Thursday, September 27, 2007

Achieving universal coverage with health interventions

ScienceDirect - The Lancet : Achieving universal coverage with health interventions:

Cost-effective public health interventions are not reaching developing country populations who need them. Programmes to deliver these interventions are too often patchy, low quality, inequitable, and short-lived. We review the challenges of going to scale—ie, building on known, effective interventions to achieve universal coverage. One challenge is to choose interventions consistent with the epidemiological profile of the population. A second is to plan for context-specific delivery mechanisms effective in going to scale, and to avoid uniform approaches. A third is to develop innovative delivery mechanisms that move incrementally along the vertical-to-horizontal axis as health systems gain capacity in service delivery. The availability of sufficient funds is essential, but constraints to reaching universal coverage go well beyond financial issues. Accurate estimates of resource requirements need a full understanding of the factors that limit intervention delivery. Sound decisions need to be made about the choice of delivery mechanisms, the sequence of action, and the pace at which services can be expanded. Strong health systems are required, and the time frames and funding cycles of national and international agencies are often unrealistically short."

In Reversal, Student Is Given Extra Exam Time to Pump Breast Milk

More in the fight for breast-feeding moms!

Wednesday, September 26, 2007

Maternal Mortality, Not Act of God

Maternal Mortality, Not Act of God - Gov Aliyu The Tide Online

Leading News Resource of Pakistan - Multi-faceted approach needed to reduce maternal mortality

Daily Times - Leading News Resource of Pakistan - Multi-faceted approach needed to reduce maternal mortality: "ISLAMABAD: A multi-faceted approach is needed for the reduction of maternal mortality in the country and international organisations should initiate further measures to help the government in its efforts to persuade the cause, stated a report released by the National Health Policy Unit [...]"

HIV and Breastfeeding

The material/discussion around HIV transmission and breastfeeding made me think and in doing some internet research I came across this article which I thought maybe of interest:

Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study

Prof Hoosen M Coovadia MD a, Prof Nigel C Rollins MD email address b c Corresponding Author Information, Ruth M Bland MB c, Kirsty Little MSc d, Prof Anna Coutsoudis PhD b, Michael L Bennish MD e and Prof Marie-Louise Newell PhD c d



Exclusive breastfeeding, though better than other forms of infant feeding and associated with improved child survival, is uncommon. We assessed the HIV-1 transmission risks and survival associated with exclusive breastfeeding and other types of infant feeding.


2722 HIV-infected and uninfected pregnant women attending antenatal clinics in KwaZulu Natal, South Africa (seven rural, one semiurban, and one urban), were enrolled into a non-randomised intervention cohort study. Infant feeding data were obtained every week from mothers, and blood samples from infants were taken monthly at clinics to establish HIV infection status. Kaplan-Meier analyses conditional on exclusive breastfeeding were used to estimate transmission risks at 6 weeks and 22 weeks of age, and Cox's proportional hazard was used to quantify associations with maternal and infant factors.


1132 of 1372 (83%) infants born to HIV-infected mothers initiated exclusive breastfeeding from birth. Of 1276 infants with complete feeding data, median duration of cumulative exclusive breastfeeding was 159 days (first quartile [Q1] to third quartile [Q3], 122–174 days). 14·1% (95% CI 12·0–16·4) of exclusively breastfed infants were infected with HIV-1 by age 6 weeks and 19·5% (17·0–22·4) by 6 months; risk was significantly associated with maternal CD4-cell counts below 200 cells per μL (adjusted hazard ratio [HR] 3·79; 2·35–6·12) and birthweight less than 2500 g (1·81, 1·07–3·06). Kaplan-Meier estimated risk of acquisition of infection at 6 months of age was 4·04% (2·29–5·76). Breastfed infants who also received solids were significantly more likely to acquire infection than were exclusively breastfed children (HR 10·87, 1·51–78·00, p=0·018), as were infants who at 12 weeks received both breastmilk and formula milk (1·82, 0·98–3·36, p=0·057). Cumulative 3-month mortality in exclusively breastfed infants was 6·1% (4·74–7·92) versus 15·1% (7·63–28·73) in infants given replacement feeds (HR 2·06, 1·00–4·27, p=0·051).


