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Efficacy of home-based peer counselling to promote exclusive breastfeeding:

A randomised controlled trial

Article  in  The Lancet · April 1999

DOI: 10.1016/S0140-6736(98)08037-4 · Source: PubMed

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Efficacy of home-based peer counselling to promote exclusive
breastfeeding: a randomised controlled trial
A rdythe L Morrow , M Lourdes Guerrero, Justine Shults, Juan J Calva, Chessa Lutter, Jane Bravo,
Guillermo Ruiz-Palacios, Robert C Morrow , Frances D B ut t er foss
Summary
Background Exclusive breastfeeding is recommended
worldwide but not commonly practised. We undertook a
randomised controlled study of the efficacy of home-
based peer counselling t o increase the proportion of
ex clusive breastfeeding among mothers and infant s
residing in periurban Mexico City.
Methods Two intervention groups with different
counselling frequencies, six visits (44) and three visits
( 52) , were compared w ith a control group (34) that had
no intervention. From March, 1995, to September, 1996,
170 pregnant w omen w ere identified by census and
invited to participate in the study. Home visits were
made during pregnancy and early post partum by peer
counsellors recruited from the same community and
trained by La Leche League. Data w ere collected by
independent interview. Exclusive breast feeding w as
defined by WHO criteria.
Findings 130 w omen participated in the study. Only 12
w omen refused participation. Study groups did not differ
in baseline factors. A t 3 mont hs post partum, ex clusive
breastfeeding w as pract ised by 67% of six-visit, 50% of
three-visit, and 12% of control mothers ( intervention
groups v s controls, p<0·001; six-visit v s t hr ee- v i si t ,
p=0·02). Duration of breastfeeding was significantly
( p=0·02) longer in intervention groups than in controls,
and fewer intervention than control infants had an
episode of diarrhoea ( 12% v s 26%, p=0·03).
Interpretation This is the first reported community-based
randomised trial of breastfeeding promotion. Early and
repeated contact with peer counsellors was associated
w ith a significant increase in breastfeeding exclusivity
and duration. The two-fold decrease in diarrhoea
demonstrates the importance of breastfeeding promotion
to infant health.
Lanc et 1999; 353: 1226–31
Centre for Pediatric Research, Children’s Hospital of The King’s
Daughters, Eastern Virginia Medical School, Norfolk, VA 23510-
1001, USA (A L Morrow PhD, J Shults PhD, F D Butterfoss PhD);
Departamento de Infectologia, Instituto Nacional de la Nutricion,
Mexico Federal District, Mexico (M L Guerrero MD, J J Calva MD,
G Ruiz-Palacios MD); Pan American Health Organization,
Washington, DC, USA (C Lutter PhD ); La Leche League of Mexico,
Mexico Federal District, Mexico (J Bravo EdD) ; and Eastern Virginia
Medical School, Norfolk, Virginia, USA (R C Morrow MD)
Correspondence to: Dr Ardythe L Morrow
(e-mail: amorrow@chkd.com)
1226
Introduction
The promotion and support of breastfeeding is a global
priority.1–3 A vast scientific literature demonstrates
substantial health, social, and economic benefits
associated with appropriate breastfeeding, including
lower infant morbidity and mortality from diarrhoea and
other infectious diseases.3–11 Experts agree that exclusive
breastfeeding (ie, breastmilk as the sole source of food)
is the ideal method of feeding infants up to about 6
months of age, after which breastfeeding should be
continued but complemented with other sources of
nutrition.2 Nevertheless, exclusive breastfeeding remains
uncommon, even in countries with high rates of
breastfeeding initiation.12,13 Programmes that increase
breastfeeding do not necessarily improve the rate of
exclusive breastfeeding.14–19
To improve breastfeeding practices, global initiatives
have concentrated on hospital policies and
procedures.1,15–17,19–21 Although hospital-based
programmes have shown significant impact on
breastfeeding outcomes,15–17,19–21 community-based
support of breastfeeding is also needed. An important
model for community-based breastfeeding promotion is
peer counselling, which involves training lay community
members to contact and advise peers from the same
community.22,23 Peer counselling is being used worldwide
for various purposes, including the social and
informational support that mothers need for successful
initiation and maintenance of breastfeeding.18,24–26
Although peer counselling is a promising method of
outreach, well-designed, controlled studies are needed
to assess the efficacy of this approach for the promotion
of exclusive breastfeeding.
