Support for healthy breastfeeding mothers with healthy term babies

An Examination of the Benefits of Lactation Consultant Services in NICUs for Mothers and Their Newborn: A Systematic Review

Background: It is well accepted that lactation consultant (LC) services can enhance the breastfeeding success in mother-infant dyads. However, despite such advantages, not all neonatal intensive care units (NICUs) offer LC services. The objective of this systematic review was to assess the available evidence on the effect of LC service on breastfeeding outcomes for mothers whose infants are in the NICU. Methods: The PRISMA Extension for Systematic Reviews were used to conduct this systematic review. The following databases: Embase, Medline, CINAHL, and Cochrane library were searched. An initial 464 studies were obtained. Duplicates and studies that did not fit the inclusion criteria were removed, leaving 30 full-text articles to review. Nineteen were further excluded after full-text review. A total of 11 studies were included. Due to the heterogeneity of the included studies, a meta-analysis could not be performed, instead a qualitative numerical summary was conducted. Results: Overall, 10/11 (90%) of studies observed a 6-31% increase in the number of infants who received mother's own milk, and 11-27% in the number of infants who received direct breastfeeds associated with the implementation of LC services in the NICU. The two most common types of LC services studied included: i) multidisciplinary lactation support-described as a team-based approach that includes at least one LC and ii) designation of LC formal role in the NICU. Conclusions: This review highlights that having LC services in the NICU is vital for meeting the unique needs and enhancing breastfeeding outcomes for mothers whose infants are in the NICU.

The Effect of Baby Friendly Neonatal Intensive Care Initiative on Exclusive Breastfeeding Rates following Discharge in Very Preterm Infants

AIM

We aimed to investigate the effect of "Baby Friendly NICU" practice on exclusive breastfeeding rates following discharge in very preterm infants.

BACKGROUND

The Baby-Friendly Hospital Initiative (BFHI) is a global program launched by the World Health Organization (WHO) and UNICEF.

METHODS

The feeding technique, type of nutrition (breastfeeding, formula, mixed) and anthropometric measurements of the very preterm infants (≤32 gestational weeks) were recorded for every month following discharge up to corrected 6 months of age. Exclusive breastfeeding rates were compared between 2 periods before "Baby Friendly NICU" practice (group 1) and after (group 2).

RESULTS

Data of 252 infants, 135 in group 1 and 117 in group 2 were analyzed. Exclusive formula feeding rates decreased by 6 months age in group 2 (46 vs. 32%, P = .02); however, exclusively breastfeeding rates did not changed significantly (20% vs. 29%, P = .14).

CONCLUSION

Baby friendly NICU practices significantly decreased formula feeding rates at 6 months; however, it did not have an effect on exclusive breastfeeding rates at any time point during follow-up probably due to small sample size.

Association Between Prepregnancy Body Mass Index and Newborn Breastfeeding Initiation

Background: The benefits of breastfeeding a newborn are well documented. Identification of mothers who do not initiate breastfeeding is essential for developing initiatives to improve breastfeeding initiation. Methods: The study used data from the National Center for Health Statistics (NCHS) National Vital Statistics System (NVSS) birth certificate data (2014-2021) to identifying 15,599,930 in-hospital deliveries. We used multivariable logistic regression to assess the association between seven body mass index (BMI) categories and initiation of breastfeeding before hospital discharge. Prepregnancy BMI (weight in kilograms/height in meters2) included underweight (<18.5), healthy weight (18.5-24.9), overweight (25.0-29.9), Obesity Class I (30-34.9), Obesity Class II (35-39.9), and Obesity Class III (40-49.9) classes, in addition to a class newly identified in the literature as super obese (≥50), hereafter "Obesity Class IV." "This project was deemed non-human subjects research." Results: Approximately, 83% of mothers initiated breastfeeding before hospital discharge. Compared to mothers with a healthy prepregnancy BMI, the likelihood of breastfeeding initiation before hospital discharge decreased with increasing prepregnancy BMI. Specifically, we found reduced likelihood of initiation for mothers who were overweight (adjusted odds ratio [aOR]: 0.952, 95% confidence interval [CI]: [0.948-0.955]), Obesity Class I (aOR: 0.884, 95% CI: [0.880-0.888]), Obesity Class II (aOR: 0.816, 95% CI: [0.811-0.820]), Obesity Class III (aOR: 0.750, 95% CI: [0.745-0.755]), and Obesity Class IV (aOR 0.672: 95% CI: [0.662-0.683]). Conclusions: Mothers with prepregnancy BMI above the healthy range had reduced likelihood of initiating breastfeeding prior hospital discharge. This information should be used to develop and initiate interventions for mothers who wish to breastfeed but may need additional lactation assistance support.

Postpartum Breastfeeding Practices and Attitudes in Parents: A Randomized Study to Evaluate the Effects of Individual and Group Breastfeeding Education of Mothers and Fathers

Background Antenatal breastfeeding training is defined as the provision of breastfeeding information during pregnancy, which can be given in various ways, such as individual training and group training. The inclusion of fathers in this educational approach is associated with the initiation of breastfeeding, exclusive breastfeeding and duration of breastfeeding. However, studies involving fathers are limited. This randomized controlled study aimed to compare the effects of individual and group training given to parents and those of normal hospital practices on mothers' breastfeeding self-efficacy and fathers' attitudes toward breastfeeding. Methods The study was conducted randomly in a training and research hospital between March 2014 and September 2014 and included 180 people. Of them, 90 were prospective mothers who were in the third trimester of their pregnancy and were living with their husbands and received service from the obstetrics outpatient clinic of the hospital. The expecting mothers and their husbands were randomly assigned to three groups: individual training, group training and control group. After randomization, prospective mothers and fathers in all groups received training. In the first week, sixth week, and fourth month after delivery, the mothers' breastfeeding self-efficacy and breastfeeding attitudes as well as the attitudes of the fathers' toward breastfeeding were evaluated. Results There were no differences between the groups in terms of variables such as age, education status, family type, breastfeeding education status, and mode of delivery. There were significant differences between the scores obtained from the Breastfeeding Self-Efficacy Scale and its subscales in all three groups during the postpartum period (p <0.05). The highest scale scores were obtained at the postpartum fourth month in the individual training and control groups and at the postpartum sixth week in the group training group. There were differences between the scores obtained by the mothers and fathers during the postpartum process from the Iowa Infant Feeding Attitude Scale (p<0.05). Conclusion The analysis of all the results indicates that breastfeeding education given to parents in the antenatal period increases their breastfeeding self-efficacy and provides them with a positive attitude toward breastfeeding. However, further research is needed to determine whether individual or group training contributes to the development of breastfeeding self-efficacy and attitudes.

