Introduction
The state recognizes the protection of children’s health as one of the most important and necessary conditions for the physical and mental development of children1. Maternity in the Russian Federation is protected and encouraged by the state2,3. Full nutrition of pregnant women, nursing mothers, and children under the age of three can be considered as a guarantee of the future health of the nation4-7. Breast milk is an ideal food for newborns and infants. It serves as a source of all easily digestible nutrients and biologically active compounds necessary for a child8. Therefore, increasing breastfeeding rates is crucial for improving the health of the child population9-11.
WHO estimates that one third of the 8.8 million annual deaths of children under age of five are due to malnutrition, which can be a direct cause of death, as well as the most important single risk factor for morbidity among young children12. To ensure maternal and child health services provide the right start in life for every infant and the necessary support for mothers in the area of breastfeeding, WHO and UNICEF developed “Ten principles for successful breastfeeding”. Currently, this checklist is used by medical organizations in more than 150 countries13-15.
Too many mothers still stop exclusive breastfeeding a few weeks after birth16,17. It is estimated that only about 35% of children under the age of 6 months worldwide are currently exclusively breastfed18. This is due to various reasons, including the lack of advice on breastfeeding19, in which the main role is given to neonatologists and pediatricians.
In the medical organizations of the obstetric profile neonatologists at the birth of the child carry out procedures for the care of the newborn, including those aimed at supporting breastfeeding20. The organization of child care after discharge from the obstetric hospital is not less important. Dynamic monitoring of physical and neuro-psychological development of the attached children falls on the children’s clinic (department), medical workers from which carry out not less than two times patronage of the newborn21. The first visit is carried out by the pediatrician no later than the third day after discharge from the obstetric hospital. The organization of rational nutrition of children under the age of three is also included in the main tasks of the clinic. During the visit, the health worker should consult on the nutrition of the mother and the child, teach the woman the technique of feeding the child, conduct interviews with the nursing mother and her environment, aimed at supporting breastfeeding22-24. In addition, the structure of the children’s clinic is recommended to include a healthy child’s office, the main functions of which are to promote a healthy image and training in child care skills, including promotion of breastfeeding25,26.
Thus, the correct organization of breastfeeding, which is a competent promotion and fight against the abandonment of natural feeding of the child held in the organizations of obstetric care and children’s clinics, is an important task to preserve and promote the health of the child population.
The Purposed of Research: Evaluation of the breastfeeding organization in obstetric hospitals and children’s clinics of St. Petersburg.
Research Results and Discussion
Analysis of the dynamics of the proportion of breastfed children from 3 to 6 months and from 6 to 12 months in the Russian Federation for 2013-2017 showed that over the past five years, the value of these indicators changed in waves. Data on the dynamics of breastfeeding coverage in the period from 3 to 6 months and from 6 to 12 months in the Russian Federation are presented in table 1.
Table 1
Dynamics of specific weight of breastfed children from 3 to 6 months and from 6 to 12 months in Russia (in %)
In 2016, the Russian Federation saw the highest value of indicators of specific weight of children breastfed for 3 to 6 months and from 6 months to one year for the last five years, but in 2017 there was a decline in indicators.
The period of applying the baby to the breast is crucial for further successful breastfeeding. According to the findings, most of the children in the obstetrics ward were immediately put to the breast (79.8 per cent). 14.5% of them were applied to the breast not immediately: on the first day-7.8%, on the second day-5.1%, on the third day-1.6%. The reasons for which the child was not immediately applied to the breast were: the child was in intensive care - 2.9%, due to prematurity-5.9%, due to cesarean section - 76.6%, due to the presence of hypoxia during pregnancy and childbirth - 2.9%, due to operational benefits in childbirth - 2.9%, due to the unwillingness of the mother to start breastfeeding-8.8%. The study found that 5.7% of children were not breastfed at all.
There is no doubt that the correct technique of breastfeeding creates a comfortable environment for mother and child. It is ensured by timely and comprehensive advice received from health professionals in maternity facilities. Therefore, the competent work of a neonatologist in an obstetric hospital is of great importance for successful breastfeeding. The study showed that although 100% of the respondents had a neonatologist’s examination and consultation after childbirth, only 84.3% of the mothers received recommendations from him on breastfeeding. During the study, women were asked to evaluate the completeness and informativity (informative value) of the data by the neonatologist during the consultation of recommendations on breastfeeding. It is revealed that it was estimated as “excellent” by 28.9% of mothers, “good” - 42,1%, “satisfactory” - by 25.3%, “unsatisfactory” - 3,7%. The average score that respondents gave to neonatologists was 3.9±0.08 points.