In San Pedro Martir, a periurban area of Mexico, a
longitudinal study of protection against diarrhoeal
disease by breastmilk found that 92% of 316 mothers
studied between 1988 and 1991 started breastfeeding,
but only 4% practised exclusive breastfeeding at 2 weeks
or at 3 months, and half had ceased any breastfeeding
by 6 months post partum.8,9,27 We undertook a
randomised controlled trial in the San Pedro Martir area
to examine the hypothesis that home visits by peer
counsellors to pregnant and lactating women would
significantly increase the rate of exclusive breastfeeding,
and that more frequent visits would result in a higher
rate of exclusive breastfeeding. In addition, we
examined the efficacy of an intervention to increase
breastfeeding duration and to decrease the risk of infant
diarrhoea.
Methods
Study participants
San Pedro Martir is a periurban community on the
southwestern outskirts of Mexico City, compromising three
subdivisions that vary in sociodemographic characteristics. In
the most established area, families typically live in houses with
THE LANCET • Vol 353 • April 10, 1999
running potable water, tiled floors, and access to central
sewage and garbage removal services. In the most recently
settled area, families typically live in crowded conditions, in
huts with earth floors, and obtain water from pipe outlets some
distance away. The total population is about 30 000. Medical
care is provided to this population by a government clinic,
various private primary-care doctors, and public, private, and
military hospitals. The study population has been fully
described elsewhere.27 At the time of this study, many hospitals
serving the area were changing policies and procedures to
support breastfeeding, following international standards known
as the Baby Friendly Hospital Initiative. 1,19
This randomised, community-based intervention trial
included two intervention groups and a control group. Mother-
infant pairs in the intervention groups received either six or
three home visits from peer counsellors. In the six-visit group,
mothers were visited in mid and late pregnancy, in the first
week and weeks 2, 4, and 8 post partum. In the three-visit
intervention group, mothers were visited in late pregnancy, in
the first week, and week 2 post partum. Furthermore, peer
counsellors were permitted to respond to occasional requests
for additional support that were initiated by intervention-group
mothers. Control-group mothers with lactation problems were
referred to their own physicians. No other sources of
breastfeeding counselling were available in the community.
This study was approved by the institutional review boards of
the Instituto Nacional de la Nutricion in Mexico City and
Eastern Virginia Medical School in Norfolk (Virginia, USA).
Before the study started, San Pedro Martir was mapped into
39 clusters with two to four city blocks each. 13 clusters were
allocated randomly to each study group, stratified by
subdivision. This randomisation schedule was generated by
computer. Clusters rather than individuals were randomised to
keep to a minimum the contamination of influences expected if
relatives and close neighbours were assigned to different study
groups.
Enrolment began in March, 1995, and continued to
September, 1996. Study mothers were identified by a
semiannual door-to-door census and continuous reporting of
new pregnancies in the community by study staff and mothers.
For more than 15 years, this method has been used to identify
virtually all eligible mothers in the study community; 8–11 no
record system is available for comparison. All pregnant women
residing in the study area were considered eligible, visited at
home by a study physician to verify eligibility, and invited to
participate in a study of breastfeeding practices. Mothers were
provided with an oral and written description of procedures for
their study group; other study groups were not discussed.
Mothers’ consent was obtained in writing. Women were
considered ineligible and excluded from the study if they
refused participation or moved out of the area before the first
postpartum home visit, or if the baby died. Infants were
followed up until 3 months of age to assess exclusive
breastfeeding and diarrhoea, and 6 months of age to assess
duration of any breastfeeding. The study ended in December,
1996.
