Original Article
REVISTA PAULISTA DE MEDICIN ABre astfe e ding training for he alth profe ssionals
and re sultant change s in bre astfe e ding duration
Breastfeeding Promotion in Health Services,
Universidade Federal de São Paulo / Escola Paulista de Medicina, São Paulo, Brazil
a b s t r a c t
CON TEX T: Pro mo tio n o f breastfeeding in Braz ilian maternity ho spi-tals.
OBJECTIVE: To quantify chang es in the breastfeeding duratio n amo ng mo thers served by ho spitals expo sed to the W ellstart-SLC co urse, co mparing them with chang es amo ng mo thers attended by institutio ns no t expo sed to this co urse.
DESIGN : Rando miz ed Institutio nal Trial.
SETTIN G: The effec ts o f tra ining o n b rea stfeeding dura tio n wa s assessed in eig ht Braz ilian ho spitals assig ned at rando m to either an expo sed g ro up (staff attending the W ellstart-SLC co urse) o r a co ntro l g ro up.
SAM PLE: Fo r each o f the eig ht study ho spitals, two co ho rts o f abo ut 5 0 children were visited at ho me at o ne and six mo nths after birth. The first co ho rt (n = 4 9 4 ) was co mpo sed o f babies bo rn in the mo nth prio r to expo sure to the W ellstart-SLC co urse, and the seco nd co ho rt (n = 4 7 6 ) was co mpo sed o f babies bo rn six mo nths subsequent to this expo sure.
M AIN M EASUREM EN TS: Ka pla n-Meier c urves were plo tted to describe the weaning pro cess and lo g -rank tests were used to assess sta tistic a l differenc es a mo ng surviva l c urves. Ha z a rd ra tio (HR) estimates were calculated by fitting Co x pro po rtio nal haz ard re-g ressio n mo dels to the data.
RESULTS: The increases in estimated, adjusted rates fo r children bo rn in ho spitals with trained perso nnel were 2 9 % (HR = 0 .7 1 ) and 2 0 % (HR = 0 .8 0 ) fo r exclusive and full breastfeeding , respectively. N o chang es were identified fo r to tal breastfeeding .
CON CLUSION : This rando miz ed trial suppo rts a g ro wing bo dy o f evidence that training ho spital health pro fessio nals in breastfeeding pro mo tio n and pro tectio n results in an increase in breastfeeding duratio n.
KEY W ORDS: Breastfeeding . Develo ping co untries. Ho spital prac-tices. Medical educatio n.
ABBREVIATION S: SLC, Santo s Lactatio n Center; W ellstart, the San Dieg o Lactatio n Pro g ram.
• Jo sé Aug usto de Ag uiar Carraz edo Taddei •Marcia Faria W estphal • So nia Venancio
• Cláudia Bo g us • So nia So uza
INTRODUCTION
Epidemio lo gical studies have identified breast-feeding as a practice that pro tects children, lo wering the risks o f disease and death. A review o f selected studies has sho wn that when infants no t receiving breast milk are co mpared to tho se o n exclusive breast-feeding, the median relative risk o f diarrhea mo rbid-ity ranges fro m 3.5 to 14.9 at different ages during the first six mo nths o f life.1 A well-co ntro lled co ho rt study
which include d m o re than 2000 sub je cts fro m 33 co m m unitie s o r b arangays in m e tro po litan Ce b u, Philippines, fo und relative risks fo r diarrhea diseases o f 17, 14, and 13 when the weaned children were co m-pared to the exclusively breastfeed o nes at ages o f 2, 4 and 6 mo nths respectively.2
A mo re recent analysis o f the Cebu lo ngitudinal sample including 9,942 chil-dren fitted Co x pro po rtio nal hazard regressio n mo d-els to the data. The adjusted risk ratio fo r diarrhea mo rtality in the first six mo nths o f life was 9.7 when no n-breastfed children were co mpared to breastfed o nes.3 A study co nducted in Peruvian slums sho wed
that the relative risks o f upper and lo wer respirato ry infectio ns amo ng children in their first six mo nths o f life are 5.5 and 4.1 respectively fo r no n-b reastfeed children, when co mpared to exclusive breastfed o nes.4
