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Midwifery (2010) 26, e6 – e13
Incorrect advice: the most signiﬁcant negative determinant on breast feeding in Malta
Simon Attard Montalto, MBChB, MD (L’pool), FRCP, FRCPCH, DCH (Professor)a,Ã, Helen Borg, RM, BSc (Infant Feeding Specialist Midwife)b, Mary Buttigieg-Said, SRN, RM, Dappsocst (Practice Development Midwife)b, Edward J Clemmer, BA, MS (R), PhD (Medical Statistician)c
Department of Paediatrics, St. Luke’s & Mater Dei Hospitals, Malta Breastfeeding Counselling Unit, Department of Midwifery, St. Luke’s & Mater Dei Hospitals, Malta c The Medical School, University of Malta, Msida, Malta
E-mail address: email@example.com (S. Attard Montalto).
Received 25 October 2007; received in revised form 7 June 2008; accepted 15 June 2008
Abstract Objective: this study reviewed breast-feeding rates in Malta for the ﬁrst six months of life and identiﬁed reasons why mothers discontinue breast feeding in this small island state. Design and participants: a random sample of 405 new mothers who chose to breast feed in the only major state hospital were contacted by phone one week postnatally and again each month up to six months, and presented with a questionnaire relating to their feeding experience. Findings: breast-feeding attrition rates were high with just 152 (38%) of 403 analysable babies still breast feeding at six months. The reasons for stopping breast feeding were categorised by: maternal choice; medical reasons; lack of information; social reasons, incorrect advice and no reason provided. 200 (50%) of the total cohort stopped breast feeding following incorrect advice from health professionals. Just 14 (3.5%) and 17 (4.2%) mothers stopped as a result of their own choice or a medical problem, respectively. Of the total of 403, 77 (19%) mothers introduced supplementary bottle feeds in hospital; of these, 70 (91%) stopped breast feeding altogether soon afterwards. This compared with just 180 (55%) of 326 women who did not introduce bottle feeds in hospital yet subsequently discontinued breast feeding (po0.001). Key conclusions: many health professionals in Malta are not sufﬁciently committed to supporting breast-feeding mothers, and artiﬁcial feeds are widely recommended without any scientiﬁc-based rationale. Incorrect advice on breast feeding is often given early prior to discharge from hospital. As a result, many Maltese mothers introduce supplementary artiﬁcial milk feeds in hospital, and this is signiﬁcantly associated with subsequent cessation of breast feeding within six months of discharge. Implications for practice: the introduction of a clear hospital breast-feeding policy and appropriate education for all health professionals involved in maternity care is strongly recommended. & 2008 Published by Elsevier Ltd. Keywords Incorrect advice; Breast feeding
0266-6138/$ - see front matter & 2008 Published by Elsevier Ltd. doi:10.1016/j.midw.2008.06.002
. Care was taken to ensure that any mother whose baby may have died/was stillborn was not enrolled into the study. whilst complete anonymity was 100 90 80 70 60 50 40 30 20 10 0 U K ly n ce ta al M d w ay an ni ai Ita an ua Po l Sp N or th Ire Fr la nd a percentage of live births Fig. 2005). 2003). Luke’s with 890 beds in 2004–5). 1998 ¼ 4488. 2001. Luke’s Hospital. 1990. 2002). mode of birth. Taveras et al. 2001. 2001. Leon-Cava et al. Most mothers who stop breast feeding do so within the ﬁrst few weeks after birth (Colin and Scott. Methods Participants At the time of the study. Despite unequivocal beneﬁts supporting breast feeding over artiﬁcial milk feeds (Ball and Bennett. and this situation is no different in Malta. this ﬁgure rose to 56% in 2000 and to 61% in 2006. 2001. is likely to have a signiﬁcant impact on future attrition rates in breast feeding. 45% of Maltese mothers were breast feeding (exclusively or mixed feeding) at the time of discharge from St. 1). and this subgroup was just 17% in 2006 (National Obstetric Information and Statistics. 2001. Picciano. 2001. Table 1 Institution Li Percentage of mothers breast/mixed feeding in Malta and Gozo. 2002). Luke’s Hospital (state) Gozo hospital (state) Private hospitals National rate 81 9 10 100 45 29 55 45 Ã Total live births: 1995 ¼ 5234. Furthermore. 2001). Luke’s Hospital during the period June 2004 to March 2005. parity and number of babies. Luke’s Hospital was the only large state hospital in Malta and catered for approximately 80–90% of all deliveries. in Malta as elsewhere (Meek. totalling 3500–4000 per annum. Whilst in 1995. in order to highlight the more important and potentially remediable problems. nationality. 2005. 2006 ¼ 3857. This study was designed to review the reasons for cessation of breast feeding in Malta within the ﬁrst six months after birth. only 18% of Maltese mothers were still exclusively or partially breast feeding nine months after birth. St. Malta retains one of the lowest rates for breast-feeding initiation in Europe (Fig. encouragement and attitude of staff toward mothers whilst still in the hospital. The choice of feeding was left entirely up to each individual mother. 