Evaluation of Mothers Knowledge, Attitudes, and Practice

Towards the Ten Steps to Successful Breastfeeding in Egypt

Azza M.A.M. Abul-Fadl,
1
Maissa Shawky,
2
Amal El-Taweel,
3
Karin Cadwell,
4
and Cynthia Turner-Maffei
5
Abstract
Background: Despite the proven effectiveness of the Ten Steps to Successful Breastfeeding of the Baby-Friendly
Hospital Initiative (BFHI), its impact on community practices in Egypt has yet to be assessed. The aim of this
investigation was to evaluate the knowledge, attitudes, and practice (KAP) of Egyptian mothers towards the Ten
Steps. We interviewed 1,052 breastfeeding mothers with infants less than 24 months of age from 12 governorates
representing Upper Egypt (UE) and Lower Egypt (LE).
Results: Marked regional variations are noted in the KAP of the samples from UE and LE. These differences can
be explained to some extent by socioeconomic factors. Hospital delivery, lower parity, and a higher level of
education were characteristic of mothers in LE compared with UE. More mothers in UE did not know about the
protective effects of breastfeeding to the mother. In LE, 75% delayed breastfeeding initiation until after the rst
hour compared with 61% in UE, with the mothers reporting that they did not experience skin-to-skin care in the
rst hours after birth. Nipple pain was given as a cause for supplementation in 56% of mothers in UE and 36% in
LE ( p < 0.001). Maintaining milk by expression is practiced by 42.8% of mothers in LE and 12% in UE. Two-thirds
of the mothers in both UE and LE offer herbal drinks, and one-third feed infant milk formula before 6 months.
Offering paciers is more common in LE, and feeding by bottle is more common in UE, being pressured by the
mothers social network.
Conclusions: To increase the impact of BFHI on community breastfeeding practices, BFHI should focus on
involving the family members with the mother throughout the implementation of the Ten Steps while en-
couraging maternal support groups and taking cultural differences into account.
Introduction
T
he Baby-Friendly Hospital Initiative (BFHI) was in-
troduced by UNICEF/World Health Organization
(WHO) through the Innocenti Declaration in 1991 and revised
in 2006; health facilities are urged to change their maternity
care practices to become more supportive of breastfeeding
based on the Ten Steps to Successful Breastfeeding.
1
Over the
past two decades evidence-based medical research has shown
the effectiveness of the Ten Steps in reversal of neonatal
morbidity and mortality rates from common infectious dis-
eases and disabilities that were closely linked to practices that
disrupt breastfeeding.
2,3
Social and economic benets have
also been shown by implementation of the BFHI in both de-
veloped and developing countries. The widespread success of
the BFHI, with its proven efcacy as one of the most effective
and least costly interventions, has driven the UNICEF and
WHO to call for its revival through a 2006 update for ex-
pansion and a recommendation that it become integrated
into the WHO Global Strategy for Infant and Young Child
Feeding.
4,5
Assessment of knowledge, attitudes, and practices (KAP)
of mothers is one way to identify high-risk areas and popu-
lations in need. This can help to target interventions appro-
priately, especially when resources are limited. Over the past
decade, BFHI implementation has declined in Egypt, and
breastfeeding promotion activities were subsumed into the
WHO Integrated Management of Childhood Illness pro-
grams. As Egypt now turns to revive BFHI, previous strate-
gies need to be revised as new evidence-based strategies
1
Department of Pediatrics, Benha Faculty of Medicine, Benha University, Kaluibiya, Egypt.
2
Cairo Medical Faculty, Cairo University, Cairo, Egypt.
3
Egyptian Lactation Consultant Association, Cairo, Egypt.
4
Healthy Children Project, Inc., East Sandwich, Massachusetts.
5
The Union Institute & University, Cincinnati, Ohio.
All the authors contributed equally to this work.