There is so me evidence suggesting that breast-feeding can be enco uraged by changes in ho spital ro u-tine and by giving info rmatio n and suppo rt to mo th-ers as well. A review o f 21 studies fro m eight co untries sho ws that the mo st likely reductio n in the prevalence o f no n-breastfed infants wo uld be: 40% amo ng infants aged 0-2 mo nths, 30% amo ng tho se aged 3-5 mo nths and 10% amo ng tho se between 6 mo nths and 1 year o ld. Theo retical calculatio ns based o n these data in-dicate that breastfeeding pro mo tio n can reduce diar-rhea mo rbidity rates by 8 - 20% and diardiar-rhea mo rtality rates by 24 - 27% in the first six mo nths o f life.6
Never-theless, it sho uld be no ted that these predictio ns are based o n studies co nducted predo minantly in devel-o ped areas in an effdevel-o rt tdevel-o assess the effect devel-o f varidevel-o us interventio ns, mo st o f which suffer fro m metho do lo gi-c al p ro b le m s. The re fo re , the re d ugi-c tio n e stim ate s sho uld be co nsidered as a best available guess.7
The Wellstart Pro gram in San Diego is o ne o f the mo st pro mising experiments in breastfeeding pro -mo tio n. It was created with the o bjective o f training multidisciplinary teams fro m different regio ns in lac-tatio n management in fo ur-week intensive co urses. With their acquired kno wledge and techniques, the teams then return to their co untries in o rder to pro -mo te changes in ro utines and pro cedures aimed at impro vement o f breast-feeding practices.8 As happens
with mo st health activities, the Wellstart experience has no t been systematically evaluated. Altho ugh par-ticipant repo rts are available and can pro vide useful insights into the effects o f the experience, the info r-matio n is inco mplete and may be affected by signifi-cant selectio n bias.9
Brazil is a co untry where mo st deliveries o ccur in ho spitals. In the State o f São Paulo , the mo st in-dustrialized state in the co untry, the ho spital delivery rate is higher than 98%. The po licies and practices at these ho spitals do no t enco urage breast-feeding: very few have ro o ming-in and aro und 30% o f the deliveries are cesarean sectio ns. The mo st recent info rmatio n o n breastfeeding practices in the state, fro m a survey co nducted amo ng children attending the immuniza-tio n c am p aign in 1991, sho we d that the ave rage duratio n o f full breastfeeding was 43 days and that 23% o f the children had never been breastfed. As a result, an interventio n aimed at the pro mo tio n and pro tectio n o f breastfeeding might have a high impact o n infant mo rbidity and mo rtality rates.
In Ap ril 1990 thre e p ro fe ssio nals fro m the Santo s Lactatio n Center (SLC), in the State o f São Paulo , were trained in the San Diego Center, and in August o f the same year similar co urses fo r health
pro fessio nals were b egun in Santo s. Since then, fo ur co urses have been o ffered and 120 health pro fessio n-als have b een trained. These co urses differ slightly fro m tho se in San Die go . The y last thre e we e ks instead o f fo ur, are co nducted in Po rtuguese, and the preferred candidates are pediatricians, o b stetricians and nurses fro m ho spitals, as o ppo sed to university-b ased health pro fessio nals.
In view o f the need to pro vide a systematic evalu-atio n o f the Wellstart-SLC experience, a study was co n-ducted with the fo llo wing o bjectives: to identify the po sitive and negative characteristics o f vario us to pics co vered in the SLC co urse and hence impro ve its ef-fe ctive ne ss; to q uantify and q ualify the structural c hange s that o c c urre d in ho s p itals who s e s taff attended the co urse by co mparing them to similar institutio ns that had no t been expo sed; and to quantify changes in b reastfeeding duratio n amo ng mo thers se rve d b y ho spitals e xpo se d to the We llstart-SLC co urse by co mparing them to changes amo ng mo thers attended by institutio ns no t expo sed to this co urse.
A previo us publicatio n discussed and evaluated the training co urse as well as its impact o n the imple-mentatio n o f ho spital ro utines favo ring breastfeeding, i.e. the first two o bjectives listed abo ve.10 This article
presents results co ncerning changes in breastfeeding duratio n.
