Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review

A qualitative analysis of women's postnatal experiences of breastfeeding supports during the perinatal period in Ireland

Ireland has among the lowest rates of breastfeeding worldwide. Despite policies to support breastfeeding, breastfeeding initiation and exclusivity remain low in Ireland. Greater knowledge about support received in the maternity unit may-in part-shed light on why this is so. Our aim was to analyse women's experiences of the breastfeeding supports available in the early postnatal period in Ireland. We conducted an analysis of an open-ended question on a cross-sectional survey about breastfeeding support conducted in the Republic of Ireland in 2022. Participants were asked to provide comments about the breastfeeding support they received in the maternity unit or during your home birth. Data were analysed using Braun and Clarke's six-step Thematic Analysis Framework. There were 5,412 unique responses to the survey and 2,264 responses to the question of interest. Two themes were generated from the data: (i) 'Breastfeeding support in theory but not in practice.' Although breastfeeding was promoted by healthcare professionals antenatally, breastfeeding challenges were rarely mentioned. Participants then felt unsupported in overcoming challenges postnatally. (ii) 'Support was either inaccessible due to lack of staff/time, inadequate; i.e., unhelpful or non-specific, and/or physically inappropriate.' Most participants described receiving supports that were less than optimal in aiding them to establish breastfeeding. While many described difficulties in accessing supports, others found support to be 'non-specific,' 'rushed' and sometimes 'rough.' A lack of knowledge, time and support from healthcare professionals was frequently described, which was often recognised as a failing of the healthcare system. Women require practical, informative, and specific breastfeeding support. Barriers such as lack of time and trained staff in the maternity unit need to be addressed.

The contributions of parental lactation on offspring development: It's not udder nonsense!

The Developmental Origins of Health and Disease (DOHaD) hypothesis describes how maternal stress exposures experienced during critical periods of perinatal life are linked to altered developmental trajectories in offspring. Perinatal stress also induces changes in lactogenesis, milk volume, maternal care, and the nutritive and non-nutritive components of milk, affecting short and long-term developmental outcomes in offspring. For instance, selective early life stressors shape the contents of milk, including macro/micronutrients, immune components, microbiota, enzymes, hormones, milk-derived extracellular vesicles, and milk microRNAs. In this review, we highlight the contributions of parental lactation to offspring development by examining changes in the composition of breast milk in response to three well-characterized maternal stressors: nutritive stress, immune stress, and psychological stress. We discuss recent findings in human, animal, and in vitro models, their clinical relevance, study limitations, and potential therapeutic significance to improving human health and infant survival. We also discuss the benefits of enrichment methods and support tools that can be used to improve milk quality and volume as well as related developmental outcomes in offspring. Lastly, we use evidence-based primary literature to convey that even though select maternal stressors may modulate lactation biology (by influencing milk composition) depending on the severity and length of exposure, exclusive and/or prolonged milk feeding may attenuate the negative in utero effects of early life stressors and promote healthy developmental trajectories. Overall, scientific evidence supports lactation to be protective against nutritive and immune stressors, but the benefits of lactation in response to psychological stressors need further investigation.

Impact of the COVID-19 pandemic on infant feeding practices in the United States: Food insecurity, supply shortages and deleterious formula-feeding practices

The coronavirus disease 2019 (COVID-19) pandemic increased food insecurity among US households, however, little is known about how infants, who rely primarily on human milk and/or infant formula, were impacted. We conducted an online survey with US caregivers of infants under 2 years of age (N = 319) to assess how the COVID-19 pandemic impacted breastfeeding, formula-feeding and household ability to obtain infant-feeding supplies and lactation support (68% mothers; 66% White; 8% living in poverty). We found that 31% of families who used infant formula indicated that they experienced various challenges in obtaining infant formula, citing the following top three reasons: the formula was sold out (20%), they had to travel to multiple stores (21%) or formula was too expensive (8%). In response, 33% of families who used formula reported resorting to deleterious formula-feeding practices such as diluting formula with extra water (11%) or cereal (10%), preparing smaller bottles (8%) or saving leftover mixed bottles for later (11%). Of the families who fed infants human milk, 53% reported feeding changes directly as a result of the pandemic, for example, 46% increased their provisioning of human milk due to perceived benefits for the infant's immune system (37%), ability to work remotely/stay home (31%), concerns about money (9%) or formula shortages (8%). Fifteen percent of families who fed human milk reported that they did not receive the lactation support they needed and 4.8% stopped breastfeeding. To protect infant food and nutrition security, our results underscore the need for policies to support breastfeeding and ensure equitable and reliable access to infant formula.

Is the Frequency of Postpartum Breastfeeding Counseling Associated with Exclusive Breastfeeding at Six Months? An Analytical Cross-Sectional Study

Breastfeeding counseling is an essential public health tool in postpartum maternal and infant health. In this study, we aimed to explore the relationship between the frequency of postpartum breastfeeding counseling and the type of feeding outcome at six months. The study design was an analytical, cross-sectional study on mothers of 6-24-month-old children living in Riyadh, Saudi Arabia. We conducted an analysis with descriptive statistics as well as logistic regression models. The findings from our study can be summarized in the following points: First, only 31.9% of the women in our study received postnatal breastfeeding counseling in the first six months after delivery, with the majority receiving fewer than four sessions. Second, there seemed to be a drop in exclusive breastfeeding with time: from 35.3% in the first two months to 29.7% in the second two months and then 20.7% in the final two months. Third, previous exclusive breastfeeding increased the odds of exclusive breastfeeding in the proceeding delivery. Finally, exposure to one or more postnatal breastfeeding counseling sessions increased the odds of exclusive or predominant breastfeeding in the first six months. This study helps to guide decision makers in planning maternal child health services and relevant community-based efforts.

Early initiation of breastfeeding up to six months among mothers after cesarean section or vaginal birth: A scoping review

Background

Early initiation of breastfeeding is important for establishing continued breastfeeding. However, previous research report that cesarean section (C-section) may hinder early initiation of breastfeeding. Despite this, there is currently a lack of literature that examines the rates of breastfeeding after both cesarean section and vaginal birth globally.

Research aims

The objective of this scoping review was to systematically assess the available literature on the rate of early initiation of breastfeeding within the first hour and exclusive breastfeeding up to 6 months after C-section and vaginal birth, as well as any other factors associated with initiation and exclusive breastfeeding.

Methods

We adhered to the PRISMA extension guidelines for scoping reviews in conducting our review. In August 2022, we carried out an electronic database search on CINALH, PubMed, EMBASE, and Cochrane Library, and also manually searched the reference list.

Results

A total of 55 articles were included in the scoping review. The majority of these studies found that mothers who delivered vaginally had higher rates of breastfeeding compared to those who underwent a C-section, at various time points such as breastfeeding initiation, hospital discharge, one month, three months, and six months postpartum. Notably, there was a significant difference in the rate of early initiation of breastfeeding between the two groups. However, at 3 and 6 months after delivery the gap of exclusive breastfeeding rate between C-section and vaginal delivery is narrow. Breastfeeding education, health care providers support, and mother and baby bonding are other factors associate with initiation and exclusive breastfeeding.

Conclusions

The rate of breastfeeding initiation after C-section has remained low to date. This is due in part to insufficient knowledge about and support for breastfeeding from healthcare providers.

Effect of Mobile-Based Counselling on Breastfeeding in Spain: A Randomized Controlled Trial Protocol (COMLACT Study)

PURPOSE

The primary aim of this study is to determine the influence of an intervention in women based on a free mobile application (LactApp^®, Barcelona, Spain) in maintaining breastfeeding (BF) up to 6 months postpartum. The secondary aim is to assess the effect of health literacy (HL) on breastfeeding duration.

METHODS

A multicenter, randomized controlled clinical trial of parallel groups will be carried out. Women will be randomly assigned to each of the parallel groups. In the control group, usual clinical practice will be followed from the third trimester of pregnancy to promote BF. In the intervention group, and in addition to usual clinical practice, the women will use a free mobile application (LactApp^®) from the third trimester to 6 months postpartum. The type of BF at birth, at 15 days and at 3 and 6 months postpartum and the causes of cessation of BF in both groups will be monitored. The hypothesis will be tested using inferential analysis, considering an alpha of 5%. The study protocol was approved by the Clinical Research Ethics Committee of Hospital de la Ribera (Alzira, Valencia, Spain) in February 2021. A per protocol analysis and an intention-to-treat analysis will be performed.

DISCUSSION

This study will identify the influence of a mobile application on improving BF rates. If the application proves effective, we will have a tool with free information available to any user at any time of day, which may be complemented by normal clinical practice and be integrated into our health care system.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05432700.

Breastfeeding friendly pharmacy from pharmacists perspective

<b>Objective:</b> The primary goals of our research were to explore pharmacists’ perception of breastfeeding friendly pharmacy (BFPh) requirements and factors associated with their awareness about these requirements.<br /> <b>Methods:</b> A cross-sectional study design was conducted using a self-administered survey. A convenience sample (n=381) of community pharmacists, was recruited through social media resources. Data were entered and analyzed using SPSS software version 35. The frequency or percentages were used for categorical variables while means and standard deviations were used for continuous variables. Also, linear regression analysis was used to evaluate factors affecting pharmacists’ awareness about BFPh requirements.<br /> <b>Results:</b> The majority of recruited pharmacists were female (n=329, 86.4%), aged between 23 to 30 years of age (78.7%, n=300). The most common steps to describe a pharmacy as a BFPh from the perspective of surveyed pharmacists were training all pharmacy staff to develop the necessary skills (n=239, 62.7%)) followed by informing all pregnant women about the benefits of breastfeeding (n=225, 59.1%)) and having a written policy on feeding infants and young children according to the recommendations of the WHO and in compliance with the international code (n=209, 54.9%)). Furthermore, pharmacists aging 40 years or less showed a significantly higher awareness about BFPh requirements compared to those aging above 40 years (beta=-0.013, p= 0.045). In addition, 37% (n=142) of pharmacists perceived that answering general questions or concerns on general medication intake while breastfeeding babies is their major role in breastfeeding support.<br /> <b>Conclusion:</b> Breastfeeding support is a promising area for promoting professional pharmacy services. Training all pharmacy staff and informing all pregnant about the benefit of breastfeeding are the most common two steps to describe a pharmacy as BFPh. Additionally, the awareness of BFPh requirement was associated with pharmacists age. Future focus should be placed on implementing BFPh project in Jordanian pharmacies, where the steps of this project are modified in line with the capabilities of pharmacies in Jordan within governmental pharmaceutical control.

