Session 14ON-GOING SUPPORT FOR MOTHERS – STEP 10

Session Objectives

On completion of this session, participants will be able to:

Materials and Preparation

Slide 14/1: Mother-to-mother support

Contact details for support in the area, such as mother’s groups, community support or feeding clinics in the health centre.

Information on any national legislation or directives on workplace support for breastfeeding.

Information on any national complementary feeding guidelines and policies – check that these materials support exclusive breastfeeding for six months.

Flip chart of Communication Skills from Session 2.

Ask two participants to play the part of ‘mothers’ in the group support activity and give them the questions to ask.

Further reading for facilitators

Community based strategies for breastfeeding promotion and support in developing countries. WHO, Department of Child and Adolescent Health and Development (CAH), 2003.

Green, C P. Mother Support Groups: A Review of Experience in Developing Countries. BASICS II. 1998 http://www.basics.org/publications/pub/msg/contents.htm

Guiding principles for complementary feeding of the breastfed child. PAHO/WHO, 2003.

1. Preparing a mother for discharge

15 minutes

  • Step 10 of the Ten Steps to Successful Breastfeeding states:

    “Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic”.

  • The health facility where the baby is born can do much to initiate and establish breastfeeding or safer replacement feeding if necessary. However, the need for support continues after she is discharged.
  • In some communities, mothers are well supported by friends and family. Where this is not available, for example if the mother is living away from her own family, the health facility needs to arrange some alternative follow up. This must be discussed with mothers before discharge.
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Tell the next point in the “story”:

Fatima and Miriam are preparing to go home from the hospital with their babies.

Ask: What does a mother need before she leaves the hospital to go home with her baby?

Wait for a few responses.

  • Before a mother leaves a maternity facility, she needs to:
    -

    Be able to feed her baby.

    -

    Understand the importance of exclusive breastfeeding for 6 months and continued breastfeeding after the introduction of complementary foods to two years and beyond.

    -

    Be able to recognize that feeding is going well.

    -

    Find out how to get the on-going support that she needs.

Be able to feed her baby

  • A health worker trained in breastfeeding support should observe every mother and baby at a breastfeed and make sure that the mother and baby know how to breastfeed.
  • A mother should:
    -

    Know about baby-led, or demand feeding, and how babies behave.

    -

    Be able to recognise her baby’s feeding signs.

    -

    Be able to position her baby for good attachment at the breast.

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    Know the signs of effective breastfeeding and a healthy baby.

    -

    Know what to do if she thinks that she does not have enough milk.

    -

    Be able to express her milk.

  • If a mother is not breastfeeding, a health worker trained to assist with replacement feeding needs to check the mother knows:
    -

    What type of replacement feeding to use that is acceptable, feasible, affordable, sustainable and safe for her situation.

    -

    How to obtain the replacement milk in sufficient quantities.

    -

    How to reduce the risks associated with replacement feeding.

  • A health worker should observe that the mother (or other caregiver) is able to prepare a replacement feed and feed the baby in a safe manner before the mother and baby are discharged from the maternity unit.

Understand the importance of exclusive breastfeeding and continued breastfeeding

  • When a mother returns home there may be pressures on her to supplement her baby with foods or fluids other than breast milk. Before she leaves the maternity facility, remind her of the importance of exclusive breastfeeding for the first six months.
  • After six months, a baby needs foods in addition to breast milk. Breast milk continues to provide good nutrition and protection from illness as well as closeness to the mother. Breast milk is valuable for health and nutrition for two years and longer.
  • If the mother is HIV-positive and is breastfeeding, it is best if the baby is exclusively breastfeeding. Mixed feeding, giving both breastfeeding/breast milk and other foods and fluids has been shown to increase the risk of transmission of HIV.

Be able to recognize that feeding is going well

  • Sometimes we might say to a mother to contact us if there is a problem. A new mother may not know what is normal and what is a problem. Signs that a mother with a young baby can look for that indicate breastfeeding is going well include:
    -

    Baby is alert and active, feeding at least 8 times in 24 hours.