METHODS
Study design. The effect o f training o n the length o f time infants were breastfed was assessed in eight ho spitals assigned at rando m to either the expo sed gro up (staff attending the SLC co urse) o r the co ntro l gro up.11 In o rder to achieve co mparability, the eight
institutio ns satisfied the fo llo wing criteria: public o r philanthro pic; lo cated near the city o f São Paulo , Bra-zil (within 100 Km); no previo us expo sure to a similar co urse; pro fessio nal staff (two physicians and o ne nurse) available to attend the co urse full time fo r a 3 week perio d; and at least two births per day in the maternity ward.
after co urse co ho rts. Of the o riginal 609 b ab ies that co mprised the b efo re-co urse co ho rt, 494 (81%) were include d in the final analysis, whe re as o f the 555 o riginal b ab ies that co mprised the afterco urse co -ho rt, 469 (84%) were included in the final analysis. Such lo sses are likely to have similar directio n and intensity in b o th the expo sed and no nexpo sed co -ho rts, since they are no t related to the pro cess o f data co llectio n, b ut have to do with the characteris-tic s o f lo w-inc o m e urb an p o p ulatio ns. Cause s o f lo sses were: family mo ved to ano ther state, mo ther intentio nally gave wro ng address at the time deliv-ery to o k place, husb and ab used wife and wife ran away fro m ho me , mo the r was se nt to priso n, and b ab ie s we re ado pte d. Five childre n die d and o ne mo ther refused to participate at the six-mo nth visit. Six q uestio nnaire versio ns were revised, dis-cussed and pre-tested by members o f the research team befo re deciding o n the final versio ns o f the ques-tio nnaires fo r the o ne and six mo nth po stpartum vis-its. The questio nnaires were develo ped alo ng with a manual that gave so me field o rientatio ns and direc-tio ns o n ho w to fill o ut the fo rms. Bo th quesdirec-tio nnaires gathered info rmatio n o n the so cial, eco no mic and demo graphic characteristics o f the family, o n the use o f health services, o n the health co nditio ns o f the baby and the mo ther, o n feeding co unseling at health ser-vices during gestatio n, delivery and puerperium, and o n child and sibling care and feeding practices. Ho me interviews were carried o ut by 16 female interviewers who were lo cal residents with high-scho o l diplo mas, and who had no t attended any health co urse no r par-ticipated in any activity in the area o f health. All inter-viewers to o k a 25-ho ur training co urse and, under supervisio n, interviewed at least five mo thers during the pre-test phase. Eight additio nal ho urs o f refresher training were given befo re field surveys began in Oc-to ber 1992 fo r the six mo nth fo llo w-up o n the befo re-co urse re-co ho rt, again in January 1993 fo r the o ne mo nth o bservatio n o n the after-co urse co ho rt, and finally in June 1993 fo r the six mo nth o bservatio ns o n the
after-co urse after-co ho rt. Ten percent o f all interviews were ran-do mly selected and repeated by a field superviso r to check fo r info rmatio n reliability.