Desi g n
All data were collected through structured interviews of
mothers residing in study households by two experienced staff
other than the peer counsellors. The study hypothesis could
not be concealed from these staff, but they were trained to
adminster all questions in a standard manner, and they
undertook an equal proportion of interviews in each study
group. Baseline interviews were carried out in the last trimester
of pregnancy to examine sociodemographic factors,
breastfeeding history and intention, and other factors. A
perinatal questionnaire ascertained pregnancy history, the
health of mother and infant, and early infant-feeding practices.
Five follow-up interviews were scheduled for all study mothers
at 2, 4, and 6 weeks, and at 2 and 3 months post partum to
record infant-feeding practices in the previous week and any
THE LANCET • Vol 353 • April 10, 1999
lactation problems experienced. During weeks in which both a
counselling visit and a data-collection interview were due, the
data-collection interview was scheduled to follow the
counselling visit by 2–3 days. During these interviews, mothers
were asked whether the infant had experienced diarrhoea since
the last interview, and to describe any episodes and whether
they had taken the infant to a doctor. An exit interview at 6
months post partum examined the duration of breastfeeding
and maternal attitudes towards the peer counsellors.
Three women who had previously worked for the Instituto
Nacional de la Nutricion as field data collectors were trained to
promote breastfeeding as peer counsellors. Each was a resident
of San Pedro Martir, aged 25–30 years, had a high-school
education, and had a commitment to breastfeeding, although
they did not necessarily have previous personal breastfeeding
experience. These peer counsellors were trained and supervised
by staff of La Leche League of Mexico and the physician study
coordinator (MLG), who was also trained in lactation
management. The peer-counsellor training consisted of 1 week
of classes, 2 months in lactation clinics and with mother-to-
mother support groups, and 1 day of observation and
demonstration by visiting experts. Finally, the peer counsellors
practised in a neighbourhood nearby San Pedro Martir for 6
months before the intervention trial, during which the content
of messages and problem-solving skills were refined.
A rapid ethnographic study of infant feeding was done in
San Pedro Martir before the intervention trial to guide
educational approaches. 27 A set of visual aids was developed
specifically for this project on the basis of existing materials of
La Leche League. Home visits to pregnant women focused on
the benefits of exclusive breastfeeding, especially during illness;
basic lactation anatomy and physiology; positioning of the
infant and “latching on”; common myths; typical problems and
solutions; and preparation for birth. Postpartum visits with the
mother focused on establishing a healthy breastfeeding pattern,
addressing maternal concerns, and providing information and
social support. Key family members who could provide support
to mothers also were included in these counselling visits.
The primary study outcome was exclusive breastfeeding,
defined as giving maternal milk at the only infant food source
in the previous week, with no other liquids or food given. 28
Secondary outcomes were duration of breastfeeding, the
proportion of infants who had an episode of diarrhoea in the
first 3 months (cumulative incidence), and maternal
satisfaction with counselling. Diarrhoea was defined as more
frequent and liquid stools than normal for the infant, as
reported by the mother.
Statistical analysis
On the basis of primary hypothesis, we calculated the
minimum required sample size to be 120 participants, setting
␣=0·05, and a one-sided test of hypothesis. This sample size
gave 86% power to detect a 20% absolute difference in
exclusive breastfeeding in intervention versus control
participants (24% vs 4%), if there was no design effect, or 76%
power to detect the same difference if there was a design effect
of 1·2. 29
Data were analysed by means of Stata statistical software
(release 5·0). Because randomisation was based on clusters,
within-cluster correlation and design effects were assessed.
Descriptive analyses included frequencies, contingency tables,
and odds ratios. Associations between categorical variables
were tested with ␹2 or Fisher’s exact test. The effect of the
intervention on exclusive breastfeeding was analysed by means
of generalised estimating equation (GEE) models that
accounted for within-individual correlation of outcomes
measured at five timepoints from 2 weeks to 3 months post
partum. We also used GEE models to compare outcomes at
each timepoint, accounting for correlation within clusters.