The association between mixed breastfeeding and increased HIV transmission risk, together with evidence that exclusive breastfeeding can be successfully supported in HIV-infected women, warrant revision of the present UNICEF, WHO, and UNAIDS infant feeding guidelines.

Full text can be found at:

Tuesday, September 25, 2007

Breastfeeding and family planning

Rural studies in Nigeria, Senegal, Rwand, Bangaldesh and Jave showed a potponement of menstruation by more than a year in breast feeding women compared with those who did not breast feed. In Korea, Tawiwan and India, a postponement of between 8 and 12 months has been found. By comparison, women who do no breast feed return to regular menstuation in about 3 months after the birth of the baby.

Nutrition in Mother and Child Health, G.J. Ebrahim 1983

As this resource is slightly dated here is a link to a recent metanalysis on pubmed. You can also access to other articles through the website.

Contraceptive efficacy of lactational amenorrhoea.
Kennedy KI, Visness CM.
Family Health International, Research Triangle Park, North Carolina 27709.
Pregnancy is rare among breastfeeding women with lactational amenorrhoea. The lactational amenorrhoea method (LAM) is the informed use of breastfeeding as a contraceptive method by a woman who is still amenorrhoeic, and who is not feeding her baby with supplements, for up to 6 months after delivery. Under these three conditions, LAM users are thought to have 98% protection from pregnancy. It can be difficult, however, to determine when supplementation of the baby's diet begins. We have analysed data from nine studies of the recovery of fertility in breastfeeding women to assess the effectiveness of lactational amenorrhoea alone, irrespective of whether supplements have been introduced, as a fertility regulation method post partum. Cumulative probabilities of ovulation during lactational amenorrhoea were 30.9 and 67.3 per 100 women at 6 and 12 months, respectively, compared with 27.2 at 6 months when all three criteria of the LAM were met. Cumulative pregnancy rates during lactational amenorrhoea were 2.9 and 5.9 per 100 women at 6 and 12 months, compared with 0.7 at 6 months for the LAM. The probability of pregnancy during lactational amenorrhoea calculated from these studies is similar to that of other modern contraceptive methods, and it seems reasonable for a woman to rely on lactational amenorrhoea without regard to whether she is fully or partly breastfeeding. So that amenorrhoea and fertility suppression can be maintained, counselling about good breastfeeding and weaning practices remains important.
PIP: Researchers analyzed data on 346 women from prospective studies conducted in 8 different countries which examined return of ovulation in breast feeding mothers to determine the contraceptive effectiveness of lactational amenorrhea. The countries included Mexico, Thailand, Egypt, Pakistan, Philippines, Canada, Australia, and England. As a result of the Bellagio conference on breast feeding, health researchers have promoted the lactational amenorrhea method (LAM) as a family planning method for 6 months postpartum. Lactational amenorrhea provided significant protection from pregnancy. The researchers learned that the effect of LAM during amenorrhea and before food supplementation was a life table pregnancy rate of 0.7/100 women at 6 months postpartum. Indeed when they considered food supplementation the rates for 6 months and 12 months postpartum stood at 2.9 and 5.9 respectively. These rates showed that LAM provided either greater than or equal protection against pregnancy during the 1st 12 months postpartum in the US than typical modern contraceptive method use. The researchers did observe, however, that LAM had high discontinuation rates. For example, by 12 months, menstruation had returned to 87.5% of all the women. The researchers recommended that health workers continue to promote breast feeding practices that encourage increased suckling since reduced suckling precipitates the return of ovulation. In fact, they hypothesized that improved breast feeding practices which increase the duration of lactational amenorrhea may actually result in greater protection. Since the findings revealed that LAM had low pregnancy rates and high discontinuation rates, LAM can be used to time when to begin other contraceptive methods.
PMID: 1346183 [PubMed - indexed for MEDLINE]

Another article from 1993

Important websites and Advocacy groups

Advocacy groups and important websites

BFHI international

Centers for Disease Control & Prevention - Breastfeeding resources

Healthy Children Project, Inc. - Breastfeeding resources for health professionals

Innocenti Declaration on the Protection, Promotion, and Support of Breastfeeding, Innocenti 15