Main measurements. The dependent o r effect vari-able was breastfeeding duratio n, measured in days, with three co mpo nents: exclusive breastfeeding (age at intro ductio n o f water, tea, o r any fo o d o ther than breast milk), full (age at intro ductio n o f any o ther milk) and to tal (age at which any breastfeeding was termi-nated). The independent o r expo sure variab le was whe the r o r no t ho s p ital s taff had atte nd e d the We lls tart- SLC c o urs e . Po te ntial c o nfo und e rs o r co variates included the mo ther’s age (
≤
19 and >19 years), parity (primiparae and o thers), kind o f delivery (no rmal and o thers), birth weight (< and≥
2500 g) and sex. Ano ther gro up o f variables that measured changes in ho s p ital p ro c e d ure s re late d to b re as tfe e d ing pro tectio n was also taken into co nsideratio n. These were five variables regarding whether o r no t the mo ther go t suppo rt fo r breastfeeding in the ho spital, go t help fo r breastfeeding in the ho spital, breastfed in the de-livery ro o m, breastfed within six ho urs after dede-livery, and stayed in a ro o ming-in facility with her baby.Statistical methods. To assess statistical signifi-cance between gro ups, chi-square tests were used fo r catego ry variables and t-tests fo r co ntinuo us variables. Kap lan - Me ie r c u rve s we re p lo tte d to d e s c rib e breastfeeding duratio n and lo g-rank tests were used to assess statistical differences amo ng survival curves. The pro po rtio nal hazards assumptio n was satisfied since there was no stro ng evidence o f no n-parallel-ism o f the lo g-lo g curves. Hazard ratio (HR) estimates were calculated by fitting Co x pro po rtio nal hazard re-gressio n mo dels to the data using the SAS PHREG pro cedure. Thirteen regressio n mo dels were fitted. Six mo dels were fo r generating crude HR fo r exclusive, full and to tal breastfeeding duratio n, co mparing be-fo re and after co ho rts be-fo r co ntro ls and expo sed ho spi-tals. Ano ther six mo dels were fo r estimating HR fo r the same o utco me variables and co mparing the same co ho rts, but adjusted fo r po tential co nfo unding
vari-Table 1. Comparison of be fore and afte r cohorts for e xpose d and control groups for pote ntial confounding variable s
CON TROL EXPOSED
Variables before after P value before after P value
n 2 3 9 2 3 7 2 5 3 2 4 1
% male 4 8 .2 5 1 .8 0 .3 5 6 4 7 .1 5 5 .9 0 .0 4 9
Mean birth weight (g) 3 1 8 4 3 1 9 4 0 .4 9 8 3 1 4 0 3 1 8 9 0 .1 9 9
Mean mo ther‘ s age (years) 2 8 .9 2 5 .8 0 .0 9 4 2 6 .4 2 6 .0 0 .6 2 5
% mo thers bo rn in urban areas 7 7 7 5 0 .6 4 9 7 6 7 7 0 .2 2 2
% mo thers living with fathers 8 9 8 6 0 .2 6 2 8 2 8 6 0 .1 4 6
% literate mo thers 9 4 9 3 0 .8 4 3 9 2 9 3 0 .4 9 1
% mo thers intending to breastfeed 9 5 9 6 0 .3 8 8 9 4 9 0 0 .0 8 2
% primiparae 4 4 3 7 0 .2 5 2 3 4 3 5 0 .4 3 9
ab les. And the last o ne included b efo re and after-co urse after-co ho rts fo r expo sed and after-co ntro l ho spitals to assess the interactio n o f befo re and after and co ntro l-e xp o s url-e l-e ffl-e c ts . To as s l-e s s c o - linl-e arity am o ng co variates in the mo dels, an SAS-macro develo ped by Zack & Ro sen was utilized. The pro bability o f erro ne-o usly rejecting the null hypne-o thesis (type I errne-o r) was established at 0.05 fo r all statistical inferences.2-14
RESULTS
Tab le 1 sho ws that the distrib utio ns o f the po -tential co nfo unding variab les were no t statistically different fo r the b efo re and after-co urse co ho rts. The typical mo ther included in the study co uld b e de-scrib ed as yo ung, literate, b o rn in a urb an area, hav-ing a stab le matrimo nial relatio nship with the child’s father and willing to b reastfeed. Ro ughly o ne third were primiparae and two thirds had no rmal deliver-ies.
Figures 1 and 2 display Kaplan-Meyer survival curves co mparing breastfeeding duratio n fo r the befo re and after-co urse co ho rts. When children bo rn in the fo ur expo sed ho spitals befo re the SLC co urse to o k place were co mpared with children bo rn six mo nths afterwards in the same ho spitals, survival pro babilities fo r the three breastfeeding co mpo nents (exclusive, full and to tal) we re always highe r afte r e xpo sure . The changes were statistically significant fo r exclusive and full breastfeeding duratio n amo ng the expo sed co ho rt. When befo re and after co ntro l co ho rts were co mpared,
no particular pattern o f change co uld be identified fo r the exclusive breastfeeding co mpo nent, while survival curves fo r full and to tal breastfeeding duratio n sho wed significant decreases.