BREASTFEEDING MEDICINE
Volume 7, Number 3, 2012
Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2011.0028
173
emerge. Assessment of the needs of mothers in Upper and
Lower Egypt (UE and LE, respectively) would be helpful in
this respect, especially since the Egypt Demographic Health
Surveys show that there are distinct ecological and social
differences between these regions, with signicantly in-
creased rates of poverty in UE.
6
Hence the aim of this work is
to study and analyze the KAP of mothers towards practices
related to the Ten Steps of the BFHI in a representative sample
of the country.
Subjects and Methods
This is a cross-sectional descriptive study that was con-
ducted by interviewing 1,052 mothers who were breastfeed-
ing infants less than 24 months of age selected from 12
governorates: ve in UE and ve in LE and the two major
urban governorates of Cairo and Alexandria located in LE.
Data were collected in the interval of JanuaryMay 2008. The
logistics included receiving permission from the central as
well as the governorate health ofces of the directorates vis-
ited. The work was conducted by local as well as centrally
recruited interviewers. The tools used were questionnaires
that were locally prepared and adapted and tested. The in-
terviews were conducted one to one, face to face, compiled by
the interviewer, and sent to the researchers.
Ethical considerations were taken into consideration. The
mothers participated anonymously and gave informed con-
sent for participation and to use their responses. They were
made aware that the information collected would be used to
develop and improve on the breastfeeding promotional
messages and campaigns so that more mothers could
breastfeed successfully.
Sample characteristics
Surveys were conducted and information was collected
from a convenience sample of 1,052 mothers recruited from
Maternal Child Health Clinics with breastfeeding babies
whose ages ranged between 6 weeks to 24 months. Five
hundred eleven mothers fromLE and 541 fromUE completed
the interviews. The LE governorates included Alexandria
(n =77), Beheira (n =155), Cairo, (n= 72), Dakhlia (n= 99),
Dameitta (n= 43), Ismailia (n = 60), and Port Saed (n = 5), to-
taling 511 motherinfant pairs. The UE governorates included
Assiut (n= 110), Aswan (n =217), Luxor (n =40), Qena (n= 84),
and Sohag (n =90), totalling 541 motherinfant pairs.
Data entry and statistical analysis
Data were entered on Excel (Microsoft, Redmond, WA)
sheets, coded, and revised for consistency. The Statistical
Package for Social Science (SPSS

) version 13 (SPSS, Inc.,

Chicago, IL) was used for the analysis. Mean, mode, median,
and SD were used for continuous numerical values. Values
were estimated for v
2
tests (Fishers exact test was applied
whenever tested values were below 5).
Results
Demographic prole
Most of the mothers interviewed lived in urban areas
(61.7%), whereas only 30.2% came from rural areas and 8.1%
from slum areas. Half of the mothers (53%) had received at
least 9 years of education, whereas 34.2% had received no or
little education. The majority gave their occupation as
housewives (62.2%); working mothers made up 37.8% of the
survey population, whereas 2.3% of mothers worked without
pay.
Parity
Worldwide, mothers with higher levels of education tend
to have fewer children. That was true in our survey popula-
tion as well. The highest parity was seen among those with
minimal or no education (19.5%), whereas those with higher
educational level reported the smallest family size (fewer than
three children).
Delivery practices
Fifty-seven percent of the mothers in the UE sample de-
livered their babies in hospitals compared with 71.5% in LE.
Only 11.1% of the mothers in UE gave birth via cesarean
section compared with 20% in LE. Normal vaginal delivery
occurred in 88.9% of deliveries in UE and 79.6% in LE.
KAP towards Ten Steps
Step 3 of the BFHI relates to prenatal education of the
mother and urges health workers to inform pregnant women
about the benets of breastfeeding. Table 1 shows that there is
a signicant difference in the knowledge of the mothers about
the benets of breastfeeding between UE and LE. LE mothers
tend to have more knowledge about the protective effects of
breastfeeding for the mother and child, whereas a signi-
cantly lower percentage of mothers in UE knows about the
protective effects of breastfeeding, particularly against breast
cancer. The lowest level of knowledge is about the potential
contraceptive effect of exclusive breastfeeding, particularly
among the mothers interviewed in UE. Less than one-third of
the mothers in UE and one-half of those in LE report they
know how to use breastfeeding as a method of contraception
in the rst 6 months. Table 2 shows that less than one-half of
the mothers know about the benets of skin-to-skin care; this
was signicantly lower among mothers of UE, particularly
with regard to its effect on weight gain and breathing. Such
ndings indicate that Step 3 needs to be adequately im-
plemented in both UE and LE.