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.

Marketing of commercial milk formula: a system to capture parents, communities, science, and policy

Despite proven benefits, less than half of infants and young children globally are breastfed in accordance with the recommendations of WHO. In comparison, commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more infants and young children receiving formula products than ever. This Series paper describes the CMF marketing playbook and its influence on families, health professionals, science, and policy processes, drawing on national survey data, company reports, case studies, methodical scoping reviews, and two multicountry research studies. We report how CMF sales are driven by multifaceted, well resourced marketing strategies that portray CMF products, with little or no supporting evidence, as solutions to common infant health and developmental challenges in ways that systematically undermine breastfeeding. Digital platforms substantially extend the reach and influence of marketing while circumventing the International Code of Marketing of Breast-milk Substitutes. Creating an enabling policy environment for breastfeeding that is free from commercial influence requires greater political commitment, financial investment, CMF industry transparency, and sustained advocacy. A framework convention on the commercial marketing of food products for infants and children is needed to end CMF marketing.

The Work of Breastfeeding Among Women of Low Socioeconomic Status: A Qualitative Metasynthesis

A theory-generating qualitative metasynthesis was used to explore the questions: (a) How do mothers of low socioeconomic status in the United States express their attitudes and beliefs on breastfeeding? (b) How do mothers of low socioeconomic status in the United States describe the types of support received related to breastfeeding? Databases were searched from January 2000 to June 2022. Eleven qualitative studies were evaluated, and six themes were identified. A model was developed illustrating how the themes impact a mother's decision to breastfeed. Positive factors included shared narratives, knowledge of breastfeeding physiology, and social network. However, more negative influences were heard such as opinions passed on from family and friends, lack of teaching and anticipatory guidance, limited support and follow up, and the perception of conflicting messages from health care professionals. This model identifies constructs that can be used as starting points for interventions, policy development and/or health promotion education.

Validity and reliability of the Turkish version of the paternal breastfeeding self-efficacy scale - Short form for fathers

BACKGROUND

Women supported by their partners are more likely to initiate and maintain breastfeeding and overcome related challenges. Therefore, reliable measurement tools are needed to determine whether fathers can provide this support.

AIM

This study aimed to (1) examine the psychometric properties of the Paternal Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) in Turkish fathers, including internal consistency reliability, test-retest reliability, construct validity using Confirmatory Factor Analysis (CFA); and (2) assess the relationship between the BSES-SF and paternal demographic factors.

METHODS

A methodologically study was conducted between December 26-2018 and June 26-2019 at the pediatrics clinics of two research hospitals of medical schools in Konya, Turkey. The sample consisted of 221 fathers of infants aged 2 to 6 weeks who visited the clinics for routine examinations. Data were collected using a sociodemographic questionnaire and the Turkish version of the Paternal BSES-SF. After evaluating the language equivalence and content validity of the scale, test-retest reliability, internal consistency and construct validity were examined. In evaluation of the data frequency/percentage, mean, standard deviation, independent groups t test, ANOVA Analysis, Bartlett's Test of Sphericity, Confirmatory Factor Analysis, Pearson Product-Moment correlation and Cronbach α analysis were used. The study was approved by Interventional Clinical Research Ethics Committee of the Faculty of Health Sciences of Selcuk University in Turkey.

RESULTS

The translated Paternal BSES-SF had a Cronbach's alpha of 0.93 and a test-retest reliability coefficient of 0.96. The factor loadings ranged from 0.42 to 0.76. The Paternal BSES-SF had a one-factor structure similar to the original scale. Fathers who were unemployed, had lower economic status, and unplanned pregnancy had significantly lower mean Paternal BSES-SF scores. Paternal education regarding breastfeeding increased mean Paternal BSES-SF retest scores (p<0.05).

CONCLUSIONS

The Paternal BSES-SF was a valid and reliable measure to assess fathers' confidence in their ability to assist mothers with breastfeeding in Turkey. Turkish researchers and health workers can use this instrument as a reference for promoting exclusive breastfeeding.

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.

Experiences that influence how trained providers support women with breastfeeding: A systematic review of qualitative evidence

INTRODUCTION

There is a need to improve breastfeeding support interventions as although many are evidence-based, a sequential increase in breastfeeding rates is not evident. It is crucial to understand why the implementation of evidence-based guidelines in practice does not always translate to positive experiences for women and improve breastfeeding rates. This systematic review aims to synthesise breastfeeding support experiences of trained support providers and their impact on breastfeeding support practices.

METHODS

A strategy was developed to search seven databases including Medline and CINAHL and grey literature for qualitative studies. Studies eligible for inclusion reported professional and trained peer experiences of supporting women to breastfeed. PRISMA guidelines were followed and included studies were quality appraised using the CASP Qualitative Checklist. A thematic synthesis of included studies was undertaken and confidence in the review findings was assessed using the CERQual tool. The study protocol, registered in the International Prospective Register of Systematic Reviews PROSPERO registration number: CRD42020207380, has been peer reviewed and published.

FINDINGS

A total of 977 records were screened, which identified 18 studies (21 papers) eligible for inclusion comprising 368 participants. Following quality appraisal, all studies were deemed suitable for inclusion. The thematic synthesis resulted in four analytical themes: 1) A personal philosophy of breastfeeding support 2) Teamwork and tensions in practice 3) Negotiating organisational constraints and 4) Encounters with breastfeeding women. Findings demonstrated that a range of experiences influence practice, and practice evolves on continued exposure to such experiences. The potential of each experience to facilitate or inhibit breastfeeding support provision is fluid and context specific.

CONCLUSIONS

Experiences, as named above, are modifiable factors contributing to the development of a philosophy of breastfeeding support based on what the provider believes works and is valuable in practice. Further research is required into the range of factors which underpin context-specific breastfeeding support practice, to improve both women's experiences and intervention effectiveness.

Autistic women's views and experiences of infant feeding: A systematic review of qualitative evidence

LAY ABSTRACT

What is already known about the topic?Mothers are encouraged to breastfeed their babies due to known health benefits for both babies and mothers. However, although breastfeeding is 'natural', that does not make it easy and many women experience challenges. Autistic women may face additional barriers to breastfeeding when compared to neurotypical women.What this paper adds?We reviewed all existing evidence on Autistic mothers' infant feeding experiences (22 pieces) and found that although many Autistic women wanted to breastfeed, breastfeeding was difficult for Autistic mothers for three key reasons. First, maternity and infant feeding services were inaccessible and unsupportive to Autistic mothers, meaning they did not receive help when needed. Second, becoming a mother was challenging because of exhaustion, loss of control over routines and a lack of social support. Third, when breastfeeding Autistic mothers experienced sensory challenges, such as 'being touched out', and pain, which could feel unbearable. Despite these difficulties, many Autistic mothers had done a lot of reading about breastfeeding and were determined to breastfeed their babies; some mothers found breastfeeding positive. Infant formula was often viewed as second-best compared to breastmilk, but some mothers found the ritual of preparing bottles of formula to be calming.Implications for practice, research or policyThe findings of this work show that Autistic mothers urgently need better support from health professionals to help meet their breastfeeding goals, including how to remove or reduce the extra barriers being Autistic brings to breastfeeding.