Intervention groups were specified in the models as dummy
variables. Maternal, infant, and hospital factors were examined
as risk factors, and for potential confounding and interaction
1227
 Figure 2: Proportion of mothers who exclusively breastfed their
infants by infant age and study group
Figure 1: Trial profile Vertical bars represent 95% CI.

effects relative to study outcomes. We also used survival mother–infant pairs participated in the study, of whom
analysis and the log-rank procedure to test differences between 125 remained in the study at 3 months. Exit interviews
groups in time to first failure of exclusive breastfeeding and were done in 117 participants: 104 at 6 months, and 13
duration of any breastfeeding. One-sided tests of significance between 3 and 6 months post partum. Study
were used to test intervention efficacy, defined as a significant participants were identified and enrolled in 31 of the 39
increase in exclusive breastfeeding, increased duration of any
geographically defined clusters.
breastfeeding, and decreased infant diarrhoea in the
intervention groups compared with the control group.
No significant differences were found among study
Justification of a one-sided hypothesis was based on the need to groups in baseline factors, including breastfeeding
test programme efficacy (ie, demonstration of significant initiation (table 1). The proportion who initiated
improvement) and the lack of evidence of potential for harm. breastfeeding within a few hours of delivery was similar
Significance was set at p<0·05. All analyses were by intention in each study group. 35 (27%) mothers were
to treat. primiparous, and 31% gave birth by caesarean section.
The peer counsellors were assigned approximately
Results equal numbers of study mothers in the two intervention
P ar t i c i pant s groups. No differences were found between intervention
170 pregnant women were identified in San Pedro groups in the timing of the first postpartum visit.
Martir and were asked to participate. Of these, only 12 Furthermore, no differences were found among
(7%) refused, and 28 were ineligible and excluded counsellors in terms of their clients’ breastfeeding
(figure 1). Participants and non-participants did not outcomes.
differ by location within study area or by study group,
and did not differ in socioeconomic status. 130 Confounding and interactions
Sociodemographic, health, and hospital factors (table 1)
Characteristic Six-visit Three-visit Control were analysed in relation to the intervention and
group (n=44) group (n=52) group (n=34) exclusive breastfeeding. None of these factors was found
Maternal demographics to be a significant predictor of exclusive breastfeeding or
Educational attainment
Primary school or none 20 (45%) 20 (38%) 18 (53%)
to modify the efficacy of the intervention; thus, final
Secondary 12 (27%) 19 (37%) 8 (24%) models specified only intervention groups as
Married 24 (55%) 34 (65%) 22 (65%) independent variables.
Employed outside home 3 (7%) 8 (15%) 4 (12%)
Within-cluster correlation values were calculated for
Infant birthplace each study outcome and interview time and were found
Home 4 (9%) 3 (6%) 1 (3%)
Baby-friendly hospital* 23 (52%) 27 (52%) 17 (50%)
to be negligible: ⫺0·011 at the 2-week visit and 0·074 at
3 months. Design effects were calculated and found to
Perinatal conditions
Primiparous mother 13 (30%) 15 (29%) 7 (21%) approach unity (no effect) for each study group. These
Delivery by caesarean section 10 (23%) 21 (40%) 9 (26%) results show that the cluster randomisation design
Infant birthweight ⭐2500 g 8 (18%) 8 (15%) 3 (9%) achieved the equivalent of individual randomisation.