Figure 1 shows that early initiation of breastfeeding (Step 4
of the BFHI) is signicantly delayed more in LE as three-
quarters of the mothers do not initiate breastfeeding until after
the rst hour. This is compared with about 39% of mothers in
Table 1. Percentage Distribution of Mothers
Regarding Their Knowledge About the Value
of Breastfeeding in Upper Egypt Versus Lower Egypt
Geographical site
Knowledge about breastfeeding
benets
Lower
Egypt
Upper
Egypt p value
Protects children from disease 64.9 60.8 0.0001
Protects mothers from cancer 61.5 38.8 0.0001
Can be used as a method
of contraception
49.3 30.7 0.0001
174 ABUL-FADL ET AL.
UE who initiate breastfeeding in the rst hour. Early initiation
through skin-to-skin contact was poorly implemented in both
UE and LE. However, this is more prevalent among mothers
in the middle age group (2040 years old) compared with very
young ( < 20 years old) and older ( > 40 years old) mothers. The
difference was signicant at p < 0.006.
Lactation management issues and assuring an adequate
milk supply are included in Step 5 of the BFHI. Nipple pain is
reported as a cause for supplementation in 56% of mothers in
UE and 36% in LE ( p < 0.001). Expression of milk is practiced
as a method to increase or maintain milk supply by 42.8% of
mothers in LE compared with only 12% in UE. More mothers
in LE report that the best ways to increase milk supply was to
increase uid intake (91.3%), to eat certain types of foods
(82%), and to increase frequency of breastfeeding (71.9%)
compared with mothers in UE (76.6%, 73.4%, and 69.4%, re-
spectively) ( p < 0.001).
KAP related to avoiding unnecessary supplements (Step 6
of the BFHI) shows that two-thirds of the mothers in both UE
and LE introduce herbal drinks or decoctions to their babies in
the rst 6 months. One-third of the mothers in both UE and LE
give infant milk formula before their babies are 6 months old.
More mothers in LE believe that infants need foods before the
age of 6 months (63% in LE compared with 43% in UE). The
source of information of mothers about formula and baby
food is fromrelatives and friends, followed by media, with the
least from health workers. More mothers in the extremes of
age ( > 40 years and < 20 years old) gave decoctions.
Rooming-in (Step 7) is practiced by almost all mothers in
both LE and UE (87.6% and 83.5%, respectively). On-demand
feeding (Step 8) occurs in 78.9% and 76.3% of births in LE and
UE, respectively ( p <0.03). Most mothers (95%) breastfeed
their babies during the night. About 75.5% of the mothers in
LE and 79.3% of mothers in UE believe that night feeding is
useful ( p < 0.002).
Step 9 of the BFHI seeks to limit the use of articial teats and
paciers; however, a large proportion of mothers (43.2%in LE
and 39.2%in UE) report offering paciers to their babies. Most
of these mothers believe that these paciers are the best way to
soothe the baby. In two-thirds of the cases a relative is the one
who provided the mother with the advice to use a pacier.
Many mothers described carrying the baby as a better way to
soothe the baby than to give him or her a pacier; however,
mothers in LE were more knowledgeable than UE mothers in
this regard (80.8% in LE compared with 71.6% in UE;
p < 0.001). More than half of the mothers in LE (55%) knowthe
negative effect of paciers on breastfeeding compared with
40.4% in UE ( p < 0.001).
Table 3 shows that the use of bottles is more common than
paciers, as over one-half of mothers use a bottle to feed their
baby (56.8% in UE and somewhat less in LE [51.9%]). This
may be because almost two-thirds (60.5%) of the mothers in-
terviewed in UE think that babies cannot feed away from the
breast except by a bottle, compared with only one-third in LE
(39.2%). The difference is statistically signicant at p < 0.001.