Table 2 sho ws that SLC training co rrespo nded to lo wer rates o r velo cities in the weaning pro cess fo r the exclusive and full breastfeeding co mpo nents. No c hange s o c c urre d fo r to tal b re astfe e d ing am o ng children bo rn in expo sed ho spitals. Fo r children bo rn in co nco mitant co ntro l ho spitals no changes o ccurred fo r exclusive breastfeeding, while an increase in the rate o f full and to tal breastfeeding was detected. The results were similar fo r crude and adjusted hazard ratio e stim ate s fo r e xp o se d and c o ntro l gro up s. Thus, e xclusive and full b re astfe e ding duratio n b e cam e lo nger amo ng expo sed ho spitals while full and to tal b re as tfe e d in g d u ratio n g o t s h o rte r am o n g co nco mitant co ntro l ho spitals.
Table 3 sho ws that there were marked befo re and after changes amo ng variab les related to ho spital practices amo ng children bo rn in expo sed ho spitals, and alm o st no change s in the sam e variab le s fo r children bo rn in co ntro l ho spitals. The o nly signifi-cant impro vement amo ng children b o rn in co ntro l ho spitals was the increase in the pro po rtio n o f children that were breastfed in the delivery ro o m (fro m 2% to 8%). On the o ther hand, fo r expo sed ho spitals the pro po rtio n that were breastfed in the delivery ro o m increased fro m 2% to 23% while the pro po rtio n o f newbo rns that were breastfed in the first six ho urs o f life increased fro m 41% to 53%. Impro vements were
Table 2. Crude and adjuste d hazard ratio (HR) e stimate s for bre astfe e ding
duration compone nts (e xclusive , full and total) of be fore and afte r cohorts for e xpose d and control groups
P va lue
Breastfeeding CON TROL EX POSED intera ction***
Duration Crude Adjusted Crude Adjusted control-ex posed/
Components HR* 9 5 % CI* HR 9 5 % CI HR 9 5 % CI HR 9 5 % CI before-a fter
Exclusive 1 .0 1 0 .8 4 -1 .2 1 0 .9 8 0 .7 9 - 1 .2 2 0 .6 9 0 .5 7 -0 .8 3 0 .7 1 0 .5 9 -0 .8 5 0 .0 0 2 0
Full 1 .2 0 1 .0 0 -1 .4 5 1 .1 6 0 .9 3 -1 .4 5 0 .8 2 0 .6 8 -0 .9 8 0 .8 0 0 .6 7 -0 .9 7 0 .0 0 1 9
Total 1.58 1.30-1.93 1.55 1.23-1.96 1.02 0.84-1.44 1.01 0.83-1.22 0.0019
* HR = Haz ard Ratio estimates; 9 5 % CI = co nfidence intervals; calculated by fitting pro po rtio nal haz ard Co x reg ressio n mo dels.
* * adjusted fo r ho spital o f birth, mo ther’s ag e (≤ 1 9 and >1 9 years), parity (primiparae and o thers), kind o f delivery (no rmal and o thers), birth weig ht (< and >= 2 5 0 0 g ) and sex.; * * * p values fo r the interactio n term o f co ntro l-expo sed and befo re-after variables fro m the mo del that included bo th co ho rts fro m all ho spitals (n=9 7 0 ).
Table 3. Comparison of be fore and afte r cohorts for e xpose d and control groups for variable s re late d to change s in institutional practice s
Va ria bles CON TROL EX POSED
before a fter P va lue before a fter P va lue
Frequency 2 3 9 2 3 7 2 5 3 2 4 1
% g o t suppo rt fo r breastfeeding in ho spital 5 8 6 1 0 .4 2 3 4 8 6 4 0 .0 0 0
% g o t help fo r breastfeeding in ho spital 3 5 3 6 0 .5 8 3 2 9 4 9 0 .0 0 0
% breastfed in delivery ro o m 2 8 0 .0 1 3 2 2 3 0 .0 0 0
% breastfed within six ho urs 4 8 5 0 0 .6 9 1 4 1 5 3 0 .0 0 9
Figure 1. Adjusted* Kaplan-Meier survival curves for breastfeeding duration components (exclusive, full and total), comparing before and after groups for exposed hospitals. *adjusted for hospital of birth, mother’s age (≤ 19 and > 19 years), parity (primiparae and others), kind of delivery (normal and others), birth weight (< and ≥ 2500 g) and sex.
