Focus group discussions were conducted to elicit the perceived incentives and barriers to exclusive breastfeeding in Ghana. Thirty-five breastfeeding women were recruited from the Manya and Yilo Krobo districts of the eastern region. Participants had a mean age of 27.5 years and had at least one child < 4 months old. Almost all of the participants believed that exclusive breastfeeding is the superior infant feeding method and should be practiced for the first 6 months postpartum. However, there was widespread belief that infants can be given water if it is clean. Mothers reported that exclusive breastfeeding was easier when breast milk began to flow soon after delivery. The main obstacles to exclusive breastfeeding identified were maternal employment, breast and nipple problems, perceived milk insufficiency, and pressure from family. Addressing the concerns put forward by these participants can be used to enhance exclusive breastfeeding promotion in this region.

IntoductionThe recent interest in maternity ward practices demonstrated by international health agencies' is justified. Rooming-in can have a beneficial impact on the health of the newborn,2-4 and, as this review will show, there are strong reasons to believe that beneficial infant feeding policies in the maternity ward can contribute to lactation success. In 1989, the World Health Organization (WHO), in conjunction with the United Nations Children's Fund (UNICEF),1 made several recommendations to promote breast-feeding in institutions that provide maternity services. These recommendations included rooming-in throughout the hospital stay, breast-feeding on demand, early initiation of breast-feeding, breast-feeding guidance by health personnel, and avoidance of supplementary fluids. Given the high number ofbirths attended in clinics or hospitals worldwide,4,5 an in-depth assessment of the impact of such policies is worthwhile.In 1980, Winikoff and Baer6 concluded that maternity ward policies similar to those advocated by WHO and UNICEF could have a positive impact on breast-feeding. However, they did not fully address the methodological limitations of the studies included in their review. Although Margen et al.7 recognized that the majority of such studies did not account for confounders, they too concluded that lactation performance can be improved by encouraging mother-infant contact, providing breast-feeding information, and restricting bottle-feeding. follow-up, but that in-hospital formula supplementation and breast-feeding support without phone follow-up had no significant impact. Their review did not consider policies such as discharge packs, rooming-in, and breast-feeding on demand, and it did not include any studies in developing countries.Considering the limitations of these previous reviews, it is worthwhile to reexamine this issue. The intent of our review is to examine the plausibility of a causal relationship between maternity ward practices and lactation success, using the procedures ofmeta-analysis whenever possible. MethudsThis review is restricted to articles on the relationship between maternity ward practices and lactation success published in English or Spanish between 1951

OBJECTIVES: This study examined the effectiveness of a hospital program to promote exclusive breast-feeding in Santos, Brazil. METHODS: In a prospective design, women who delivered at a hospital with an active breast-feeding promotion program (n = 236) were compared with women who delivered at a nearby control hospital (n = 206). RESULTS: The two groups had similar demographic characteristics and previous breast-feeding histories. Exposure to breast-feeding activities, assessed by maternal recall prior to discharge, was universally high at the program hospital and universally low at the control hospital. Multivariate survival analysis showed that exclusive breast-feeding lasted 53 days longer among women who delivered at the program hospital. CONCLUSIONS: Hospital-based breast-feeding promotion programs may be effective in extending the duration of exclusive breast-feeding.

OBJECTIVES: This study examined the impact of cesarean section delivery on the initiation and duration of breast-feeding in the 1987 Mexican Demographic and Health Survey. METHODS: The subsample (n = 2517) was restricted to women whose delivery of their last-born children (aged 5 years and younger) was attended by a physician. Multivariate logistic regression was used to examine the association between cesarean section and likelihood of either not initiating breast-feeding or doing so for less than 1 month. Among women who breast-fed for 1 month or more, multivariate survival analysis was used to examine the relationship between cesarean section and breast-feeding duration. RESULTS: Cesarean section was a risk factor for not initiating breast-feeding (odds ratio [OR] = 0.64, 95% confidence interval [CI] = 0.50, 0.82) and for breast feeding for less than 1 month (OR = 0.58, 95% CI = 0.37, 0.91) but was unrelated to breast-feeding duration among women who breast-fed for 1 month or more (OR = 0.97, 95% CI = 0.86, 1.11). CONCLUSIONS: It is desirable to provide additional breast-feeding support during the early postpartum period to women who deliver via cesarean sections.