Also, more mothers in LE (66%) than in LE (44%) know the
negative effects of bottles on breastfeeding ( p <0.0001). The
Table 2. Percentage Distribution of Mothers
with Knowledge About the Various Benets
of Skin-to-Skin Contact in Lower Egypt
Versus Upper Egypt
Geographical site
Benets of skin-to-skin contact
Lower
Egypt
Upper
Egypt p value
Provides warmth for the baby 54.8 47.6 0.000
Promotes growth of baby 43.1 40.8 0.000
Promotes weight gain 35.9 26.2 0.000
Better breathing 38.1 26.4 0.000
Better quality of sleep 50.0 44.4 0.000
Less crying 60.2 49.9 0.000
Supports breastfeeding 52.7 54.5 0.000
0
10
20
30
40
50
60
70
80
Immediately Within 1-3 hrs >3 hrs
Lower Egypt
Upper Egypt
FIG. 1. Percentage of timely initiation of breastfeeding in
the early postpartum period in Upper Egypt versus Lower
Egypt.
Table 3. Percentage Distribution of the Knowledge,
Attitudes, and Practices of Breastfeeding
Mothers Toward Paciers and Feeding Bottles
in Lower Egypt Versus Upper Egypt
Geographical site
KAP for paciers and bottles
Lower
Egypt
Upper
Egypt p value
Mother gave her baby a pacier 43.2 39.4 0.2
Thinks pacier calms her baby 44.0 47.2 0.3
A relative provided a pacier 63.4 64.2 0.05
Knows that carrying the baby
is better than providing
a pacier
80.8 71.6 0.001
Mother carried the baby instead
of giving a pacier
77.6 66.5 0.003
Mother used a bottle for feeding 51.9 56.8 0.2
Thought that a baby cannot drink
except with a bottle
39.2 60.5 0.000
Knows negative effect of
Paciers on breastfeeding 55.3 40.4 0.000
Using bottles on breastfeeding 63.4 44.0 0.000
Used bottle in response to
Relatives 52.7 55.8 0.000
Mass media 17.4 17.4 0.000
Hospital advertisement 11.1 9.1 0.000
KAP, knowledge, attitudes, and practices.
EVALUATION OF COMMUNITY KAP TO BREASTFEEDING 175
practice of feeding babies by bottles comes from pressure by
the mothers social network of family and friends (52.7%in LE
and 55.8% in UE) and by media (17%) as shown in Table 3.
Discussion
Prenatal education is a powerful tool for increasing the
rates of any breastfeeding. Prenatal education can be highly
effective in empowering vulnerable populations, especially
the young and illiterate mothers. Printed materials given
alone during pregnancy were also found to increase womens
knowledge; however, a person-to-person approach might be
more effective.
7,8
Effectiveness of prenatal education is in-
creased when it is combined with postpartum follow-up.
9
We
suggest a multifaceted public health intervention by com-
bining education by the health facility and the family-centered
approach with educational messages fromthe mass media for
encouraging positive breastfeeding attitudes in the family and
wider community.
Our study indicates that early initiation of breastfeeding
continues to be signicantly delayed among all mothers but
more in LE than those of UE and that early initiation through
skin-to-skin contact is rarely implemented. These ndings
could be explained by the higher prevalence of hospital de-
liveries among mothers of LE compared with those in UE.
Hospital routines may foster early separation of the mother
and newborn, delaying breastfeeding. This is in contrast to
home deliveries, where early mother and baby contact is
common. Hospital practices can affect breastfeeding even
months after discharge.
10,11
Mothers overall knowledge about the benets of skin-to-
skin care is poor, especially in UE. This is probably due to
the effect of education, as the higher the education level of
the mother the more likely she was to know more about the
benets of both early initiation and skin-to-skin care for
the baby and mother. The difference was again statistically
signicant for almost all of the benets of skin-to-skin care
except its effect on breastfeeding. In another study we re-
ported that staff resisted skin-to-skin care and regarded as
culturally inappropriate.