Effect of maternal nutrition education on early initiation and exclusive breast-feeding practices in south Ethiopia: a cluster randomised control trial

Introduction: Optimal breast-feeding practices make a major contribution to the promotion of healthy growth and development through much prevention of diarrheal and respiratory diseases which majorly cause morbidity and mortality in under-five children. However, breast-feeding practices remain suboptimality in Ethiopia. Objective: The study objective was to determine the effect of maternal nutrition education on early initiation and exclusive breast-feeding practice in the Hawela Tulla sub-city. Methods: A cluster randomised, parallel-group, single-blinded trial was used. About 310 pregnant women (155 for the intervention group and 155 for the control group) were included. Result: An early initiation of breast-feeding was significantly higher among women who received breast-feeding education than those who did not receive (104(72·7 %) v. 85(59·9 %), P = 0·022) and exclusive breast-feeding practice was also significantly higher among women who received breast-feeding education than those who did not receive (106(74·1 %) v. 86(60·6 %), P = 0·015). Breast-feeding education [AORs 1·55, 95 % CI (1·02, 2·36)], institutional delivery [AOR 2·29, 95 % CI (1·21, 4·35)], vaginal delivery [AOR 2·85, 95 % CI (1·61, 5·41)] and pre-lacteal feeding [AOR 0·47, 95 % CI (0·25, 0·85)] were predictors of early initiation of breast-feeding. Breast-feeding education [AOR 1·72, 95 % CI (1·12, 2·64)] and institutional delivery [AOR 2·36, 95 % CI (1·28, 4·33)] were also determinants of exclusive breast-feeding practices. Conclusion: Breast-feeding education improved early initiation of breast-feeding and exclusive breast-feeding practices. Providing sustained education to women regarding early initiation and exclusive breast-feeding practice should be strengthened.

Breastfeeding experiences during the COVID-19 pandemic in Spain:a qualitative study

Background

The pandemic caused by COVID-19 has affected reproductive and perinatal health both through the infection itself and, indirectly, as a consequence of changes in medical care, social policy or social and economic circumstances.

The objective of this study is to explore the impact of the pandemic and of the measures adopted on breastfeeding initiation and maintenance.

Methods

A qualitative descriptive study was conducted by means in-depth semi-structured interviews, until reaching data saturation. The study was conducted between the months of January to May 2021. Participants were recruited by midwives from the Primary Care Centres of the Andalusian provinces provinces of Seville, Cádiz, Huelva, Granada, and Jaén. The interviews were conducted via phone call and were subsequently transcribed and analysed by means of reflexive inductive thematic analysis, using Braun and Clarke’s thematic analysis.

Results

A total of 30 interviews were conducted. Five main themes and ten subthemes were developed, namely: Information received (access to the information, figure who provided the information), unequal support from the professionals during the pandemic (support to postpartum hospitalization, support received from Primary Health Care during the postpartum period), social and family support about breastfeeding (support groups, family support), impact of confinement and of social restriction measures (positive influence on breastfeeding, influence on bonding with the newborn), emotional effect of the pandemic (insecurity and fear related to contagion by coronavirus, feelings of loneliness).

Conclusion

The use of online breastfeeding support groups through applications such as WhatsApp®, Facebook® or Instagram® has provided important breastfeeding information and support sources. The main figure identified that has provided formal breastfeeding support during this period was that of the midwife. In addition, the social restrictions inherent to the pandemic have exerted a positive effect for women in bonding and breastfeeding, as a consequence of the increase in the time spent at their homes and in the family nucleus co-living.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00453-0.

Impact of telelactation services on breastfeeding outcomes among Black and Latinx parents: protocol for the Tele-MILC randomized controlled trial

BACKGROUND

Breastfeeding offers many medical and neurodevelopmental advantages for birthing parents and infants; however, the majority of parents stop breastfeeding before it is recommended. Professional lactation support by the International Board Certified Lactation Consultants (IBCLCs) increases breastfeeding rates; however, many communities lack access to IBCLCs. Black and Latinx parents have lower breastfeeding rates, and limited access to professional lactation support may contribute to this disparity. Virtual "telelactation" consults that use two-way video have the potential to increase access to IBCLCs among disadvantaged populations. We present a protocol for the digital Tele-MILC trial, which uses mixed methods to evaluate the impact of telelactation services on breastfeeding outcomes. The objective of this pragmatic, parallel design randomized controlled trial is to assess the impact of telelactation on breastfeeding duration and exclusivity and explore how acceptability of and experiences with telelactation vary across Latinx, Black, and non-Black and non-Latinx parents to guide future improvement of these services.

METHODS

2400 primiparous, pregnant individuals age > 18 who intend to breastfeed and live in the USA underserved by IBCLCs will be recruited. Recruitment will occur via Ovia, a pregnancy tracker mobile phone application (app) used by over one million pregnant individuals in the USA annually. Participants will be randomized to (1) on-demand telelactation video calls on personal devices or (2) ebook on infant care/usual care. Breastfeeding outcomes will be captured via surveys and interviews and compared across racial and ethnic groups. This study will track participants for 8 months (including 6 months postpartum). Primary outcomes include breastfeeding duration and breastfeeding exclusivity. We will quantify differences in these outcomes across racial and ethnic groups. Both intention-to-treat and as-treated (using instrumental variable methods) analyses will be performed. This study will also generate qualitative data on the experiences of different subgroups of parents with the telelactation intervention, including barriers to use, satisfaction, and strengths and limitations of this delivery model.

DISCUSSION

This is the first randomized study evaluating the impact of telelactation on breastfeeding outcomes. It will inform the design and implementation of future digital trials among pregnant and postpartum people, including Black and Latinx populations which are historically underrepresented in clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04856163. Registered on April 23, 2021.

