Breastfeeding support in Peru: bridging science, policy and practice

December 2012

Yvette Fautsch

Exclusive breastfeeding is the optimal way of feeding infants for the first six months of life (WHO & UNICEF, 2003). During the first months of life, breast milk is the best food for healthy growth and development as it provides the essential nutrients and energy infants need. Compared to other types of feeding, exclusive breastfeeding has many benefits: it protects infants from infections, such as diarrhea or pneumonia, and helps protect them against chronic diseases in adulthood, including diabetes and cardiovascular diseases (WHO, 2009). In Peru, there is a positive culture towards breastfeeding. In the 1980s, Peru became a leader in breastfeeding protection by being the first Latin American country to implement policies to protect breastfeeding in health services and public places. Since then, the Ministry of Health has created guidelines to support breastfeeding at the individual level and regularly funds activities in favour of exclusive breastfeeding in communities.

However, despite all these measures, exclusive breastfeeding before six months of age has decreased in urban areas (from 64.5% in 2007 to 59.9% in 2010) and the coastal region of the country (from 60.1% in 2007 to 52.8% in 2010). This was the starting point of the MSc Thesis research study I conducted under the supervision of Dr. Grace Marquis from the School of Dietetics and Human Nutrition. The research examined health services breastfeeding support provided to mothers of infants 0-6 months of age in the coastal city of Lima, the capital of Peru, so as to better understand the role of health professionals in the decline of exclusive breastfeeding. In effect, health services are key sites to promote the initiation and establishment of optimal breastfeeding practices, as health care providers play an essential role in influencing mothers’ feeding decisions (WHO 2009).

After obtaining approvals from the Research Ethics Board and the local health authorities, I travelled to Lima and started my fieldwork. The qualitative study took place in a community of low socio-economic conditions situated on the outskirts of Lima. The study was conducted in coordination with the Instituto de Investigación Nutricional (the Nutrition Research Institute; IIN), a non-governmental organization that has been conducting research in the community for more than 30 years. I started the study by making observations during counselling sessions and educational group sessions provided by nurses, nutritionists, pediatricians, general practitioners and midwives to mothers of infants 0-6 months receiving in-patient and out-patient services in three government health institutions. I then recruited eleven mothers and sixteen health care providers and interviewed them to explore their individual experiences. Recruitment was not easy as many potential participants were hesitant to be interviewed by a foreigner. However, after I met with them several times during observations, we created a familiarity and trust between us, which made interviews have a natural flow. I also conducted two focus group discussions with seven mothers to explore specific aspects of breastfeeding support identified in individual interviews. I encouraged mothers to talk to one another, ask questions, comment on others’ experiences and points of view, and exchange anecdotes.

Yvette conducting field work in Peru

After data collection, the time had come to start data analysis and thesis writing. Several areas of improvement of breastfeeding support were identified: in the majority of individual encounters observed, mothers received verbal standard recommendations such as “Continue breastfeeding” that were not always helpful, according to them. Many mothers also felt that their support needs were unmet and complained about the scarce support received and the authoritative approach of health care providers. Some mothers hid information from health care providers for fear of being blamed. According to health care providers, many felt pressured to rush through consultations to reach the ministry’s targets of number of encounters per shift. For that reason, hasty evaluations of feeding practices impeded them from providing practical recommendations tailored to the mothers’ needs and offering strategies to overcome feeding difficulties. This kind of support was only provided after a careful evaluation of individual feeding practices, which in turn was only provided when problems arose (such as weight loss or hypoglycemia). Additionally, more than half of the mothers received erroneous or conflicting recommendations, which reflected the lack of breastfeeding knowledge and management skills of health care providers. Finally, aggressive promotion of infant formula in health services made some health professionals more inclined to prescribe formula.

After my thesis submission, I started to work on two manuscripts for publication in journals; however, I felt the need to go beyond scientific publication and report the results to institutions that have the authority to make things change. Therefore, I travelled back to Peru a couple of months later and, with the support of the director of the IIN, was able to meet with staff of the Ministry of Health in Lima. I had prepared a report with the main findings, conclusions and recommendations for distribution inside the ministry. I met in person with the Director of Public Health, who asked me to present the report orally to discuss and exchange ideas with the team in charge of maternal and child health.

The presentation went really well! The director and the team, composed of nurses, nutritionists, pediatricians and a psychologist, showed deep interest in the results, all being focused in listening to my presentation. My recommendations were to improve the evaluation of feeding practices, to provide regular and compulsory training to health care providers on breastfeeding counselling, to evaluate the quality of the consultations, and to counteract the aggressive promotion of infant formula by strengthening policy compliance. The team was taking notes, asking questions and reflecting back to my recommendations. At the director’s request, teams were formed to work on the issues presented, which generated at times heated discussions about what concrete things could be done to change the situation. After the question period, the participants were all thankful for having been invited to the presentation. The director added that the presentation was timely, as his team was preparing the next year’s budget and the recommendations would definitely be taken into account. He also mentioned the possibility of working with universities to improve the training of new health care providers. In my opinion, the authorities’ reaction to the results and recommendations could not have been better!

As I left the ministry, I felt that I had contributed in some way to the improvement of programs and future policy decisions related to infant nutrition. I not only had a feeling of self-accomplishment, I also had been involved in making a real change that could have major implications for the health of Peruvian infants. This is exactly what I encourage McGill students and recent graduates to do – make a difference!

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