12
A systematic review that evalu-
ated evidence about promotion programs that are effective at
increasing the number of women who start to breastfeed and
their impact on the duration and/or exclusivity of breast-
feeding showed that BFHI implementation, training of health
professionals, social support from health professionals, peer
support, and media campaigns were most effective, but they
concluded that mostly it was the multifaceted interventions
that were most effective in improving such practices.
13,14
Bedding-in was much more common than rooming-in be-
cause of the limited number of infant cots in Egyptian hos-
pitals. Separation was more common in private hospitals.
Younger mothers preferred to keep their baby in a cot near
their bed, whereas older mothers seemed to prefer to keep
their baby in the same bed.
13
The practice of scheduled feeding by mothers has signi-
cantly decreased compared with the preliminary BFHI sur-
veys conducted in the early 1990s in Egypt. More mothers
with higher education mentioned that they know the benets
of responding to their babies cues.
12,14
Pain in the nipple was more common among mothers in
UE. In LE it was the commonest cause for supplementation
followed by maternal illness. Nipple pain, as a cause for
supplementation, was signicantly more commonly reported
by younger mothers with little or no education. Incorrect at-
tachment at the breast is the commonest cause of nipple pain,
particularly in rst-time mothers. This ts the prole of the
young, inexperienced, and undereducated mothers. It indi-
cates the need for training primary healthcare staff and peer
counsellors to counsel and monitor those mothers more clo-
sely in the early postpartum period and rst 6 weeks of life to
ensure successful continuation of exclusive breastfeeding.
15,16
The practice of feeding babies by bottles is common and
could also possibly lead to incorrect latch on and nipple pain.
Bottle use is pressured by the social network of family and
friends (50%) and less from the media (17%). However,
mothers report they are inuenced by hospital advertise-
ments of bottles and infant milk formula (11.1% in LE and 9%
in UE; p < 0.001).
It is clear that more mothers in LE are knowledgeable about
the hazards of bottles and paciers and that they prefer to
soothe and comfort their baby by carrying them(77.9%) rather
than to give them nipples or teats, compared with 66.5% of
mothers in UE who practiced holding their babies as a means
for soothing them.
The use of paciers and baby bottles is prevalent among the
younger mothers, who are probably also primiparous moth-
ers. These mothers may receive more pressure from their so-
cial network to offer their babies teats and nipples, with no
knowledge about their negative effect on breastfeeding and
without teaching regarding alternative ways to soothing their
babies. It is clear that health staff and media campaigns need
to focus on raising awareness of young, rst-time mothers and
their family members about the hazards of nipples and teats.
Such campaigns will need to develop materials that would
provide mothers with ways of soothing babies other than use
of paciers.
17,18
It was observed that the practice of giving unaltered animal
milk to infants before 6 months of age has decreased signi-
cantly over the past decade.
6
The rise in the use of infant milk
formula reects a change in attitudes of mothers toward the
type of supplements to give to babies. The change in practice
from feeding animal milk to formula feeds as a supplement
with breastfeeding reects either more afuence or access to
subsidized formula or unnecessary prescription by pediatric
staff inuenced by the aggressive marketing tactics of infant
milk formula companies. Egypt has not fully enacted the In-
ternational Code of Marketing of Breastmilk Substitutes as a
law, and many healthcare staff are not knowledgeable about
the Code. In another study we found that many of the staff
reported that they accepted free supplies and gifts forminfant
milk formula companies.
14
This reinforces the need to train
staff (Step 2 of the Ten Steps).
13,14
The knowledge of mothers about the hazards of unneces-
sary supplements was signicantly higher in the mothers of
LE compared with those of UE. This widespread practice of
supplementation without clinical need contributes to the
continued morbidity rates in Egypt from diarrhea and other
diseases despite the success achieved by the diarrheal control
programs in the past.
