Refugee and migrant women's views of antenatal ultrasound on the Thai Burmese border: a mixed methods study

Background

Antenatal ultrasound suits developing countries by virtue of its versatility, relatively low cost and safety, but little is known about women’s or local provider’s perspectives of this upcoming technology in such settings. This study was undertaken to better understand how routine obstetric ultrasound is experienced in a displaced Burmese population and identify barriers to its acceptance by local patients and providers.

Methodology/Principal Findings

Qualitative (30 observations, 19 interviews, seven focus group discussions) and quantitative methods (questionnaire survey with 644 pregnant women) were used to provide a comprehensive understanding along four major themes: safety, emotions, information and communication, and unintended consequences of antenatal ultrasound in refugee and migrant clinics on the Thai Burmese border. One of the main concerns expressed by women was the danger of childbirth which they mainly attributed to fetal malposition. Both providers and patients recognized ultrasound as a technology improving the safety of pregnancy and delivery. A minority of patients experienced transitory shyness or anxiety before the ultrasound, but reported that these feelings could be ameliorated with improved patient information and staff communication. Unintended consequences of overuse and gender selective abortions in this population were not common.

Conclusions/Significance

The results of this study are being used to improve local practice and allow development of explanatory materials for this population with low literacy. We strongly encourage facilities introducing new technology in resource poor settings to assess acceptability through similar inquiry.     

Long-term effects of birth weight and breastfeeding duration on inflammation in early adulthood

Chronic inflammation is a potentially important physiological mechanism linking early life environments and health in adulthood. Elevated concentrations of C-reactive protein (CRP)—a key biomarker of inflammation—predict increased cardiovascular and metabolic disease risk in adulthood, but the developmental factors that shape the regulation of inflammation are not known. We investigated birth weight and breastfeeding duration in infancy as predictors of CRP in young adulthood in a large representative cohort study (n = 6951). Birth weight was significantly associated with CRP in young adulthood, with a negative association for birth weights 2.8 kg and higher. Compared with individuals not breastfed, CRP concentrations were 20.1%, 26.7%, 29.6% and 29.8% lower among individuals breastfed for less than three months, three to six months, 6–12 months and greater than 12 months, respectively. In sibling comparison models, higher birth weight was associated with lower CRP for birth weights above 2.5 kg, and breastfeeding greater than or equal to three months was significantly associated with lower CRP. Efforts to promote breastfeeding and improve birth outcomes may have clinically relevant effects on reducing chronic inflammation and lowering risk for cardiovascular and metabolic diseases in adulthood.     

Determinants of early initiation of breastfeeding in rural Niger: cross-sectional study of community based child healthcare promotion

Background

Most child deaths are preventable and caused by behaviorally modifiable factors. By promoting optimal breastfeeding, we can reduce neonatal and child mortality risks by 45%. This paper provides new family and community based perspectives to identify factors interfering with the program impact on promoting early initiation of breastfeeding among the most vulnerable populations in rural Niger.

Methods

A secondary analysis of a retrospective cross-sectional study evaluated a UNICEF behavior change program on child healthcare. The study sample is based on a post-hoc constitution of two groups exposed and unexposed to the program. All women (n = 1026) aged 14–49 years having at least one child below 24 months of age were included. We measured crude and adjusted odds ratios with chi-square and multivariate logistic regression models.

Results

Independent variables shown to be associated with early breastfeeding include sales activities compared to household work with no direct income (AOR 7.7; 95% CI 1.3, 47.8) and mutual decision for harvest use (AOR 8.6; 95% CI 2.0, 36.8). Antenatal care did not modify the timing of breastfeeding initiation.

Conclusions

A high risk group of mothers with social and economic vulnerability are prone to suboptimal breastfeeding within the first hour of birth. Support from family and neighbors positively influenced early breastfeeding. Those who had no direct income and limited access to health services were a high-risk group, prone to delayed initiation of breastfeeding.

     

Assessment of initiation of breastfeeding practice in Kassala,Eastern Sudan: a community-based study

Background

The World Health Organization (WHO) encourages early initiation of breastfeeding within the first hour after birth with the objective of saving children’s lives. There are few published research papers about factors associated with the initiation of breastfeeding in Sudan.The aim of this study was to investigate the prevalence of and factors associated with the timely initiation of breastfeeding among mothers with children two years and under in Kassala, Eastern Sudan.

