Evaluation of Mothers' Knowledge,Attitudes,and Practice Towards the Ten Steps to Successful Breastfeeding in Egypt

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 first hour compared with 61% in UE, with the mothers reporting that they did not experience skin-to-skin care in the first 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 pacifiers is more common in LE, and feeding by bottle is more common in UE, being pressured by the mother's 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 encouraging maternal support groups and taking cultural differences into account.

Introduction

The Baby-Friendly Hospital Initiative (BFHI) was introduced 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 diseases and disabilities that were closely linked to practices that disrupt breastfeeding.^2,3 Social and economic benefits have also been shown by implementation of the BFHI in both developed and developing countries. The widespread success of the BFHI, with its proven efficacy 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 expansion 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 populations in need. This can help to target interventions appropriately, 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 programs. As Egypt now turns to revive BFHI, previous strategies need to be revised as new evidence-based strategies 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 significantly increased 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 conducted by interviewing 1,052 mothers who were breastfeeding infants less than 24 months of age selected from 12 governorates: five in UE and five in LE and the two major urban governorates of Cairo and Alexandria located in LE. Data were collected in the interval of January–May 2008. The logistics included receiving permission from the central as well as the governorate health offices of the directorates visited. 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 interviews 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 consent 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 from LE and 541 from UE 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), totaling 511 mother–infant pairs. The UE governorates included Assiut (n=110), Aswan (n=217), Luxor (n=40), Qena (n=84), and Sohag (n=90), totalling 541 mother–infant 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 χ² tests (Fisher's exact test was applied whenever tested values were below 5).

Results

Demographic profile

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 population 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 delivered 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 benefits of breastfeeding. Table 1 shows that there is a significant difference in the knowledge of the mothers about the benefits 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 significantly 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 first 6 months. Table 2 shows that less than one-half of the mothers know about the benefits of skin-to-skin care; this was significantly lower among mothers of UE, particularly with regard to its effect on weight gain and breathing. Such findings indicate that Step 3 needs to be adequately implemented in both UE and LE.

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 benefits	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

Table 2.

Percentage Distribution of Mothers with Knowledge About the Various Benefits of Skin-to-Skin Contact in Lower Egypt Versus Upper Egypt

	Geographical site
Benefits 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

Figure 1 shows that early initiation of breastfeeding (Step 4 of the BFHI) is significantly delayed more in LE as three-quarters of the mothers do not initiate breastfeeding until after the first hour. This is compared with about 39% of mothers in UE who initiate breastfeeding in the first 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 (20–40 years old) compared with very young (<20 years old) and older (>40 years old) mothers. The difference was significant at p<0.006.

FIG. 1.

Percentage of timely initiation of breastfeeding in the early postpartum period in Upper Egypt versus Lower Egypt.

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 fluid 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%, respectively) (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 first 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 from relatives 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 artificial teats and pacifiers; however, a large proportion of mothers (43.2% in LE and 39.2% in UE) report offering pacifiers to their babies. Most of these mothers believe that these pacifiers 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 pacifier. Many mothers described carrying the baby as a better way to soothe the baby than to give him or her a pacifier; 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%) know the negative effect of pacifiers on breastfeeding compared with 40.4% in UE (p<0.001).

Table 3 shows that the use of bottles is more common than pacifiers, 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 interviewed 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 significant 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 practice of feeding babies by bottles comes from pressure by the mother's social network of family and friends (52.7% in LE and 55.8% in UE) and by media (17%) as shown in Table 3.

Table 3.

Percentage Distribution of the Knowledge, Attitudes, and Practices of Breastfeeding Mothers Toward Pacifiers and Feeding Bottles in Lower Egypt Versus Upper Egypt

	Geographical site
KAP for pacifiers and bottles	Lower Egypt	Upper Egypt	p value
Mother gave her baby a pacifier	43.2	39.4	0.2
Thinks pacifier calms her baby	44.0	47.2	0.3
A relative provided a pacifier	63.4	64.2	0.05
Knows that carrying the baby is better than providing a pacifier	80.8	71.6	0.001
Mother carried the baby instead of giving a pacifier	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
Pacifiers 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.

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 women's knowledge; however, a person-to-person approach might be more effective.^7,8 Effectiveness of prenatal education is increased when it is combined with postpartum follow-up.⁹ We suggest a multifaceted public health intervention by combining education by the health facility and the family-centered approach with educational messages from the mass media for encouraging positive breastfeeding attitudes in the family and wider community.