    -

    Baby settles and sleeps for some periods in 24 hours.

    -

    Baby has six or more wet diapers/nappies in 24 hours with pale, diluted urine and is passing stools three or more times a day67.

    -

    Breasts are fuller before feeds than after feeds. Breasts and nipples are comfortable and not sore.

    -

    Mother feels confident caring for her baby in general.

Discuss how to get the support that she needs

  • Mothers need support. When a mother goes home she needs a family member, friend, health worker or other person who will help her to become confident as she learns about caring for her baby. A mother needs help particularly if she:
    -

    Has many demands on her time such as caring for other children and household tasks.

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    Is a first time mother.

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    Has difficulty feeding her baby.

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    Needs to work outside the home and leave her baby.

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    Is isolated with little contact with supportive people.

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    Receives confusing and conflicting advice from many people.

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    If she or the baby has a health problem.

  • Sometimes a mother thinks that she should be able to do everything without needing any help. She may think that if she looks for help it will be thought that she is a bad mother or cannot cope.
  • When any of us learn a new job or skill we need to take time to learn it and we may need to ask for help from other people. It is similar with learning to be a mother; there are new skills to learn. It may not be enough that support services exist in the area. A new mother may need encouragement to look for help and to use support that is available.
  • Follow-up of the mother who is replacement feeding is very important to ensure that she is using the option properly and if she should want to change feeding option at any time she is assisted.
  • When talking to a woman during her pregnancy it can be helpful to mention that there are support services available in case she has any difficulty. This may help her to feel confident from the beginning.

2. Follow-up and support after discharge

10 minutes

Resources available in the local community

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Show slide 14/1: Mother-to-mother support

Fatima and Miriam meet sometimes, sit, and talk about their babies. Fatima likes to hear what Miriam has to say because this is Miriam’s second child and Fatima values Miriam’s experience and knowledge.

Ask: Who in the community could provide ongoing support for a mother in feeding and caring for her baby?

Wait for a few replies.

Family and friends

  • Families and friends can be an important source of support for breastfeeding in general. However, support for exclusive breastfeeding through six months is often lacking in families where other women have always given early supplements and foods.
  • Mothers who are replacement feeding need support from family and friends also. The mother who is HIV-positive may need support to replacement feed exclusively, and avoid mixing breastfeeding and replacement feeding.

Primary Care and community health workers

  • Any time a health worker is in contact with a mother and young child, the health worker can help and support the mother in feeding and caring for her baby. If the health worker cannot do so themselves, they may be able to refer the mother to someone else who can provide support.
  • Community health workers are often nearer to families than are hospital-based health workers and may be able to spend more time with them. To be effective, community health workers need to be trained to support mothers to feed and care for their babies.
  • Community health centres can have “lactation clinics” which means that there are trained staff who will help a breastfeeding mother at the time that she contacts the clinic rather than waiting for an appointment. It may be effective to see more than one mother together so they can exchange experiences. A mother support group can come out of these clinics.
  • Health workers can set an example in their own communities by exclusive breastfeeding their own babies with the addition of appropriate complementary foods after six months of age.

Mother to mother support

  • This support is usually community-based and may be provided one-to-one or group-based. An experienced mother can provide individual support to a new mother. Ask the experienced mother for permission to give her name to new mothers in her area.
  • A group may be started by a few mothers themselves or by a health or community worker. There may be special support groups for women who are HIV-positive.
  • The help is easily accessible and free or very inexpensive. Ideally mothers who have been trained to give support are available at any time to help a mother with difficulties68.
  • In a mother-to-mother support group:
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    Help can be available in the mother’s own community.

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    Women’s traditional patterns of getting information and support from relatives and friends are reinforced.

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    Feeding and caring for a baby are seen as normal activities rather than problems that need to be solved by a health worker.