Methods

A community-based cross-sectional study was conducted from December 2016 to March 2017. Mothers were interviewed using a structured questionnaire.

Results

A total of 250 mother-child pairs participated in the study. The mean (standard deviation) of maternal age and children’s age was 27.1 (5.68) years and 11.9 (6.9) months, respectively.Of the 250 mothers, 218 (87.2%) initiated breastfeeding within the first hour. In multivariable logistic regression analysis, factors associated with the delay of breastfeeding initiation were having a male baby (Adjusted Odds Ratio [AOR] 3.90, 95% Confidence Interval [CI]1.33, 11.47), and mothers with medical disorders (AOR 5.07, 95% CI 1.22, 21.16).

Conclusion

There was a high prevalence of early initiation of breastfeeding. An association with delayed initiation of breastfeeding was found amongst mothers who had medical disorders and those who had a male infant. Wherever possible, early initiation of breastfeeding should be promoted for all infants, regardless of gender.

     

Effects of mother-infant skin-to-skin contact on severe latch-on problems in older infants: a randomized trial

Background

Infants with latch-on problems cause stress for parents and staff, often resulting in early termination of breastfeeding. Healthy newborns experiencing skin-to-skin contact at birth are pre-programmed to find the mother’s breast. This study investigates if skin-to-skin contact between mothers with older infants having severe latching on problems would resolve the problem.

Methods

Mother-infant pairs with severe latch-on problems, that were not resolved during screening procedures at two maternity hospitals in Stockholm 1998–2004, were randomly assigned to skin-to-skin contact (experimental group) or not (control group) during breastfeeding. Breastfeeding counseling was given to both groups according to a standard model. Participants were unaware of their treatment group. Objectives were to compare treatment groups concerning the proportion of infants regularly latching on, the time from intervention to regular latching on and maternal emotions and pain before and during breastfeeding.

Results

On hundred and three mother-infant pairs with severe latch-on problems 1–16 weeks postpartum were randomly assigned and analyzed. There was no significant difference between the groups in the proportion of infants starting regular latching-on (75% experimental group, vs. 86% control group). Experimental group infants, who latched on, had a significantly shorter median time from start of intervention to regular latching on than control infants, 2.0 weeks (Q₁ = 1.0, Q₃ = 3.7) vs. 4.7 weeks (Q₁ = 2.0, Q₃ = 8.0), (p-value = 0.020). However, more infants in the experimental group (94%), with a history of “strong reaction” during “hands-on latch intervention”, latched-on within 3 weeks compared to 33% in the control infants (Fisher Exact test p-value = 0.0001). Mothers in the experimental group (n = 53) had a more positive breastfeeding experience according to the Breastfeeding Emotional Scale during the intervention than mothers in the control group (n = 50) (p-value = 0.022).

Conclusions

Skin-to-skin contact during breastfeeding seems to immediately enhance maternal positive feelings and shorten the time it takes to resolve severe latch-on problems in the infants who started to latch. An underlying mechanism may be that skin-to-skin contact with the mother during breastfeeding may calm infants with earlier strong reaction to “hands on latch intervention” and relieve the stress which may have blocked the infant’s inborn biological program to find the breast and latch on.

Trial registration

Karolinska Clinical Trial Registration number CT20100055     

Maternal sociodemographic characteristics and the use of the Iowa Infant Attitude Feeding Scale to describe breastfeeding initiation and duration in a population of urban,Latina mothers: a prospective cohort study

Background

The World Health Organization recommends exclusive breastfeeding until 6 months of age. Maternal attitudes toward infant feeding are correlated with chosen feeding method and breastfeeding duration. The Iowa Infant Feeding Attitude Scale (IIFAS) has been used to assess attitudes towards breastfeeding prenatally and is predictive of breastfeeding decisions in certain population groups.

Methods

In a cohort of pregnant Latina women recruited from two hospitals in the San Francisco Bay Area (n=185), we administered the IIFAS prior to delivery. Information regarding feeding choice, maternal sociodemographic information, and anthropometrics were collected at 6 months and 1 year postpartum. Analysis of predictors for breastfeeding initiation, breastfeeding at 6 and 12 months and exclusive breastfeeding at 6 months were evaluated using multivariate logistic regression adjusting for potential confounders.

