Focus: Health Equity: The Social Value of Implementing the Ten Steps to Successful Breastfeeding in an Indonesian Hospital: A Case Study

Background: Despite the known importance of breastfeeding for women’s and children’s health, global exclusive prevalence among infants under 6 months old is estimated at only 41%. In 2018, Indonesia had a lower exclusive breastfeeding rate of 37% at 6 months postpartum; ranging from 20% to 56%, showing unequal breastfeeding support throughout the country. The World Health Organization (WHO) launched the Ten Steps to Successful Breastfeeding (Ten Steps) in 1989, later embedded in UNICEF’s Baby-Friendly Hospital Initiative (BFHI) program in 1991. The BFHI aims to encourage maternity facilities worldwide to ensure adequate education and support for breastfeeding mothers by adhering to the Ten Steps and complying with the International Code of Marketing of Breastmilk Substitutes. An Indonesian survey in 2011 found that less than one in 10 government hospitals implemented the Ten Steps. It has been common for Indonesian health services to collaborate with infant formula companies. While no Indonesian hospitals are currently BFHI-accredited, the WHO/UNICEF Ten Steps (updated in 2018) have been adopted in Indonesia’s national regulation of maternity facilities since 2012. Internationally, implementation of the Ten Steps individually and as a package has been associated with benefits to breastfeeding rates and maternal and infant health. However, to date, few studies have examined the impact of implementing the Ten Steps in economic terms. This study aims to measure the economic benefit of Ten Steps implementation in an Indonesian hospital. Methods: The study was conducted in January 2020 in Airlangga University Hospital, Surabaya, Indonesia, which has implemented the Ten Steps since it was established in 2012. To understand and generate evidence on the social value of the Ten Steps, we conducted a “Social Return on Investment (SROI)” study of implementing the Ten Steps in this maternity facility. To estimate the costs relating to the Ten Steps we interviewed the financial and nursing managers, a senior pediatrician, and senior midwife due to their detailed understanding of the implementation of the Ten Steps in the hospital. The interview was guided by a questionnaire which we developed based on the 2018 WHO/UNICEF Ten Steps to Successful Breastfeeding. The analysis was supported with peer-reviewed literature on the benefits of Ten Steps breastfeeding outcomes. Results: The total per annum value of investment (cost) required to implement Ten Steps in Airlangga University Hospital was US$ 972,303. The estimate yearly benefit was US$ 22,642,661. The social return on the investment in implementing Ten Steps in this facility was calculated to be US$ 49 (sensitivity analysis: US$ 18-65). Thus, for every US$ 1 invested in Ten Steps implementation by Airlangga Hospital could be expected to generate approximately US$ 49 of benefit. Conclusions: Investment in the Ten Steps implementation in this Surabaya maternity facility produced a social value 49 times greater than the cost of investment. This provides novel evidence of breastfeeding as a public health tool, demonstrating the value of the investment, in terms of social impact for mothers, babies, families, communities, and countries. Breastfeeding has the potential to help address inequity throughout the lifetime by providing the equal best start to all infants regardless of their background. Indonesia’s initial moves towards implementing the WHO/UNICEF Ten Steps can be strengthened by integrating all elements into the national regulation and health care system.     

No evidence that reproductive bumblebee workers reduce the production of new queens

Kin selection theory predicts potential conflict between queen and workers over male parentage in hymenopteran societies headed by one, singly mated queen, because each party is more closely related to its own male offspring. In ‘late-switching’ colonies of the bumblebee Bombus terrestris, i.e. colonies whose queens lay haploid eggs relatively late in the colony cycle, workers start to lay male eggs shortly after the queen lays the female eggs that will develop into new queens. It has been hypothesized that this occurs because workers recognize, via a signal given by the queen instructing female larvae to commence development as queens, that egg laying is now in their kin-selected interest. This hypothesis assumes that aggressive behaviour in egg-laying workers does not substantially reduce the production of new queens, which would decrease the workers' fitness payoff from producing males. We tested the hypothesis that reproductive activity inB. terrestris workers does not reduce the production of new queens. We used microsatellite genotyping to sex eggs and hence to select eight size-matched pairs of ‘late-switching’ colonies from a set of commercial colonies. From one colony of each pair we removed every egg-laying or aggressive worker observed. From the other colony, we simultaneously removed a nonegg-laying, nonaggressive worker. Removed workers were replaced with young workers from separate colonies at equal frequencies within the pair. There was no significant difference in queen productivity between colonies with reduced or normal levels of egg-laying or aggressive workers. Therefore, as predicted, reproductive B. terrestris workers did not significantly reduce the production of new queens.     

Differential gene expression in queen-worker caste determination in bumble-bees

Investigating how differential gene expression underlies caste determination in the social Hymenoptera is central to understanding how variation in gene expression underlies adaptive phenotypic diversity. We investigated for the first time the association between differential gene expression and queen-worker caste determination in the bumble-bee Bombus terrestris. Using suppression subtractive hybridization we isolated 12 genes that were differentially expressed in queen- and worker-destined larvae. We found that the sets of genes underlying caste differences in larvae and adults failed to overlap greatly. We also found that B. terrestris shares some of the genes whose differential expression is associated with caste determination in the honeybee, Apis mellifera, but their expression patterns were not identical. Instead, we found B. terrestris to exhibit a novel pattern, whereby most genes upregulated (i.e. showing relatively higher levels of expression) in queen-destined larvae early in development were upregulated in worker-destined larvae late in development. Overall, our results suggest that caste determination in B. terrestris involves a difference not so much in the identity of genes expressed by queen- and worker-destined larvae, but primarily in the relative timing of their expression. This conclusion is of potential importance in the further study of phenotypic diversification via differential gene expression.     

Agricultural biometeorology

Summary A more scientific approach to agriculture generally, coupled with the interest of the emergent nations of the world in a planned rural development, has led to a boom in agricultural meteorology. Major developments include an improvement in interdisciplinary communication at both the national and international level, a move toward standardization with the publication of the WMO GUIDE TO AGRICULTURAL METEOROLOGICAL PRACTICES, and the application of the principles of agroclimatic classification, in a pilot project, to the arid and semi-arid zones of the Near East. Other advances are recorded in such questions as the responses of crops and farm animals to weather conditions, the forecasting of agricultural diseases and pests, and the effect of environmental factors on the storage of agricultural products. An intensified research effort is being devoted to long-term weather forecasting for agriculture,and to questions of soil moisture balance.     

Bumetanide: Potent New “Loop” Diuretic

Bumetanide, a pharmacologically new diuretic, was evaluated in 27 subjects. Its onset of action was within 30 minutes with a peak at 90 minutes and a total duration of action of about 270 minutes. In a controlled study in oedematous patients it was equipotent with frusemide at one-fortieth the molar dosage and did not differ from frusemide with regard to its pattern of electrolyte excretion. On continuous oral administration for eight days it produced effective diuresis with minimal alteration in biochemical and haematological status. The only adverse effect was gastric discomfort in one patient.     

Phenylaminopyrimidines as inhibitors of Janus kinases (JAKs)

A series of phenylaminopyrimidines has been identified as inhibitors of Janus kinases (JAKs). Development of this initial series led to the potent JAK2/JAK1 inhibitor CYT387 (N-(cyanomethyl)-4-[2-[[4-(4-morpholinyl)phenyl]amino]-4-pyrimidinyl]-benzamide). Details of synthesis and SAR studies of these compounds are reported.