Social Behavior Changes Communication Intervention for Stunting Prevention: A Systematic Review

Purpose: T Social and behaviour change approach most used, and the only one used without other communication interventions was interpersonal communication and media and community/social mobilization. The current review sought to to review and synthesize the current literature regarding social and behavior communication change intervention at community-based programs, summarize treatment models and outcome measures, and evaluate the evidence. Methods: We searched Medline, PsychINFO, and PubMed (January 2000 and December 2020) and conducted ancestral and online searches in peer-reviewed, English language journals for eligible studies. Results: A total of 5 articles were included in review. All studies reported that SBCC was feasible to increased expenditures on eggs and flesh foods, minimum dietary diversity, early initiation of breastfeeding (EIBP, exclusive breastfeeding (EBP), knowledge and practices towards infant and youth complementary feeding (IYCF) , and reduced stunting prevalence. Conclusion: Future studies could be re-tested using more sample size in different place or region of others countries with relatively high prevalence of stunting.

Predicting Risk for Early Breastfeeding Cessation in Israel

OBJECTIVES

This study aimed to 1) Examine factors associated with cessation of exclusive breastfeeding in Israel and 2) Develop predictive models to identify women at risk for early exclusive breastfeeding cessation.

METHODS

The study used data from longitudinal national representative infant nutrition survey in Israel (n = 2119 participants). Logistic regression was used to identify risk factors and build predictive models.

RESULTS

The rate of exclusive breastfeeding cessation increased from 45.4% at 2 months to 85.7% at 6 months. Five factors were significantly associated with higher odds of exclusive breastfeeding cessation at 2 months: being a primapara, low educational level, lack of previous breastfeeding experience, negative attitude towards birth, and lack of intention to breastfeed. Six factors were significantly associated with higher odds of exclusive breastfeeding cessation at 6 months: younger age, being in a relationship with a partner, lower religiosity level, cesarean delivery, not taking folic acid during pregnancy, and negative attitude towards birth. Both 2 and 6-months models had good predictive performance (C-statistic of .72 and .68, accordingly).

CONCLUSIONS FOR PRACTICE

This nationwide study successfully identified several predictors of exclusive breastfeeding cessation and created breastfeeding cessation prediction tools for two time periods (2 and 6 months). The resulting tools can be applied to identify women at risk for stopping exclusive breastfeeding in hospitals or at community clinics. Further studies should examine practical aspects of applying these tools in practice and explore whether applying those tools can lead to higher exclusive breastfeeding rates.

Dysphoric Milk Ejection Reflex: The Psychoneurobiology of the Breastfeeding Experience

Breastfeeding, given its biochemical and physiological basis, is known for its many benefits for both the lactating mother and the infant. Among the many challenges new breastfeeding mothers experience is the feeling of aversion in response to their newborn's suckling which has been termed dysphoric milk-ejection reflex (D-MER). Characterized by intense feelings of dysphoria which may eventually interfere with the mother's ability to breastfeed regularly, evidence suggests both the neurobiological and psychological basis of D-MER in an attempt to explain its complexity. Biologically, breastfeeding is expressed by the intracerebral release of oxytocin, an increased expression of oxytocin receptors in specific brain regions, increased mesocorticolimbic reward region activation, the secretion of prolactin and possibly the inhibition of dopamine. Hence, different theories explain D-MER in terms of disrupted neurotransmitter and hormonal activity. Breastfeeding has also proven to influence mood and stress reactivity in nursing mothers with a potential link with postpartum depression. Psychological theories attempt to explain D-MER from a sociopsychosexual lense shedding light on the significance of mother-infant attachment, the sexualization of the female body and the motherhood experience as a developmental stage in a woman's lifespan. The aim of this review is to provide a literature update of D-MER incorporating both neurobiological and psychological theories calling for raising awareness about the complexity of breastfeeding and for the need for mother-centered interventions for the management of D-MER and other postpartum-specific conditions.

The Effect of a Structured Individualized Educational Intervention on Breastfeeding Rates in Greek Women

Breastfeeding rates remain extremely low in Greece and women with gestational diabetes mellitus and hypothyroidism may experience additional difficulties. The aim of the study was to investigate the effect of a structured individualized lactation educational intervention by a midwife on increasing breastfeeding rates in women with endocrine disorders and low-risk women compared to women receiving standard care, 24 months after delivery. Two-hundred women made up the study population. Half of them were experiencing endocrine pregnancy disorders and 100 women constituted the low-risk pregnancy standard care control group. Women who were breastfeeding exclusively were significantly higher in the midwifery intervention group with endocrine disorders, namely breastfeeding continued at four months (breastfeeding: 20% vs. 12%, exclusive breastfeeding: 50% vs. 26%, p = 0.0228), and at six months after childbirth (breastfeeding: 54% vs. 28%, exclusive breastfeeding: 32% vs. 12%, p = 0.0011), compared to the standard care control group with endocrine disorder. The low-risk midwifery intervention group breastfed at four months (22% vs. 14%, p = 0.0428) and at six months (52% vs. 26%, p = 0.0018) at higher rates compared to the standard care control group. In addition, exclusive breastfeeding was significantly higher in the low-risk midwifery intervention group at four months (46% vs. 20%, p = 0.0102) and six months (38% vs. 4%, p < 0.0001) compared to the standard care control group. This study was the first attempt of a structured midwifery breastfeeding education in Greece and its major contribution reflects a significant positive impact on breastfeeding rates in terms of duration and exclusivity in women with gestational endocrine disorders as well as in low-risk women, and could possibly be applied and instituted in everyday clinical practice to increase the low breastfeeding rates in Greece.

The experiences of trained breastfeeding support providers that influence how breastfeeding support is practised: A protocol for a qualitative evidence synthesis

BACKGROUND

Many women stop breastfeeding before they intend to as they cannot overcome breastfeeding difficulties. Breastfeeding support, as an evidence-based intervention by trained lay or professional breastfeeding support providers, can prevent early unintended cessation. Yet some women report dissatisfaction with support and reluctantly stop breastfeeding despite receiving this intervention. Understanding the experiences which shape how support is provided can inform effective implementation of breastfeeding support interventions. This review aims to synthesise experiences of trained breastfeeding support providers in high income settings and how these may influence their breastfeeding support practices.

METHODS

A qualitative systematic review of trained breastfeeding supporters' experiences of supporting women to breastfeed, as part of a generic healthcare role or focused breastfeeding support role, will be conducted. A systematic search will be performed of the databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL +), MEDLINE ALL, Maternity and Infant Care, EMBASE, APA PsycINFO, Web of Science and Scopus. Title and abstract screening using eligibility criteria will be conducted using Covidence software. Eligible papers will be agreed by the review team following full text screening and reported using PRISMA guidelines. CASP and COREQ tools will assess study methodological quality and quality of reporting. Data will be extracted using a bespoke form and coded, using Excel software for data management. Analysis will involve the three stages of thematic synthesis: initial free coding, development of descriptive and subsequent analytical themes. Confidence in findings will be assessed using the CERQual framework.