1995–2007). Data were collected on maternal age. mo ¼ month.. Cattaneo et al. and only those who indicated that they had chosen to breast feed were invited to enter the study prospectively. social class. Reynolds. and the instruction. A sample of every fourth new mother who chose to breast feed was selected sequentially after they gave birth in St. and had one major national hospital (St. 2005). in 2001. Heinig. Malta is a small island state in Europe with a population of 402. 2000 ¼ 4205. Verbal consent was obtained prior to enrolment. It has yet to achieve the Ten Steps toward the Baby Friendly Hospital Initiative (BFHI).. Total births (%) 1995Ã 3 days 1 mo 20 15 45 22 1998Ã 3 days 46 31 64 47 1 mo 26 19 51 28 2000Ã 3 days 56 35 75 56 1 mo 31 22 55 33 2006Ã 3 days 61 37 77 60 1 mo 33 25 57 35 St.ARTICLE IN PRESS Incorrect advice: the most signiﬁcant negative determinant on breast feeding in Malta e7 Introduction Many countries including Malta are not yet compliant with the WHO/UNICEF declaration and global strategy in support of breast feeding (1989.000. There is a steady decrease in breast feeding even in countries with initial high rates of breast feeding (Cattaneo et al. 1 Breast-feeding rates at outset in selected European countries. Labbok. a small general hospital on the sister island of Gozo and three small private hospitals. 2002). Although recent reports have suggested a slow but steady improvement in breast-feeding initiation locally (Attard Montalto. this upward trend has not continued over the past three years (Table 1). (Naylor.
with 403 successfully completing the six month study. 1650 (53%) chose to breast feed. An explanatory deﬁnition for each category is presented in Table 2. parity and number of babies between the groups. artiﬁcial milk. analysed the likelihood of discontinuing breast feeding altogether within the six month study period. Furthermore.6% had singleton pregnancies. All 405 mothers had given birth to live. as there was no signiﬁcant difference in maternal age. incorrect advice and no reason. median 29). events impacting on feeding practice. Statistical analysis Attrition rates for breast feeding were analysed using non-parametric univariate Kaplan–Meier survival curves where the number of subjects who persisted with breast feeding (the ‘survivors’) was compared at the designated study time intervals between the study groups.ARTICLE IN PRESS e8 respected and all subjects were free to exit the study without justiﬁcation at any stage. The latter were analysed and could be grouped into the following arbitrary but tightly deﬁned categories: maternal choice. or earlier if breast feeding was discontinued (i. mode of feeding (breast. Data collection All those entered into the study were contacted by phone at one postnatally and then again every month up to six months. mode of birth. 14. Of these. Explanatory deﬁnition Breast feeding stopped due to mother’s own personal choice.0 for Windows. reasons for discontinuing breast feeding. 4. namely: mode of birth and birth experience. Findings A total of 3124 mothers with an age range of 14–46 years (mean 28. incorrect advice. independent of any external inﬂuence Breast feeding stopped following advice based on the medical condition of the mother or infant Breast feeding stopped as a result of mother’s concerns or misconceptions without consultation for professional advice Breast feeding stopped after social pressure/inﬂuence from relatives and/or society. 18. the study compared all mothers who had introduced any supplementary bottle feeds with those who breast fed exclusively prior to discharge. and no reason. where appropriate. Attard Montalto et al. of whom 94% were Maltese nationals. 52% primigravidae and 98. medical reasons. S. applied to compare the curves. They were asked to provide details relating to the birth and their feeding practice. time interval to ﬁrst breast feed. against mother’s personal choice Breast feeding stopped after advice from health professionals with no scientiﬁc basis. Details of these replies are listed in Table 3. medical reasons. lack of information. taking pp0. and. at time 0. lack of information. 22 and 26 weeks). 99% Maltese. of those. mixed). The study group was representative of the total 1650 who chose to breast feed as well as the 3124 mothers who delivered during the recruitment period. just two declined to participate after entry. mean and median 29 years. and every fourth mother up to a total of 405 (aged 19–42. 51% primigravidae and 100% singleton pregnancies) were invited to enter the study. Table 2 Category Detailed explanation of study categories.e. using SPSS 15. 1. surviving babies and. social reasons. for these two groups. The comparative likelihood for discontinuing breast feeding between those who gave supplementary feeds and those who did not was analysed using w2. advice received relating to breast feeding. nationality. 8.05 to represent signiﬁcance in all analyses. The log-rank test was Reasons for discontinuing breast feeding The reasons for stopping breast feeding over the six month study were analysed and divided into the six groups: maternal choice. delivered during the 10month study period. social reasons. and. clear misconceptions and incorrect presumptions Breast feeding stopped without any explanation given Maternal choice Medical reasons Lack of information Social reasons Incorrect advice No reason . no clinical evidence-based reasoning. There was no difference in mean age. social class.
