Promoting Breastfeeding in Russia to Improve Infant Health

During the AIHA Russian Regional Partnership Conference held in St. Petersburg in June, representatives from other USAID-funded NGOs gave brief presentations on

The Breastfeeding Media Campaign's logo. It reads: "Natural breastfeeding - a healthy baby, a happy mom."

healthcare programs they are carrying out in Russia that are similar to those of AIHA partners. The goal of the conference was to share ideas and to foster collaboration between AIHA partners and other NGOs. Hoping that attendees would learn from each others' programs, conference organizers welcomed several presentations that expand on AIHA's family medicine and primary healthcare focus. One such project, the Breastfeeding Media Campaign, promotes the practice of breastfeeding through community mobilization, education, training, and support.

Breastmilk is considered one of the most important contributors to infant health. According to the US Department of Health and Human Services (HHS) and the American Association of Health Plans, studies show that breastfeeding provides a wide range of benefits for infant growth, development, and immunity, including enhanced immune responses to fight polio, diphtheria, tetanus, and common respiratory infections. Consistent with the US Department of Health and Human Services' Blueprint for Action on Breastfeeding—developed by health and scientific experts from federal agencies and healthcare organizations, including the American Academy of Pediatrics and the American Academy of Family Physicians—breastfeeding has also been shown to improve maternal health, including less postpartum bleeding, earlier return to pre-pregnancy weight, a possible reduced risk of ovarian and pre-menopausal breast cancer, and positive hormonal, physical and psychosocial effects.

This infant shirt and the breastfeeding educational materials were among the many promotional items distributed in the cities of Perm, Berezniky and Veliky Novgorod during the Breastfeeding Media Campaign.

Because of the many health benefits, the Blueprint for Action recommends that infants be exclusively breastfed during the first four to six months of life, and ideally through the first year. To ensure that breastfeeding mothers have adequate training and support, HHS recommends that professionals who provide maternal and child healthcare should be trained in the basics of lactation and breastfeeding counseling, and that social support and information resources should be established.

Despite the many benefits of breastmilk, not enough babies are breastfed and few are breastfed for the recommended one year, according to the American Academy of Pediatrics. Breastfeeding appears to be an ideal primary prevention intervention because it can be done for a fairly short period of time, yet produces lifelong benefits. Armed with this knowledge, healthcare providers worldwide are establishing programs within primary care practices that promote and support breastfeeding.

AIHA Breastfeeding Efforts
In its effort to improve women and infant health, AIHA has established a network of Women's Wellness Centers (WWCs) in

This 1919 poster from Russia advocating breastfeeding illustrates that the practice is a good start for raising healthy children. The poster begins: "Mothers! If you want strong and healthy children..."

the NIS and in Albania and Romania to provide quality clinical and educational services. Through "Partners in Birth," a program offered at many WWCs, AIHA promotes breastfeeding with an emphasis on health promotion and education. The program prepares couples for parenthood by providing them with information on proper pre- and post-natal care, nutrition, breastfeeding, and infant care, as well as encourages husbands and partners to take active roles in the labor and delivery process. AIHA collects quarterly statistics by region on breastfeeding programs carried out at its Centers. Staff at the Dubna WWC, for example, trained 124 new mothers how to properly breastfeed their infants during the period from July through September 2001. A total of 2,914 women at AIHA WWCs received breastfeeding education during this same period. Promoting women and infant health is an ongoing concern of AIHA partners who continue to train and re-train physicians and educate women in efforts to improve overall community health.

Other USAID-funded NGOs' Breastfeeding Promotion
Several other NGOs are also promoting breastfeeding and some are engaging in more targeted efforts to encourage the practice. One such program is the Women and Infant Health (WIN) Strategy project. Implemented in 1999 through a partnership with USAID/Russia, the Russian Ministry of Health, John Snow Inc. (JSI), Engender Health, Johns Hopkins University's Center for Communications Program, and University Research Corporation, the WIN project was designed to improve the health of women and infants in Russia, where women continue to endure health problems that include high rates of sexually transmitted infections (STIs) and the adverse effects of repeat abortions abortions during their child-bearing years. With three main goals—to improve the quality of maternal and newborn services, to increase access to high-quality reproductive health services, and to increase the demand for these services among women in the community—the WIN project underscores service restructuring and provider training to identify, counsel, and treat women on health-related issues. The WIN project can potentially be used as a training model for partnerships and healthcare facilities that seek to create a model for their own breastfeeding programs.

This illustration of a healthy infant along with the slogan "Mom! For the first six months - just you and your milk!" is the "official" poster of the Campaign.

Launched under the WIN project and as part of the JSI Maternal and Infant Health Program, the Breastfeeding Media Campaign targets women ranging in age from 18 to 30 with at least a secondary school educational level. The project was introduced in the Russian oblasts of Perm and Veliky Novgorod to encourage women in these communities to exclusively breastfeed their newborns in order to improve the health of babies and reduce the number of perinatal deaths in Russia, where the infant mortality rate is 18 per 1,000 live births, according to a 2000 UNICEF report. As part of the program WIN helps the maternity hospitals to make a number of structural changes that allow rooming-in and feeding on demand. JSI specialists train local medical personnel in lactation counseling so that they can assist and guide new mothers, as well as encourage positive breastfeeding experiences. The Breastfeeding Media Campaign uses the local media to promote breastfeeding and increase the number of women who exclusively breastfeed their babies.