DISCUSSION

This review is the first to date to synthesise qualitative evidence on experiences which influence how trained lay and professional providers support women with breastfeeding. Findings will enable deeper understanding of the underpinning mechanisms of breastfeeding support provision and inform the development of tailored interventions to improve breastfeeding rates.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42020207380.

Association between early essential newborn care and breastfeeding outcomes in eight countries in Asia and the Pacific: a cross-sectional observational -study

Objective

To explore the association between early essential newborn care (EENC) policy, practice and environmental interventions and breastfeeding outcomes.

Design

Cross-sectional observational study.

Setting

150 national, provincial and district hospitals implementing EENC in eight countries in East Asia and the Pacific.

Participants

1383 maternal interviews, chart reviews and environmental assessments during 2016 and 2017.

Main outcome measures

Exclusive breastfeeding (EBF), that is, feeding only breastmilk without other food or fluids since birth and before discharge, and, early breastfeeding initiation, that is, during skin-to-skin contact (SSC) with the mother without separation.

Results

Fifty-nine per cent of newborns initiated breastfeeding early and 83.5% were EBF. Duration of SSC showed a strong dose–response relationship with early breastfeeding initiation. SSC of at least 90 min was associated with 368.81 (95% CI 88.76 to 1532.38, p<0.001) times higher early breastfeeding. EBF was significantly associated with SSC duration of 30–59 min (OR 3.54, 95% CI 1.88 to 6.66, p<0.001), 60–89 min (OR 5.61, 95% CI 2.51 to 12.58, p<0.001) and at least 90 min (OR 3.78, 95% CI 2.12 to 6.74, p<0.001) regardless of delivery mode. Non-supine position (OR 2.80, 95% CI 1.90 to 4.11, p<0.001), rooming-in (OR 5.85, 95% CI 3.46 to 9.88, p<0.001), hospital breastfeeding policies (OR 2.82, 95% CI 1.97 to 4.02, p<0.001), quality improvement mechanisms (OR 1.63, 95% CI 1.07 to 2.49, p=0.02) and no formula products (OR 17.50, 95% CI 5.92 to 51.74, p<0.001) were associated with EBF.

Conclusion

EENC policy, practice and environmental interventions were associated with breastfeeding outcomes. To maximise the likelihood of early and EBF, newborns, regardless of delivery mode, should receive immediate and uninterrupted SSC for at least 90 min.

The association of breastfeeding self-efficacy with breastfeeding duration and exclusivity: longitudinal assessment of the predictive validity of the Greek version of the BSES-SF tool

INTRODUCTION

While breastfeeding self-efficacy (BSES) is an important modifiable determinant of breastfeeding, a structured assessment is not standard practice in Cyprus. We assessed the Greek version of the Breastfeeding Self-Efficacy Scale (BSES-SF), including its predictive validity in terms of Breastfeeding (BF) and Exclusive Breastfeeding (EBF) up to the sixth month.

METHODS

A methodological study with longitudinal design among 586 mother-infant dyads, as part of the "BrEaST Start in Life" project. BSES was assessed 24-48 h after birth and at the first month. Breastfeeding status was assessed at the clinic, the 1st, 4th and 6th month. The association between BSES and breastfeeding was estimated in logistic regression models and its diagnostic ability in ROC analysis.

RESULTS

With Mean = 3.55 (SD = 0.85), BSES was moderate, and lower among Cypriot women, primiparas and those who delivered by Cesarean Section (C/S). There was good internal consistency across the 14 items (Cronbach's α = 0.94) while factor analysis revealed a two-factor structure. BSES scores were higher among mothers who initiated exclusive breastfeeding (M = 3.92, SD = 0.80) compared to breastfeeding not exclusively (M = 3.29, SD = 0.84) and not breastfeeding (M = 3.04, SD = 1.09; p-value < 0.001). There was a stepwise association with exclusivity (40.5% in the highest vs 7.9% lowest quartile of self-efficacy). The association between in-hospital BSES and long-term EBF persisted in multivariable models. Women in the upper quartile of BSES at 48 h were more likely to breastfeed exclusively by adjOR = 5.3 (95% CI 1.7-17.1) at the 1st and adjOR = 13.7 (95% CI 2.7-68.6) at the 4th month. Similar associations were observed between self-efficacy at the 1st month and BF at subsequent time-points. High first month BSES (> 3.96 as per ROC) had 58.9% positive and 79.6% negative predictive value for breastfeeding at 6 months which reflects higher sensitivity but lower specificity.

CONCLUSIONS

The Greek version of BSES-SF showed good metric properties (construct, know-group, concurrent and predictive validity). In the absence of community support structures or programmes in Cyprus, prevalence of breastfeeding remains low. This suggests a need for policy, educational and community support interventions, including the systematic use of BSES scale as a screening tool to identify those at higher risk for premature BF discontinuation.

Maintenance of Maternal Breastfeeding up to 6 Months: Predictive Models

BACKGROUND

There is evidence of the benefits of exclusive breastfeeding (EBF) but maintaining EBF for the minimum recommended time of 6 months is challenging.

AIMS

This study aimed to determine the prevalence of breastfeeding types in a Spanish setting, explore the influencing factors, and analyze the relationships between the reasons for EBF cessation and the EBF durations achieved.

METHOD

This longitudinal descriptive study included 236 healthy children with standard weight followed up by the public health system. A baseline survey and three telephone interviews (1, 3, and 6 months) were conducted.

RESULTS

The prevalence of EBF at 6 months was 19.49%. The mean age of the mothers was 32.3 (±5.3). The variables influencing EBF maintenance were the prior decision to practice EBF (p = 0.03), the belief that EBF is sufficient (p = 0.00), not offering water or fluid to the child (p = 0.04), delaying pacifier use (p < 0.001), a longer gestation time (p = 0.05), and previous experience with practicing EBF for more than 6 months (p = 0.00). The reason for the earliest EBF cessation (mean 52.63 ± 56.98 days) was the mother's lack of self-efficacy (p = 0.05).

CONCLUSION

Knowing the reasons for EBF cessation among mothers is important for helping mothers and preventing early weaning. A safe environment and support can prevent early weaning.

Adapting breastfeeding support in areas of socio-economic deprivation: a case study approach

BACKGROUND

There are inequalities in breastfeeding initiation and continuation rates, whereby socio-economically disadvantaged mothers are least likely to breastfeed. Breastfeeding peer support (BPS) interventions are recommended as a solution, and in the UK non-profit organisations are commissioned to deliver BPS services in areas of socio-economic deprivation. BPS interventions have a mixed evidence base, offering limited knowledge about the interaction between context and intervention and how this affects women's experiences.