Infant roomed with mother in hospital 14 (32%) 21 (40%) 19 (56%)
Infant stay in hospital >7 days 3 (7%) 6 (12%) 3 (9%)
Infant female 27 (61%) 28 (54%) 17 (50%) Main outcome
Initial breastfeeding practices In the six-visit group, 35 (80%) of 44 women were
Breastfed within a few hours of birth 29 (66%) 31 (60%) 23 (68%) exclusively breastfeeding at 2 weeks and 28 (67%) of 42
Ever breastfed 44 (100%) 51 (98%) 32 (94%)
were doing so at 3 months; in the three-visit group, the
Frequencies are presented only for selected categories and variables and therefore corresponding numbers were 32 (62%) of 52 at 2 weeks
do not add up to 100%. *Born in a hospital certified by or before 1996 as
“baby-friendly” (ie, following international standards for breastfeeding support). and 25 (50%) of 50 at 3 months (figure 2). In the control
Table 1: Sociodemographic characteristics and perinatal group eight (24%) of 34 women were exclusively
conditions of 130 study mothers and infants breastfeeding at 2 weeks, a significantly greater

1228 THE LANCET • Vol 353 • April 10, 1999


Measure Number/total
Intervention
Duration of any breastfeeding†
肁3 months 87/92 (95%)
肁6 months 65/75 (87%)
Diarrhoea in infants 0–3 months of age 12/96 (12%)
Mother reported that the peer 83/85 (98%)
counsellor was helpful and supportive
*One-sided p-value by ␹2 analysis. †Log-rank test, intervention versus control,
p=0·024.
Table 2: Secondary measures of intervention efficacy
(p<0·05) proportion than in the 1988–91 historical
cohort (4%), and four (12%) of 33 were exclusively
breastfeeding at 3 months post partum, which did not
differ significantly from previously recorded rates.
Both the six-visit and three-visit intervention groups
had significantly (p<0·001) more exclusive
breastfeeding over time than controls, as shown by GEE
models. GEE models fitted at each timepoint that
accounted for within-cluster correlation confirmed this
finding. Furthermore, the higher rate of exclusive
breastfeeding in the six-visit group compared with the
three-visit group was significant (p=0·015 by GEE
analysis), but this difference seems to have been
establised by 2 weeks, when an 18% absolute difference
in exclusive breastfeeding was observed (p=0·028, by ␹2).
Some study mothers who breastfed exclusively gave
their infants supplementary feedings for a short time,
then returned to exclusive breastfeeding, a pattern
observed in all study groups, typically associated with
perceived illness, stress, or doctor’s advice. In the six-
visit group, the prevalence of exclusive breastfeeding
varied from 66% at 4 weeks to 75% at 6 weeks and 67%
at 3 months post partum. Practice of exclusive
breastfeeding at all five measurement times, 2 weeks to
3 months, was found in 21 (50%) of 42 in the six-visit
group, 19 (38%) of 50 in the three-visit group, and four
(12%) of 33 controls (p<0·001, log-rank test). Thus,
17% of the six-visit group and 12% of the three-visit
group exclusively breastfed at 3 months but failed to
maintain exclusive breastfeeding throughout follow-up.
Examination of the types of supplementary feedings
introduced by 3 months shows that higher rates of
exclusive breastfeeding in the intervention groups were
achieved by less use of formula-milk feedings, solid
foods, teas, and water feedings.
Secondary outcomes
To provide sufficient power to detect differences in
secondary outcomes, the two intervention groups were
collapsed into a single group for comparison with
controls. Duration of any breastfeeding was signifiantly
(p=0·024, log-rank test) greater among intervention-
group than control-group mothers (table 2). 21 infants
had at least one episode of diarrhoea between birth and
3 months of age: eight of the six-visit group, four of the
three-visit goup, and nine controls. Of the 21 diarrhoea
episodes, 18 were associated with a visit to a doctor, two
with dehydration, and four with vomiting, and four
episodes lasted longer than 1 week. Control infants had
a significantly greater incidence of diarrhoea than
intervention infants (relative risk 2·1 [90% CI
1·11–4·04]; p=0·029).