Results

In our cohort of Latina mothers, breastfeeding a previous infant was associated with breastfeeding initiation (OR 8.29 [95% CI 1.00, 68.40] p = 0.05) and breastfeeding at 6 months (OR 18.34 [95% CI 2.01, 167.24] p = 0.01). College education was associated with increased exclusive breastfeeding at 6 months (OR 58.67 [95% CI 4.97, 692.08] p = 0.001) and having other children was associated with reduced breastfeeding at six months (OR 0.08 [95% CI 0.01, 0.70] p = 0.02). A higher IIFAS score was not associated with breastfeeding initiation, breastfeeding at 6 or 12 months or exclusive breastfeeding at 6 months of age.

Conclusions

Initial choices about breastfeeding will likely influence future breastfeeding decisions, so breastfeeding interventions should specifically target new mothers. Mothers with other children also need additional encouragement to maintain breastfeeding until 6 months of age. The IIFAS, while predictive of breastfeeding decisions in other population groups, was not associated with feeding decisions in our population of Latina mothers.

     

Early father-infant skin-to-skin contact and its effect on the neurodevelopmental outcomes of moderately preterm infants in China: study protocol for a randomized controlled trial

Background

Skin-to-skin contact (SSC) is an evidence-based intervention that benefits low birth weight /preterm infants. However, China’s health institutional policy inhibits parents from visiting their baby in the neonatal intensive care unit (NICU). In addition, the Chinese traditional postpartum behavioral practice of confining women to home raises barriers to mother-infant contact. Thus, to shorten the duration of parent-infant separation, father-infant SSC is considered a possible alternative. This study determines whether it is safe to perform father-infant SSC in the NICU and investigates how paternal SSC affects outcomes compared with traditional care (TC) for moderately preterm infants.

Methods/design

A randomized controlled trial will be used to investigate the effects of paternal-infant SSC in NICU wards in China. Preterm infants born at a gestational age in the range of 32⁰–34⁶?weeks with a birth weight >?1500?g will be eligible. A simple random sampling method will be used to allocate infants to the SSC group (n =?25) or the TC group (n =?25). After medical stability, infants in the SSC group will be provided SSC by fathers for one hour every day until discharged from hospital. The primary outcome is neurodevelopmental measures, specifically salivary cortisol and Premature Infant Pain Profile (PIPP) during hospitalization. At 40?weeks of corrected age, infants will be assessed using the Infant Neurological International Battery (INFANIB) and neuroimaging. Secondary outcomes include infants’ physiological stability during SSC and throughout hospitalization and state observation at discharge. The fathers’ mental health will be assessed with the State-Trait Anxiety Inventory (STAI) 1?day to 3?days after the infant’s admission to the NICU and at discharge. Father-infant attachment will be evaluated at 4 and 6?months after the infants’ discharge, measured by the Paternal Postnatal Attachment Scale (PPAS). Statistical analyses will be conducted using a two-sided significance level of 0.05.

Discussion

The effects of paternal-infant SSC on moderately preterm infants will be assessed. The data gathered in this study may have important implications for medical practice and policy in the NICU regarding the care methods of premature infants in China.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-IOR-1701274. Registered on 20 September 2017. Retrospectively registered.

     

Determinants of breastfeeding initiation among mothers in Sydney,Australia: findings from a birth cohort study

Background

Breastfeeding has short-term and long-term benefits for both the infant and the mother. The objective of this study was to identify the incidence of breastfeeding initiation among women in South Western Sydney, and the factors associated with the initiation of breastfeeding.

Methods

Child and Family Health Nurses recruited mother-infant dyads (n = 1035) to the Healthy Smiles Healthy Kids birth study in South Western Sydney, an ethnically and socio-economically diverse area, at the first post-natal home visit. A sample of 935 women completed a structured, interviewer-administered questionnaire at 8 weeks. Multivariate logistic regression analysis was used to identify those factors independently associated with the initiation of breastfeeding.