Interventions and Programs to Promote Breastfeeding in Arabic-Speaking Countries: A Scoping Review

INTRODUCTION

Low prevalence of exclusive breastfeeding in the Arab world is concerning and suboptimal breastfeeding is a leading child health risk factor in several Arab States. Breastfeeding education has the capacity to improve breastfeeding knowledge and practice, thus positively impacting infant and maternal health. The purpose of this review is to identify and examine the impact of breastfeeding promotion interventions across the Arab world.

METHOD

A scoping review of the literature was conducted across seventeen databases for relevant publications published through October 2021 to find studies in Arab countries, that involved breastfeeding as an intervention component. Twenty-one articles met inclusion criteria and were reviewed.

RESULTS

Individual and community based educational interventions offer the opportunity to positively impact the knowledge, attitudes, and practices of breastfeeding in new mothers in Arab countries. Increased breastfeeding has the potential to lead to improved neonate and maternal health. In addition to significant benefits found across individual and community-based interventions in a variety of Arab countries, there is also evidence that interventions that improve the knowledge of health care professionals and/or the practices of a health care system can contribute to subsequent increases in breastfeeding rates.

DISCUSSION

Breastfeeding education is a low-cost and high-impact public health tool that can impact infant and maternal health and potentially increase breastfeeding adherence in the Arab world.

Educating Housekeeping Staff to Encourage a Culture Supportive of Breastfeeding

Latina women breastfeed at high rates immediately postpartum but also frequently introduce formula. Formula negatively affects breastfeeding, and maternal and child health. The Baby Friendly Hospital Initiative (BFHI) has been shown to improve breastfeeding outcomes. A BFHI-designated hospital must facilitate lactation education for clinical and non-clinical personnel. Housekeepers, often the sole hospital employees sharing the linguistic and cultural heritage of Latina patients, have frequent patient interactions. This pilot project at a community hospital in New Jersey investigated Spanish-speaking housekeeping staff's attitudes and knowledge regarding breastfeeding before and after implementing a lactation education program. After the training the housekeeping staff overall had more positive attitudes toward breastfeeding. This may, in the short-term, contribute to a hospital culture more supportive of breastfeeding.

Effects of breastfeeding training programmes for midwives on breastfeeding outcomes: a systematic review and meta-analysis

BACKGROUND

Appropriate breastfeeding training for midwives is necessary to enhance their knowledge, attitude, and practice (KAP). However, evidence surrounding the effects of midwife breastfeeding training programmes is insufficient to draw a conclusion of its effectiveness on breastfeeding initiation, duration, and rates.

OBJECTIVE

The aim of this systematic review was to identify, summarise, and critically analyse the available literature to evaluate the effects of midwife breastfeeding training programmes on the midwives' KAP towards breastfeeding and breastfeeding initiation, duration and rates among postnatal mothers.

METHODS

Nine English and six Chinese databases were searched with relevant key words. The methodological quality of the included studies were assessed by two reviewers independently using the Joanna Briggs Institute critical appraisal checklists.

RESULTS

Nine English and one Chinese articles were included in this review. Five articles investigating midwives' KAP towards breastfeeding reported positive results (p < 0.05). The meta-analysis revealed that breastfeeding training programmes significantly improved midwives' breastfeeding-related knowledge and skills (standardised mean difference = 1.33; 95% confidence interval, 0.98 to 1.68; p < 0.01; I² = 36%), as well as their attitude towards breastfeeding (p < 0.05). An additional five articles measured the effects of breastfeeding training programmes on the initiation, duration, and rates of breastfeeding among postnatal mothers. Following the implementation of a breastfeeding training programme for midwives, mothers had significantly longer durations of exclusive breastfeeding (p < 0.05), fewer breastfeeding challenges (p < 0.05) (e.g. breast milk insufficiency), and higher satisfaction with breastfeeding counselling (p < 0.01), and fewer infants received breast milk substitutes in their first week of life without medical reasons (p < 0.05) in the intervention group compared with the control group. However, no significant effects were seen on the initiation and rates of breastfeeding after implementation of the programmes.

CONCLUSIONS

This systematic review has demonstrated that midwife breastfeeding training programmes could improve midwives' KAP towards breastfeeding. However, the breastfeeding training programmes had limited effects on breastfeeding initiation and rates. We suggest that future breastfeeding training programme should incorporate counselling skills alongside breastfeeding knowledge and skills training.

REVIEW REGISTRATION

This systematic review has been registered in the International prospective register of systematic reviews (PROSPERO) (ID: CRD42022260216).

Improving breastfeeding support through the implementation of the Baby-Friendly Hospital and Community Initiatives: a scoping review

BACKGROUND

Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund, which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) grew out of step 10, with a focus on community-based implementation. The aim of this scoping review is to map and examine the evidence relating to the implementation of BFHI and BFCI globally.

METHODS

This scoping review was conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria followed the Population, Concepts, Contexts approach. All articles were screened by two reviewers, using Covidence software. Data were charted according to: country, study design, setting, study population, BFHI steps, study aim and objectives, description of intervention, summary of results, barriers and enablers to implementation, evidence gaps, and recommendations. Qualitative and quantitative descriptive analyses were undertaken.

RESULTS

A total of 278 articles were included in the review. Patterns identified were: i) national policy and health systems: effective and visible national leadership is needed, demonstrated with legislation, funding and policy; ii) hospital policy is crucial, especially in becoming breastfeeding friendly and neonatal care settings iii) implementation of specific steps; iv) the BFCI is implemented in only a few countries and government resources are needed to scale it; v) health worker breastfeeding knowledge and training needs strengthening to ensure long term changes in practice; vi) educational programmes for pregnant and postpartum women are essential for sustained exclusive breastfeeding. Evidence gaps include study design issues and need to improve the quality of breastfeeding data and to perform prevalence and longitudinal studies.

CONCLUSION

At a national level, political support for BFHI implementation supports expansion of Baby-Friendly Hospitals. Ongoing quality assurance is essential, as is systematic (re)assessment of BFHI designated hospitals. Baby Friendly Hospitals should provide breastfeeding support that favours long-term healthcare relationships across the perinatal period. These results can help to support and further enable the effective implementation of BFHI and BFCI globally.

PARENTAL BREASTFEEDING BEHAVIOR AND ATTITUDE QUESTIONNAIRE

A validated questionnaire is required to evaluate scientifically community-based breastfeeding support and promotion. The aim of this study was to create a valid and reliable questionnaire to measure parents' behavior and attitudes about breastfeeding. The items in the questionnaire were selected by the authors according to regular data from the professional literature, and in consultation with three pediatric lecturers at higher and secondary health education, fellow pediatricians, and parents. A working version of the questionnaire was available on the website of the For a Healthy and Happy Childhood association from February 1, 2019 to May 31, 2019. The study was approved by the Ethics Committee of the Bjelovar General Hospital. After item analysis, 15 behavioral questions that showed good internal consistency were retained. Concerning the attitudes, principal component analysis showed a four-factor structure with 17 items explaining 46.11% of total variance. Cronbach's alpha (0.88) indicated acceptable internal consistency. To analyze the ability of the questionnaire to differentiate parents according to the desired outcome, the χ2-test, correlation and logistic regression were used. In the study, the desired outcome was defined as exclusive breastfeeding for 5 or 6 months, as well as breastfeeding for 12 months or more. In conclusion, the final instrument is reliable and valid for collecting breastfeeding data and evaluating changes in parents' behaviors and attitudes achieved through participation in breastfeeding promotion and support programs. The questionnaire may, in addition to the BIAKQ questionnaire, support professionals and activists involved in breastfeeding to create methodologically well-conceived programs.

Exclusive breastfeeding, breastfeeding problems, and maternal breastfeeding attitudes before and after the baby-friendly hospital initiative: A quasi-experimental study

BACKGROUND

Breastfeeding practices remain globally suboptimal despite many known maternal and neonatal health benefits and the Baby-Friendly Hospital Initiative as a global effort to support breastfeeding.

OBJECTIVE

We aimed to evaluate the effects of the implementation of the Baby-Friendly Hospital Initiative for a proportion of mothers who exclusively breastfed during a 6-month period, including breastfeeding problems, and maternal breastfeeding attitudes.

METHODS

Using a quasi-experimental non-equivalent two-group design, we recruited two independent samples of postpartum mothers in a maternity hospital to compare the situation before (N = 162) and after (N = 163) the implementation. We measured breastfeeding status and possible breastfeeding problems via text-message questions at 2 weeks, 1, 4 and 6 months after birth. We measured Mothers' attitudes toward breastfeeding at the maternity hospital and 4 months after birth using the Iowa Infant Feeding Attitude Scale.

RESULTS

The implementation of the Baby-Friendly Hospital Initiative had no effect on the proportion of mothers who exclusively breastfed, and we found no significant differences in exclusive breastfeeding at 6 months (41.3 % vs 52.9 %, p =.435). The intervention did not influence the reported number of breastfeeding problems (p =.260) or maternal breastfeeding attitudes (p =.354). More favourable breastfeeding attitudes (p <.001) and less problematic breastfeeding (p <.001) were associated positively with exclusive breastfeeding.

CONCLUSION

Exclusive breastfeeding rates did not increase after the intervention; however, the rates at baseline were already high. Ensuring the Baby-Friendly Hospital Initiative practices through pre- and postnatal periods and preparing mothers to manage common breastfeeding problems might improve breastfeeding rates. This trial was registered (0307-0041) with ClinicalTrials.gov on 03/03/2017.

In-hospital supplementation and subsequent breastfeeding practices in Finland: A cross-sectional population-level study

BACKGROUND

The Baby-Friendly Hospital Initiative suggests that in-hospital supplementation should be avoided unless medically indicated. The supporting evidence is contradictory, as nonexperimental studies have shown an association between supplementation and decreased breastfeeding rates, whereas trials have failed to do so. The aim of this study was to investigate whether in-hospital supplementation is associated with exclusive breastfeeding to the age of 5 months and any breastfeeding to the age of 12 months in full-term, normal-weight singleton infants.