METHODS

This interpretive study used a case study methodology to explore how and why two BPS services developed their services in socio-economically deprived contexts. Methods aimed to generate holistic understanding of BPS service development. Data collected across both cases comprised; observation (n = 1), and semi-structured interviews with: mothers who had (n = 10) and had not (n = 9) engaged with the BPS services, peer supporters (PSs) (n = 9), community health professionals (n = 5), infant feeding co-ordinators (n = 2), non-profit organisation managers (n = 3), and public health commissioners (n = 2). Inductive grounded theory analytic techniques of open coding and constant comparisons, followed by cross case comparisons, were used to analyse the data.

RESULTS

The over-arching theme - 'the transcending influence of society' - offers insights into the underlying context and drivers impacting service development. It reflects how funding and data sharing arrangements determined service operation and the peer's access to women. Four underpinning themes explain how: peer supporters were resourceful in adapting their services ('adapting and modifying the support'); BPS organisations worked to enable women's access to supportive breastfeeding environments, but did not necessarily focus service development on the needs of women living in areas of deprivation ('supporting women's journeys to access'); the BPS-professional connections for supporting access and how BPS could result in more supportive community environments ('embedding within healthcare practice'); and how management practices precluded meaningful use of data to provide context led service development ('ways of using knowledge').

CONCLUSIONS

Findings suggest that while PSs are commissioned to focus on those most in need, there is limited discussion, collection, or use of knowledge about women's lives to develop needs-led service delivery. The key recommendation is the development of a social ecological tool to facilitate the use and application of contextual knowledge.

"The kind of support that matters to exclusive breastfeeding" a qualitative study

BACKGROUND

Worldwide, only 41 % of infants are exclusively breastfed for the first six months while South Africa has an alarming figure of only 12 %. First-time mothers are inexperienced in the initiation and maintenance of exclusive breastfeeding, hence a need for support. Data on forms and quality of exclusive breastfeeding support as experienced by first-time mothers is minimal. The study explored the exclusive breastfeeding support available to first-time mothers in the Buffalo City Metro, South Africa.

METHODS

A qualitative explorative, descriptive and contextual study, and a non-probability, purposive sampling was used with 10 first-time mothers within the first six months postpartum. The in-depth face-to-face semi-structured individual interviews for data collection and Creswell's steps of thematic analysis were used.

RESULTS

Two themes emerged; challenges, empowerment, support and resilience during initiation of exclusive breastfeeding, and diverse support and resilience during maintenance of exclusive breastfeeding. First-time mothers received practical support majorly from nurses and other mothers during the initiation; social support was from family members, friends, and community members for the maintenance of exclusive breastfeeding. Sometimes there was a disjuncture between practical support from nurses and that from family members and the community. There were instances where the support was needed but not given or not supportive of exclusive breastfeeding.

CONCLUSIONS

These findings illustrate that professional, practical and social support for first-time mothers is crucial in the initiation and maintenance of exclusive breastfeeding for the first six months. Timing and the kind of support given to these mothers is crucial for successful exclusive breastfeeding.

Effectiveness of educational and supportive intervention for primiparous women on breastfeeding related outcomes and breastfeeding self-efficacy: A systematic review and meta-analysis

BACKGROUND

Breastmilk is the most nutritious food for infants to support their growth and protect them from infection. Breastfeeding promotion is an important topic for infant health; and different educational and supportive approaches to interventions have been prompted and targeted at antenatal, postnatal or both periods to promote and sustain exclusive breastfeeding. This systematic review aimed to identify the effective approaches to educational and supportive interventions to improve breastfeeding.

OBJECTIVE

To examine the effects of different approaches to educational and supportive interventions that can help sustain breastfeeding and improve breastfeeding self-efficacy for primiparous postnatal women; and to identify key characteristics of the effective interventions in terms of delivery time, format and mode, main components, use of theoretical framework, and number of sessions.

METHODS

Eleven electronic databases and reference lists of the eligible articles were searched. Randomised controlled trials of educational and supportive interventions published in English and Chinese language over recent 20 years were identified and screened against the review criteria. Risk of bias of the included studies was assessed. Primary outcome measures were exclusive breastfeeding and partial breastfeeding rate. Secondary outcomes included breastfeeding self-efficacy, breastfeeding knowledge and other breastfeeding related outcomes. Meta-analysis was performed in terms of ≤2 months, 3-5 months and ≥6 months postpartum.

RESULTS

Thirteen articles that met the inclusion criteria were included and showed an acceptable risk of bias. Educational and supportive interventions were found effective in increasing exclusive breastfeeding rate at ≤2 months and 6 months, partial breastfeeding rate as well as enhancing breastfeeding self-efficacy at ≤2 months. The optimal delivery time, format and structure of the interventions included: (a) delivering from antenatal to postnatal period; (b) multicomponent involving antenatal group education, postnatal individual breastfeeding coaching and telephone follow-ups; (c) both individual and group basis; (d) being guided by self-efficacy theory; and (e) having ≥3 sessions.

CONCLUSIONS

The findings suggest multicomponent, theory-based intervention with ≥3 sessions delivered via both face-to-face teaching and telephone follow-ups across antenatal and postnatal period can be effective to enhance exclusive breastfeeding over 6-month, partial breastfeeding and breastfeeding self-efficacy over 2-month postpartum.

REGISTRATION NUMBER

CRD42020175473 at the International Prospective Register of Systematic Reviews (PROSPERO).

Effectiveness of a breastfeeding program for mothers returning to work in Japan: a quasi-experimental study

BACKGROUND

Maternal employment has been described as a barrier to breastfeeding in many countries. In Japan, many mothers quit breastfeeding after returning to work because they do not know how to continue breastfeeding. The primary objective of this study was to investigate the effectiveness of a breastfeeding support program for mothers. The secondary objective was to explore the effectiveness of a pamphlet for mothers returning to work.

METHODS

This was a quasi-experimental design study with a program group (n = 48), pamphlet group (n = 46) and comparison group (n = 47) that took place from February 2017 to August 2018. Participants in the program and pamphlet groups were women who planned to return to work within 4-12 months after giving birth, while the comparison group included women who had been back at work for at least 3 months. The program involved a 90-min breastfeeding class, a pamphlet, a newsletter, and email consultation. The pamphlet group was sent only the pamphlet, while the comparison group received no intervention. The outcome was breastfeeding continuation rate at 3 months after returning to work.

RESULTS

The breastfeeding continuation rate 3 months after returning to work was significantly higher in the program group than in the comparison group (79.2% vs. 51.1%, p = 0.004). After adjusting for background factors, the program intervention had an effect on breastfeeding rates (adjusted odds ratio = 4.68, 95% confidence interval: 1.57, 13.96; p = 0.006). However, comparing the pamphlet and comparison groups revealed no significant differences in breastfeeding continuation rates at 3 months after returning to work (69.6% vs. 51.1%, p = 0.07).