1923
In other countries, strategies that used the risk approach to
improve exclusive breastfeeding rates in the rst 6 months
have been shown to be effective in decreasing the introduction
of necessary supplements given to babies. The risk approach
focuses on highlighting the harms associated with a certain
176 ABUL-FADL ET AL.
practice. Learning from the success stories in these countries
may be useful in design of social marketing campaigns based
on the risk approach.
1519
Only one-half of the mothers participating in this study
knewthat exclusive breastfeeding entails feeding babies on no
other solid foods or liquids other than breastmilk and with an
emphasis on increasing the frequency of a breastfeed (on-
demand feeding) and that this is the optimal way to increase
milk supply. Other previous KAP studies conducted in Egypt
have shown that the most common cause for early cessation of
breastfeeding was inadequate breastmilk supply.
20
Methods
for increasing milk supply include increasing the frequency of
feeding, expressing breastmilk after a feed to ensure adequate
emptying of milk, and cuddling and holding the baby as a
means of stimulating more brain oxytocin through skin-to-
skin contact.
24,25
Such practices were less readily used by
mothers, especially by mothers of UE. The use of galactago-
gues is not reported as a commonly used method for in-
creasing milk supply except among the younger age group of
mothers. Teenage childbearing in Egypt represents 10%of the
motherhood prevalence, and two-thirds of teen-aged mothers
(8%) had their rst child before 18 years of age.
6
Mothers learned about how to increase their milk supply
mainly from their social network of family or friends in LE.
Rarely were healthcare workers mentioned as a source of
breastfeeding information. In LE more mothers mentioned
that infant feeding information came from media (43%)
compared with 20% in UE. The older the mother and the
higher her level of education, the more likely was she to be
inuenced by the media. Mothers who were younger and less
educated were more likely to be inuenced by information
received from their circle of family and friends.
16
Media plays
an important role in the mothers lives and represents an
important source of information that inuences mothers
practices and child health. When used in a culturally effective
manner it becomes a vitally important educational tool for
reaching out to mothers of different needs and socioeconomic
levels in the society. The design and formulation of effective,
well-studied media campaigns can shape the health and
survival proles of Egyptian children.
2630
Poverty remains a major problem in Egypt, as 19% of the
population are below the poverty line, and poverty ap-
proaches 4060% in some UE governorates. Poverty is asso-
ciated with illiteracy and ignorance, which is prevalent
among older family members who can have adverse effects on
breastfeeding practices. Also, those mothers living in poverty
also suffer from depression, which can adversely inuence
breastfeeding duration.
3133
Our study is unique in that it compares the regional dif-
ferences between UE, which has higher mortality rates, with
those of LE, which has lower mortality rates.
6
Because
breastfeeding saves lives, an evaluation of the differences in
unfriendly breastfeeding practices can identify some of the
determinants associated with higher infant mortality rates.
Most important is that family members andsocial networks
were identied in this study as key inuential groups. Other
in-depth studies have shown how the father, mothers mo-
ther, and mother-in-law have a great impact on the mothers
decisions and practices in the perinatal period.
34
In this study
lower educational levels were consistently associated with
poor feeding practices. Given the higher illiteracy rates of
older family members, particularly in UE, their inuence
would explain the link between the prevailing poor practices
and persistently higher mortality rates in UE.
6
This study was limited by the sampling method (conve-
nience sample) and that the mothers were beyond the im-
mediate postpartum period (up to 24 months). Prospective
studies designed to elicit similar information for family
members about their KAP towards breastfeeding support in
Egypt would be an ideal next step.
Conclusions
Implementing the Ten Steps of the updated BFHI for
achieving successful breastfeeding throughout the community
could be a powerful educational tool when expanded to target
both home and hospital-based deliveries. This requires in-
volving the Maternal Child Health midwives and traditional
birth attendants with the training of hospital staff. In addition,
work is needed at the community level through peer counsel-
ors and mother-to-mother support groups, taking into account
cultural differences. Targeting family members throughout the
implementation of BFHI educational activities and media
campaigns is a need identied by this study for improving the
outcome of the BFHI on community practices. Training media
personnel on how to address the different needs of mothers in
various social classes and age groups and having different
levels of education can be also effective in reaching masses.