METHODS

This is a secondary analysis of national-level, cross-sectional survey data. The data were collected in child health clinics in Finland. Families attending a regular health examination with a child aged 2 weeks to 12 months were eligible to participate. Full-term, normal-weight, singleton infants (n = 3025) were included in this study. Multivariate logistic regression was performed using in-hospital supplementation and socioeconomic characteristics as covariates and exclusive and any breastfeeding as outcomes.

RESULTS

In total, 55.3% (n = 1631) of the infants received in-hospital supplementation. After controlling for socioeconomic factors, in-hospital supplementation was associated with decreased exclusive breastfeeding to the age of 5 months and with a decrease in any breastfeeding to the age of 7 months.

CONCLUSIONS

Our findings suggest that noncontrolled supplementation, without a trial's rigorous procedures of care, is associated with decreased breastfeeding postdischarge. Both donor milk and infant formula use were associated with lower breastfeeding rates, although the association was stronger with formula use. In clinical settings, liberal, nonmedically indicated supplementation should be avoided.

The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress

Despite increasing evidence about the value and importance of breastfeeding, less than half of the world's infants and young children (aged 0-36 months) are breastfed as recommended. This Series paper examines the social, political, and economic reasons for this problem. First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support. These reasons are the gendered and biomedical power systems that deny women-centred and culturally appropriate care; the economic and ideological factors that accept, and even encourage, commercial influence and conflicts of interest; and the fiscal and economic policies that leave governments with insufficient funds to adequately protect, promote, and support breastfeeding. We outline six sets of wide-ranging social, political, and economic reforms required to overcome these deeply embedded commercial and structural barriers to breastfeeding.

Breastfeeding: crucially important, but increasingly challenged in a market-driven world

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

Providing Low-Income Women With a Manual Pump: A Pilot Study

OBJECTIVES

Low-income, first-time mothers generally breastfeed exclusively and, overall, for a shorter average duration than high-income, multiparous mothers. A potential barrier to breastfeeding success is access to a breast pump for home use. In this pilot study, we estimated the effect of providing a manual breast pump during birth hospitalization for home use on any/exclusive breastfeeding and investigated participant attitudes about manual pumps and their breastfeeding experiences.

METHODS

Sixty low-income, first-time mothers were enrolled in a pilot randomized controlled trial. One-half received a manual breast pump and the other half received an attention control. Breastfeeding exclusivity, duration, and use of the manual pump were assessed at 6 and 12 weeks. Qualitative interviews regarding the breastfeeding experience were completed. Thirty-one women answered 13 questions that were then transcribed, coded, and grouped into themes.

RESULTS

Participants who were randomized to manual breast pump receipt during birth hospitalization had increased manual pump use at 6 weeks (13/19 [68%] versus controls 5/17 [29%]), there was no effect of pump receipt on any nor exclusive breastfeeding at 12 weeks. In qualitative analysis of the overall breastfeeding experience, participants expressed a need for additional support and had conflicting attitudes regarding breastfeeding and the pumping experience.

CONCLUSIONS

Manual breast pump receipt in hospital among low-income, first-time mothers did not affect breastfeeding exclusivity or duration. Participants reported that early and ongoing lactation support is essential. Strategies to improve breastfeeding outcomes low-income, first-time mothers are needed.

Infant Feeding Practices and Social Support Networks Among Immigrant Chinese American Mothers With Economic Disadvantage in New York City

BACKGROUND

Maternal social support promotes healthy infant feeding practices, which influence healthy growth and development. Less is known about how the interplay of social support networks and multicultural health beliefs may influence infant feeding practices, particularly among immigrant Chinese American mothers with economic disadvantage and low breastfeeding rates.

RESEARCH AIM

To explore the role of social support networks in the development of infant feeding practices in immigrant Chinese American mothers with infants.

METHODS

This was a prospective, cross-sectional qualitative study where we conducted semi-structured interviews in Mandarin, Cantonese, or English with Chinese American mothers of infants (N = 25) at a federally qualified health center in the Sunset Park neighborhood of Brooklyn, New York. Data were analyzed by a multicultural, multidisciplinary team using qualitative thematic analysis and the constant comparative method to identify and iteratively refine emerging codes.

RESULTS

Three themes emerged describing how broad transnational communities and close family and friends influence maternal-infant feeding practices: (1) Gathering and processing infant feeding information from broad transnational resources (i.e., from both the mother's country of residence and the mother's country of origin); (2) aligning maternal feeding attitudes with cultural health beliefs of local social networks; and (3) gaining confidence with transactional maternal-infant feeding interactions.

CONCLUSIONS

Strategies to promote healthy infant feeding should consider how family supports and culturally-relevant coaching can help align multilevel transnational social networks with healthy infant feeding practices.

A Quasi-realist Synthesis Investigating Professional Breastfeeding Support Failure

Background/Purpose: To conduct a synthesis based on a realist perspective, -investigating how professional breastfeeding support can sometimes be ineffective and/or unsatisfactory from the viewpoint of the mother and fail to address the needs of the breastfeeding dyad. Methods: An innovative, targeted "quasi-realist" -synthesis technique was used to explore the context of the interpersonal relationships through which professional breastfeeding intervention is delivered and identify any unintended mechanisms and/or consequences. Results: Multiple expressions of failed breastfeeding support were revealed which had a negative impact on maternal empowerment, informed decision-making, and breastfeeding self-efficacy. The overarching theme, inadequate breastfeeding information/ support, was elucidated by several subthemes: giving inconsistent/contradictory advice, use of the hands-on approach, provision of insensitive care, and making parents feel scrutinized/judged Mothers who experienced inadequate breastfeeding information/support often resorted to the mechanism of duplicity/evasion and withdrew from seeking or following further professional advice. Finally, unintended consequences of not breastfeeding as recommended included feelings of guilt and a sense of failure This was particularly true for mothers who intended to exclusively breastfeed. Implications for Practice: The findings of this unique synthesis suggest that to sustain breastfeeding support relationships and prevent unintentional consequences of inadequate support, professionals must pay more attention to the manner in which breastfeeding intervention is provided. The findings also suggest that they must strive to provide more consistent, engaging, -sensitive, and nonjudgmental care that better meets the needs of breastfeeding dyads.

Use of Telemedicine Healthcare Systems in Children and Adolescents with Chronic Disease or in Transition Stages of Life: Consensus Document of the Italian Society of Telemedicine (SIT), of the Italian Society of Preventive and Social Pediatrics (SIPPS), of the Italian Society of Pediatric Primary Care (SICuPP), of the Italian Federation of Pediatric Doctors (FIMP) and of the Syndicate of Family Pediatrician Doctors (SIMPeF)

Telemedicine is considered an excellent tool to support the daily and traditional practice of the health profession, especially when referring to the care and management of chronic patients. In a panorama in which chronic pathologies with childhood onset are constantly increasing and the improvement of treatments has allowed survival for them into adulthood, telemedicine and remote assistance are today considered effective and convenient solutions both for the chronic patient, who thus receives personalized and timely assistance, and for the doctors, who reduce the need for direct intervention, hospitalizations and consequent management costs. This Consensus document, written by the main Italian Scientific Societies involved in the use of telemedicine in pediatrics, has the objectives to propose an organizational model based on the relationships between the actors who participate in the provision of a telemedicine service aimed at minors with chronic pathologies, identifying specific project links between the areas of telemedicine in the developmental age from the first 1000 days of life to the age adult. The future scenario will have to be able to integrate digital innovation in order to offer the best care to patients and citizens. It will have to be able to provide the involvement of patients from the very beginning of the design of any care pathway, increasing where possible the proximity of the health service to citizens.

Interventions for promoting and optimizing breastfeeding practices: An overview of systematic review

Background

Optimal breastfeeding (BF) practices are essential for child survival and proper growth and development. The purpose of this overview is to evaluate the effectiveness of different interventions for promoting and optimizing breastfeeding.

Methods

We included systematic reviews (SRs) [including trials from Low-Income (LICs) and Low Middle-Income countries (LMICs)] that have evaluated the effect of various interventions for promoting and optimizing breastfeeding and excluded non-systematic reviews, and SRs based on observational studies. We searched various electronic databases. We followed the standard methodology as suggested by the Cochrane Handbook for Systematic Reviews of Interventions. Two sets of reviewers undertook screening followed by data extraction and assessment of the methodological quality of included SRs.

Result

We identified and screened 1,002 Cochrane SRs and included six SRs in this overview. Included SRs reported only two of the primary outcomes, early initiation of breastfeeding (EIBF) and/or exclusive breastfeeding (EBF). None of the included SR reported continued BF up to 2 years of age. The results were evaluated using two major comparisons groups: BF intervention against routine care and one type of BF intervention vs. other types of BF intervention. Overall results from included SRs showed that there were improvements in the rates of EIBF and EBF among women who received BF intervention such as BF education sessions and support compared to those women who received only standard care. However, BF intervention via mobile devices showed no improvements. In Target Client Communication (TCC) via mobile devices intervention group, no significant improvements were reported in BF practices, and also the reported evidence was of very low certainty.

Conclusion

Community Based Intervention Packages (CBIP) delivered to pregnant and reproductive-age women during their Antenatal care (ANC) and/or Postnatal care (PNC) periods by Ancillary Nurse-Midwives reported the highest improvement in EIBF compared to women who received standard care. However, insufficient evidence was reported to suggest that BF intervention showed improvements in EBF in both the comparison groups. This overview highlighted the gaps in primary research regarding the uncertainty about the settings such as LICs or LMICs, lack of evidence from LMICs, and also identified gaps in the availability of reliable up-to-date SRs on the effects of several BF interventions to promote and optimize practices.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020174998, PROSPERO [CRD42020174998].

Encouraging and Reinforcing Safe Breastfeeding Practices during the COVID-19 Pandemic

AIM

Promote safe breastfeeding during the pandemic.

METHODS

All participants were encouraged to request safe breastfeeding education from their prenatal provider. Pregnant mothers received appropriate breastfeeding and COVID-19 safe breastfeeding education in line with the CDC's COVID-19 breastfeeding guidelines. Data were obtained from 39 mothers attending Nashville General Hospital pediatric well-baby clinics (Group I: from December 2019 to June 2020) and 97 pregnant women attending prenatal clinics (Group II: from July 2020 to August 2021).