CONCLUSIONS

Program intervention was associated with a significant increase in breastfeeding continuation rates 3 months after returning to work. Randomized controlled trials are needed to make this program applicable in practice. Pamphlet intervention resulted in no significant difference. Further study is necessary after examining the contents of the pamphlet.

Perinatal psychological interventions to promote breastfeeding: a narrative review

Background

Emotional distress in mothers inhibits the let-down reflex, thus affecting breastfeeding self-efficacy. A breastfeeding mother may have to cope with both physical discomfort and psychological distress. However, literature on initiatives to improve breastfeeding rates has focused mainly on providing community-based peer support, or social policies. The aim of this review is to assess evidence on the effectiveness of a broad range of psychological interventions to facilitate breastfeeding for mothers facing difficulties around the time of delivery.

Methods

The review of the literature is derived from a search on Cochrane Library, PubMed, EBSCOhost, and PsycINFO for papers published since 1980. The approach was to explore quantitative and qualitative parameters. Quantitative parameters included breastfeeding initiation, duration, and composition. Qualitative parameters recorded the evaluation of maternal perceptions on breastfeeding success. The high heterogeneity of the studies led to a narrative review; 20 selected papers that report on breastfeeding outcomes and psychological programs met the inclusion criteria.

Results

The evidence on breastfeeding support through psychotherapy is heterogeneous and scant. Out of the included studies, 11 were randomized controlled trials, two were non-randomised trials, and two used a quasi-experimental design. None of the studies reported an increase in adverse breastfeeding outcomes. Three studies failed to report an association between psychological procedures and improved breastfeeding outcomes. A literature review showed that 17 (85%) analyses support stress-releasing techniques to facilitate breastfeeding.

Conclusions

This review suggests that relaxation interventions carefully tailored to address perinatal emotional distress may lead to important health benefits, including improvement in breastfeeding outcomes. There is also some indication that psychotherapy support while breastfeeding may have more impact than routine counselling. Conversely, this review did not find an association between self-hypnosis and breastfeeding outcomes. Data from this study can be used in designing prevention programs and future research with appropriate theoretical underpinning.

Cost-effectiveness evidence for strategies to promote or support breastfeeding: a systematic search and narrative literature review

BACKGROUND

Global health policy recommends exclusive breastfeeding until infants are 6 months. Little is known about the cost-effectiveness of breastfeeding promotion strategies. This paper presents a systematic search and narrative review of economic evaluations of strategies to support or promote breastfeeding. The aim of the review is to bring together current knowledge to guide researchers and commissioners towards potentially cost-effective strategies to promote or support breastfeeding.

METHODS

Searches were conducted of electronic databases, including MEDLINE and Scopus, for economic evaluations relevant to breastfeeding, published up to August 2019. Records were screened against pre-specified inclusion/exclusion criteria and quality was assessed using a published checklist. Costs reported in included studies underwent currency conversion and inflation to a single year and currency so that they could be compared. The review protocol was registered on the PROSPERO register of literature reviews (ID, CRD42019141721).

RESULTS

There were 212 non-duplicate citations. Four were included in the review, which generally indicated that interventions were cost-effective. Two studies reported that breastfeeding promotion for low-birth weight babies in critical care is associated with lower costs and greater health benefits than usual care and so is likely to be cost-effective. Peer-support for breastfeeding was associated with longer duration of exclusivity with costs ranging from £19-£107 per additional month (two studies).

CONCLUSIONS

There is limited published evidence on the cost-effectiveness of strategies to promote breastfeeding, although the quality of the current evidence is reasonably high. Future studies should integrate evaluations of the effectiveness of strategies with economic analyses.

Mega-map of systematic reviews and evidence and gap maps on the interventions to improve child well-being in low- and middle-income countries

Background

Despite a considerable reduction in child mortality, nearly six million children under the age of five die each year. Millions more are poorly nourished and in many parts of the world, the quality of education remains poor. Children are at risk from multiple violations of their rights, including child labour, early marriage, and sexual exploitation. Research plays a crucial role in helping to close the remaining gaps in child well-being, yet the global evidence base for interventions to meet these challenges is mostly weak, scattered and often unusable by policymakers and practitioners. This mega-map encourages the generation and use of rigorous evidence on effective ways to improve child well-being for policy and programming.

Objectives

The aim of this mega-map is to identify, map and provide an overview of the existing evidence synthesis on the interventions aimed at improving child well-being in low- and middle-income countries (LMICs).

Methods

Campbell evidence and gap maps (EGMs) are based on a review of existing mapping standards (Saran & White, 2018) which drew in particular of the approach developed by 3ie (Snilstveit, Vojtkova, Bhavsar, & Gaarder, 2013). As defined in the Campbell EGM guidance paper; "Mega-map is a map of evidence synthesis, that is, systematic reviews, and does not include primary studies" (Campbell Collaboration, 2020). The mega-map on child well-being includes studies with participants aged 0-18 years, conducted in LMICs, and published from year 2000 onwards. The search followed strict inclusion criteria for interventions and outcomes in the domains of health, education, social work and welfare, social protection, environmental health, water supply and sanitation (WASH) and governance. Critical appraisal of included systematic reviews was conducted using "A Measurement Tool to Assess Systematic Reviews"-AMSTAR-2 rating scale (Shea, et al., 2017).

Results

We identified 333 systematic reviews and 23 EGMs. The number of studies being published has increased year-on-year since 2000. However, the distribution of studies across World Bank regions, intervention and outcome categories are uneven. Most systematic reviews examine interventions pertaining to traditional areas of health and education. Systematic reviews in these traditional areas are also the most funded. There is limited evidence in social work and social protection. About 69% (231) of the reviews are assessed to be of low and medium quality. There are evidence gaps with respect to key vulnerable populations, including children with disabilities and those who belong to minority groups.

Conclusion

Although an increasing number of systematic reviews addressing child well-being topics are being published, some clear gaps in the evidence remain in terms of quality of reviews and some interventions and outcome areas. The clear gap is the small number of reviews focusing explicitly on either equity or programmes for disadvantaged groups and those who are discriminated against.