1. Feachem RG, Ko blinsky MA. Interventio ns fo r the co ntro l o f diarrhea diseases amo ng yo ung children: pro mo tio n o f breast-feeding. Bull WHO 1984;62:271-91
2. Po pkin BM, Adair L, Akin JS, Black R, Brisco e J, Flieger W. Breast-feeding and diarrhea mo rbidity. Pediatrics 1990;89(6):874-82
3. Yo o n PW, Black RE, Mo ulto n LH, Becker S. Effect o f no t breastfeeding o n the risk o f diarrhea and respirato ry mo rtality in children under 2 ye ars o f age in Me tro Ce b u, the Philip p ine s . Am J Ep id e m io l 1996;143:1142-48
4. Bro wn KH, Black RE, Lo pez de Ro mana G, Creed de Kanashiro H. Infant feeding practices and their relatio nship with diarrhea and o ther diseases in Huascar (Lima), Peru. Pediatrics 1989;83(1):31-40.
5. Victo ra CG, Smith PG, Vaughan JP, et al. Evidence fo r pro tectio n by breast-feeding against infant deaths fro m infectio us diseases in Brazil. Lancet 1987;2(8554):319-22
6. Feachem RG, Ko blinsky MA. Interventio ns fo r the co ntro l o f diarrhea diseases amo ng yo ung children: pro mo tio n o f breast-feeding. Bull WHO 1984;62:271-91.
7. Pérez-Escamilla R, Po llitt E, Lö nnerdal B, Dewey KG. Infant feeding po licies in maternity wards and their effect o n breast-feeding success: an analytic o verview. Am J Public Health 1994;84:89-97.
8. Wellstart: the San Diego Lactatio n Pro gram: Statement o f co rpo rate c ap ab ilitie s. San Die go , CA. We llstart: the San Die go Lac tatio n Pro gram; 1990.
REFERENCES
also detected in the pro po rtio n o f mo thers that go t suppo rt and help fo r breastfeeding their babies fro m ho s p ital p e rs o nne l. The p ro p o rtio n o f c hild re n ro o ming-in decreased fo r co ntro l ho spitals but sho wed no significant change in expo sed ho spitals.
DISCUSSION
A seaso nal bias co uld have influenced the re-sults, since children included in the b efo re-co urse co ho rt were bo rn in April (fall) and the after-co urse co ho rt children in December (summer). Ho wever, it seems unlikely that the co ho rts’ birth mo nths wo uld affect the results since a) seaso ns are no t markedly different in the State o f São Paulo , b) mo st o f the mo thers lived in urban areas where go o ds and ser-vices are available thro ugho ut the year, and c) the co nco mitant co ntro l co ho rts sho wed no changes in h azard ratio e s tim ate s fo r e xc lu s ive an d fu ll breastfeeding duratio n and an increase in the hazard ratio estimates fo r to tal breastfeeding duratio n. If, fo r the sake o f argument, a seaso nal bias had existed it wo uld have had the e ffe c t o f hid ing a signific ant d e c re as e in h azard ratio e s tim ate s fo r to tal breastfeeding duratio n, since the expected change with no e xpo sure wo uld have b e e n an incre ase in this estimate.
Ano ther impo rtant po int to co nsider is whether the o bserved changes are permanent o r tempo rary. Acco rding to o ur findings, mo dificatio ns in ho spital
practices that were significant were related to staff b ehavio r rather than to structural changes. Fo r in-stance, no changes were identified fo r ro o ming-in, a physical change, while all the o ther variables presented in Tab le 3, d e p e nd e nt up o n p e rso nne l p rac tic e s, re sulte d in signific ant c hange s. Re sults fro m the qualitative co mpo nent o f this trial suggest that fo llo w-up sw-uppo rt sho uld be pro vided fo r the trained team in o rder to pro mo te permanent institutio nal changes.10
Fo llo w-up activities sho uld include a critical analysis o f the institutio nal changes required fo r establishing an effective breastfeeding pro tectio n and pro mo tio n pro gram. Success wo uld depend o n better co hesio n b e twe e n th e in s titu tio n al d o m ain s fo r p o lic y, management and services.15
CONCLUSION
r e s u m o
CON TEX TO: Pro mo ção do aleitamento materno em maternidades brasileiras.
