Sonja Merten

Do Baby-Friendly Hospitals Influence Breastfeeding Duration on a National Level?

Objectives. In Switzerland, the Baby-Friendly Hospital Initiative (BFHI) proposed by the United Nations Childrens Fund (UNICEF) was introduced in 1993 to promote breastfeeding nationwide. This study reports results of a national study of the prevalence and duration of breastfeeding in 2003 throughout Switzerland and analyzes the influence of compliance with UNICEF guidelines of the hospital where delivery took place on breastfeeding duration. Methods. Between April and September 2003, a random sample of mothers who had given birth in the past 9 months in Switzerland received a questionnaire on breastfeeding and complementary feeding. Seventy-four percent of the contacted mothers (n = 3032) participated; they completed a 24-hour dietary recall questionnaire and reported the age at first introduction of various foods and drinks. After excluding questionnaires with missing information relevant for the analyses, we analyzed data for 2861 infants 0 to 11 months of age, born in 145 different health facilities. Because it was known whether each child was born in a designated baby-friendly hospital (45 hospitals) or in a health facility in the process of being evaluated for BFHI inclusion (31 facilities), we were able to assess a possible influence of the BFHI on breastfeeding success. For this purpose, we merged individual data with hospital data on compliance with the UNICEF guidelines, from a data source collected on an annual basis for quality monitoring of designated baby-friendly hospitals and health facilities in the evaluation process. Information on actual compliance with the guidelines allowed us to investigate the relationship between breastfeeding outcomes and compliance with UNICEF guidelines. We were also able to compare the breastfeeding results with those for non–baby-friendly health facilities. The comparison was based on median durations of exclusive, full, and any breastfeeding calculated for each group. To allow for other known influencing factors, we calculated adjusted hazard ratios by using Cox regression; we also conducted logistic regression analyses with the 24-hour dietary recall data, to calculate adjusted odds ratios for validation of results from the retrospectively collected data. Results. In 2003, the median duration of any breastfeeding was 31 weeks at the national level, compared with 22 weeks in 1994, and the median duration of full breastfeeding was 17 weeks, compared with 15 weeks in 1994. The proportion of exclusively breastfed infants 0 to 5 months of age was 42% for infants born in baby-friendly hospitals, compared with 34% for infants born elsewhere. Breastfeeding duration for infants born in baby-friendly hospitals, compared with infants born in other hospitals, was longer if the hospital showed good compliance with the UNICEF guidelines (35 weeks vs 29 weeks for any breastfeeding, 20 weeks vs 17 weeks for full breastfeeding, and 12 weeks vs 6 weeks for exclusive breastfeeding). To control for differences in the study population between the different types of health facilities, hazard and odds ratios were calculated as described above, taking into account socioeconomic and medical factors. Although the analysis of the retrospective data showed clearly that the duration of exclusive and full breastfeeding was significantly longer if delivery occurred in a baby-friendly hospital with high compliance with the UNICEF guidelines, whereas this effect was less prominent in other baby-friendly health facilities, this difference was less obvious in the 24-hour recall data. Only for the duration of any breastfeeding could a positive effect be seen if delivery occurred in a baby-friendly hospital with high compliance with the UNICEF guidelines. Known factors involved in the evaluation of baby-friendly hospitals showed the expected influence, on the individual level, on duration of exclusive, full, and any breastfeeding. If a child had been exclusively breastfed in the hospital, the median duration of exclusive, full, and any breastfeeding was considerably longer than the mean for the entire population or for those who had received water-based liquids or supplements in the hospital. A positive effect on breastfeeding duration could be shown for full rooming in, first suckling within 1 hour, breastfeeding on demand, and also the much-debated practice of pacifier use. After controlling for medical problems before, during, and after delivery, type of delivery, well-being of the mother, maternal smoking, maternal BMI, nationality, education, work, and income, all of the factors were still significantly associated with the duration of full, exclusive, or any breastfeeding. Conclusions. Our results support the hypothesis that the general increase in breastfeeding in Switzerland since 1994 can be interpreted in part as a consequence of an increasing number of baby-friendly health facilities, whose clients breastfeed longer. Nevertheless, several alternative explanations for the longer breastfeeding duration for deliveries that occurred in baby-friendly hospitals can be discussed. In Switzerland, baby-friendly hospitals actively use their certification by UNICEF as a promotional asset. It is thus possible that differences in breastfeeding duration are attributable to the fact that mothers who intend to breastfeed longer would choose to give birth in a baby-friendly hospital and these mothers would be more willing to comply with the recommendations of the UNICEF guidelines. Even if this were the case, however, this selection bias would not explain the differences in breastfeeding duration between designated baby-friendly health facilities with higher compliance with the UNICEF guidelines and those with lower compliance. Especially this last point strongly supports a beneficial effect of the BFHI, because mothers do not know how well hospitals comply with the UNICEF program. The fact that breastfeeding rates have generally improved even in non–baby-friendly health facilities may be indirectly influenced by the BFHI; its publicity and training programs for health professionals have raised public awareness of the benefits of breastfeeding, and the number of professional lactation counselors has increased continuously. Breastfeeding prevalence and duration in Switzerland have improved in the past 10 years. Children born in a baby-friendly health facility are more likely to be breastfed for a longer time, particularly if the hospital shows high compliance with UNICEF guidelines. Therefore, the BFHI should be continued but should be extended to include monitoring for compliance, to promote the full effect of the BFHI.