Acknowledgments
We would like to express our gratitude to the UNICEF,
Cairo Ofce that partly funded the Egyptian Lactation Con-
sultant Association to do the survey as well as the ofcials of
Maternal and Child Health in the Ministry of Health of Egypt
who facilitated and participated in the eld work of the sur-
vey. We are particularly grateful to the primary healthcare
ofcials and coordinators of breastfeeding in the 12 gover-
norates for facilitating and supervising the data collection
phase. We would like to thank the Centre of Social and Pre-
ventive Medicine at Cairo University for facilitating the ad-
ministration of the survey. We would like to thank the
Healthy Children Project for funding the participation of their
faculty in this research project.
Disclosure Statement
The Egyptian authors worked as a team, with most vo-
lunteering their activity as Egyptian Lactation Consultant
Association members, and were responsible for the design,
acquisition of the data, analysis of the data, and the writing of
this article. The authors from Healthy Children Project in the
United States provided technical assistance throughout the
study and in the writing of this article. No competing nancial
interests exist.
References
1. WHO/UNICEF: Innocenti Declaration and Innocenti Infant and
Young Child Feeding. WHO Press, Geneva, 2008.
2. Betran AP, de Onis M, Lauer JA, Villar J: Ecological study of
effect of breast feeding on infant mortality in Latin America.
BMJ 2001;323:1.
3. Dewey KG, Heinig MJ, Nommsen-Rivers LA: Differences
in morbidity between breast-fed and formula-fed infants. J
Pediatr 1995;126:696702.
EVALUATION OF COMMUNITY KAP TO BREASTFEEDING 177
4. Fairbank L, OMeara S, Renfrew MJ, et al. A systematic re-
view to evaluate the effectiveness of interventions to pro-
mote the initiation of breastfeeding. Health Technol Assess
2000;4(25):1171.
5. UNICEF Baby-Friendly Hospital Initiative: Revised, Updated and
Expanded for Integrated Care, Section 1: Background and Im-
plementation; Section 2: Strengthening and Sustaining BFHI: A
Course for Decision-Makers; Section 3: Breastfeeding Promotion
and Support in a Baby-Friendly Hospital; a 20-Hour Course;
Section 4: Hospital Self-Appraisal and Monitoring; Section 5:
External Assessment and Reassessment. UNICEF, New York,
2009.
6. El-Zanaty F, Way AA. Egypt Demographic and Health Survey.
Ministry of Health and Population (Arab Republic of Egypt)
and National Population Council (Arab Republic of Egypt),
Cairo, 2005.
7. Kistin N, Benton D, Rao S, et al. Breast-feeding rates among
black urban low-income women: effect of prenatal educa-
tion. Pediatrics 1990;86:741746.
8. Kaplowitz DD, Olson CM. The effect of an education pro-
gram on the decision to breastfeed. J Nutr Educ 1983;15:
6165.
9. Hoyer S, Horvat L. Successful breast-feeding as a result of a
health education programme for mothers. J Adv Nurs 2000;
32:11581167.
10. Anderson GC, Moore E, Hepworth J, et al. Early skin-to-skin
contact for mothers and their healthy newborn infants. Birth
2003;30:206207.
11. Kind C, Schubiger G, Schwarz U, et al. Provision of sup-
plementary uids to breast fed infants and later breast
feeding success. Adv Exp Med Biol 2000;478:347354.
12. Abul-Fadl A, Shawki M. UNICEF-MoH-ELCA 2008 baseline
survey for BFHI in Egypt. Egypt J Breastfeed 2011;(1):3469.
13. Green CP. Media Promotion of Breastfeeding: A Decades
Experience. Academy for Educational Development, Wa-
shington DC, 1989.
14. El-Kerdany I, Abul-Fadl A. Pre and Post Implementation of
BFHI in Egypt. UNICEF Cairo Ofce, Cairo, 1994.