Results

In total, 92% of women (n = 860) commenced breastfeeding in hospital. Women who completed a university degree were more likely to initiate breastfeeding compared to those who did not complete high school (AOR = 7.16, 95% CI 2.73, 18.79). Vietnamese women had lower odds of breastfeeding initiation compared to Australian born women (AOR = 0.34. 95% CI 0.13, 0.87). Women who had more than one child were less likely to breastfeed than those who had one child (AOR = 0.38, 95% CI 0.19, 0.79). Women who gave birth via a caesarean section were less likely to breastfeed their baby compared to those who had a vaginal delivery (AOR = 0.27, 95% CI 0.14, 0.52). Women who drank alcohol during pregnancy had 72% lower odds to breastfeed compared to those who did not drink alcohol during pregnancy (AOR = 0.28, 95% CI 0.11, 0.71). Women who reported that their partner preferred breastfeeding were more likely to initiate breastfeeding (AOR = 11.77, 95% CI 5.73, 24.15) and women who had chosen to breastfeed before pregnancy had more than 2.5 times the odds of breastfeeding their baby compared to those women who made their decision either during pregnancy or after labour (AOR = 2.80, 95% CI 1.31, 5.97).

Conclusions

Women with lower levels of education, who consume alcohol during pregnancy, have more than one child, and make infant feeding decision after becoming pregnant, and those born in Vietnam should be targeted when implementing breastfeeding promotion programs. Further, women who deliver by caesarean section require additional breastfeeding support post-delivery and it is important to include fathers in breastfeeding related decisions and encourage them to participate in antenatal programs.

     

Burden of soil-transmitted helminth infection in pregnant refugees and migrants on the Thailand-Myanmar border: Results from a retrospective cohort

BackgroundSoil-transmitted helminth (STH) infections are widespread in tropical and subtropical regions. While many STH infections are asymptomatic, vulnerable populations such as pregnant women face repercussions such as aggravation of maternal anaemia. However, data on prevalence and the effect of STH infections in pregnancy are limited. The aim of this analysis was to describe the burden of STH infections within and between populations of pregnant women from a local refugee camp to a mobile migrant population, and to explore possible associations between STH infection and pregnancy outcomes.MethodologyThis is a retrospective review of records from pregnant refugee and migrant women who attended Shoklo Malaria Research Unit antenatal care (ANC) clinics along the Thailand-Myanmar border between July 2013 and December 2017. Inclusion was based on provision of a stool sample during routine antenatal screening. A semi-quantitative formalin concentration method was employed for examination of faecal samples. The associations between STH mono-infections and maternal anaemia and pregnancy outcomes (i.e., miscarriage, stillbirth, preterm birth, and small for gestational age) were estimated using regression analysis.Principal findingsOverall, 12,742 pregnant women were included, of whom 2,702 (21.2%) had a confirmed infection with either Ascaris lumbricoides, hookworm, Trichuris trichiura, or a combination of these. The occurrence of STH infections in the refugee population (30.8%; 1,246/4,041) was higher than in the migrant population (16.7%; 1,456/8,701). A. lumbricoides was the predominant STH species in refugees and hookworm in migrants. A. lumbricoides and hookworm infection were associated with maternal anaemia at the first ANC consultation with adjusted odds ratios of 1.37 (95% confidence interval (CI) 1.08–1.72) and 1.65 (95% CI 1.19–2.24), respectively. Pregnant women with A. lumbricoides infection were less likely to miscarry when compared to women with negative stool samples (adjusted hazard ratio 0.63, 95% CI 0.48–0.84). STH infections were not significantly associated with stillbirth, preterm birth or being born too small for gestational age. One in five pregnant women in this cohort had STH infection. Association of STH infection with maternal anaemia, in particular in the event of late ANC enrolment, underlines the importance of early detection and treatment of STH infection. A potential protective effect of A. lumbricoides infection on miscarriage needs confirmation in prospective studies.     

Dispersion of cardiac action potential duration and the initiation of re-entry: A computational study

Background  

The initiation of re-entrant cardiac arrhythmias is associated with increased dispersion of repolarisation, but the details are difficult to investigate either experimentally or clinically. We used a computational model of cardiac tissue to study systematically the association between action potential duration (APD) dispersion and susceptibility to re-entry.     