RESULTS

The participants' ages ranged from 15 to 45 years, with a mean of 27.5 ± 6.2. The women in both groups were similar in age, education, employment, and breastfeeding experience. They were equally unlikely to use face masks at home even while receiving guests or holding their babies. Although 121 (89.0%) women claimed face mask use while shopping, the rate for never doing so was 7 (18.0%) vs. 8 (8.3%) (p < 0.006) for Groups I and II, respectively. Safe practices included limited outing (66 (48.5%)), sanitized hands (62 (45.6%)), restricted visitors (44 (32.4%)), and limited baby outing (27 (19.9%)), and 8 (8.3%) in Group II received COVID-19 vaccinations. About half described fair and accurate COVID-19 safe breastfeeding knowledge, but 22 (30.1%) of them claimed they received no information. Breastfeeding contraindication awareness for Groups I and II were as follows: cocaine = 53.8% vs. 37.1%, p < 0.06; HIV = 35.9% vs. 12.4%, p < 0.002; breast cancer = 17.9% vs. 16.5%; and COVID-19 with symptoms = 28.2% vs. 5.2%, p < 0.001. The information source was similar, with family, friends, and media accounting for 77 (56.6%) of women while doctors, nurses, and the CLC was the source for 21 (15.4%) women. Exclusive breastfeeding one month postpartum for Groups I and II was 41.9% and 12.8% (p < 0.006), respectively.

CONCLUSION

The mothers were not more knowledgeable regarding breastfeeding safely one year into the COVID-19 pandemic. Conflicting lay information can create healthy behavior ambivalence, which can be prevented by health professionals confidently advising mothers to wear face masks when breastfeeding, restricting visitors and outings, and accepting COVID-19 vaccination. This pandemic remains an open opportunity to promote and encourage breastfeeding to every mother as the default newborn feeding method.

Integrative Review of Mental Health and Feeding Styles in Parents of Bottle-Fed Infants

OBJECTIVE

To review the literature regarding the relationship between symptoms of anxiety and depression and feeding styles in parents of bottle-fed infants.

DATA SOURCES

We conducted literature searches in PubMed, CINAHL, Scopus, and PsycINFO.

STUDY SELECTION

We used Covidence systematic review management software during the selection process to allow for full blinding of decisions by team members. Articles were eligible for inclusion if they were reports of primary research, written in English, and focused on the relationship between symptoms of anxiety or depression and feeding styles in parents of term, bottle-fed infants younger than 12 months of age. We placed no restriction on date of publication because of the sparse amount of published literature on this topic. We identified a total of 1,882 articles. After removing duplicates, we screened 988 articles and retained six articles that met criteria for our review.

DATA EXTRACTION

We used Whittemore and Knafl's integrative review methodology to guide data extraction and reporting. We extracted relevant data from all primary data sources and compiled the data into a matrix. We used the Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies to assess the quality of the studies.

DATA SYNTHESIS

Using an a priori coding scheme, we summarized the data using categorization of established parental feeding styles in infancy applicable to bottle-feeding. We synthesized the data into two broad categories: responsive and nonresponsive feeding styles.

CONCLUSION

Although research on the topic is limited, our findings suggest that symptoms of postpartum depression may be associated with nonresponsive feeding styles in parents of bottle-fed infants. We suggest several areas for future research and recommend increased emotional and feeding support in practice for parents of bottle-feeding infants.

Becoming breastfeeding friendly in Wales: Recommendations for scaling up breastfeeding support

Breastfeeding and the provision of human milk is established as protecting infant and maternal health. However, breastfeeding rates in many countries, including Wales, are low. Given the significant health, economic and environmental impacts of this, the need to strengthen breastfeeding promotion, protection and support is paramount. As part of this, the becoming breastfeeding friendly: a guide to global scale-up (BBF) initiative sets out a methodology to enable countries to assess their readiness to scale up breastfeeding protection, promotion and support by gathering data and scoring progress under eight areas, termed 'gears', shown to be essential for large-scale change. Recently, Wales took part in the BBF initiative. A cross-sector committee, including stakeholders from Universities, Welsh Government, Public Health Wales and Health Boards alongside critical friends scored Wales' support for breastfeeding across the eight gears. The overall score for Wales was 1.1 out of a possible 0-3, representing a moderate scaling up the environment for breastfeeding. Six gears were rated in the moderate gear strength category and two ('Promotion' and 'Advocacy') in the weak gear strength category. Gaps in breastfeeding support were identified and 31 recommendations covering six themes for change were put forward. These included a strategic action plan, consistent and long-term funding, a nuanced, cocreated engagement and promotion framework, strengthened education and training, robust monitoring and evaluation mechanisms and ensuring maternity rights and the International Code of Marketing of Breastmilk Substitute are upheld. Taken together, the analysis and recommendations present a clear vision for protecting and not merely promoting breastfeeding in Wales.

Perinatal Hospital Practices Are Associated with Breastfeeding through 5 Months Postpartum among Women and Infants from Low-Income Households

BACKGROUND

Breastfeeding (BF) provides optimal nutrition during the first 6 mo of life and is associated with reduced infant mortality and several health benefits for children and mothers. However, not all infants in the United States are breastfed, and sociodemographic disparities exist in BF rates. Experiencing more BF-friendly maternity care practices at the hospital is associated with better BF outcomes, but limited research has examined this association among mothers enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a population at risk of low BF rates.

OBJECTIVES

We assessed the association between BF-related hospital practices (rooming-in, support from hospital staff, and provision of a pro-formula gift pack) and the odds of any or exclusive BF through 5 mo among infants and mothers enrolled in WIC.

METHODS

We analyzed data from the WIC Infant and Toddler Feeding Practices Study II, a nationally representative cohort of children and caregivers enrolled in WIC. Exposures included maternal experience of hospital practices reported at 1 mo postpartum, and BF outcomes were surveyed at 1, 3, and 5 mo. ORs and 95% CIs were obtained using survey-weighted logistic regression, adjusting for covariates.

RESULTS

Rooming-in and strong hospital staff support were associated with higher odds of any BF at 1, 3, and 5 mo postpartum. Provision of a pro-formula gift pack was negatively associated with any BF at all time points and with exclusive BF at 1 mo. Each additional BF-friendly hospital practice experienced was associated with 47% to 85% higher odds of any BF over the first 5 mo and 31% to 36% higher odds of exclusive BF over the first 3 mo.

CONCLUSIONS

Exposure to BF-friendly hospital practices was associated with BF beyond the hospital stay. Expanding BF-friendly policies at the hospital could increase BF rates in the United States WIC-served population.

Early initiation of breastfeeding is inversely associated with public and private c-sections in 73 lower- and middle-income countries

Although studies in low- and middle-income countries (LMICs) have examined the effects of c-sections on early initiation of breastfeeding (EIBF), the role of the place of birth has not yet been investigated. Therefore, we tested the association between EIBF and the type of delivery by place of birth. Data from 73 nationally representative surveys carried out in LMICs between 2010 and 2019 comprised 408,013 women aged 15 to 49 years. Type of delivery by place of birth was coded in four categories: home vaginal delivery, institutional vaginal delivery, c-section in public, and c-section in private health facilities. We calculated the weighted mean prevalence of place of birth and EIBF by World Bank country income groups. Adjusted Poisson regression (PR) was fitted taking institutional vaginal delivery as a reference. The overall prevalence of EIBF was significantly lower among c-section deliveries in public (PR = 38%; 95% CI 0.618-0.628) and private facilities (PR = 45%; 95% CI 0.54-0.566) compared to institutional vaginal deliveries. EIBF in c-sections in public facilities was slightly higher in lower-middle (PR = 0.650, 95% CI 0.635-0.665) compared to low (PR = 0.544, 95% CI 0.521-0.567) and upper-middle income countries (PR = 0.612, 95% CI 0.599-0.626). EIBF was inversely associated with c-section deliveries compared to institutional vaginal deliveries, especially in private facilities compared to public ones.

How midwives and nurses experience implementing ten steps to successful breastfeeding: a qualitative case study in an Indonesian maternity care facility

BACKGROUND

The in-hospital stay following childbirth is a critical time for education and support of new mothers to establish breastfeeding. The WHO/UNICEF 'Ten Steps to Successful Breastfeeding (Ten Steps)' was launched globally in 1989 to encourage maternity services to educate and support mothers to breastfeed. The strategy is effective, however its uptake within health systems and facilities has been disappointing. We aimed to understand midwives' and nurses' experiences of implementing the Ten Steps in an Indonesian hospital.

METHODS

This qualitative study was conducted in an Indonesian hospital which has been implementing the Ten Steps since the hospital's establishment in 2012. Fourteen midwives and nurses participated in a focus group in January 2020. Data were analyzed using thematic analysis.

RESULTS

We identified five themes that represented midwives' and nurses' experiences of implementing the Ten Steps in this Indonesian maternity unit: 1) Human rights of child and mother, 2) Dependency on precarious leadership, 3) Lack of budget prioritization, 4) Fragmented and inconsistent implementation of the Ten Steps across the health system, and 5) Negotiating with family, community and culture. The results highlighted a dependency on local hospital champions and a lack of budget prioritization as barriers to implementation, as well as health system gaps which prevented the enablement of mothers and families to establish and maintain breastfeeding successfully in Indonesian maternity services.

CONCLUSIONS

As Indonesia has one of the largest populations in South East Asia, it is an important market for infant milk formula, and health services are commonly targeted for marketing these products. This makes it especially important that the government invest strongly in Ten Steps implementation. Continuity of care within and across the health system and leadership continuity are key factors in reinforcing its implementation. The study findings from this Indonesian maternity care facility re-emphasize WHO recommendations to integrate the Ten Steps into national health systems and increase pre-service education on breastfeeding for health care professionals.

Factors associated with exclusive breastfeeding at discharge during the COVID-19 pandemic in 17 WHO European Region countries

BACKGROUND

Exclusive breastfeeding is the optimal infant nutrition, providing infants immunoprotection against many diseases including SARS-CoV-2 infection. Restrictions during the COVID-19 pandemic may have negatively affected breastfeeding practices in maternity care facilities. The aims of the study were to examine exclusive breastfeeding rates at discharge over time and to identify factors associated with exclusive breastfeeding during the pandemic.