usually without any medical indication. although few mothers stopped breast feeding due to medical complications. On analysing the attrition rates by ‘underlying cause’. Half of the entire study cohort. social class. parity and number of babies between the six groups. 2 ¼ pressure of other children. 3 ¼ more calories in formula milk 6 ¼ advised to stop by relatives/family. however. Just 14 (3. nationality. eight (2%) due to lack of Information. 2 ¼ altered social circumstances 15 ¼ told breasts too small. 500 400 number 300 200 100 0 0 1 4 8 14 18 study time point (weeks) 22 26 (4. po0. those mothers who stopped through their own choice tended to do so toward the end of the study period. 4 ¼ decided ﬂow inadequate Infant: 2 ¼ required urgent surgery overseas Mother: 11 ¼ breast complications (e.6%) was on the incorrect advice of health professionals. 3. they did so very early after the birth. 1 unconﬁrmed ‘anaemia’).7%) were still breast feeding at six months. 1 ¼ unrelated medical disease. from the initial 403 subjects.f. those who did not seek advice or support (lack of information) also discontinued breast feeding relatively early. still breastfeeding stopped for other reasons stopped due to incorrect advice Differences in attrition rates by cause at different time points As shown in Figs. just 152 (37. d. cracked nipples. 3 ¼ depression Opted to discontinue (but did not seek advice): concerns/ misconceptions included: 1 ¼ previous breast feeding failure. 9 ¼ poor weight gain (not validated). mode of birth.5%) mothers discontinued breast feeding due to maternal choice. and the attrition rate of this group was distributed across the study period with a plateau toward the later phase. eight (2%) for social reasons and four (1%) for no reason. Similarly. Breast-feeding attrition rates were high. 2 ¼ infant colic 4 ¼ no reason provided e9 Replies by category Maternal choice Medical reasons Lack of information 8 Social reasons Incorrect advice 8 200 No reason 4 Ã One hundred and ﬁfty-two women continued to breast feed until the study end point at six months.001). 139 ¼ insufﬁcient amount of milk. and all bar one had stopped by eight weeks. 1 ¼ on special ‘incompatible’ diet. ¼ 1. 15 of 17 women in this category had stopped breast feeding by the ﬁrst week. stopped after receiving incorrect advice. 3 ¼ engorgement only relieved by stopping. incorrect advice was the most signiﬁcant factor that correlated with the overall decrease in breast feeding over the study period (po0. The attrition in breast feeding for each individual group is shown on the Kaplan–Meier curve in Fig. In contrast. 21 ¼ maternal illness (20 mild mastitis. difﬁculties ‘latching on’). 5 ¼ maternal antibiotics (not contraindicated). The difference in attrition rates between the groups and those who continued breast feeding was highly signiﬁcant (w2 ¼ 301.2%) for a valid medical reason.ARTICLE IN PRESS Incorrect advice: the most signiﬁcant negative determinant on breast feeding in Malta Table 3 Reasons for stopping breast feeding. Fig. 2 and 3. 2 Breast-feeding attrition due to incorrect advice vs other reasons.g. 9 ¼ milk of ‘poor quality’ (no evidence). with four stopping at the halfway mark and 10 stopping by six months. 17 . 2. the most common reason for introducing artiﬁcial feeding in 200 babies (49. Number (total 403Ã) 14 17 Breakdown of replies 8 ¼ work commitments. As shown in Fig.001).