According to the results of the survey, the planned and actual terms of the duration of breastfeeding were studied. The scheduled time allows evaluating the performance of neonatologists and obstetric hospitals to support breastfeeding, the actual work of the medical staff at children’s clinics (departments).Of all those who started breastfeeding in the maternity hospital, 4.9% of the women interviewed immediately planned to transfer the child to artificial feeding, and 96.1% of the mothers planned to continue breastfeeding. Among those who were not going to continue to breastfeed, the main reasons were: called their own or the child’s disease, as well as the presence of implants in the breast. Of those who planned to continue breastfeeding, most were going to feed for up to 12 months (50.5%). It was believed that they would continue to breastfeed only up to 3 months - 2.4% of women, up to 6 months-9.9%, up to 9 months-5.9%. And 26.4% of mothers assumed that they would continue breastfeeding after a year (up to one and a half or two years). On average, in the maternity hospital they planned to feed the baby with breast milk to 12.1±0.08 months.
According to Orders of the Ministry of Healthcare of Russia, the pediatrician and the nurse of children’s clinic during the first month of life have to carry out patronage of the child at home. During the visit, they should give recommendations on the organization of free feeding, psychologically adjust her to long-term lactation and directly monitor the correctness of the applying of the child to the breast. Patronage in the first 2-3 days was at 90.1% of respondents, was not-9.9%. 72.1% of the respondents of those who had patronage received the recommendations on breastfeeding from the health worker of the children’s clinic; did not receive - 27.9% of mothers. Assessment of informativity (informative value) of the advice on feeding the child with breast milk f 32.4% of women rated as “excellent”, “good” - 53,6%, “satisfactory” - 11,9%, “unsatisfactory”- 2.1%. The average score given by the respondents for the completeness of the information obtained during the patronage was 4.1±0.09 points. The calculation of the reliability criterion between the average estimates given by the respondents to neonatologists and pediatricians for the completeness and informativity (informative value) of the recommendations given during the consultation and primary patronage showed no statistically significant difference (t<2).
The actual terms of the child’s breastfeeding (only breast milk, liquids and complementary foods by age) differed from the planned ones. After the discharge of obstetric hospital within the first month 11.3% of women ceased to continue breastfeeding (4.9 per cent planned). Breast milk was fed up to 3 months - 21.8% of women, up to 6 months - 25.3%, up to 9 months - 8.9%, up to 12 months - 16.8%, continued feeding after a year 15.9% of mothers. On average, the actual duration of breastfeeding was 7.3±0.09 months. Thus, the coverage of breastfeeding from 3 to 6 months was 47.1%, and from 6 to 12 months was 51.0%, which is higher than the average for the Russian Federation.
The study showed that the main reason for refusal to breastfeed in 41.2% of respondents was the lack of milk. In addition, the reasons for the refusal were: refusal of the child from the breast – 14.7%; unwillingness to continue breastfeeding – 11.2%; the need to go to work – 14.5%; mother’s disease - 4.7%; child’s disease – 2.6%; pain associated with the appearance of cracks on the nipples, pumping – 3.4%; fear that will change the figure, breast shape – 1.8%; reduction in the possibility of communication, movement, “attachment” to the child – 2.3%; other - 3.6%.
The study examined the reasons why women refused to breastfeed at certain times. It was found that the main reason for refusal of breastfeeding in women who fed only up to 3 months in 47.1% of cases was the lack of milk. The refusal of the child to breastfeed led to the cessation of further breastfeeding in 17.7% of respondents, the same number (17.7%) stopped breastfeeding because of the need to go to work. In addition, at 11.8% of women their disease became the cause, and at 5.7% - fear that the physique, shape of the breast will change.
As a rule, parents have an opinion that the child should be fed with breast milk up to six months. The main reason for the refusal to breastfeed the child in 50.0% of women, who fed up to 6 months, was the lack of milk. The need to go to work led to the refusal of breastfeeding in 21.2% of mothers. Further, the main reason for refusal to breastfeed the women, who fed up to six months, called: mother’s disease-10.5%; refusal of the child from the breast, the child’s disease-5.2%; unwillingness to breastfeed-5.2%; pain associated with the appearance of cracks on the nipples, pumping – 2.7%.