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    Discussion groups are led and help is given by experienced mothers.

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    Mothers feel reassured and become more self-confident.

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    Pregnant women as well as more experienced mothers are welcome.

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    Mothers can help each other outside of group meetings and build friendships.

  • Some mother-to-mother support groups are part of larger networks that provide training, written materials and other services. The experienced mothers leading or facilitating the groups can be invited to contribute to health worker training, and to visit wards and clinics to introduce themselves to pregnant women and new mothers.

When formal support is not available

  • If there are no existing support groups available in your area, before the mother leaves the maternity facility:
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    Discuss what family support she has at home.

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    If possible, talk with family members about how they can help.

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    Give the mother the name of a person to contact at the hospital, or at a clinic. She should go for a follow-up check for her and her baby in the first week after birth, which should include observation of a breastfeed. She should also go at any other time if she has any difficulties or questions.

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    She should also go for her routine postpartum 6-week check-up, and take her baby with her, so that she or he can be followed-up too.

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    Remind mothers of the key points about optimal feeding.

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    It is often helpful to give written materials as a reminder. These must be accurate, and not from companies that produce or distribute breast-milk substitutes, bottles or teats.

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    If possible, contact mothers after they are home to learn how feeding is going.

  • Some hospitals establish mother support groups that are lead by a health worker and meet in the hospital. There may also be a feeding clinic where the mother can attend if she has a feeding difficulty.
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Give any specific information such as contact details for any sources of support in the area.

Baby-friendly communities

  • Some communities have established the concept of “baby-friendly communities.” Your facility may wish to foster this concept in the surrounding area. While there is no internationally recognized approach, the basic elements include community discussion of needs as reflects all applicable Ten Steps to Successful Breastfeeding.
  • Baby-friendly communities may include:
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    Health system, or local health care provision, is designated “baby-friendly” and actively supports both early and exclusive breastfeeding.

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    Access to a referral site with skilled support for early, exclusive and continued breastfeeding is available and community approved.

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    Support is provided for age-appropriate, frequent, and responsive complementary feeding with continued breastfeeding.

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    Mother-to-mother support system, or similar, is in place.

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    No practices, distributors, shops or services that violate the International Code are present in the community.

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    Local government or civil society creates and supports the implementation of change that actively supports mothers and families to succeed with optimal infant feeding practices. Examples of this change could be time-sharing of tasks, granting authority to transport a breastfeeding mother for referral if needed, identification of “breastfeeding advocates or protectors” among community leaders, and breastfeeding supportive workplaces.

3. Protecting breastfeeding for employed women

10 minutes

  • Many mothers introduce early supplements or stop breastfeeding because they have to return to work. Health workers can help mothers to continue to give their babies as much breast milk as possible when they return to work.

    Ask: Why is continuing to breastfeed after return to employment recommended?

    Wait for a few replies.
  • As well as the general importance of breastfeeding discussed earlier in the course, a woman who works outside the home may value breastfeeding because of:
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    Less illness in the baby, so she misses less time from work to care for a sick child.

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    Ease of night feeds, thus mothers gets more sleep.

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    Opportunity to spend time with the baby and continue the closeness to the baby.

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    A chance to a rest while she feeds the baby.

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    A special, personal relationship with her baby.

Ask: If an employer asked you why she or he should support a woman to breastfeed after she returns to employment, what could you say?

Wait for a few replies.

  • Employers who support women to continue breastfeeding benefit also:
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    Mothers are away from work less because their children are healthy.

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    Mothers can concentrate on their work because they have less concern about their babies’ health.

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    Employers retain skilled workers.

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    Women are more interested in working for employers who are supportive.

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    Families and the community think well of the employers that are supportive.

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    Breastfed babies grow up to be a healthy future workforce.

Ask: What are the key points to discuss with a mother preparing to return to employment?

Wait for a few replies.

  • Some weeks before the mother is due to go back to work, discuss:
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    Could the baby go to work with her?