po0. 77 (19. a ﬁgure well below the Healthy People 2010 goal of 50% at six months. 326 (80. The reasons given for discontinuation of breast feeding were categorised into six groups that highlighted some interesting trends. these generally presented soon after birth or may have had a signiﬁcant impact on maternal health.001 Total 403 152 Practice prior to discharge Breast feeding at discharge Breast feeding at six months Relationship of discontinuing breast feeding with supplementary feeds in hospital Finally.1%) had introduced supplementary bottle feeds prior to discharge from hospital. Attard Montalto. Exclusive breast feeding 326 145 Supplemented breast feeding 77 7 w2 ¼ 32. Discussion Breast-feeding rates in Malta have been relatively low since records have been collected over the past 15 years. Hence. although few mothers stopped breast feeding due to medical complications. from the total of 403 breast-feeding mothers. 3 Survival functions. this improvement is not sustained.9%) mothers breast fed exclusively whilst in hospital and 181 of those subsequently stopped breast feeding. Hence. The likelihood of subsequently stopping breast feeding was signiﬁcantly greater in those who introduced supplementary feeds whilst still in hospital (w2 ¼ 32. as reported by the mothers themselves. By their very nature. Although more recent national statistics would suggest an increasing trend in the ﬁrst month after birth (National Obsteric Information and Statistics. 001. although the national current rate of breast feeding at hospital discharge is around 60%. this study has reported that just 38% of babies were still breast feeding at six months. 2002). the study questionnaire conﬁrmed that. po0. In contrast. Table 4 Breast-feeding attrition related to exclusive or supplemented breastfeeding in hospital. of those. regardless of the reason given for stopping breast feeding (Table 4). 1995–2007. these did so relatively early after the birth. The reasons for this stubbornly low rate is probably multifactorial and this study was designed to explore these reasons in the ﬁrst six months after birth. This was not surprising as most of the medical complications were related to problems with the breasts and signiﬁcant systemic medical and/or surgical disorders in the baby or mother. Attard Montalto et al.ARTICLE IN PRESS e10 S. Table 4). either way . Fig. 70 admitted to ‘lacking in conﬁdence’ and discontinued breast feeding within the six month study period.
2005. this postpartum advisory role is presently shared amongst postnatal obstetric staff..and out-of-hospital paediatricians and community midwives/nurses. In contrast. Historically.) is solely responsible. the converts to artiﬁcial feeding from the 1950–1980 era are now grandmothers. this was ‘justiﬁed’ by ‘inadequate weight gain’ although. addressing and eliminating this single misconception alone would signiﬁcantly increase breast-feeding rates in this group fourfold. the majority of these health professionals are not providing appropriate postpartum advice. The current negative attitude to breast feeding by those expected to be its strong proponents is of concern. Furthermore. in.g. this study. marital status. this study has clearly shown that. presumably as they represented a relatively unmotivated subgroup with an increased likelihood ‘to give up’. This. and no single ‘unit’ (e. locally. those mothers who stopped ‘by choice’ tended to do so toward the end of the six month study period. 2005). However.. In Malta. ward staff. (1998). if possible. multiparity. health authorities and the Catholic Church. therefore. breast feeding has been supported in the Maltese islands since prehistory with evidence of cults dedicated to suckling and use of wet nurses dating to several centuries BC (Savona-Ventura. In the ‘incorrect advice’ group. 1990). 2005). analyses of the reasons that staff provided to ‘justify’ discontinuation of breast feeding (Table 2) would suggest a lack of a uniﬁed educational programme. sustained communication. smoking and incorrect advice including ‘insufﬁcient milk’ (Savona-Ventura and Grech.3% (Savona-Ventura and Grech. McCann et al. 1884.. Further discouragement for new mothers comes from a still-prevailing cultural distaste for breast feeding in public. changing attitudes toward the woman’s role in society and women entering the workforce. whilst wet nursing and midwifery were promoted in preference to artiﬁcial feeds if direct feeding at the breast was not possible. This practice continued to be strongly encouraged throughout the 18th. Importation of condensed milk to Malta commenced in 1905 and escalated by the 1950s. Manche. Similarly. together with signiﬁcant social upheaval. 2000). employment. that the trend toward artiﬁcial feeds has prevails despite advice to the contrary and those in favour of breast feeding being eminent medical doctors. 