15. Hillenbrand KM, Larsen PG. Effect of an educational inter-
vention about breastfeeding on the knowledge, condence,
and behaviors of pediatric resident physicians. Pediatrics
2002;110:e59.
16. Kistin N, Abramson R, Dublin P. Effect of peer counselors on
breastfeeding initiation, exclusivity, and duration among
low-income urban women. J Hum Lact 1994;10:1115.
17. Howard CR, Howard FM, Lanphear B, et al. The effects of
early pacier use on breastfeeding duration. Pediatrics 1999;
103:e33.
18. Howard CR, Howard FM, Lanphear B, et al. Randomized
clinical trial of pacier use and bottle-feeding or cup feed-
ing and their effect on breastfeeding. Pediatrics 2003;111:
511518.
19. Hossain MM, Radwan MM, Arafa SA, et al. Prelacteal infant
feeding practices in rural Egypt. J Trop Pediatr 1991;38:317322.
20. Eissa AM, Khashaba A, Abul-Fadl MAM, et al. Breastfeed-
ing and health status in Qaluibiya governorate in Egypt
(1990). Gaz Egypt Pediatr Assoc 1993;41:4557.
21. Victora CG, Vaughan JP, Lombardi C, et al. Evidence for
protection by breastfeeding against infant deaths from in-
fectious diseases in Brazil. Lancet 1987;2:319321.
22. Howie PW, Forsyth JS, Ogston SA, et al. Protective effect of
breastfeeding against infection. BMJ 1990;300:1116.
23. Wright AL, Holberg CJ, Martinez FD, et al. Breastfeeding
and lower respiratory tract illness in the rst year of life. BMJ
1989;299:946949.
24. Gerhardt S. Why Love Matters: How Affection Shapes a Babys
Brain. Routledge, Taylor and Francis Group, London, 2006.
25. Gunnar M, Donzeella B. Social regulation of the cortisol
levels in early human development. Psychoneuroendocrinol-
ogy 2002;27:199220.
26. Lal S, Khanna P, Gaur DR, et al. Participatory health com-
munication and action through women groups in rural
areas. Indian J Pediatr 1992;59:255260.
27. Cadwell K, Turner-Maffei C. Continuity of Care in Breast-
feeding. Jones & Bartlett, Sudbury, MA, 2009.
28. Segall-Correa AM. Breastfeeding promotion and priority
setting in health. Health Policy Plan 1996;11:156168.
29. Sikorski J, Renfrew MJ, Pindoria S, et al. Support for
breastfeeding mothers. Cochrane Database Syst Rev 2002;(1):
CD001141. Update in Cochrane Database Syst Rev 2007;(1):
CD001141.
30. Wright AL, Naylor A, Wester R, Bauer M, Sutcliffe E: Using
cultural knowledge in health promotion: Breastfeeding
among the Navajo. Health Educ Behav 1997;24:625639.
31. Ball TM, Wright AL. Health care costs of formula-feeding in
the rst year of life. Pediatrics 1999;103:870876.
32. Auerbach KG, Renfrew MJ, Minchin M. Infant feeding com-
parisons: A hazard to infant health? J Hum Lact 1991;7:6368.
33. Beasley A, Amir LH. Infant feeding, poverty and human
development. Int Breastfeed J 2007;2:14.
34. Abul-Fadl AM. Evaluation of family-centred maternity care.
In: ELCA Scientic Journal, Special Issue Dedicated to the Pro-
ceedings of the Egyptian Lactation Consultant Associations First
Scientic Meeting 29 June, 2006 in Nile Hilton, Cairo, Egypt.
AlTobgi Press, Cairo, 2006, pp. 2336.
Address correspondence to:
Azza M.A.M. Abul-Fadl, M.Sc., M.P.H., M.D., IBCLC
Department of Pediatrics
Benha Faculty of Medicine
Benha University
Kaluibiya, 11211, Egypt
E-mail: azfadl@yahoo.com
178 ABUL-FADL ET AL.