Information Gathering and Pre-testing Results
"Prior to implementing the Breastfeeding Media Campaign, we conducted in-depth interviews and household and facility-based surveys, as well as used focus groups to give us a sense of the general level of knowledge, misconceptions, and obstacles," says Michele Berdy, senior program officer and resident advisor in Russia for Johns Hopkins University's Center for Communication Programs. Berdy who presented on the Campaign at the Russian Regional Partnership Conference, explains: "We pre-tested everything, including the text, slogans, logos, scripts, brochures, and designs, to have a good idea that the materials would be well understood and accepted."

A trained specialist fields calls at the Breastfeeding Media Campaign's hotline in Novgorod.

From these surveys WIN partners learned that women in Perm and Veliky Novgorod did not breastfeed exclusively. In fact, while 61 percent of the mothers breastfed for three months, only 34 percent breastfed for six months—the minimum recommended period for best practices. In addition, over 70 percent of the mothers begin giving their babies supplements by the third month. The focus group discussions indicated that although women in the targeted areas are aware of the benefits of breastfeeding, many of them do not have a clear goal about how to nurse their babies or how long they wanted to breastfeed. Furthermore, the surveyors learned that while healthcare providers play a vital role in educating and training women to promote breastfeeding, relatives, friends, and support resources play equally important roles and are determining factors in a woman's decision to breastfeed and for what length of time.

Women in Perm and Veliky Novgorod ranked the most credible sources for information

This brochure (left) and newspaper clipping represent a small sample of the Campaign's public relations materials.

on breastfeeding in the following order: relatives, literature, intuition, friends, and physicians. Therefore, a grandmother, for example, who did not breastfeed and claims that her children grew up fine, often counteracts pro-breastfeeding messages, especially because women get conflicting information from different physicians who then ultimately lose credibility. For this reason, the WIN project set out to both re-educate and re-train healthcare providers, as well as to directly educate the public through a wide range of pro-breastfeeding promotional strategies in an effort to reach every woman.

Although many mothers successfully breastfeed their newborns after experiencing initial difficulties during the early postpartum period, many of them discontinue breastfeeding prior to six months for several reasons. Returning to work or school, fears of not producing enough milk, and fears that she or the child is ill were a few of the reasons given by women in Perm and Veliky Novgorod through the survey.

"Mothers-to-be," actually men dressed as women are taught breastfeeding techniques during a class for fathers-to-be in Perm.

Berdy also notes that conducting the pre-tests established that many women did not fully understand that "exclusive breastfeeding" means that no supplements of water, juice, or mashed food is given to a newborn during their first six months.

Because at first the women were highly opposed to and rejected the idea of exclusive breastfeeding, referring to the concept as "unrealistic, incorrect, and impossible," the Campaign adopted a gentle and gradual promotional approach to present breastfeeding as a positive and viable experience, and as a choice, rather than a command.

Using the Media and the Public to Promote Breastfeeding
A major component of the Campaign is its use of the local mass media. Four 30-second television public service announcements and three 30-second radio spots are aired free of charge on local broadcast media to raise awareness about the benefits of exclusive breastfeeding for six months. Because 30 seconds is not enough time to really inform the public, Berdy explains that in addition to the television news and magazine shows' segments about [the Campaign], "local newspapers publish articles to increase awareness and attract the public's interest." During the first six months of the Campaign, the television and radio spots were aired locally for almost 1,000 times. Because the Campaign relies so heavily on this approach, local physicians and

KVN comedy revue.

breastfeeding advocates took part in three-day workshops on community mobilization to learn the basics of communication theory and practice. The goal of the workshops was to prepare them to assist with planning activities for the Campaign that appeal to a diverse audience. This use of the media supplements the changes that have been made at local clinics to encourage patients and their partners' involvement in fun, on-site, pro-breastfeeding programs including classes held for fathers only and lactation education for new and expecting mothers. The Campaign also sponsors breastfeeding hotlines through which women and family members can contact trained specialists for information. Promotional materials for the hotline, such as bookmarks and stickers, are distributed at maternity hospitals and clinics; posters announcing the hotline appear on buses and other public transportation; and advertisements appear on television. Berdy says that the hotlines currently receive about 80 calls a month.

More than thirty public relations activities were also conducted to promote the Campaign. For example, in Novgorod a

The audience enjoy the KVN comedy revue held in Novgorod.

competition for medical students asked contestants to submit pro-breastfeeding posters. The winner was awarded a copy of the Campaign poster, which depicts a healthy infant and the slogan "Mom! For the first six months — just you and your milk!" The students' posters were distributed among clinics in Novgorod to promote the Breastfeeding Media Campaign. In Novgorod, the "KVN," or Club of the Lighthearted and Quickwitted, organized a comedy revue with the theme: "spring, love, and babies." During the event, teams of university and medical school students performed skits about breastfeeding and several other topics. Brochures and condoms were placed on the auditorium seats. One thousand students attended the event, which was filmed for broadcast on local television. In Perm, during a class held for fathers-to-be at a maternity home, the men were dressed as pregnant women and taught the "how-to's" and benefits of breastfeeding. Another group in Perm is leading volunteers who have breastfed their children and want to support other women in either a group or one-on-one setting.

Innovative programs like the Breastfeeding Media Campaign and AIHA's "Partners in Birth" not only teach lactation techniques to enhance the health of mothers and infants, but they involve the community and have fun while doing so. As Berdy says, "Through collaboration and creativity, we can reach the hearts and minds of our audience."