In the exit interview, nearly all intervention-group
mothers reported that the peer counsellor was helpful
THE LANCET • Vol 353 • April 10, 1999
and supportive. The most important source of infant-
p* feeding advice for intervention-group mothers typically
Control was a peer counsellor (66%), followed by a physician
(19%), and their mothers (7%). In contrast, among
28/33 (85%) 0·039 controls, 50% listed a physician as their most important
22/29 (76%) 0·090
source of infant-feeding advice, 22% listed their
9/34 (26%) 0·029
mothers, and 2% listed a peer counsellor.
·· ··
Discussion
This experimental study of home-based peer counselling
showed a striking effect of the intervention on the
duration of exclusive and partial breastfeeding in a
transitional, periurban neighbourhood of Mexico City.
At 3 months post partum, exclusive breastfeeding was
practised by only 12% of control mothers, compared
with 67% of the mothers who have visited six times, and
50% of the mothers who were visited three times by a
peer counsellor. Maternal and infants’ characteristics
and hospital factors did not significantly influence
intervention efficacy. Our findings indicate that more
frequent counselling visits are advantageous. Although
the relative gain observed in the six-visit group
compared with the three-visit group could be attributed
largely to the additional counselling visit made during
pregnancy, the counselling visits made in the six-visit
group at 4 weeks and 2 months post partum seem to
have helped restore some mothers to exclusive
breastfeeding after they had introduced supplementary
liquids for a short time. We did not detect differences
among study groups in feeding choices made on the day
of delivery, which may be more strongly influenced by
hospital initiatives.
Although allocation concealment from staff and
participants was not possible, bias is unlikely to explain
our findings. Interviewer bias was controlled by careful
standardisation of procedures across study groups.
Mothers were not informed of the study hypotheses.
Although peer counsellors taught intervention-group
mothers that breastfeeding offers protection against
diarrhoea and respiratory-tract infections, there were
fewer reports of infant diarrhoea in the intervention
group than in the control group but no difference in
non-specific respiratory signs and symptoms.
Furthermore, most cases of infant diarrhoea were
confirmed by a visit to a physician. The Hawthorne
effect (ie, improved outcomes due to the mere presence
of a home visitor) does not offer a plausible explanation
of our results. Before this study, we undertook
longitudinal studies that involved more intensive (ie,
weekly) home visits; however, exclusive breastfeeding
remained uncommon.8–11
These findings support previous research that showed
improved breastfeeding practices among women who
receive timely counselling.15–21,24–26,30,31 Lutter and
colleagues15 found that mothers who gave birth in a
hospital in Brazil that had an active breastfeeding
promotion programme, including a talk and support for
breastfeeding, were more likely to practise exclusive
breastfeeding at 3 months post partum than mothers
who gave birth in a matched control hospital with no
breastfeeding support programme (46% and 20%,
respectively). Similarly, a study of selected Mexican
hospitals showed that counselling combined with babies
staying with their mothers significantly increased full
breastfeeding among primiparous mothers.21 A
1229
randomised trial in Bangladesh examined the efficacy of
hospital-based and home-based lactation counselling of
mothers whose infants were admitted to hospital
because of diarrhoea; these infants were partially
breastfed at admission.17 This study found that 2 weeks
after discharge from hospital, 75% of intervention-group
mothers were breastfeeding exclusively, compared with
8% of control mothers. A comprehensive community-
based project in Chile, which included clinic-based and
home-based counselling, found that exclusive
breastfeeding at 3 months of age increased from 56%
before to 76% after the programme.18 In the USA, the
Women, Infants, and Children programme incorporated
lactation counselling of clients, with significant
improvement in breastfeeding rates.24,26
Most breastfeeding promotion programmes have been
hospital-based owing to the opportunity to reach many
mothers and to establish successful breastfeeding from
the moment of birth.1,19 However, community-based
approaches are needed for early counselling and follow-
up. Peer counsellors offer a potentially less costly
outreach model than use of professional staff.18,24,25 They
should not be expected to have a professional
background, but should be given sufficient training to
provide accurate information and problem-solving
support to mothers. In general, peer counsellors should
be natural helpers who are respected, trusted, in control
of their own life circumstances, and responsive to the
needs of others.22,23 A controlled study of the efficacy of
peer counselling among mothers in the Women, Infants,
and Children programme found that those who received
such counselling were more likely to breastfeed than
those who were not counselled. The impact depended
on the background and training of the counsellor and
adequate duration of interaction between peer
counsellors and their clients.24
The results of this study suggest that early and
repeated counselling contact with mothers promotes
successful breastfeeding outcomes. Future studies will
need to establish the independent effects of prenatal and
postnatal counselling and breastfeeding, and the ideal
number and timing of counselling visits. Nevertheless,
our findings support a counselling schedule of two
contacts during pregnancy, two contacts soon after the
birth, when mothers are most likely to experience
difficulties with breastfeeding, and thereafter as needed.