Early initiation of breastfeeding: a systematic literature review of factors and barriers in South Asia

Background

Early or timely initiation of breastfeeding is crucial in preventing newborn deaths and influences childhood nutrition however remains low in South Asia and the factors and barriers warrant greater consideration for improved action. This review synthesises the evidence on factors and barriers to initiation of breastfeeding within 1 h of birth in South Asia encompassing Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka.

Methods

Studies published between 1990 and 2013 were systematically reviewed through identification in Academic Search Complete, CINAHL, Global Health, MEDLINE and Scopus databases. Twenty-five studies meeting inclusion criteria were included for review. Structured thematic analysis based on leading frameworks was undertaken to understand factors and barriers.

Results

Factors at geographical, socioeconomic, individual, and health-specific levels, such as residence, education, occupation, income, mother’s age and newborn’s gender, and ill health of mother and newborn at delivery, affect early or timely breastfeeding initiation in South Asia. Reported barriers impact through influence on acceptability by traditional feeding practices, priests’ advice, prelacteal feeding and discarding colostrum, mother-in-law’s opinion; availability and accessibility through lack of information, low access to media and health services, and misperception, support and milk insufficiency, involvement of mothers in decision making.

Conclusions

Whilst some barriers manifest similarly across the region some factors are context-specific thus tailored interventions are imperative. Initiatives halting factors and directed towards contextual barriers are required for greater impact on newborn survival and improved nutrition in the South Asia region.

     

Rural-urban differences on the rates and factors associated with early initiation of breastfeeding in Nigeria: further analysis of the Nigeria demographic and health survey, 2013

Background

This study investigates and compares the rates and factors associated with early initiation of breastfeeding (EIBF) within one hour of birth in rural and urban Nigeria.

Methods

Data from the 2013 Nigeria Demographic and Health Survey (NDHS) were analyzed. The rates of EIBF were reported using frequency tabulation. Associated factors were examined using Chi-Square test and further assessed on multivariable logistic regression analysis.

Results

The rates of EIBF were 30.8% (95% confidence interval [CI] 29.0, 32.6) and 41.9% (95% CI 39.6, 44.3) in rural and urban residences, respectively (p?<?0.001). The North-Central region had the highest EIBF rates both in rural (43.5%) and urban (63.5%) residences. Greater odds of EIBF in rural residence were significantly associated with higher birth order (Adjusted Odds Ratio [AOR] 1.29, 95% CI 1.10, 1.60), large birth size (AOR 1.33, 95% CI 1.10, 1.60), and health facility delivery (AOR 1.46, 95% CI 1.23, 1.72). Rural mothers in the rich wealth index, not working and whose husbands obtained at least a secondary school education had significantly higher odds of early initiation of breastfeeding. Regardless of residence, greater odds of EIBF were significantly associated with non-cesarean delivery (Rural AOR 3.50, 95% CI 1.84, 6.62; Urban AOR 2.48, 95% CI 1.60, 3.80) and living in North-Central (Rural AOR 1.84, 95% CI 1.34, 2.52; Urban AOR 4.40, 95% CI 3.15, 6.15) region. Also, higher odds of EIBF were significantly associated with living in North-East (Rural AOR 1.48, 95% CI 1.05, 2.08; Urban AOR 3.50, 95% CI 2.55, 4.83), South-South (Rural AOR 1.51, 95% CI 1.11, 2.10; Urban AOR 2.84, 95% CI 2.03, 3.97) and North-West (Urban residence only AOR 2.08, 95% CI 1.54, 2.80) regions.

Conclusions

Rural-urban differences in the rates and factors associated with EIBF exist in Nigeria with rural residence having significantly lower rates. Intervention efforts which address the risk factors identified in this study may contribute to improved EIBF rates. Efforts need to prioritize rural mothers generally, (particularly, those in rural North-West region) as well as mothers in urban South-West region of Nigeria.

     

Timely initiation of breastfeeding and its association with birth place in Ethiopia: a systematic review and meta-analysis

Background

Timely initiation of breastfeeding is defined as putting the newborn to the breast within 1 h of birth. In Ethiopia, different studies have been conducted to assess the prevalence of timely initiation of breastfeeding and associated factors. The findings of these studies were inconsistent and characterized by great variability. Therefore, the aim of this systematic review and meta-analysis was to estimate the pooled prevalence of timely initiation of breastfeeding and its association with birth place in Ethiopia using the available studies.