Our study indicates that early initiation of breastfeeding continues to be significantly 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 findings could be explained by the higher prevalence of hospital deliveries 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 benefits 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 benefits of both early initiation and skin-to-skin care for the baby and mother. The difference was again statistically significant for almost all of the benefits of skin-to-skin care except its effect on breastfeeding. In another study we reported that staff resisted skin-to-skin care and regarded as culturally inappropriate.¹² A systematic review that evaluated 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 breastfeeding 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 because of the limited number of infant cots in Egyptian hospitals. 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 significantly decreased compared with the preliminary BFHI surveys conducted in the early 1990s in Egypt. More mothers with higher education mentioned that they know the benefits 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 significantly more commonly reported by younger mothers with little or no education. Incorrect attachment at the breast is the commonest cause of nipple pain, particularly in first-time mothers. This fits the profile of the young, inexperienced, and undereducated mothers. It indicates the need for training primary healthcare staff and peer counsellors to counsel and monitor those mothers more closely in the early postpartum period and first 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 influenced by hospital advertisements 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 pacifiers 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 pacifiers and baby bottles is prevalent among the younger mothers, who are probably also primiparous mothers. These mothers may receive more pressure from their social 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, first-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 pacifiers.^17,18

It was observed that the practice of giving unaltered animal milk to infants before 6 months of age has decreased significantly over the past decade.⁶ The rise in the use of infant milk formula reflects 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 reflects either more affluence or access to subsidized formula or unnecessary prescription by pediatric staff influenced by the aggressive marketing tactics of infant milk formula companies. Egypt has not fully enacted the International 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 form infant 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 unnecessary supplements was significantly 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.^19–23

In other countries, strategies that used the risk approach to improve exclusive breastfeeding rates in the first 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 practice. Learning from the success stories in these countries may be useful in design of social marketing campaigns based on the risk approach.^15–19

Only one-half of the mothers participating in this study knew that 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 galactagogues is not reported as a commonly used method for increasing 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 first 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 influenced by the media. Mothers who were younger and less educated were more likely to be influenced 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 influences 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 profiles of Egyptian children.^26–30

Poverty remains a major problem in Egypt, as 19% of the population are below the poverty line, and poverty approaches 40–60% in some UE governorates. Poverty is associated 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 influence breastfeeding duration.^31–33

Our study is unique in that it compares the regional differences 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 and social networks were identified in this study as key influential groups. Other in-depth studies have shown how the father, mother's mother, and mother-in-law have a great impact on the mother's 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 influence 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 (convenience sample) and that the mothers were beyond the immediate 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 involving 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 counselors 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 identified 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.

Footnotes

Acknowledgments

We would like to express our gratitude to the UNICEF, Cairo Office that partly funded the Egyptian Lactation Consultant Association to do the survey as well as the officials of Maternal and Child Health in the Ministry of Health of Egypt who facilitated and participated in the field work of the survey. We are particularly grateful to the primary healthcare officials and coordinators of breastfeeding in the 12 governorates for facilitating and supervising the data collection phase. We would like to thank the Centre of Social and Preventive Medicine at Cairo University for facilitating the administration 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 volunteering 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 financial interests exist.

References

WHO/UNICEF. Innocenti Declaration and Innocenti Infant and Young Child Feeding. WHO Press: Geneva, 2008.

Betran

, de Onis

, Lauer

, Villar

. Ecological study of effect of breast feeding on infant mortality in Latin America. BMJ, 2001; 323:1.

Dewey

, Heinig

, Nommsen-Rivers

. Differences in morbidity between breast-fed and formula-fed infants. J Pediatr, 1995; 126:696–702.

Fairbank

, O'Meara

, Renfrew

et al. A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding. Health Technol Assess, 2000; 4,25:1–171.

UNICEF Baby-Friendly Hospital Initiative. Revised, Updated and Expanded for Integrated Care, Section 1: Background and Implementation; 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.

El-Zanaty

, Way

. Egypt Demographic and Health Survey. Ministry of Health and Population (Arab Republic of Egypt) and National Population Council (Arab Republic of Egypt): Cairo, 2005.

Kistin

, Benton

, Rao

et al. Breast-feeding rates among black urban low-income women: effect of prenatal education. Pediatrics, 1990; 86:741–746.

Kaplowitz

, Olson

. The effect of an education program on the decision to breastfeed. J Nutr Educ, 1983; 15:61–65.