It was found that mothers who fed up to 9 months, the main reason for refusal of breastfeeding was also the lack of milk, but the proportion of this reason was less and amounted to 37.1%. In addition, at 20.6 per cent of women the main reason was the refusal of the child from the breastand 18.6 per cent of mothers wanted to continue breastfeeding. 12.4% of women stopped feeding due to the need to go to work, due to illness of the mother - 2.8%; due to pain associated with the appearance of cracks in the nipples, pumping-2.8%; for other reasons – 5.7%.
Mothers who continued breastfeeding until the child reached the age of one gave only three reasons why they stopped breastfeeding. More than half of the respondents named lack of milk as the main reason (51.2%). The need to go to work caused the need to stop breastfeeding in 29.4% of women, the refusal of the child from the breast–in 19.4%.
Thus, regardless of the period, the main reason for refusal to breastfeed the child was the lack of mother’s milk, the specific weight of which was the maximum to 6 and 12 months.
Health groups are a certain scale that evaluates the health and development of the child, taking into account all possible risk factors, with a forecast for the future. The copy of the form 112/u “History of child development” revealed that, in general, children in the study group were divided into health groups as follows: group I (healthy children) - 31.2%; group II (almost healthy children) - 48.5%; group III (children with chronic diseases in the compensation stage) - 15.4%; group IV (children with chronic diseases in the subcompensation stage) - 3.9%; group V (children with chronic diseases in the stage of decompensation) - 1.0%. Accordingly, 79.2% of children were healthy and practically healthy (I and II groups of health); children with chronic diseases (III, IV and V groups) - 20.3%.
The analysis of the dependence of the proportion of healthy children on the duration of breastfeeding showed the presence of a direct strong correlation (correlation coefficient 0.96). The analysis of the relationship between the duration of breastfeeding and the proportion of children with chronic diseases revealed the presence of a strong feedback (correlation coefficient -0.96). Thus, with increasing duration of breastfeeding increases the proportion of healthy children and decreases the proportion of children with chronic diseases. The distribution of children according to health status according to the duration of breastfeeding is presented in table 2.
Table 2
Distribution of children according to the assessment of health status depending on the duration of breastfeeding (in % of the total)
Evaluation of frequency of acute diseases of the child (ARI, acute respiratory infections and colds) in the first year of life, according to medical records showed that 28.1% of the children had virtually no illness,30.7 percent were sick 1-2 times, 3-5 times – 29.7%, more than 5 times - 11.5%. The average number of cases of acute diseases per year was 2.2±0.07 times.
The analysis of the relationship between the duration of breastfeeding and the average number of cases of acute diseases in a child in the first year of life, showed the presence of a strong inverse correlation (correlation coefficient -0.97). Thus, with the increase in the duration of breastfeeding, the frequency of acute diseases in the child is significantly reduced. The effect of breastfeeding duration on the incidence of acute illness in a child in the first year of life is presented in table 3.
Table 3
Effect of breastfeeding duration on the incidence of acute diseases in a child in the first year of life (number of cases per year)
From medical records it was found that the patronage in the first 2-3 days was at 96.2% of the respondents, was not at 3.8%. 100% of the respondents of those who had patronage received recommendations on breastfeeding from the medical worker of the children’s clinic. Consequently, the number of actual primary patronages did not coincide with those indicated in the medical records.
Conclusions:
1. About 80% of the children were breastfed immediately after birth and more than half of the women in the obstetric hospital planned to continue breastfeeding for up to one year (average 12.1 ±0.08 months). However, the actual feeding time was much lower (average 7.3±0.09 months).
2. The main reasons for the refusal of natural feeding in women with children under the age of one year were: the lack of milk, the refusal of the child from the breast and the need to go to work. In addition, more than 11% of respondents refused to breastfeed because of the reluctance to continue breastfeeding, which is an indicator of the poor performance of health workers in children’s clinics to support breastfeeding.
3. There is a relationship between the objective health of the child and the duration of breastfeeding. The longer a child receives breast milk, the greater the proportion of healthy children, the lower the proportion of children with chronic diseases, and the lower the incidence of acute diseases in a child in the first year of life are.
4. It was found that all respondents received advice from a neonatologist in obstetric organizations, and by 10% of children were not covered with primary care of newborns.
In general, the work of health workers in children’s clinics in support of breastfeeding was higher than that of neonatologists in obstetric hospitals (4.1±0.09 points versus 3.9±0.08 points). However, recommendations on breastfeeding from health workers in children’s clinics received 14.5% fewer women than from neonatologists in obstetric hospitals.
V.K. Yuryev info@vak24.ru
