In a recent study, Joanna (Asia) Maselko, assistant professor of psychiatry and behavioral sciences and global health at the Duke Global Health Institute (DGHI), and Pakistani colleague Siham Sikander, along with several other researchers, found that cognitive-behavioral counseling significantly extended the duration of exclusive breastfeeding (EBF) in the rural Khyber Pakhtunkhwa Province of Pakistan.
Cognitive-Behavioral Counseling Was Far More Effective than Routine Counseling
Published in Pediatrics, the study compared the effect of routine counseling (RC) versus cognitive-behavioral counseling (CBC) on mothers’ decisions to breastfeed their infants exclusively. At six months postpartum, 59.6% of mothers who received CBC were still exclusively breastfeeding, compared to only 28.6% of mothers who received RC.
In addition, mothers receiving CBC were half as likely than those receiving RC to use prelacteal feeds—that is, any food except mother’s milk given to a newborn before initiating breastfeeding. This finding is significant because prelacteal feeds are a major barrier to EBF.
Exclusive Breastfeeding Rates Are Low in Developing Countries
The World Health Organization and other experts have advocated for EBF for the first six months of an infant’s life, deeming EBF a safe, powerful and cost-effective intervention to reduce infant morbidity and mortality globally. However, in developing countries, only about 25% of infants are exclusively breastfed for six months.
And in Pakistan, despite the fact that the country has one of the world’s best-developed community health programs, the EBF rate is much lower in some areas, at just 8%. This low rate has been attributed to three main factors:
- Low levels of literacy
- Deeply ingrained cultural beliefs and practices that conflict with EBF guidelines
- High levels of psychological distress and disempowerment of women
Intervention Was Designed to Be Feasible, Sustainable and Appealing
The research team developed a culturally appropriate intervention in partnership with Pakistan’s Lady Health Worker program. Designed with an eye toward feasibility and sustainability, the intervention was integrated into the routine training, supervision and day-to-day work of these government-hired community health workers (called Lady Health Workers – LHWs). Maselko and the other researchers consider this aspect of the program critical to its success.
Community health workers delivering the intervention were expected to:
- Develop an empathic relationship with the mother and other family members
- Collaborate with the family in an equal partnership, incorporating the experiences and resources of the family as well as the skills and knowledge of the health workers
- Use established techniques to gently explore the individual and family’s health beliefs, share information about traditional harmful practices, and stimulate alternative ideas
- Encourage mothers to take small steps between sessions and build on them gradually
- Analyze problems and barriers mothers are facing, brainstorm solutions with peers and discuss these solutions with mothers and families
This approach differed significantly from the LHW’s previous counseling practices, which were more didactic and authoritarian and tended to undermine the confidence of many mothers.
One LHW commented, “We knew these messages (around breastfeeding) and had been giving these to the mothers, but the previous method presented us with more problems because we would give messages and sometimes these clashed with the traditional ways of thinking and we would get into arguments with the families. Now we can explain things in a much better way using the three steps we have learned (in this new approach), and we find that the families listen to us.”
Another LHW agreed: “Previously we used to give a lecture about the benefits of breastfeeding. Many women did not remember what we had told them. Now in each visit we use the counseling cards which have a specific message relevant to that visit and the women are much more interested.”
“These findings are very exciting because they show that interventions that are based on mutual understanding and problem solving can be effective and sustainable in very low resource settings” said Maselko.
Techniques May Hold Promise for Other Prevention and Health Promotion Programs
The success of this study shows that it’s possible to simplify sophisticated therapeutic techniques and efficiently train community health workers—the “backbone” of primary health care in low-income countries—to use these techniques effectively. The research team believes that these techniques and the training methods used in this intervention might be applicable to other prevention and health promotion initiatives in similar settings.