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    Could the baby be cared for near her workplace so that she could go to feed the baby at break times or could the baby be brought to her?

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    Could the mother work shorter hours or fewer days until the baby is older?

  • If it is not possible to breastfeed the baby during the working day, suggest:
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    Breastfeed exclusively and frequently during maternity leave.

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    Continue to breastfeed whenever mother and baby are together – nights, early morning, and days off.

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    Do not start other feeds before needed – a few days before going back to work is enough.

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    Learn to express milk and leave it for the carer to give to the baby.

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    Express milk about every 3 hours at work, if possible. This keeps up the milk supply and keeps the breasts more comfortable. The breasts will make more milk when the milk is removed69.

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    Teach the carer to give feeds in a safe and loving way, by cup rather than by bottle, so that the baby wants to suckle from the breast when mother is home.

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    Have contact and support from other mothers who are working and breastfeeding.

  • Much of the information about breastfeeding and working also applies to mothers who are students.
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(Optional) Most health workers are women and many are likely to be mothers of young children. How could your health facility be a breastfeeding supportive workplace?

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Mention any national laws or policies that protect working mothers.

4. Sustaining continued breastfeeding for 2 years or longer

10 minutes

  • There is no specific age at which breastfeeding is no longer important. Breastfeeding continues to provide closeness to the mother, protection from illness and good nutrition.
  • Breastfeeding an older baby/young child can be valuable if the child becomes ill. Often the child will be able to breastfeed when they are not interested in eating other foods. This helps the child to get fluids as well as helping to avoid weight loss during the illness.
  • Breastfeeding can be soothing to a child who is in pain or upset.
  • Breastfeeding an older baby is different from breastfeeding a newborn. As a baby becomes more alert, she or he may be distracted easily during breastfeeds by noises and activity. A mother may find that feeding in a quiet place limits distractions.
  • Young children may breastfeed once or twice a day or more frequently. Some may breastfeed only if they are hurt or upset.
  • Mothers may need special support to overcome competing pressures on her, whether from the workplace or family, as the child gets older. A discussion can help her identify what might work in her situation.

Complementary feeding70

  • After six months of age, the baby needs other foods while continuing to receive sufficient breast milk. This is called complementary feeding because it complements the breastfeeding; it does not replace it.
  • Until a baby is year old, breast milk (or breast-milk substitutes if not breastfed) should provide the main part of the baby’s diet. Continue to offer the breast frequently as well as offering suitable foods from the family meals. The period from 6–12 months of age is a time for learning how to eat a wider range of foods and textures.
  • To maintain the milk supply, encourage the mother to continue to offer the breast before the complementary food.
  • A child stops breastfeeding when they are ready as a natural part of their development. A child should not be stopped suddenly from breastfeeding, as this can cause distress to the child and the mother, sore breasts for the mother, as well removing a source of food from the child. Allow the child to decrease the number of feeds gradually, and be sure he or she gets plenty of other foods each day as well as continued attention from the mother.

Other national health programs for mother and child (include those that are locally in place)

  • Continued support for breastfeeding can occur through other national health and nutrition programs including:
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    Safe Motherhood Programmes: mothers are seen through pregnancy to ensure safe birth.

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    The Integrated Management of Childhood Illness (IMCI): child seen for recurrent illness.

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    The Expanded Programme of Immunization (EPI): child is seen at frequent intervals

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    Micronutrient supplementation programs for iron and vitamin A supplementation.

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    Neonatal screening programmes: usually done at 6–10 days after birth, which is an important time to ensure that breastfeeding is going well.

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    Early child development programmes: child is monitored for growth and development during the routine checks ups in child welfare.

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    Family planning programmes: mother seen for family planning at any point of time, usually through health visitors.