METHODS

A cross-sectional survey was conducted among mothers who gave birth in a maternity care facility in the World Health Organization (WHO) European Region countries during the COVID-19 pandemic. The socio-ecological model was employed to examine intrapersonal, interpersonal, organizational, and community/society factors associated with maternal report of exclusive breastfeeding at the time of discharge.

RESULTS

There were 26,709 participating mothers from 17 European Region countries who were included in the analysis. Among the mothers, 72.4% (n = 19,350) exclusively breastfed and 27.6% (n = 7,359) did not exclusively breastfeed at discharge. There was an overall decline in exclusive breastfeeding rates over time (p = 0.015) with a significantly lower rate following the publication of the WHO breastfeeding guidelines on 23 June 2020 (AOR 0.88; 95% CI 0.82, 0.94). Factors significantly associated with exclusive breastfeeding outcomes in the logistic regression analysis included maternal age, parity, education, health insurance, mode of birth, inadequate breastfeeding support, lack of early breastfeeding initiation, lack of full rooming-in, birth attendant, perceived healthcare professionalism and attention, facility room cleanliness, timing of birth, and location of birth.

CONCLUSIONS

Results from the study indicate the decline in exclusive breastfeeding rates in the WHO European Region during the COVID-19 pandemic. Using the socio-ecological model to identify factors associated with breastfeeding outcomes facilitates an integrated and holistic approach to address breastfeeding needs among women across the region. These findings demonstrate the need to augment breastfeeding support and to protect exclusive breastfeeding among mother-infant dyads, in an effort to reverse the declining exclusive breastfeeding rates. The study highlights the need to educate mothers and their families about the importance of exclusive breastfeeding, reduce maternal-infant separation, increase professional breastfeeding support, and follow evidence-based practice guidelines to promote breastfeeding in a comprehensive and multi-level manner.

TRIAL REGISTRATION NUMBER

Clinical Trials NCT04847336.

Maternal perceptions and experiences of breastfeeding support in Baby-Friendly hospitals: An integrative review

Background

The Baby-Friendly Hospital Initiative aims to improve breastfeeding by implementing the Ten Steps to Successful Breastfeeding (Ten Steps) into routine breastfeeding support in birth hospitals. Maternal perspective to breastfeeding support is important to consider as mothers and their infants are in the center of that support.

Objectives

To review and synthesize the existing literature on maternal perceptions and experiences of breastfeeding support in Baby-Friendly hospitals. A sub-aim was to describe differences in breastfeeding support between Baby-Friendly hospitals and non-Baby-Friendly hospitals from maternal perspective.

Data sources and review methods

An integrative literature review. A systematic literature search was conducted in October 2021 in five databases: PubMed, CINAHL, Cochrane, Scopus, Web of Science. Original peer-reviewed studies published in English exploring maternal viewpoints on breastfeeding support in Baby-Friendly hospitals were included. Two reviewers independently screened the titles (n=914), abstracts (n=226), and full texts (n=47). The review comprised of seventeen studies and includes both quantitative studies (n=14) and qualitative studies (n=3). Inductive content analysis and descriptive synthesis were conducted.

Results

Most studies (n=14) measured hospitals' compliance with the Ten Steps practices from maternal perspective. Mothers were provided with breastfeeding information and encouragement, however, a qualitative finding indicated that information focused on positive aspects of breastfeeding. Early skin-to-skin contact between the mother and infant was well facilitated although often not lasting more than 30 min. Breastfeeding was facilitated by practical support but according to findings of two qualitative studies, support was not always adequate to address mothers' problems with breastfeeding. Most mothers were exclusively breastfeeding during the hospital stay and no supplemental milk was offered to infant. Mothers were roomed-in together with their infant and were mostly encouraged to breastfeed on demand. Differences between Baby-Friendly hospitals and non-Baby-Friendly hospitals were observed particularly for steps 6 and 9: supplementary feeding and pacifier use were less common in Baby-Friendly hospitals.

Conclusions

From the maternal perspective, breastfeeding support in the Baby-Friendly hospitals was mainly but not completely in adherence with the Ten Steps practices. Low compliance with some of the Ten Steps indicates a need for a more frequent assessment of the breastfeeding support practices and consideration of strategies facilitating a more sustainable implementation of the initiative. Regardless of some shortcomings with the breastfeeding support, mothers were mainly satisfied with the support in the hospital. Mothers in the Baby-Friendly hospitals perceived that breastfeeding support was more adherent to the Ten Steps compared to mothers in non-Baby-Friendly hospitals.

Factors Associated with Breastfeeding Initiation and Duration in Greece: Data from the Hellenic National Nutrition and Health Survey

Despite its well-documented benefits, breastfeeding rates and duration worldwide do not meet the recommended goals set by the World Health Organization. Data on infant feeding, socio-demographic, lifestyle and perinatal factors were used from 490 mothers (and 958 children), participants at the Hellenic National Nutrition and Health Survey between 2013−2015. Clustered multiple logistic regression and multilevel mixed-model regression analyses were performed to identify factors associated with breastfeeding initiation and duration, respectively. Maternal lower education [Odds Ratio (OR): 2.29, 95% Confidence intervals (95% CI): 1.30−4.04; p = 0.004], smoking during pregnancy (OR: 3.08, 95% CI: 1.64−5.77; p < 0.001), caesarean section (OR = 3.26, 95% CI: 1.83−5.83; p < 0.001), prematurity (OR = 2.74, 95% CI: 1.40−5.37; p = 0.003) and higher birth order (OR = 1.30, 95% CI: 1.04−1.62; p = 0.020) were associated with increased odds of not initiating breastfeeding. Living in rural areas [beta coefficient b = −27.93, p = 0.043], smoking during pregnancy (b = −64.47, p < 0.001), caesarean section (b = −28.76, p = 0.046) and prematurity (b = −46.67, p = 0.048) were significantly associated with shorter breastfeeding duration. Children born chronologically closer to the survey were more likely to breastfeed and for longer periods. Educational promotion and enhancement of breastfeeding awareness that account for maternal exposures are required. Prevention of prematurity and avoidance of unnecessary caesarean section is crucial, while additional breastfeeding support is needed when preterm birth occurs, or caesarean section cannot be avoided.

Breastfeeding-supportive hospital practices and breastfeeding maintenance: results from the Louisiana pregnancy risk assessment monitoring system

OBJECTIVE

Identify practices associated with breastfeeding maintenance, examine breastfeeding-related hospital practices by hospital designation level (Baby Friendly vs. Gift vs. none), and assess racial disparities in hospital practices and breastfeeding maintenance.

STUDY DESIGN

The Pregnancy Risk Assessment Monitoring System is a population-based survey of mothers who have recently given birth. Non-Hispanic Black (NHB) and non-Hispanic White (NHW) participants who gave birth from 2016-2019 and initiated breastfeeding were included (n = 2200). Associations between twelve breastfeeding-related hospital and breastfeeding at 2-6 months postpartum were assessed. Baby Friendly hospital designation is based on a set of criteria related to hospital practices that promote breastfeeding. The Gift is a Louisiana program that offers a lower level designation and quality improvement support designed to help hospitals transition to and achieve Baby Friendly designation.

RESULT

Breastfeeding in the hospital, infant only receiving breast milk, and breastfeeding within one hour after birth were positively associated and receiving a gift pack with formula was negatively associated with breastfeeding maintenance in both NHW and NHB women. Associations were stronger in NHW compared to NHB mothers.

CONCLUSION

We identified several practices significantly associated with breastfeeding maintenance. However, racial disparities indicate a need for population-specific supportive practices.

The Influence of the Baby-Friendly Hospital Initiative and Maternity Care Practices on Breastfeeding Outcomes

BACKGROUND

The Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 to promote breastfeeding through hospital policy. Researchers have reported breastfeeding improvements after hospitals became "Baby-Friendly." In Hong Kong, the first public hospital was designated as a Baby-Friendly Hospital in 2016.

RESEARCH AIM

To examine the influence of the BFHI on breastfeeding by comparing breastfeeding outcomes in a study cohort recruited before the implementation of the BFHI and a cohort recruited after its implementation.

METHODS

This was a quasi-experimental interrupted time-series design. Two cohorts of mother-infant pairs (N = 2369) were recruited immediately postpartum from four public hospitals in Hong Kong and followed up prospectively. Comparisons were made in five of the BFHI steps experienced in both cohorts and the duration of any and exclusive breastfeeding.

RESULTS

A higher proportion of participants from the post-implementation cohort breastfed and breastfed exclusively at all follow-up periods. Participants in the pre-BFHI cohort, on average experienced 3.10 (SD = 1.42) of the BFHI steps, whereas the participants in the post-BFHI cohort experienced 3.59 (1.09) of the BFHI steps. Half of the participants discontinued any breastfeeding by 13 weeks in the pre-BFHI cohort; more than half in the post-BFHI cohort were still breastfeeding at 6 months postpartum (p < .001). Giving only human milk in the first 48 hr of delivery and not providing pacifiers or bottles were associated with lower risk of not exclusive breastfeeding in both cohorts.