International Code on the Marketing of Breastmilk Substitutes

International Lactation Consultant Association

La Leche League International

Lamaze International

National Alliance for Breastfeeding Advocacy

Office on Women's Health - HHS Blueprint for Action on Breastfeeding

UNICEF Data: Breastfeeding Statistics

UNICEF Breastfeeding: Foundation for a healthy future

United States Breastfeeding Committee - Breastfeeding in the United States: A National Agenda

United States Breastfeeding Committee - Publications

United States Fund for UNICEF

Wellstart International - Breastfeeding resources for health professionals

World Health Organization - Breastfeeding

World Alliance for Breastfeeding Action (conveners of World Breastfeeding Week, August 1-7)

Baby friendly hospitals in the US

61 US Baby-Friendly Hospitals
and Birth Centers as of August 2007

Alice Peck Day Memorial Hospital, Lebanon, New Hampshire
Aurora Lakeland Medical Center, Elkhorn, Wisconsin
Barstow Community Hospital, Barstow, California
Boston Medical Center, Boston, Massachusetts
Cape Canaveral Hospital, Cocoa Beach, Florida
Central Maine Medical Center , Lewiston, Maine
Community Hospital Anderson, Anderson, Indiana
Community Hospital of Anaconda, Anaconda, Montana
Community Hospital of San Bernardino, San Bernardino , California (New!)
Community Hospital of the Monterey Peninsula , Monterey, California
Corona Regional Medical Center, Corona, California
Elmbrook Memorial Hospital, Brookfield, Wisconsin
Evergreen Hospital Medical Center, Kirkland, Washington
Exempla Good Samaritan Medical Center , Lafayette, Colorado
Glendale Memorial Hospital and Health Center, Glendale, California
Goleta Valley Cottage Hospital, Santa Barbara, California
Hartford Hospital, Hartford, Connecticut
Inland Midwife Services - The Birth Center, Redlands, California
Kaiser Permanente Medical Center, Honolulu, Hawaii
Kaiser Permanente Medical Center, Hayward, California
Kaiser Permanente Riverside Medical Center
, Riverside, California
Kaiser Sunnyside Medical Center, Clackamas, Oregon
Kootenai Medical Center, Coeur d'Alene, Idaho
Lisa Ross Birth & Women’s Center, Knoxville, Tennessee
Madison Birth Center, Middleton, Wisconsin
MaineGeneral Medical Center , Augusta & Waterville, Maine
Mercy Hospital Anderson, Cincinnati, Ohio
Mercy Hospital Fairfield, Fairfield, Ohio
Meriter Hospital, Madison, Wisconsin
Methodist Hospital, Indianapolis, Indiana
Methodist Hospital, Omaha, Nebraska
Middlesex Hospital, Middletown, Connecticut
Miles Memorial Hospital, Damariscotta, Maine
Morton Plant Hospital, Clearwater, Florida
Mountains Community Hospital, Lake Arrowhead, California (New!)
Newport Hospital, Newport, Rhode Island
Northeastern Vermont Regional Hospital, St. Johnsbury, Vermont
Okanogan-Douglas District Hospital, Brewster, Washington
PeaceHealth Nurse Midwifery Birth Center, Eugene, Oregon
Pekin Hospital, Pekin, Illinois
Providence Holy Cross Medical Center, Mission Hills, California (New!)
Providence Medford Medical Center, Medford, Oregon
Reading Birth & Women’s Center, Reading, Pennsylvania
Robert E. Bush Naval Hospital, Twentynine Palms, California
Rochester General Hospital, Rochester, New York
Scripps Memorial Hospital Encinitas, Encinitas, California
St. Elizabeth Medical Center, Edgewood, Kentucky
St. Francis Hospital, Milwaukee, Wisconsin
St. John’s Hospital, Springfield, Illinois
St. Joseph Hospital, Nashua, New Hampshire
St. Mary Medical Center, Walla Walla, Washington
San Francisco General Hospital, San Francisco, Californa
South County Hospital, Wakefield, Rhode Island
Tacoma General Hospital, Tacoma, Washington
Three Rivers Community Hospital, Grants Pass, Oregon
UCSD Medical Center, San Diego, California
US Army MEDDAC , Heidelberg, Germany
Ventura County Medical Center, Ventura, California
Weed Army Community Hospital, Fort Irwin, California
Women’s Health & Birth Center, Santa Rosa, California
Women’s Wellness & Maternity Center, Madisonville, Tennessee