5. Group support - class activity

30 minutes

Introduce the activity

  • The facilitators in a mother to mother support group need to use good communication skills and have adequate infant feeding knowledge. These experienced mothers may attend a training course to gain these skills.
  • In this activity we can see how the communication skills can be used to help new mothers in a group.

    Ask 6–8 participants to sit in a circle. Give two of these participants questions to ask as ‘new mothers’. The other participants in the ‘mother-to-mother group’ are the experienced mothers providing support to the new mothers. Chose one of the participants to be the trained peer ‘facilitator’ i.e. an experienced breastfeeding mother who will help guide the discussion and ensure all ‘mothers’ have a chance to contribute.

    Ask the remaining participants to form an outer circle and to be observers. Ask the participants to talk with the mother who is asking the question and to help her, playing the part of other mothers in the group. No one should lecture. Try to keep it like a friendly conversation. Remember the communication skills practiced in this course.

    Sample discussion questions for the group discussion are given or other questions can be suggested by the group. Discussion points are included if the facilitator needs to provide information that is not coming from the group. However, if the group is responding well, do not turn it into a lecture. This is mother-to-mother group support, not a clinical case study.

    Encourage the ‘experienced mothers’ in the group to briefly share how they overcame similar concerns when their babies were the same age. This sharing helps takes some of the ‘focus’ off the ‘new mother’. It also helps bring out the essence of peer support where mothers learn from each other and common breastfeeding concerns are shown to have many solutions.

Sample “problem” 1

James is eight months old and healthy. He eats two meals of porridge every day and he breastfeeds whenever I am at home from my job. Yesterday he refused to breastfeed during the evening and the night. This morning when he woke up he also did not want the breast at all. He gets four bottle feeds a day of formula, so maybe I should stop breastfeeding.

Possible discussion points

Remember to listen to the mother and to respond in a way that encourages her to talk and to explore her own situation.

What would the mother like the situation to be?

What has the mother tried already? Has the mother any thoughts on what she could try?

  • Sometimes babies of this age refuse the breast due to teething or a sore mouth, do you think this might be happening?
  • What is the feed like? Some babies can be distracted when breastfeeding. A busy mother may rush breastfeeding.
  • How often is ‘whenever I am home’? Could more time be spent with the baby, e.g. is the baby with her and breastfeeding on her day off if she is shopping or visiting?
  • Where do the mother and baby sleep? (together?) How does the baby feed during the night?
  • How much does the baby take in the feeds when she is away, could this be reduced, especially in the afternoon so the baby is ready for a breastfeed when the mother comes home?
  • Giving some vegetable, fruit, or meat would give a wider range of foods and the baby may not be as full as when he has just porridge. What does she think about offering more variety of foods rather than only porridge?
  • Breast milk continues to be an important source of food into the second year.

Sample “problem” 2

Clara is three months old and she is breastfeeding quite frequently. But she doesn’t get satisfied. Sometimes after I finish feeding her, she cries again very soon. I think my milk is going away. Will I need to start giving her foods from a spoon or other milk?

Possible discussion points

Remember to listen to the mother and to respond in a way that encourages her to talk and to explore her own situation.

What would the mother like the situation to be?

What has the mother tried already? Has the mother any thoughts on what she could try?

  • Sometimes a baby needs some help to feed well. Has the mother asked a knowledgeable person to look at the way that the baby is feeding?
  • Sometimes a baby wants to be fed, to have contact or wants to be more comfortable before the clock says that it is time to feed. What does the mother think about carrying the baby more and giving the breast when the baby is unsettled to sooth the baby?
  • If the baby is growing well, what are some suggestions for soothing a crying baby?

Conclude the activity

Ask the ‘mothers’ in the group how they felt their concerns were discussed. Ask the ‘experienced mothers’ how they felt they used their communication skills. Then ask the ‘observers’ what they noticed. Remember to also reinforce skills that were well used.

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Ask if there are any questions. Then summarise the session.

Session 14. Summary

Preparing mothers for discharge

  • Before the mother leaves the maternity facility, she needs to:
    -

    Be able to feed her baby.