O BJETIV O : Q ua ntific a r muda nç a s na dura ç ã o do a le ita me nto materno de mães assistidas em maternidades expo stas ao curso W ellstart-SLC, co mparando -as co m mudanças em mães assistidas po r maternidades não expo stas.
TIPO DE ESTUDO: Ensaio institucio nal rando miz ado .
LOCAL: O s efeito s do treinamento na duração do aleitamento materno fo i avaliado em o ito maternidades rando micamente alo cadas ao grupo expo sto (equipe freqüenta o curso W ellstart-SLC) o u co ntro le.
AM OSTRA: Em cada uma das o ito maternidades, duas co o rtes de cerca de 5 0 crianças fo ram visitadas em suas casas ao co mpletarem um e seis meses de vida. As primeiras co o rtes (n = 4 9 4 ) fo ram c o mpo sta s de b eb ê s na sc ido s no mês a nterio r a o treina mento , enquanto que as seg undas co o rtes (n = 4 7 6 ) fo ram co mpo stas po r bebês nascido s seis meses apó s a expo sição ao curso W eelstart-SLC.
VARIÁVEIS ESTUDADAS: Para descrever o pro cesso de desmame fo ram traçadas curvas de Kaplan-Meier. Para avaliar as diferenças estatísticas entre as curvas de so brevivência fo i utilizado o teste “ lo g -rank” . Fo ram calculadas estimativas das razõ es de risco (HR) ajustando mo delo s de reg ressão de risco s pro po rcio nais de Co x ao s dado s.
RESULTADOS: O aumento estimado , a partir das raz õ es ajustadas para crianças nascidas em ho spitais co m pesso al treinado , fo i 2 9 % (HR = 0 ,7 1 ) e 2 0 % (HR = 0 ,8 0 ) para aleitamento exclusivo e pleno respectivamente. N ão fo ram identificadas mudanças para o tempo de aleitamento to tal.
CO N CLUSÕ ES: Esse e nsa io ra ndo miz a do c o nfirma e vidê nc ia s crescentes de que treinar pro fissio nais de saúde em ho spitais, na pro mo ção e pro teção do aleitamento materno , resulta em aumento do tempo de aleitamento materno .
PALAV RAS-CHAV E: Ale ita me nto . Pa íse s e m d e se nvo lvime nto . Práticas ho spitalares. Educação médica.
ABREV IAÇÕ ES: SLC C e ntro d e La c ta ç ã o d e Sa nto s W e llsta rt, Pro g rama de Lactação de San Dieg o .
José Augusto de Aguiar Carraze do Tadde i, MD, PhD.Adjunct Pro fesso r, Department o f Pediatrics, Universidade Federal de São Paulo ; Pro fesso r, Maternal and Child Health Graduate Pro gram, Universidade de Santo Amaro , São Paulo , Brazil.
Marcia Faria We stphal, PhD. Pro fesso r, Scho o l o f Public Health, Universidade Federal de São Paulo , São Paulo , Brazil.
Sonia Ve nancio, MD, PhD. Researcher, Health Institute, State o f São Paulo State Health Secretariat, São Paulo , Brazil.
Cláudia Bogus, PhD. Researcher, Health Institute, São Paulo State Health Secretariat, São Paulo , Brazil.
Sonia Souza, PhD. Assistant Pro fesso r, Scho o l o f Public Health, Universidade Federal de São Paulo , São Paulo , Brazil.
Source s of funding:WHO Diarrhea Disease Co ntro l Pro gram (Grant No . 91064). FAPESP (Grant No . 97/3614-5).
Conflict of inte re st: No t declared
Last re ce ive d: 21 June 2000
Acce pte d: 26 June 2000
Addre ss for corre sponde nce :
Jo sé Augusto Taddei
Departmento de Pediatria, Universidade Federal de São Paulo Rua Marselhesa, 630
São Paulo /SP - Brasil - CEP 04020-060 E-mail: taddei.dped@ epm.br
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