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Exclusive breast-feeding (EBF) rates remain low despite numerous health benefits associated with this behavior. We conducted a randomized trial on the effect of lactation counseling on EBF, which controlled for the Hawthorne effect while also varying the timing of the intervention. Pregnant women attending prenatal clinics in Tema were randomly assigned to 1 of 2 intervention groups (IG) or to a control group (C), as follows: 1) EBF support given pre-, peri-, and postnatally (IG1; n - 43); 2) EBF support given only peri- and postnatally (IG2; n = 44); or 3) nonbreast-feeding health educational support (C; n = 49) that had an equal amount of contact with lactation counselors. Two educational sessions were provided prenatally, and 9 home follow-up visits were provided in the 6-too postpartum period. Infant feeding data were collected monthly at the participant's home. The 3 groups did not differ in sociodemographic characteristics. At 6 mo postpartum, 90.0% in IG1 and 74.4% in IG2 had exclusively breast-fed during the previous month. By contrast, only 47.7% in C were doing so (P - 0.008). Similarly, the percentage of EBF during the 6 mo was significantly higher (P - 0.02) among IG1 and IG2 (39.5%) than among C (19.6%). The 100% increase in EBF rates can be attributed to the lactation counseling provided. Additional prenatal EBF support may not be needed within a context of strong routine prenatal EBF education. J. Nutr. 135: 1691-1695, 2005. KEY WORDS: * exclusive breast-feeding * lactation counseling * Hawthorne effect * Ghana

Background: Global recommendations on optimal maternal and child nutrition (MCN) practices are clear; however, there is limited literature 1 ) exploring how roles of family members influence those practices and on 2 ) designing programs accordingly. Researchers using a family-systems approach in the Global South find that grandmothers often play a vital role in MCN, yet most nutrition programs narrowly target mothers, thereby potentially limiting effectiveness., Objectives: This article reports on the results of qualitative research exploring the roles and influence of family members on MCN in southern Sierra Leone, the local MCN beliefs and practices, and how those findings informed the design of a culturally appropriate program., Methods: Focus group discussions (FGDs) were conducted with mothers, fathers, and grandmothers in 9 communities in Bonthe District, Sierra Leone. We used participatory tools to explore family members' roles and local MCN beliefs and practices. Interviews were recorded by notetakers and coded and analyzed using a content analysis approach., Results: A total of 88 mothers, 125 grandmothers, and 79 fathers participated in the FGDs. All groups indicated that 1 ) grandmothers are the culturally designated advisors and supervisors of women on MCN issues and 2 ) mothers are not autonomous decision makers and are greatly influenced by grandmothers. The research identified both beneficial MCN practices and gaps between optimal and existing MCN practices-particularly related to maternal diet during pregnancy and exclusive breastfeeding for 6 mo. Research findings were used to design a grandmother-inclusive program., Conclusions: Our research showed that mothers are embedded in a family system of caring and supervision where grandmothers have primary influence on MCN practices, clearly supporting the need for grandmothers to have a central role in community MCN programs. It also points to the need for increased use of a family-systems approach in designing public health nutrition programs., (Copyright © The Author(s) 2019.)