CONCLUSION

Implementation of the BFHI was associated with improvements in breastfeeding practices and outcomes.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

1. To describe types of breastfeeding support for healthy breastfeeding mothers with healthy term babies. 2. To examine the effectiveness of different types of breastfeeding support interventions in terms of whether they offered only breastfeeding support or breastfeeding support in combination with a wider maternal and child health intervention ('breastfeeding plus' support).  3. To examine the effectiveness of the following intervention characteristics on breastfeeding support:      a. type of support (e.g. face-to-face, telephone, digital technologies, group or individual support, proactive or reactive);      b. intensity of support (i.e. number of postnatal contacts);      c. person delivering the intervention (e.g. healthcare professional, lay person);     d. to examine whether the impact of support varied between high- and low-and middle-income countries.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes results of searches of CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP)) (11 May 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. Support could be provided face-to-face, over the phone or via digital technologies. All studies had to meet the trustworthiness criteria.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed risk of bias and study trustworthiness.  The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 116 trials of which 103 contribute data to the analyses. In total more than 98,816 mother-infant pairs were included.  Moderate-certainty evidence indicated that 'breastfeeding only' support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at six months (Risk Ratio (RR) 0.93, 95% Confidence Interval (CI) 0.89 to 0.97); stopping exclusive breastfeeding at six months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4-6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4-6 (RR 0.83 95% CI 0.76 to 0.90). Similar findings were reported for the secondary breastfeeding outcomes except for any breastfeeding at two months and 12 months when the evidence was uncertain if 'breastfeeding only' support helped reduce the number of women stopping breastfeeding.  The evidence for 'breastfeeding plus' was less consistent. For primary outcomes there was some evidence that 'breastfeeding plus' support probably reduced the number of women stopping any breastfeeding (RR 0.94, 95% CI 0.91 to 0.97, moderate-certainty evidence) or exclusive breastfeeding at six months (RR 0.79, 95% CI 0.70 to 0.90).  'Breastfeeding plus' interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4-6 weeks, but the evidence is very uncertain (RR 0.73, 95% CI 0.57 to 0.95). The evidence suggests that 'breastfeeding plus' support probably results in little to no difference in the number of women stopping any breastfeeding at 4-6 weeks (RR 0.94, 95% CI 0.82 to 1.08, moderate-certainty evidence). For the secondary outcomes, it was uncertain if 'breastfeeding plus' support helped reduce the number of women stopping any or exclusive breastfeeding at any time points.  There were no consistent findings emerging from the narrative synthesis of the non-breastfeeding outcomes (maternal satisfaction with care, maternal satisfaction with feeding method, infant morbidity, and maternal mental health), except for a possible reduction of diarrhoea in intervention infants.  We considered the overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions and as studies utilised self-report breastfeeding data, there is also a risk of bias in outcome assessment.   We conducted meta-regression to explore substantial heterogeneity for the primary outcomes using the following categories: person providing care; mode of delivery; intensity of support; and income status of country.  It is possible that moderate levels (defined as 4-8 visits) of 'breastfeeding only' support may be associated with a more beneficial effect on exclusive breastfeeding at 4-6 weeks and six months. 'Breastfeeding only' support may also be more effective in reducing women in low- and middle-income countries (LMICs) stopping exclusive breastfeeding at six months compared to women in high-income countries (HICs). However, no other differential effects were found and thus heterogeneity remains largely unexplained. The meta-regression suggested that there were no differential effects regarding person providing support or mode of delivery, however, power was limited.  AUTHORS' CONCLUSIONS: When 'breastfeeding only' support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points.  For 'breastfeeding plus' interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face-to-face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.

Exact Gestational Age, Term Versus Early Term, Is Associated with Different Breastfeeding Success Rates in Mothers Delivered by Elective Cesarean Section

Objectives: The study was intended to verify the association between the gestational age of newborns classified as term and the success of breastfeeding in babies born by elective cesarean section. Also, to analyze how the variability of gestational age within the term influences breastfeeding. Materials and Methods: Retrospective study of a cohort, which included full-term newborns and their mothers, whose deliveries occurred by elective cesarean section. Among the inclusion criteria are delivery due to elective cesarean section and minimum gestational age of 37 weeks. The database consisted of medical birth information and interviews with mothers. Results: This study included 954 full-term newborns born by elective cesarean section. Exclusive breastfeeding at 3 months and being breastfed at 6 months showed a statistically significant association in the correlation with the variability of gestational age. There was a statistically significant association between exclusive breastfeeding at 3 months and breastfeeding at 6 months in the correlation between early term and full term. The trend test showed a significant progressive in the breastfeeding curve versus gestational age. Conclusion: Full-term newborns show better results of exclusive breastfeeding at 3 months and continued breastfeeding at 6 months, compared with those born at early term. Gestational age, even in term, has an influence on the success of breastfeeding in newborns undergoing elective cesarean delivery.

Implementing two national responsibilities of the revised UNICEF/WHO Baby-Friendly Hospital Initiative: A two-country case study

The 2018 implementation guidance for the Baby-Friendly Hospital Initiative (BFHI) recommends institutionalising the ten Steps through nine national responsibilities for universal coverage and sustainability. As countries adapt BFHI programmes to this paradigm shift away from traditional designation programmes, documenting and sharing policy and programme experience are critical and currently sparse. This qualitative case study included desk reviews of published and grey literature on BFHI programming, national plans and policy documents specific to the selected national responsibilities for universal coverage and key informant (KI) interviews across a range of actors. In the Kyrgyz Republic, the case study explored responsibility 5, development and implementation of incentives and/or sanctions, and responsibility 6 in Malawi, providing technical assistance (TA). In both countries, the three sustainability responsibilities (national monitoring [7] communication and advocacy [8] and financing [9]) as they relate to the universal coverage of the targeted responsibilities were also explored. Thirty-eight respondents in the Kyrgyz Republic described approaches that were used in the health system, including BFHI designation plaques, performance-based financing and financial sanctions. However, currently, there are no formal incentives and sanctions. In Malawi, TA was utilised for national planning and to introduce quality improvement processes. Forty-seven respondents mostly described provisions of TA in building and strengthening the capacity of providers. More programmatic evidence to demonstrate which types of incentives or sanctions can be effective and sustained and more documentation of how TA is provided across multiple aspects of implementation are needed as countries institutionalise BFHI.

Women’s status, breastfeeding support, and breastfeeding practices in the United States

The objective of this study is to examine associations between state-level breastfeeding support and breastfeeding practices, controlling for women’s status, in the U.S. We used publicly available data on state-level breastfeeding practices and support (international board-certified lactation consultants (IBCLC), births in Baby-Friendly hospitals, and La Leche League Leaders) for births in 2015 from the CDC Breastfeeding Report Card (2018) and other CDC reported data, and indicators of women’s status from the Institute for Women’s Policy Research reports (2015). We conducted an ecological study to estimate incidence rate ratios of exclusive breastfeeding at six months and breastfeeding at 12 months with breastfeeding supports using bivariate and multivariable Poisson regression. Political participation, poverty, and employment and earnings were associated with breastfeeding practices, as was each breastfeeding support in bivariate analyses. After controlling for women’s status, only IBCLCs were positively associated with rates of exclusive breastfeeding at 6 months and continued breastfeeding at 12 months. For every additional IBCLC per 1000 live births, the rate of exclusive breastfeeding at 6 months increased by 5 percent (95% CI 1.03, 1.07) and the rate of breastfeeding at 12 months increased by 4 percent (95% CI 1.02, 1.06). Political participation, poverty, and employment and earnings were associated with breastfeeding practices, indicating a relationship between women’s political and economic status and their breastfeeding practices in the U.S. Given the influence of women’s status, increasing the number of IBCLCs may improve breastfeeding practices.

How much does it cost to implement the Baby-Friendly Hospital Initiative training step in the United States and Mexico?

The Baby-Friendly Hospital Initiative (BFHI) has been shown to increase breastfeeding rates, improving maternal and child health and driving down healthcare costs via the benefits of breastfeeding. Despite its clear public health and economic benefits, one key challenge of implementing the BFHI is procuring funding to sustain the program. To address this need and help healthcare stakeholders advocate for funds, we developed a structured method to estimate the first-year cost of implementing BFHI staff training, using the United States (US) and Mexico as case studies. The method used a hospital system-wide costing approach, rather than costing an individual hospital, to estimate the average per birth BFHI staff training costs in US and Mexican hospitals with greater than 500 annual births. It was designed to utilize publicly available data. Therefore, we used the 2014 American Hospital Association dataset (n = 1401 hospitals) and the 2018 Mexican Social Security Institute dataset (n = 154 hospitals). Based on our review of the literature, we identified three key training costs and modelled scenarios via an econometric approach to assess the sensitivity of the estimates based on hospital size, level of obstetric care, and training duration and intensity. Our results indicated that BFHI staff training costs ranged from USD 7.27–125.39 per birth in the US and from PPP 2.68–6.14 per birth in Mexico, depending on hospital size and technological capacity. Estimates differed between countries because the US had more hospital staff per birth and higher staff salaries than Mexico. Future studies should examine whether similar, publicly available data exists in other countries to test if our method can be replicated or adapted for use in additional settings. Healthcare stakeholders can better advocate for the funding to implement the entire BFHI program if they are able to generate informed cost estimates for training as we did here.

Prenatal Perception of WIC Breastfeeding Recommendations Predicts Breastfeeding Exclusivity and Duration in the Infants' First Year

BACKGROUND

Pregnant participants who perceived that the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) recommends breastfeeding only were more likely to have better early breastfeeding outcomes.

OBJECTIVES

Our objective was to examine the association between prenatal perception of WIC's breastfeeding recommendations and breastfeeding duration through the first year of infant life.

METHODS

This observational study used a national longitudinal sample of 1594 pregnant participants in the WIC Infant and Toddler Feeding Practices Study-2 in 2013. Four measures of breastfeeding duration were used: 1) a discrete measure of exclusive breastfeeding through 5 mo; 2) a continuous measure of exclusive breastfeeding (in days up to 7 mo); 3) a discrete measure of any breastfeeding through 11 mo; and 4) a continuous measure of any breastfeeding (in days up to 13 mo). The primary explanatory variable was the participant's prenatal perception of whether WIC recommended breastfeeding only. The univariate analyses of time to breastfeeding cessation were performed using Kaplan-Meier curves. The Cox regression model was adopted to estimate the likelihood of breastfeeding outcomes over time. All analyses accounted for complex survey design effects.

RESULTS

Compared with their peers who perceived WIC to recommend formula only or both breastfeeding and formula equally, participants who perceived WIC as recommending breastfeeding only were less likely to stop exclusive breastfeeding through 5 mo (HR = 0.83; 95% CI: 0.69, 0.99) or to stop any breastfeeding through 11 mo (HR = 0.80; 95% CI: 0.69, 0.92), without controlling for prenatal infant feeding intentions. Similar patterns were observed in the 2 continuous measures, as they were also less likely to stop exclusive breastfeeding by 7 mo (HR = 0.78; 95% CI: 0.69, 0.90) or to stop any breastfeeding by 13 mo (HR = 0.82; 95% CI: 0.71, 0.95).

