Logistics Personnel: Ensure breastmilk substitutes are not readily available as part of delivery supplies
Providers: Work with mother, male partner/ father, and other family members during ANC to prepare for immediate breastfeeding, including discussing the importance of colostrum and suckling to stimulate milk production, uterine contractions, and effective latch
Community
Traditional Birth Attendants, Community Midwives, and Community Health Workers : Discuss breastfeeding (immediate initiation, exclusivity, extended) during ANC, and then facilitate immediate initiation at birth
Household
Male Partners: Encourage and support new mothers to breastfeed immediately post birth
Grandmothers: Support new mothers to immediately place the baby to breast, even before wrapping or washing

POSSIBLE PROGRAM STRATEGIES

What strategies will best focus our efforts based on this analysis?

Strategy requires Communication Support

Enabling Environment
Institutional Capacity Building: Clarify policy on immediate breastfeeding for HIV-infected women
Institutional Capacity Building: Create policy to limit use of breastmilk substitutes to times when mother truly cannot breastfeed and donor milk is not available
Institutional Capacity Building: Revise clinical protocols and quality assurance for facility births to include explicit metrics for immediate breastfeeding post-birth, as well as for keeping mother and baby together.
Systems, Products and Services
Quality Improvement: Incorporate provider support to women on immediate and continued breastfeeding into supervision, mentoring, and quality improvement activities
Quality Improvement: Create support mechanisms for provider peer groups to discuss new protocols and practices and to hold each other accountable
Quality Improvement: Use Knowledge-to-Action training approach, including simulation and post-training support and follow-up, to train providers on skills, including assisting women with breastfeeding problems; elicit and resolve important feedback on learning and capacity
Demand and Use
Communication: Recognize high-performing providers (across all priority behaviors or care provision) through local and subnational media
Communication: Ensure early initiation of breastfeeding is positioned as something critical for women and babies of all socio-economic levels to do
Communication: Reframe importance of early initiation of breastfeeding as critical for newborn health even when the mom’s milk hasn’t yet come in
Communication: Include discussion on immediate initiation of breastfeeding in counseling and other birth preparedness
Communication: Add early initiation of breastfeeding to the full range of health education, communication, and counseling materials used during birth preparation, ANC, and pregnancy support groups