Hoyer

, Horvat

. Successful breast-feeding as a result of a health education programme for mothers. J Adv Nurs, 2000; 32:1158–1167.

10.

Anderson

, Moore

, Hepworth

et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Birth, 2003; 30:206–207.

11.

Kind

, Schubiger

, Schwarz

et al. Provision of supplementary fluids to breast fed infants and later breast feeding success. Adv Exp Med Biol, 2000; 478:347–354.

12.

Abul-Fadl

, Shawki

. UNICEF-MoH-ELCA 2008 baseline survey for BFHI in Egypt. Egypt J Breastfeed, 2011; 1:34–69.

13.

Green

. Media Promotion of Breastfeeding: A Decade's Experience. Academy for Educational Development: Washington DC, 1989.

14.

El-Kerdany

, Abul-Fadl

. Pre and Post Implementation of BFHI in Egypt. UNICEF Cairo Office: Cairo, 1994.

15.

Hillenbrand

, Larsen

. Effect of an educational intervention about breastfeeding on the knowledge, confidence, and behaviors of pediatric resident physicians. Pediatrics, 2002; 110:e59.

16.

Kistin

, Abramson

, Dublin

. Effect of peer counselors on breastfeeding initiation, exclusivity, and duration among low-income urban women. J Hum Lact, 1994; 10:11–15.

17.

Howard

, Howard

, Lanphear

et al. The effects of early pacifier use on breastfeeding duration. Pediatrics, 1999; 103:e33.

18.

Howard

, Howard

, Lanphear

et al. Randomized clinical trial of pacifier use and bottle-feeding or cup feeding and their effect on breastfeeding. Pediatrics, 2003; 111:511–518.

19.

Hossain

, Radwan

, Arafa

et al. Prelacteal infant feeding practices in rural Egypt. J Trop Pediatr, 1991; 38:317–322.

20.

Eissa

, Khashaba

, Abul-Fadl

MAM

et al.

Breastfeeding and health status in Qaluibiya governorate in Egypt (1990)

Gaz Egypt Pediatr Assoc, 1993; 41:45–57.

21.

Victora

, Vaughan

, Lombardi

et al. Evidence for protection by breastfeeding against infant deaths from infectious diseases in Brazil. Lancet, 1987; 2:319–321.

22.

Howie

, Forsyth

, Ogston

et al. Protective effect of breastfeeding against infection. BMJ, 1990; 300:11–16.

23.

Wright

, Holberg

, Martinez

et al. Breastfeeding and lower respiratory tract illness in the first year of life. BMJ, 1989; 299:946–949.

24.

Gerhardt

. Why Love Matters: How Affection Shapes a Baby's Brain. Routledge, Taylor and Francis Group: London, 2006.

25.

Gunnar

, Donzeella

. Social regulation of the cortisol levels in early human development. Psychoneuroendocrinology, 2002; 27:199–220.

26.

Lal

, Khanna

, Gaur

et al. Participatory health communication and action through women groups in rural areas. Indian J Pediatr, 1992; 59:255–260.

27.

Cadwell

, Turner-Maffei

. Continuity of Care in Breastfeeding. Jones & Bartlett: Sudbury, MA, 2009.

28.

Segall-Correa

. Breastfeeding promotion and priority setting in health. Health Policy Plan, 1996; 11:156–168.

29.

Sikorski

, Renfrew

, Pindoria

et al. Support for breastfeeding mothers. Cochrane Database Syst Rev 2002;(1):CD001141. Update in Cochrane Database Syst Rev, 2007; 1:CD001141.

30.

Wright

, Naylor

, Wester

, Bauer

, Sutcliffe

. Using cultural knowledge in health promotion: Breastfeeding among the Navajo. Health Educ Behav, 1997; 24:625–639.

31.

Ball

, Wright

. Health care costs of formula-feeding in the first year of life. Pediatrics, 1999; 103:870–876.

32.

Auerbach

, Renfrew

, Minchin

. Infant feeding comparisons: A hazard to infant health? J Hum Lact, 1991; 7:63–68.

33.

Beasley

, Amir

. Infant feeding, poverty and human development. Int Breastfeed J, 2007; 2:14.

34.

Abul-Fadl

. Evaluation of family-centred maternity care. ELCA Scientific Journal, Special Issue Dedicated to the Proceedings of the Egyptian Lactation Consultant Association's First Scientific Meeting 29 June, 2006 in Nile Hilton, Cairo, Egypt. AlTobgi Press: Cairo, 2006; 23–36.