CONCLUSIONS

Prenatal perception of WIC's breastfeeding recommendation can be a useful predictor of breastfeeding duration in WIC participants.

The Association Between Breastfeeding Self-Efficacy and Mode of Infant Feeding

Introduction: It is well established that low breastfeeding self-efficacy is associated with early breastfeeding cessation. Over the past several decades, expressed human milk feeding has increased among parents of healthy infants. Researchers have hypothesized an association between maternal breastfeeding confidence and expressed human milk feeding, but it has not been empirically examined. Therefore, the primary objective of this study was to assess the associations between breastfeeding self-efficacy and human milk expression practices. The secondary objective was to assess the effect of breastfeeding self-efficacy on breastfeeding duration and exclusivity. Methods: This study used a prospective cohort design. From 2017 to 2018, we recruited 821 healthy mothers with term births in two public hospitals in Hong Kong. Participants completed a self-administered questionnaire in the immediate postpartum period, which gathered information about sociodemographic characteristics and Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). Participants were followed up for 6 months or until infants were weaned. The proportion and type of infant feeding were assessed at telephone follow-up. Results: The overall mean BSES-SF score in our sample was 46.5 (standard deviation = 10.1). Every one-point increase in the BSES-SF score was associated with 4-5% lower risk of any expressed human milk feeding and 4-7% higher odds of breastfeeding continuation across the first 6 months postpartum. Conclusion: Higher breastfeeding self-efficacy is associated with a lower risk of expressed human milk feeding and a longer duration of any and exclusive breastfeeding. Further studies should explore how improving breastfeeding self-efficacy may affect the mode of human milk feeding.

Healthcare Professionals' Breastfeeding Attitudes and Hospital Practices During Delivery and in Neonatal Intensive Care Units: Pre and Post Implementing the Baby-Friendly Hospital Initiative

BACKGROUND

The Baby-Friendly Hospital Initiative represents a global effort to support breastfeeding. Commitment to this program has been associated with the longer duration and exclusivity of breastfeeding and improvements in hospital practices. Further, healthcare professionals' breastfeeding attitudes have been associated with the ability to provide professional support for breastfeeding.

RESEARCH AIMS

To determine healthcare professionals' breastfeeding attitudes and hospital practices before and after the implementation of the Baby-Friendly Hospital Initiative.

METHODS

Using a quasi-experimental pretest-posttest study design, healthcare professionals (N = 131) from the single hospital labor and delivery, maternity care, and neonatal intensive care were recruited before and after the Baby-Friendly Hospital Initiative intervention during 2017 and 2019. Breastfeeding attitudes with the validated Breastfeeding Attitude Questionnaire, breastfeeding-related hospital practices, and background characteristics were collected.

RESULTS

The healthcare professionals' breastfeeding attitude scores increased significantly after the implementation of the Baby-Friendly Hospital Initiative, difference = 0.16, (95% CI [0.13, 0.19]) and became breastfeeding favorable among all professional groups in each study unit. Positive changes in breastfeeding-supportive hospital practices were achieved. The infants had significantly more frequent immediate and uninterrupted skin-to-skin contact with their mothers. The rate of early breastfeeding, as well as the number of exclusively breastfed infants, increased.

CONCLUSIONS

After the Baby-Friendly Hospital Initiative and Baby-Friendly Hospital Initiative for neonatal wards (Neo-BFHI) interventions were concluded, we found significant improvements in the breastfeeding attitudes of healthcare professionals and in breastfeeding-related care practices.This RCT was registered (0307-0041) with ClinicalTrials.gov on 03/03/2017.

Welcoming, supportive care in US birthing facilities and realization of breastfeeding goals

BACKGROUND

Emotional and physical support for birthing parents is positively associated with realization of their breastfeeding goals. However, few studies have investigated maternal descriptions of their postnatal unit experience of these domains.

RESEARCH AIM

The objective was to investigate maternal report of their birthing facility experiences and quantify the extent to which accounts of postpartum support were associated with meeting their breastfeeding goals.

METHODS

After IRB review, data were obtained through an online survey distributed from November 2016-May 2017. This analysis utilizes data from 2,771 birthing parents who were at least 18 years of age, experienced maternity care in the United States within five years, and reported that they had intended to breastfeed. Bivariate analysis was followed by logistic regression controlling for significant covariates.

RESULTS

In this sample of primarily non-Hispanic white birthing parents with intent to exclusively breastfeed, the following postnatal unit variables were associated with higher odds of meeting their breastfeeding goals, birthing parents feeling: welcomed (adjusted OR=1.36), that health care promoted their physical health (adjusted OR=1.41), that care promoted their emotional health (adjusted OR=1.38), that they were supported (adjusted OR=1.56), and that they were recognized by their health care team (adjusted OR=1.30). All the measured postnatal unit support variables were significantly correlated with each other, with correlation coefficients ranging from 0.15 to 0.81.

CONCLUSIONS

Before the COVID-19 pandemic, birthing parents' experiences on the postnatal unit were interrelated and associated with meeting their breastfeeding goals. As health care services are reviewed and prioritized during the COVID-19 pandemic and as part of ongoing strengthening of systems, qualitative and observational research can address the mechanisms underlying breastfeeding outcomes to inform the provision of more holistic and effective support.

Harassment of health professionals by the infant food industry at scientific events

OBJECTIVE

To analyze the receipt of sponsorships from breast-milk substitute companies by health professionals in scientific events.

METHODS

Multicenter study (Multi-NBCAL) performed from November 2018 to November 2019 in six cities in different Brazilian regions. In 26 public and private hospitals, pediatricians, nutritionists, speech therapists, and a hospital manager were interviewed using a structured questionnaire. Descriptive analyses were carried out regarding the health professionals’ knowledge about the Norma Brasileira de Comercialização de Alimentos para Lactentes e Crianças de Primeira Infância, Bicos, Chupetas e Mamadeiras (NBCAL – Brazilian Code of Marketing of Infant and Toddlers Food and Childcare-related Products), companies sponsoring scientific events, and material or financial sponsorships received, according to profession.

RESULTS

We interviewed 217 health professionals, mainly pediatricians (48.8%). Slightly more than half of the professionals (54.4%) knew NBCAL, most from Baby-friendly Hospitals. Most health professionals (85.7%) attended scientific events in the last two years, more than half of them (54.3%) sponsored by breast-milk substitute companies, especially Nestlé (85.1%) and Danone (65.3%). These professionals received sponsorships in the events, such as office supplies (49.5%), meals or invitations to parties (29.9%), promotional gifts (21.6%), payment of the conference registration fee (6.2%) or ticket to the conference (2.1%).

CONCLUSION

The infant food industries violate NBCAL by harassing health professionals in scientific conferences, offering diverse material and financial sponsorships.

Determinants of Delayed Initiation of Breastfeeding: A Cross-Sectional Multicenter Study in Abu Dhabi, the United Arab Emirates

One of the best practices to reduce the risk of infant morbidity and mortality is the early initiation of breastfeeding, specifically within the first hour of birth, as the World Health Organization (WHO) recommends. Limited data exist on breastfeeding initiation and its related factors in the United Arab Emirates (U.A.E.). Therefore, the purpose of this research study was to evaluate and analyze the determinant factors associated with delayed initiation of breastfeeding among mothers with children aged <2 years old in a cross-sectional multicenter setting in Abu Dhabi, U.A.E. Seven governmental community and healthcare centers participated in the study from diverse geographic areas of Abu Dhabi. A trained female research assistant collected information from mothers with young children attending the centers. All participants were informed in detail about the purpose of the study and signed a written consent form. A total of 1610 mother−child pairs were included in the study. The mean (standard deviation) of maternal age and children’s age was 30.1 (5.1) years and 8.1 (5.9) months, respectively. Six hundred and four (604) (37.5%) reported delayed initiation of breastfeeding. Factors associated with delayed breastfeeding initiation were being of non-Arab nationality (adjusted odds ratio (A.O.R.) 1.30, 95% confidence interval (CI) 1.03, 1.63), caesarean section (AOR 2.85, 95% CI 2.26, 3.58), non-rooming-in (AOR 2.82, 95% CI 1.53, 5.21), first birth order (AOR 1.34, 95% CI 1.07, 1.69), and mothers with low-birth-weight children (AOR 3.30, 95% CI 2.18, 4.99) as was analyzed by multivariate logistic regression analysis. In conclusion, approximately four out of ten mothers delayed initiation of breastfeeding for more than one hour after delivery. The results of this study call for urgent policy changes to improve the early initiation rates of breastfeeding mothers in the U.A.E.

Factors That Influence Posthospital Infant Feeding Practices Among Women Who Deliver at a Baby Friendly Hospital in Southern United States

Introduction: The Baby Friendly Hospital Initiative has had a positive impact on breastfeeding initiation; however, little is known about posthospital infant feeding practices among women who deliver at baby friendly hospitals. Therefore we sought to evaluate posthospital breastfeeding outcomes among women who deliver at a baby friendly hospital (BFH) by (1) estimating exclusive breastfeeding rates at the postpartum visit (PPV), (2) quantifying the exclusive breastfeeding discontinuation rate, and (3) identifying which factors are associated with breastfeeding discontinuation. Methods: This was a prospective cohort study of women aged 14 and over, who delivered at the University of Alabama at Birmingham. The primary outcome was mode of infant feeding categorized as exclusive breastfeeding (EBF), combination breastfeeding and formula feeding (CF), and exclusive formula feeding (EFF) at the PPV. Secondary outcome was EBF discontinuation rate. Patients who initiated formula and/or who stopped breastfeeding were asked what influenced their decision. Results: At hospital discharge, 71.1% of the participants were EBF, 21.7% were CF, and 7.2% were EFF. At the PPV, the frequency of the primary outcome of EBF was 31.6% (95% confidence interval: 25.2-38.8); 34.6% (28.0-41.9) were CF, and 33.8% (27.3-41.1) were EFF. Therefore, the EBF absolute and relative discontinuation rates were 39.5% and 55.6%, respectively. No demographic factors, delivery characteristics, or maternal medical morbidities were associated with EBF in the multivariable logistic regression. However, women in the EBF group were more likely to report a workplace environment conducive to breastfeeding and partner and friend support. Conclusion: Significant breastfeeding discontinuation rates occur even among women who deliver at a BFH. Our findings suggest that multifactorial interventions, including a focus on the prevention of formula introduction, are needed in the early postpartum period to achieve higher EBF rates at the PPV.