Ideally, counselling should be accessible to mothers in
the community as a routine component of primary care,
a substantial challenge that will require a change of
priorities and further study in different health-care
systems. Although our study demonstrates the efficacy
of peer counsellors, it does not address other important
questions, such as the relative efficacy of different types
of counsellors (eg, professional lactation specialists),30,31
nor whether peer counsellors should be paid or should
volunteer.22,23 Many different models of counselling are
imaginable, and further studies are needed to address
the questions raised.
Breastfeeding is a highly cost-effective disease-
prevention practice and is a global health priority, yet
there is a lack of scientific evidence on the efficacy of
different strategies for breastfeeding promotion. The
size of increase in exclusive breastfeeding achieved in
our study is higher than that reported by any other
population-based study that we have identified.
Interpretation of this increase should take account of the
1230
characteristics of the San Pedro Martir study
population, which values breastfeeding as an ideal
practice and the relationship of trust with the Instituto
Nactional de la Nutricion, which has worked in the area
for many years. This study took place at the time when
the Baby Friendly Hospital Initiative began to affect the
birth experience of mothers in all study groups.
Nevertheless, our findings encourage the idea that
through the combination of health-care system changes
and community outreach, exclusive breastfeeding can be
restored as normal practice in urban areas. The clinical
significance of breastfeeding promotion is underscored
by the lower rate of diarrhoea episodes found in the
intervention groups. This randomisation trial provides
critical scientific evidence of the efficacy of timely and
accessible lactation counselling and support. Although
the findings of this study are relevant to many countries,
more studies of this type are needed, and the cost-
effectiveness of this intervention approach needs to be
established before it is widely adopted.
C ont r i but or s
All investigators contributed substantially to the design, execution,
analysis, and writing of the paper. Ardythe L Morrow held overall
responsibility for research aims, study design, project management, and
analysis, and wrote the first draft; M Lourdes Guerrero was responsible
or study and questionnaire design, project coordination, and finalising
visual aids and educational approaches; Juan Calva for study and
questionnaire design, development of census procedures, and
physicians’ education; Chessa Lutter for research aims, design, and
interpretation; Guillermo Ruiz-Palacios for development of the study
site and community-based approach; Justine Shults for statistical
methods and data analysis; Jane Bravo for training and supervision of
promotoras, counselling methods and materials; Robert Morrow for
medical anthropology applied to questionnaire construction and
intervention messages; and Fran Butterfoss for health-education
methods.
A c k now l edg ment s
We thank Larry Pickering for his review and support; Judy Canahuati,
Sandra Huffman, and WELLSTART International for technical
assistance; Paulina Smith, Edith Nava, and others at La Leche League
for their collaboration and expertise; Hilda Ortega-Gallegos, Luz del
Carmen Mendez, Maria del Refugio Martinez, Genoveva Figueroa
Ontiveros, and Rosalba Martinez Sanchez for their outstanding work
and contributions to breastfeeding promotion; and Anne Wright and
Nancy Stromann for their assistance with word processing.
This study was supported by research grants from Wellstart
International’s Expanded Promotion of Breastfeeding Program
(USAID) cooperative agreement DPE-5966-A-00-1045-00) and the US
National Institute of Child Health and Human Development
(HD13021).
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