Methods

Databases, including PubMed, Google scholar, Science direct and Cochrane library were systematically searched. All original studies reporting the prevalence of timely initiation of breastfeeding in Ethiopia were considered. Two authors independently extracted all necessary data using a standardized data extraction format. STATA 11 statistical software was used to analyze the data. The Cochrane Q test statistics and I ² test were used to assess the heterogeneity between the studies. A random effect model was computed to estimate the pooled prevalence of timely initiation of breastfeeding. In addition, the associations between timely initiation of breastfeeding and place of birth were determined.

Results

Sixteen studies were finally included in the meta-analysis. The findings of this meta-analysis revealed that, the pooled prevalence of timely initiation of breastfeeding in Ethiopia was 61.4% (CI: 51.4, 71.5%). The study also indicated that rural mothers had lower rate of initiating breastfeeding within the first 1 h after delivery as compared to their urban counterparts. Additionally, mothers who gave birth at health institution were almost 2.11 times more likely to initiate breastfeeding within 1 h as compared to mothers who did not give birth at health institution.

Conclusion

In this study, timely initiation of breastfeeding in Ethiopia was significantly low compared to the current global recommendation on breastfeeding. Women from rural area were less likely to initiate breastfeeding within 1 h as compared with women from urban areas. Mothers who give birth at health institution were more likely to initiate breastfeeding timely.

     

Advantages of social foraging in crab spiders: Groups capture more and larger prey despite the absence of a web

Among group‐living spiders, subsocial representatives in the family of crab spiders (Thomisidae) are a special case, as they build protective communal leaf nests instead of extensive communal capture webs. It could thus be inferred that antipredator benefits (e.g., enhanced protection in larger nests) rather than foraging‐related advantages (e.g., capture of more and larger prey) promote sociality in this family. Nonetheless, subsocial crab spiders do share prey, and if this behaviour does not reflect mere food scramble but has a cooperative character, crab spiders may offer insights into the evolution of social foraging applicable to many other cooperative predators that hunt without traps. Here, we performed a comparative laboratory feeding experiment on three of the four subsocial crab spider species—Australomisidia ergandros, Australomisidia socialis and Xysticus bimaculatus—to determine if crab spiders derive advantages from foraging in groups. In particular, we tested artificially composed groups of five sibling spiderlings vs. single siblings in terms of prey capture success and prey size preference. Across species, groups had higher prey capture success (measured in terms of capture rates and capture latency) and were more likely to attack large, sharable prey—dynamics leading to reduced food competition among group members in favour of living and foraging in groups. Within groups, we further compared prey extraction efficiency among the three applied social foraging tactics: producing, scrounging and feeding alone. In A. ergandros, individuals were exceptionally efficient when using the non‐cooperative scrounger tactic, which entails feeding on the prey provided by others. Thus, our multispecies comparison confirms foraging advantages in maintaining a cooperative lifestyle for crab spiders, but also demonstrates the relevance of research into exploitation of cooperative foraging in this family.     

Protein stability in mixed solvents: a balance of contact interaction and excluded volume

Changes in excluded volume and contact interaction with the surface of a protein have been suggested as mechanisms for the changes in stability induced by cosolvents. The aim of the present paper is to present an analysis that combines both effects in a quantitative manner. The result is that both processes are present in both stabilizing and destabilizing interactions and neither can be ignored. Excluded volume was estimated using accessible surface area calculations of the kind introduced by Lee and Richards. The change in excluded volume on unfolding, deltaX, is quite large. For example, deltaX for ribonuclease is 6.7 L in urea and approximately 16 L in sucrose. The latter number is greater than the molar volume of the protein. Direct interaction with the protein is represented as the solvent exchange mechanism, which differs from ordinary association theory because of the weakness of the interaction and the high concentrations of cosolvents. The balance between the two effects and their contribution to overall stability are most simply presented as bar diagrams as in Fig. 3. Our finding for five proteins is that excluded volume contributes to the stabilization of the native structure and that contact interaction contributes to destabilization. This is true for five proteins and four cosolvents including both denaturants and osmolytes. Whether a substance stabilizes a protein or destabilizes it depends on the relative size of these two contributions. The constant for the cosolvent contact with the protein is remarkably uniform for four of the proteins, indicating a similarity of groups exposed during unfolding. One protein, staphylococcus nuclease, is anomalous in almost all respects. In general, the strength of the interaction with guanidinium is about twice that of urea, which is about twice that of trimethylamine-N-oxide and sucrose. Arguments are presented for the use of volume fractions in equilibrium equations and the ignoring of activity coefficients of the cosolvent. It is shown in the Appendix that both the excluded volume and the direct interaction can be extracted in a unified way from the McMillan-Mayer formula for the second virial coefficient.     