The impact of a package of behaviour change interventions on breastfeeding practices in East Java Province, Indonesia

Suboptimal infant young child feeding practices are frequently reported globally, including in Indonesia. This analysis examined the impact of a package of behaviour change interventions on breastfeeding practices in Malang and Sidoarjo Districts, East Java Province, Indonesia. The BADUTA study (which in the Indonesian Language is an acronym for BAwah DUa TAhun, or children aged less than 2 years) was an impact evaluation using a cluster‐randomized controlled trial with two parallel treatment arms. We conducted household surveys in 12 subdistricts from Malang and Sidoarjo. We collected information from 5175 mothers of children aged 0–23 months: 2435 mothers at baseline (February 2015) and 2740 mothers at endline (January to February 2017). This analysis used two indicators for fever and diarrhoea and seven breastfeeding indicators (early initiation of breastfeeding, prelacteal feeding, exclusive breastfeeding under 6 months, predominant breastfeeding, continued breastfeeding, age‐appropriate breastfeeding and bottle‐feeding). We used multilevel logistic regression analysis to assess the effect of the intervention. After 2 years of implementation of interventions, we observed an increased odds of exclusive breastfeeding under 6 months (adjusted odds ratio [aOR] = 1.85; 95% confidence interval [CI]: 1.35–2.53) and age‐appropriate breastfeeding (aOR = 1.39; 95% CI: 1.07–1.79) in the intervention group than in the comparison group, at the endline survey. We found significantly lower odds for prelacteal feeding (aOR = 0.52; 95% CI: 0.41–0.65) in the intervention than in the comparison group. Our findings confirmed the benefits of integrated, multilayer behaviour change interventions to promote breastfeeding practices. Further research is required to develop effective interventions to reduce bottle use and improve other breastfeeding indicators that did not change with the BADUTA intervention.

The integrated package of behaviour change interventions in the BADUTA study (which in the Indonesian Language is an acronym for BAwah DUa TAhun, or children aged less than 2 years) increased exclusive and age‐appropriate breastfeeding practices in children under 2 years old in Indonesia.

The BADUTA study interventions did not significantly affect early breastfeeding initiation, breastfeeding in the last 24 h, ever breastfed, continued breastfeeding, predominant breastfeeding, bottle‐feeding practices, fever and diarrhoea 2 weeks before the interview.

Further research is required to develop effective interventions to improve continued breastfeeding after 12 months of age and reduce predominant breastfeeding for children aged 0–5 months and bottle‐feeding practices.

Using art to raise awareness of breastfed children with medical complexity

Background

Current infant feeding support is often targeted at establishing breastfeeding in healthy term infants, or supporting lactation for preterm infants in the neonatal setting. Breastfeeding presents different challenges for children beyond the neonatal period who have a medical complexity. The tendency to focus on breastfeeding as a preventative public health intervention overlooks the fact that mothers and children with medical complexity often require additional and targeted support to continue to breastfeed. Despite this identified need, there is very little research, policy or clinically specific teaching within paediatrics that is nuanced enough to support this vulnerable population.

Raising awareness of breastfed children with medical complexity in paediatrics

While research, policy and embedded Baby Friendly Health Initiative (BFHI) standards in both the maternity and neonatal directorates exists, paediatrics is a separate discipline and contrastingly, has very little lactation support infrastructure. To this end, a doctoral study was commenced aiming to identify the differences for this vulnerable and largely overlooked group. One of the related outputs of the ongoing research is the use of creative methods to raise awareness. This commentary highlights a project with an artist to develop a series of portraits alongside a book and health professional education to increase awareness of these children’s needs.

Conclusions

The breastfeeding needs and challenges of children in the paediatric setting are unique and require additional awareness, creativity and skills to support optimal infant and young child breastfeeding. Using art can connect professionals to the lived experiences of families trying to persevere through medical complexity.

Associations between use of expressed human milk at 2 weeks postpartum and human milk feeding practices to 6 months: a prospective cohort study with vulnerable women in Toronto, Canada

OBJECTIVES

To examine whether use of expressed human milk in the first two weeks postpartum is associated with cessation of human milk feeding and non-exclusive human milk feeding up to 6 months.

DESIGN

Pooled data from two prospective cohort studies SETTING: Three Canada Prenatal Nutrition Program (CPNP) sites serving vulnerable families in Toronto, Canada.

PARTICIPANTS

337 registered CPNP clients enrolled prenatally from 2017 to 2020; 315 (93%) were retained to 6 months postpartum.

EXCLUSIONS

pregnancy loss or participation in prior related study; Study B: preterm birth (<34 weeks); plan to move outside Toronto; not intending to feed human milk; hospitalisation of mother or baby at 2 weeks postpartum.

PRIMARY AND SECONDARY OUTCOME MEASURES

Main exposure variable: any use of expressed human milk at 2 weeks postpartum.

OUTCOMES

cessation of human milk feeding by 6 months; non-exclusive human milk feeding to 4 months and 6 months postpartum.

RESULTS

All participants initiated human milk feeding and 80% continued for 6 months. Exclusive human milk feeding was practiced postdischarge to 4 months by 28% and to 6 months by 16%. At 2 weeks postpartum, 34% reported use of expressed human milk. Any use of expressed human milk at 2 weeks was associated with cessation of human milk feeding before 6 months postpartum (aOR 2.66; 95% CI 1.41 to 5.05) and with non-exclusive human milk feeding to 4 months (aOR 2.19; 95% CI 1.16 to 4.14) and 6 months (aOR 3.65; 95% CI 1.50 to 8.84).

TRIAL REGISTRATION NUMBERS

NCT03400605, NCT03589963.

Predicting exclusive breastfeeding in maternity wards using machine learning techniques

BACKGROUND AND OBJECTIVE

Adequate support in maternity wards is decisive for breastfeeding outcomes during the first year of life. Quality improvement interventions require the identification of the factors influencing hospital benchmark indicators. Machine Learning (ML) models and post-hoc Explainable Artificial Intelligence (XAI) techniques allow accurate predictions and explaining them. This study aimed to predict exclusive breastfeeding during the in-hospital postpartum stay by ML algorithms and explain the ML model's behaviour to support decision making.

METHODS

The dataset included 2042 mothers giving birth in 18 hospitals in Eastern Spain. We obtained information on demographics, mothers' breastfeeding experiences, clinical variables, and participating hospitals' support conditions. The outcome variable was exclusive breastfeeding during the in-hospital postpartum stay. We tested algorithms from different ML families. To evaluate the ML models, we applied 10-fold stratified cross-validation. We used the following metrics: Area under curve receiver operating characteristic (ROC AUC), area under curve precision-recall (PR AUC), accuracy, and Brier score. After selecting the best fitting model, we calculated Shapley's additive values to assign weights to each predictor depending on its additive contribution to the outcome and to explain the predictions.

RESULTS

The XGBoost algorithms showed the best metrics (ROC AUC = 0.78, PR AUC = 0.86, accuracy = 0.75, Brier = 0.17). The main predictors of the model included, in order of importance, the pacifier use, the degree of breastfeeding self-efficacy, the previous breastfeeding experience, the birth weight, the admission of the baby to a neonatal care unit after birth, the moment of the first skin-to-skin contact between mother and baby, and the Baby-Friendly Hospital Initiative accreditation of the hospital. Specific examples for linear and nonlinear relations between main predictors and the outcome and heterogeneity of effects are presented. Also, we describe diverse individual cases showing the variation of the prediction depending on individual characteristics.

CONCLUSION

The ML model adequately predicted exclusive breastfeeding during the in-hospital stay. Our results pointed to opportunities for improving care related to support for specific mother's groups, defined by current and previous infant feeding experiences and clinical conditions of the newborns, and the participating hospitals' support conditions. Also, XAI techniques allowed identifying non-linearity relations and effect's heterogeneity, explaining specific cases' risk variations.

A mixed-methods study on the association of six-month predominant breastfeeding with socioecological factors and COVID-19 among experienced breastfeeding women in Hong Kong

Background

In the past decade, various breastfeeding policies were implemented in Hong Kong, including changes in perinatal guidelines in public hospitals, adoption of the Baby-Friendly Hospital Initiative (BFHI), provision of guidelines for the marketing of formula milk, penalisation of discrimination towards breastfeeding, and extension of the statutory maternity leave. Meanwhile, the COVID-19 pandemic brought new challenges and opportunities to breastfeeding practices. Infection control measures in public hospitals included the cancellation of antenatal classes, hospital tours, and postnatal classes; suspension of perinatal visiting periods; and compulsory separation of COVID-19 positive mothers from newborns. In addition, work-from-home policies were widely implemented. This study aimed to identify the associated factors of six-month predominant breastfeeding (PBF), and to evaluate the impact of COVID-19 on breastfeeding practice.

Methods

This study was conducted from 1 March 2021 to 7 April 2021 using a mixed-methods approach. An electronic questionnaire was distributed to members of breastfeeding or parenting groups who have had breastfeeding experience in the past 10 yrs. Logistic and linear regression analyses were conducted to identify factors associated with six-month PBF both in general and during the pandemic period. A qualitative content analysis was conducted using an inductive approach.

Results

The study included 793 participants. Giving birth in a public hospital (OR 2.21; 95% CI 1.46, 3.34) and breastfeeding support from family and friends (OR 1.28; 95% CI 1.05, 1.57) were significantly associated with six-month PBF, even during COVID-19. Factors associated with the self-rated impact of COVID-19 on breastfeeding include working from home, the perceived immunological benefits of breastfeeding, and the wish to avoid breastfeeding or expressing breast milk in public premises. Furthermore, breastfeeding practice in public hospitals was more likely to be affected by the busyness of staff, while private hospitals had worse rooming-in practices and staff who had inadequate breastfeeding knowledge.

Conclusions

Giving birth in a public hospital and having breastfeeding support from family and friends were associated with six-month PBF. Furthermore, COVID-19 in Hong Kong had an overall positive impact on six-month PBF. Further studies should investigate the impact of hospital practices and the COVID-19 pandemic on breastfeeding behaviours.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00484-7.