Lack of family inclusion linked to reduced impact of UNICEF’s 10 Steps to Breastfeeding (The Congo)


The World Health Organisation has recently declared that engaging fathers is important for maternal and newborn health. This applies to breastfeeding. Is the time now right to review UNICEF’s Ten Steps to Successful Breastfeeding? The need to tackle family inclusion in this area has been brought to light in research published this month.

UNICEF’s Ten Steps are specified without reference to fathers or family:

  1. Having a written breastfeeding policy that is routinely communicated to all health-care staff.
  2. Training all health-care staff in skills necessary to implement this policy.
  3. Informing all pregnant women about the benefits and management of breastfeeding.
  4. Helping mothers to initiate breastfeeding within 30 min of birth.
  5. Showing mothers how to breastfeed and maintain lactation, even if they are separated from their infants.
  6. Giving newborn infants no food or drink other than breastmilk, unless medically indicated, and not accepting free or low-cost breastmilk substitutes, feeding bottles, or teats.
  7. Allowing mothers and infants to remain together 24 h per day.
  8. Encouraging breastfeeding on demand.
  9. Giving no artificial teats or pacifiers to breastfeeding infants.
  10. Fostering the establishment of breastfeeding support groups and referring mothers to them on discharge from a hospital or clinic.

Giving families information but not discussing it with them linked to reduced breastfeeding rates in a controlled trial

A controlled trial in The Congo, reported in The Lancet this month by Dr Marcel Yotebieng (Ohio State University) and colleagues, compared two programmes: delivery of UNICEF’s steps 1-9 only and delivery of all 10 steps plus distribution of printed information to mothers (only) just after birth and during postnatal clinic visits: “flyers containing locally developed materials with culturally appropriate messages addressing behaviours identified in a pretrial survey as the main contributors to suboptimum breastfeeding practices (such as giving the baby water in the first 6 months of life), in French (the official language of DR Congo) and Lingala (the main spoken language in Kinshasa)”.

The addition of step 10 and printed material reduced breastfeeding rates compared to just steps 1-9:

  • Breastfeeding at 14 weeks: control / steps 1-9 / steps1-10 with info = 29 / 65 / 42%
  • Breastfeeding at 24 weeks: control / steps1-9 / steps1-10 with info = 12 / 46 / 33%

The authors discuss what might explain this decrease. One explanation proposed is a negative influence from the family:

“Engagement of family members might have led to misunderstandings or incorrect advice that were not sufficiently countered by group counselling from nurses during well-child visits. This theory is at least partly evident because the PRs comparing the steps 1–10 and control groups at 6 months was larger and significant when the analysis was restricted to mother–infant pairs who attended well-child clinics. Good breastfeeding practices might also have been inappropriately changed by engaged family members in the steps 1–10 group.”

The article stops short of recommending engagement with the family, leaving family defined as part of the problem, not part of the solution.


Yotebeing M et al (2015), Ten Steps to Successful Breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trial, The Lancet

Photo: David D. Creative Commons.