1990). 2004. community services. 2001). Others have shown that successful and sustained breast feeding is dependent on education. primary doctor. access to appropriate advice postnatally (Deshpande and Gazmararian. It is not surprising. exclusive breast feeding was encouraged for at least nine months (before weaning) and. mothers who did not seek advice or support also discontinued breast feeding by 12 weeks. and include information on the beneﬁts and possible contraindications of breast milk. 148 of 200 women reported that they were instructed to stop breast feeding due to ‘insufﬁcient or poor quality milk’. etc. 2004). Those who stopped after receiving incorrect advice from health professionals amounted to half of the entire group. Laberere et al. inaccuracies and inconsistent advice on their behalf. and possibly augmented by a peer-support group (Ingram et al. 2002). resulting in the cessation of breast feeding in 50% of the study cohort. like Humenick et al. Taveras et al.. importantly. 2007). In addition. this suggests a general lack of support for breast feeding in the workplace. Indeed. 1998. Indeed. This suggests that poor advice is being given consistently at all time intervals after birth. Hence. and sustained pressure from milk companies whose inﬂuence on the public and health professionals remains strong... a critical determinant for successful breast feeding after 3 months or longer (Meek. the . attendance at antenatal classes and. primary doctors. although problems attributed to the mothers’ milk are very commonly offered to justify discontinuing breast feeding (Colin and Scott. 2005). At all times. for the ﬁrst year (Borg.ARTICLE IN PRESS Incorrect advice: the most signiﬁcant negative determinant on breast feeding in Malta increasing the chances of early weaning off the breast. 1911). these instructions could not be validated on assessing case notes. From the 1950s until the 1980s. and retain their antipathy for breast feeding. As many in this group stopped breast feeding due to work commitments. and perils of artiﬁcial feeding. Unfortunately. midwives. has conﬁrmed the importance of establishing breast feeding in hospital as those mothers who introduced supplementary bottle feeds prior to discharge (regardless of the frequency) were far more likely to discontinue breast feeding altogether before the six month study endpoint. in all cases. genuine problem cases are extremely uncommon (Amir and Cwikel. but the attrition rate of this group was evenly distributed over the study period. encouragement and support for the mother would appear to be critical for successful breast feeding (Humenick e11 et al. resulted in a signiﬁcant shift toward ‘more convenient’ artiﬁcial milks for baby feeding and an initial breast-feeding rate of just 19. artiﬁcial feeding predominated and was associated with lower social class. Occasionally. The latter may be provided during routine community-based postnatal preventive visits run by a doctor or trained counsellor (Graffy et al. 19th and 20th Centuries where much published data exist.
. this programme would need to be applied to all health professionals and at all stages in breast-feeding management. Breast-feeding education and support: association with the decision to breast-feed. 2005. 2000.patho. 2001.. 1884.. Pediatric Clinics of North America 48. Williams. breast-feeding rates are low if the majority of health professionals are not sufﬁciently committed to supporting breast-feeding mothers.. A. randomised. 26. Moreover. open trial of 226 mother-infant pairs. Humenick. Pediatric Clinics of North America 48. Host defence beneﬁts of breastfeeding for the infant: effect of breastfeeding duration and exclusivity. community-based initiative to ensure a ‘breast-feeding friendly’ workplace. this problem could be eliminated with relative ease through an educational training programme for professional staff (Ekstro ¨m et al. National Obstetric Information and Statistics: Quarterly and Annual Reports.. 2003). 105–124. often based on a lack of education.B. Why do women stop breastfeeding? A closer look at ‘not enough milk’ among Israeli women in the Negev region. 9. 2004). Journal of Human Lactation 14.ARTICLE IN PRESS e12 predominant religion in the country (SavonaVentura. Breastfeeding in the workplace. L. 1998. The economic impact of breastfeeding. Nutrient composition of human milk.. 2006). Pediatric Clinics of North America 48. Infant feeding in Malta. F.Y. Labbok. 37–40. Pediatric Clinics of North America 48. Meek. Protection. C Busuttil. Mard ﬁt-trabi. 353–359. 2006. Nevertheless.. Cwikel.. J.M. 141–143. this needs to be combined with a serious. Conclusion This study highlights that. 2004. 