The influence of acculturation on breast-feeding initiation and duration in low-income women in the US

While the 'immigrant health paradox' posits better health behaviours and outcomes for immigrants upon arrival to the US, research suggests that this advantage may deteriorate over time. This study analysed the relationship of acculturation and breast-feeding initiation and duration among a sample of predominantly Latina, low-income women in the US. The four measures of acculturation included: mother's nativity (foreign born vs US born), mother's parents' nativity (foreign born vs US born), years of US residence (<8 years vs > or =8 years) and a dichotomous measure of language acculturation adapted from three items on Marin's acculturation scale (preferred language spoken at home, reading language and writing language) as exclusive use of native language versus non-exclusive use (mixed or English only) (Marin et al., 1987; Marin & Gamba, 1996). Final multivariable models showed that mothers who exclusively used their native language were more likely to initiate breast-feeding as well as breast-feed for longer duration compared with mothers with non-exclusive use, whereas years of US residence and mother's nativity were not significantly associated with breast-feeding initiation or duration. Mother's parents' nativity also emerged as a significant predictor of breast-feeding duration, both within final models for immigrants and across study participants. Programmes providing nutrition education to low-income women may wish to consider the role of language as an important determinant of breast-feeding. The role of mother's parents' nativity on breast-feeding practices deserves exploration in future studies, as the cultural practices taught by family members born outside the US may exert strong pressure within immigrant families now living in the US.     

Development and evaluation of a self care program on breastfeeding in Japan: A quasi-experimental study

Background

When and how to wean breastfed infants exposed to HIV infection has provoked extensive debate, particularly in low-income countries where safe alternatives to breastfeeding are rarely available. Although there is global consensus on optimal infant-feeding practices in the form of guidelines, practices are sub-optimal in much of sub-Saharan Africa. Policy-makers and health workers face many challenges in adapting and implementing these guidelines.

Methods

This paper is based on in-depth interviews with five policy-makers and 11 providers of interventions to prevent mother-to-child transmission (PMTCT) of HIV, participant observations during clinic sessions and site visits.

Results

The difficulties with adapting the global infant-feeding guidelines in Malawi have affected the provision of services. There was a lack of consensus on HIV and infant-feeding at all levels and general confusion about the 2006 guidelines, particularly those recommending continued breastfeeding after six months if replacement feeding is not acceptable, feasible, affordable, sustainable and safe. Health workers found it particularly difficult to advise women to continue breastfeeding after six months. They worried that they would lose the trust of the PMTCT clients and the population at large, and they feared that continued breastfeeding was unsafe. Optimal support for HIV-infected women was noted in programmes where health workers were multi-skilled; coordinated their efforts and had functional, multidisciplinary task forces and engaged communities. The recent 2009 recommendations are the first to support antiretroviral (ARV) use by mothers or children during breastfeeding. Besides promoting maternal health and providing protection against HIV infection in children, the new Rapid Advice has the potential to resolve the difficulties and confusion experienced by health workers in Malawi.

Conclusions

The process of integrating new evidence into institutionalised actions takes time. The challenge of keeping programmes, and especially health workers, up-to-standard is a dynamic process. Effective programmes require more than basic resources. Along with up-to-date information, health workers need contextualized, easy-to-follow guidelines in order to effectively provide services. They also require supportive supervision during the processes of change. Policy-makers should ensure that consensus is carefully considered and that comprehensive perspectives are incorporated when adapting the global guidelines.