A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa

BackgroundDespite Sub-Saharan Africa (SSA) being the epicenter of the HIV epidemic, uptake of HIV testing is not optimal. While qualitative studies have been undertaken to investigate factors influencing uptake of HIV testing, systematic reviews to provide a more comprehensive understanding are lacking.MethodsUsing Noblit and Hare’s meta-ethnography method, we synthesised published qualitative research to understand factors enabling and deterring uptake of HIV testing in SSA. We identified 5,686 citations out of which 56 were selected for full text review and synthesised 42 papers from 13 countries using Malpass’ notion of first-, second-, and third-order constructs.ResultsThe predominant factors enabling uptake of HIV testing are deterioration of physical health and/or death of sexual partner or child. The roll-out of various HIV testing initiatives such as ‘opt-out’ provider-initiated HIV testing and mobile HIV testing has improved uptake of HIV testing by being conveniently available and attenuating fear of HIV-related stigma and financial costs. Other enabling factors are availability of treatment and social network influence and support. Major barriers to uptake of HIV testing comprise perceived low risk of HIV infection, perceived health workers’ inability to maintain confidentiality and fear of HIV-related stigma. While the increasingly wider availability of life-saving treatment in SSA is an incentive to test, the perceived psychological burden of living with HIV inhibits uptake of HIV testing. Other barriers are direct and indirect financial costs of accessing HIV testing, and gender inequality which undermines women’s decision making autonomy about HIV testing. Despite differences across SSA, the findings suggest comparable factors influencing HIV testing.ConclusionsImproving uptake of HIV testing requires addressing perception of low risk of HIV infection and perceived inability to live with HIV. There is also a need to continue addressing HIV-related stigma, which is intricately linked to individual economic support. Building confidence in the health system through improving delivery of health care and scaling up HIV testing strategies that attenuate social and economic costs of seeking HIV testing could also contribute towards increasing uptake of HIV testing in SSA.

Patient‐reported barriers and drivers of adherence to antiretrovirals in sub‐Saharan Africa: a meta‐ethnography

This meta‐ethnography aims at providing a synthesis and an interpretation of the findings of recent social science research on the questions of retention in antiretroviral therapy (ART) programmes in sub‐Saharan Africa (SSA). The literature reviewed comprises ethnographic studies of the barriers to adherence to ART in various cultural settings. The results show that the quality of services, treatment‐related costs, as well as the need to maintain social support networks – which can be negatively affected by HIV‐related stigma – are important barriers to adherence. In addition, they show how African concepts of personhood are incompatible with the way services are conceived and delivered, targeting the individual. In SSA, individuals must balance physical health with social integrity, which is sometimes achieved by referring to traditional medicine. The ability of local concepts of illness to address social relations in addition to health, together with a historically grounded distrust in Western medicine, explains why traditional medicine is still widely used as an alternative to ART.

Culture changing livelihoods and HIV / AIDS discourse: reframing the institutionalization of fish-for-sex exchange in the Zambian Kafue Flats.

Discussions about the cultural dimensions of the spread of HIV/AIDS in Africa persist. Drawing on data on fish‐for‐sex deals between local Ila or Tonga women and immigrant fishermen in the Zambian Kafue Flats, we argue against the notion that traditional institutions governing extra‐marital sexual relationships are responsible for the spread of HIV/AIDS. We argue that fish‐for‐sex exchanges are based not on tradition, but on the economic opportunities provided by the fish trade in conditions of poverty and changing livelihoods. Stigmatization of women involved in fish‐for‐sex deals is, however, on the increase, since they are accused of spreading the disease in their community. Womens inability to follow the sexual prescriptions conveyed by HIV prevention programmes produces shame and moral distress, associated with the fear of social exclusion. In this situation, lubambo, a former customary regulation of extramarital sexual relations among the Ila, may provide women with legitimacy for sexual transactions. Additionally, customary marriage arrangements institutionally secure their access to fish.