143–158. J. 2001. Picciano.M. this study would suggest that the campaign still has some way to go before Malta attains breast-feeding rates comparable to other European countries. Breastfeed Review 10. Attard Montalto.. 1911.. Proprint Ltd. S. Notwithstanding. this could translate into breast-feeding rates from the current 38% to 90% at six months. Savona-Ventura. et al. J. is of critical importance as a determinant of breast-feeding rates. Baby Friendly Hospital Initiative: protecting. Scandinavian Journal of Public Health 33. Naylor.htmS. Breastfeeding in Malta: a review. Breastfeeding peer supporters and a community support group: evaluating their effectiveness. Breastfeeding attitudes and reported problems in a national sample of WIC participants.A. that is more difﬁcult to implement). Ekstro ¨m. R. A.. even in a small country with easy access to the population such as Malta. Breast versus bottle. Effects of breastfeeding on the mother. 7–13. J... 475–484. Heinig.. A.P.M. Ingram. Midwifery 19. 53–67. Kelmtein fuq is-sahha tal ulied.. Leon-Cava. Attard Montalto et al. Deshpande. Breastfeed Review 13. et al.F. International Breastfeeding Journal 28. 2004. this exercise could potentially improve the low national rates of breast feeding by an additional 50%.... promoting and supporting breastfeeding in the twenty-ﬁrst century. J. et al.J. Effects of Clinical Practice 3. Malta. Pan American Health Organisation. Washington. Cattaneo.H. Breastfeeding: reasons for starting.J. Finally. 2003. Bennett.. 461–474. The introduction of a clear hospital policy and compulsive education for all health professionals involved in maternity care within the framework of the BFHI is urgently required. A. Ingram.. Malta Medical Journal XIII. N... Maternal Child Nutrition 1. This study has clearly shown that incorrect advice from health professionals. 2001.. Pediatric Clinics of North America 48. Reynolds. Pediatric Clinics of North America 48... preventive visit: a prospective. M.. 2005.S. Moghdija taz-zmien 110. . Quantifying the Beneﬁts of Breastfeeding: A Summary of the Evidence. 305–310. Randomised controlled trial of support from volunteer counsellors for mothers considering breast feeding. A. C. promotion of breastfeeding in Europe: current situation. Journal of Psychosomatic Obstetrics and Gynaecology 11. 2005... et al. C. Multi-professional training for breastfeeding management in primary care in the UK...S. which would not be particularly difﬁcult to set up in Malta. R. 2005. 2001. 2002. L.L. Public Health Nutrition 8. D.. E.. 45–48. Breastfeeding and health professional encouragement. M. 2001.. Savona-Ventura. Manche. /http://www. Association for the Study of Maltese Medical History. N. et al. et al. 39–46. J.. 2005. Malta.. DC. 314–324. et al. J. W.. Cantrill.. M. It has only started to reverse following a national multi-stakeholder educational campaign since the early 1980s to promote breast feeding... this study has shown that if this measure was combined with a serious exercise in improving support for breast-feeding in the workplace (admittedly. 2001. BMJ 328. Borg. Grech. Laberere. Division of Health.H. 2005.F. Graffy. 1990. org/English/HPP/HPN/Beneﬁts_of_BF. Pediatrics 115. Colin. 253–262. 2007. 159–172. Breastfeeding and brain development. Breastfeeding attitudes among counselling health professionals. Efﬁcacy of breastfeeding support provided by trained clinicians during an early.A. 13–19. S.D. Journal of Human Lactation 23.. M. 111–118. reasons for stopping and problems along the way. Scott. Malta.. 107–117. Pediatric Clinics of North America 48. 2002. 2001. As highlighted by this study. routine. J. et al. given the small size of the country (122 square miles) with easy access to the great majority of the population. References Amir. T. Gazmararian. S. 1995–2007. An Australian study of midwives’ breast-feeding knowledge.. Ball. 310–317.. A History of Infant Feeding in Malta. 2002. Baydar. 139–146. McCann. Ingram. Although improved knowledge is not necessarily associated with breast-feeding promotion (Cantrill et al.
.br/inno. Global Strategy for Infant and Young Child Feeding. 1 August /http://www. Protecting. Italy.htmS WHO/UNICEF. Geneva /http://www. et al. 405–411. 2005. E.htmS. Mothers’ and clinicians’ perspectives on breastfeeding counselling during routine preventive visits. 2003.org. 1989. The Innocenti Declaration on the Protection. Florence..M. Promotion and Support of Breastfeeding. e13 WHO/UNICEF. World Health Organization. promoting and supporting breastfeeding: the special role of maternity services: a joint WHO/ UNICEF statement. World Health Organization. 1990.. Pediatrics 113.org/newsline/tenstps.ARTICLE IN PRESS Incorrect advice: the most signiﬁcant negative determinant on breast feeding in Malta Taveras. Geneva.waba. WHO.unicef.