    -

    Know the importance of exclusive breastfeeding for 6 months and continued breastfeeding after the introduction of complementary foods.

    -

    If replacement feeding, know how to get suitable milk and prepare the feed in a safe manner.

    -

    Be able to recognize that feeding is going well.

    -

    Find out how to get the on-going support that she needs.

Follow-up and support after discharge

  • Before the mother leaves the maternity facility:
    -

    Discuss what family support she has at home.

    -

    If possible, talk with family members about how they can provide help and support.

    -

    Give the mother the name of a person to contact at the hospital/clinic or in the community to arrange a follow-up check in the first week at home, to include observation of a breastfeed. Arrange for the routine 6-week check-up as well.

    -

    Tell mother about any mother support groups in her area or the names of experienced mothers willing to support a new mother

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    Remind the mother of the key points about how to breastfeed and practices that help.

    -

    Be sure that the mother receives no written materials that market breast-milk substitutes or bottles.

    -

    Contact the mother after she is home to learn how feeding is going,

Protecting breastfeeding for employed women

  • Breastfeeding continues to be important when the mother returns to employment.
  • Supporting breastfeeding has benefits to the employer.
  • Some weeks before the mother is due to go back to work, discuss:
    -

    Could the baby go to work with her?

    -

    Could the baby be cared for near her workplace?

    -

    Could the mother work shorter hours or fewer days until the baby is older?

  • If it is not possible to breastfeed the baby during the working day, suggest:
    -

    Breastfeed exclusively and frequently during maternity leave.

    -

    Learn to express the milk and leave it for the carer to give to the baby.

    -

    Have contact and support from other mothers who are working and breastfeeding.

Sustaining continued breastfeeding for 2 years or longer

  • Breastfeeding continues to provide closeness to the mother, protection from illness and good nutrition to the older baby and young child.
  • Until a baby is a year old, breast milk (or breast-milk substitutes if not breastfed) should provide the main part of the baby’s diet. After six months of age, the baby needs continued frequent breastfeeding and other foods in addition to breast milk or replacement milk. Giving these foods is called complementary feeding because it complements the breastfeeding; it does not replace it.
  • Recommend that the mother continue to offer the breast frequently, preferably before complementary foods, to maintain her milk supply. If she wishes to wean, suggest that she allow the baby to reduce the number of feeds gradually and be sure he or she gets plenty of food each day.

Session 14 Knowledge Check

List three sources of support for mothers in your community.

Give two reasons why mother-to-mother support may be useful to mothers.

Give two reasons why breastfeeding is important to the older baby and the mother.

Additional information for Session 14

Developing a mother-to-mother support group
  • Mothers in many communities are best helped where there are mother-to-mother support groups. These groups do not need to be big or have highly trained facilitators. They do need warm-hearted and kind facilitators, who know how to breastfeed and who can help other women. If there is not such a support group in your community, perhaps you can help to establish one, and foster its growth.
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    Identify experienced breastfeeding mothers and learn if they would be acceptable to other mothers as “facilitators”. Young mothers can help each other well.

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    Provide accurate information and help to the facilitators, but let them lead the group.

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    Encourage the group to meet rather frequently, in a mother’s home or other community location. At meetings, mothers can share how they feel, difficulties they have had, and how they solved them. You can suggest special topics that could be discussed.

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    Tell every mother about the nearest support group and introduce her to a facilitator if possible.

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    Be available to the facilitators to give accurate information and support when asked.

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    Include facilitators in some training activities at the hospital or lactation clinic.

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    Provide training in communication and listening skills to facilitators.

Footnotes

67

In an older baby, stooling may be less frequent. Stools should be soft.

68

Support may also be provided by telephone, letter and in some areas by e-mail.

69

See Session 11 for how to express and store milk.

70

Detailed information on complementary feeding is in Infant and Young Child Feeding Counselling: An integrated course.