Caesarean sections and breastfeeding initiation among migrants in Switzerland

SummaryObjectives:Twenty-six percent of all women giving birth in Switzerland are of non-Swiss nationality. Differences in reproductive health outcomes such as preterm deliveries, Caesarean sections, and breastfeeding initiation for mother-child pairs of various nationalities are investigated, and the influence of the educational level was assessed. In order to identify trans-national differences, national breastfeeding rates from 22 countries and Caesarean section rates from 24 countries were compared to the rates in Swiss hospitals.Study Sample:Drawing on routinely collected monitoring data, 37 332 mother-child pairs from various nationalities, who delivered in Swiss Baby-Friendly hospitals between 2000 and 2002, were included in the study. All nationalities with at least 150 deliveries were coded individually, while the remaining were summarised in regional groups.Results:Sub-Saharan African, Latin American and Asian mothers had higher rates of Caesarean sections compared to Swiss mothers (OR = 1.77, 95 % CI 1.49–2.22; OR = 1.80, 1.51–2.17; OR = 1.37, 1.18.1.59). African and Asian children were at an increased risk of being transferred to neonatal care units (OR = 1.48, 95 % CI 1.19–1.83; OR = 1.45, 1.21–1.73;). In addition, infants from Balkan countries, who showed lowest Caesarean section rates, were also more likely to be transferred to an ICU (OR = 1.30, 95 % CI 1.12–1.52). Apart from the country or region of origin, the maternal educational level was an important influence and modified the effect of the mother’s nationality.Mothers from all regions, apart from Western Europe, were significantly more likely to breastfeed their children after being discharged. Established determinants for breastfeeding duration, including feeding exclusively with breast milk in maternity wards, early initiation of breastfeeding, rooming-in and pacifier use, varied according to nationality.The comparison of Caesarean section and breastfeeding rates with the rates in the mother’s country of origin additionally investigates the relation between reproductive health outcomes of migrant women in Switzerland compared to their country of origin. In both cases, a significant rank correlation (Spearman) could be established between the rate in Swiss hospitals and the rate in the mother’s country of origin (P < 0.001, P = 0.04).Conclusions:Our data confirms inequalities in reproductive health outcomes and responses to health promotion programmes among migrant women in Switzerland. These differences are dependent on educational level and on the mothers’ nationality. The large variation suggests that different trans-national experiences play some role in health-related decision-making and access to health care. This should be considered when planning health promotion programs and the individual counselling of pregnant mothers in Switzerland.

Individual and contextual factors influencing patient attrition from antiretroviral therapy care in an urban community of Lusaka, Zambia

Despite the relatively effective roll‐out of free life‐prolonging antiretroviral therapy (ART) in public sector clinics in Zambia since 2005, and the proven efficacy of ART, some people living with HIV (PLHIV) are abandoning the treatment. Drawing on a wider ethnographic study in a predominantly low‐income, high‐density residential area of Lusaka, this paper reports the reasons why PLHIV opted to discontinue their HIV treatment.

Vaginal practices as women's agency in sub-Saharan Africa: a synthesis of meaning and motivation through meta-ethnography

This paper reports on a systematic review of qualitative research about vaginal practices in sub-Saharan Africa, which used meta-ethnographic methods to understand their origins, their meanings for the women who use them, and how they have evolved in time and place. We included published documents which were based on qualitative methods of data collection and analysis and contained information on vaginal practices. After screening, 16 texts were included which dated from 1951 to 2008. We found that practices evolve and adapt to present circumstances and that they remain an important source of power for women to negotiate challenges that they face. Recent evidence suggests that some practices may increase a womans susceptibility to HIV and other sexually transmitted infections. The success of new female-controlled prevention technologies, such as microbicides, might be determined by whether they can and will be used by women in the course of their daily life.

Exclusive breastfeeding rates and associated factors in Swiss baby-friendly hospitals.

Monitoring of infant feeding and related health care practices was introduced in all 28 Swiss Baby-Friendly Hospitals to assess exclusive breastfeeding rates and potentially associated factors. Data on 5790 neonates were collected in 1999, and rates of exclusive breastfeeding in different health facilities were calculated. Odds ratios were calculated to estimate the effects of different determinants on exclusive breastfeeding rates. Of all infants, 97% were initially breastfed, but only 38% were exclusively breast milk fed in Baby-Friendly maternity wards, and proportions varied from 8% to 85% among hospitals. The strongest determinants for exclusive breastfeeding were health facility factors. Furthermore, exclusive breastfeeding rates significantly increased with every month of monitoring duration. The findings suggest that the introduction of continuous monitoring of infant nutrition and related health care practices might have a positive effect on breastfeeding management in health facilities. J Hum Lact. 20(1):9-17.

Access to HIV/AIDS care: a systematic review of socio-cultural determinants in low and high income countries

BackgroundThe role of socio-cultural factors in influencing access to HIV/AIDS treatment, care and support is increasingly recognized by researchers, international donors and policy makers. Although many of them have been identified through qualitative studies, the evidence gathered by quantitative studies has not been systematically analysed. To fill this knowledge gap, we did a systematic review of quantitative studies comparing surveys done in high and low income countries to assess the extent to which socio-cultural determinants of access, identified through qualitative studies, have been addressed in epidemiological survey studies.MethodsTen electronic databases were searched (Cinahl, EMBASE, ISI Web of Science, IBSS, JSTOR, MedLine, Psyinfo, Psyindex and Cochrane). Two independent reviewers selected eligible publications based on the inclusion/exclusion criteria. Meta-analysis was used to synthesize data comparing studies between low and high income countries.ResultsThirty-four studies were included in the final review, 21 (62%) done in high income countries and 13 (38%) in low income countries. In low income settings, epidemiological research on access to HIV/AIDS services focused on socio-economic and health system factors while in high income countries the focus was on medical and psychosocial factors. These differences depict the perceived different barriers in the two regions. Common factors between the two regions were also found to affect HIV testing, including stigma, high risk sexual behaviours such as multiple sexual partners and not using condoms, and alcohol abuse. On the other hand, having experienced previous illness or other health conditions and good family communication was associated with adherence to ART uptake. Due to insufficient consistent data, a meta-analysis was only possible on adherence to treatment.ConclusionsThis review offers evidence of the current challenges for interdisciplinary work in epidemiology and public health. Quantitative studies did not systematically address in their surveys important factors identified in qualitative studies as playing a critical role on the access to HIV/AIDS services. The evidences suggest that the problem lies in the exclusion of the qualitative information during the questionnaire design. With the changing face of the epidemic, we need a new and improved research strategy that integrates the results of qualitative studies into quantitative surveys.

Couple experiences of provider-initiated couple HIV testing in an antenatal clinic in Lusaka, Zambia: lessons for policy and practice

BackgroundCouple HIV testing has been recognized as critical to increase uptake of HIV testing, facilitate disclosure of HIV status to marital partner, improve access to treatment, care and support, and promote safe sex. The Zambia national protocol on integrated prevention of mother-to-child transmission of HIV (PMTCT) allows for the provision of couple testing in antenatal clinics. This paper examines couple experiences of provider-initiated couple HIV testing at a public antenatal clinic and discusses policy and practical lessons.MethodsUsing a narrative approach, open-ended in-depth interviews were held with couples (n = 10) who underwent couple HIV testing; women (n = 5) and men (n = 2) who had undergone couple HIV testing but were later abandoned by their spouses; and key informant interviews with lay counsellors (n = 5) and nurses (n = 2). On-site observations were also conducted at the antenatal clinic and HIV support group meetings. Data collection was conducted between March 2010 and September 2011. Data was organised and managed using Atlas ti, and analysed and interpreted thematically using content analysis approach.ResultsHealth workers sometimes used coercive and subtle strategies to enlist women’s spouses for couple HIV testing resulting in some men feeling ‘trapped’ or ‘forced’ to test as part of their paternal responsibility. Couple testing had some positive outcomes, notably disclosure of HIV status to marital partner, renewed commitment to marital relationship, uptake of and adherence to treatment and formation of new social networks. However, there were also negative repercussions including abandonment, verbal abuse and cessation of sexual relations. Its promotion also did not always lead to safe sex as this was undermined by gendered power relationships and the desires for procreation and sexual intimacy.ConclusionsCouple HIV testing provides enormous bio-medical and social benefits and should be encouraged. However, testing strategies need to be non-coercive. Providers of couple HIV testing also need to be mindful of the intimate context of partner relationships including couples’ childbearing aspirations and lived experiences. There is also need to make antenatal clinics more male-friendly and responsive to men’s health needs, as well as being attentive and responsive to gender inequality during couselling sessions.