Barriers Perceived by Managers and Clinical Professionals Related to the Implementation of Clinical Practice Guidelines for Breastfeeding through the Best Practice Spotlight Organization Program

International institutions facilitate the contact of health professionals to evidence-based recommendations for promoting exclusive breast feeding (BF). However, the achievement of good rates of exclusive BF is still far from the optimum. The intention of the present work is to determine the barriers identified by managers and health professionals involved in the implementation and sustainability of Clinical Practice Guidelines (CPG) for breastfeeding under the auspices of the Best Practice Spotlight Organization program. A qualitative research study was carried out. The participants were managers, healthcare assistants, nurses, midwives, pediatricians and gynecologists. Semi-structured interviews were conducted which were transcribed and analyzed using the six steps of thematic analysis. Twenty interviews were conducted, which defined four major themes: (1) Lack of resources and their adaptation; (2) Where, Who and How; (3) Dissemination and reach of the project to the professionals; and (4) The mother and her surroundings. This research identifies the barriers perceived by the health professionals involved in the implementation, with the addition of the managers as well. Novel barriers appeared such as the ambivalent role of the midwives and the fact that this CPG is about promoting health. The efforts for promoting the implementation program should be continuous, and the services should be extended to primary care.

Infant feeding mode predicts the costs of healthcare services in one region of Canada: a data linkage pilot study

OBJECTIVE

The aim is to perform a pilot study evaluating the differences in healthcare service use and its associated costs by infant feeding mode in an infant's first year of life. Data from a prospective cohort study and administrative databases were linked to examine healthcare use in healthy full term infants (N = 160). Exposure was categorized as exclusively breastfed, mixed fed and exclusively formula fed. Outcomes included hospitalizations, emergency room and physician visits. Descriptive statistics and generalized linear modelling were performed.

RESULTS

Overall $315,235 was spent on healthcare service use for the sample of infants during their first year of life. When compared to exclusive breastfeeding, mixed feeding and exclusive formula feeding were found to be significant predictors of total healthcare service use costs (p < 0.05), driven by costs of hospital admissions. Due to the human and economic burden associated with not breastfeeding, policies and programs that support and encourage breastfeeding should be priority.

Evaluation of the impact of breastfeeding support groups in primary health CENTRES in Andalusia, Spain: a study protocol for a cluster randomized controlled trial (GALMA project)

BACKGROUND

In 2003, the World Health Organization recommended exclusive breastfeeding (EB) during the newborn's first 6 months of life and, if possible, during the first 2 years. However, EB rates resist these recommendations. In developed countries, only 1 out of 3 babies is breastfed during its first 6 months of life, and great differences between areas and countries can be observed. Only 35% of the newborns receive breastfeeding at 3-4 months of age. There are diverse strategies described in the literature that have proven their efficiency in improving breastfeeding rates. It has also been proven that professional support is an effective tool to extend any kind of breastfeeding; besides, it has been observed that mother-to-mother support also increases breastfeeding initiation, sustainment, and exclusive duration. The overall aim of the study is to assess the impact of the support groups on the sustainment of exclusive breastfeeding until 6 months after birth.

METHODS/DESIGN

This study is a cluster-random multicentric clinical trial with a control group and an intervention group, without blinding because it is impossible to mask the intervention. A randomization by centres of primary health (clusters) will be carried out. The women allocated to the intervention or control group will be randomized with a simple randomization sampling. The participants' breastfeeding rate will be followed up at the first 10 days, and at 2, 4, and 6 months of their newborn's life.

DISCUSSION

There is a need to assess the impact of mother support groups on exclusive breastfeeding. This study aims to analyse the outcomes related to the support received and to identify what should the structure of these groups be; in other words, to describe factors related to a better breastfeeding experience in order to help women increase breastfeeding rates.

TRIAL REGISTRATION

The trial is prospectively recorded at the ISRCTN registry (Trial ID: ISRCTN17263529 ). Date recorded: 17/06/2020.

Feasibility and Effectiveness of Telelactation Among Rural Breastfeeding Women

OBJECTIVE

To evaluate the feasibility and impact of telelactation via personal electronic devices on breastfeeding duration and exclusivity among rural women.

METHODS

The Tele-MILC trial, a pragmatic, parallel design trial, recruited 203 women during their postpartum hospitalization in a critical access hospital in Pennsylvania and randomized them to receive telelactation (n = 102) or usual care (n = 101). We used intent-to-treat (ITT) and instrumental variable (IV) approaches to analyze study data for the 187 participants who completed follow-up. The primary outcomes were any breastfeeding and exclusive breastfeeding at 12 weeks postpartum.

RESULTS

Among participants in the telelactation arm, 50% (47/94) reported participating in video calls. At 12 weeks, 71% of participants in the telelactation arm versus 68% of control participants were breastfeeding in the ITT model (3% difference, P = .73), whereas 73% of participants in the telelactation arm versus 68% of control participants were breastfeeding in the IV model (5% difference, P = .74). Among participants who were still breastfeeding at 12 weeks, 51% participants in the telelactation arm were breastfeeding exclusively versus 46% of control participants in the ITT model (5% difference, P = .47), whereas 56% of participants in the telelactation arm were breastfeeding exclusively versus 45% of control participants in the IV model (11% difference, P = .48). In all models, participants in the telelactation arm were breastfeeding at higher rates; however, differences were not statistically significant.

CONCLUSIONS

This trial demonstrated that telelactation can be implemented with a rural underserved population. Though this trial was not powered to detect differences in breastfeeding duration and exclusivity, and none were observed, telelactation remains a promising approach for further investigation. ClinicalTrials.gov Identifier: NCT02870413.

Women's and peer supporters' experiences of an assets-based peer support intervention for increasing breastfeeding initiation and continuation: A qualitative study

BACKGROUND AND CONTEXT

Breastfeeding peer support is valued by women, but UK trials have not demonstrated efficacy. The ABA feasibility trial offered proactive peer support underpinned by behaviour change theory and an assets-based approach to women having their first baby, regardless of feeding intention. This paper explores women's and infant feeding helpers' (IFHs) views of the different components of the ABA intervention.

SETTING AND PARTICIPANTS

Trained IFHs offered 50 women an antenatal meeting to discuss infant feeding and identify community assets in two English sites-one with a paid peer support service and the other volunteer-led. Postnatally, daily contact was offered for the first 2 weeks, followed by less frequent contact until 5 months.

METHODS

Interviews with 21 women and focus groups/interviews with 13 IFHs were analysed using thematic and framework methods.

RESULTS

Five themes are reported highlighting that women talked positively about the antenatal meeting, mapping their network of support, receiving proactive contact from their IFH, keeping in touch using text messaging and access to local groups. The face-to-face antenatal visit facilitated regular text-based communication both in pregnancy and in the early weeks after birth. Volunteer IFHs were supportive of and enthusiastic about the intervention, whereas some of the paid IFHs disliked some intervention components and struggled with the distances to travel to participants.

CONCLUSIONS

This proactive community assets-based approach with a woman-centred focus was acceptable to women and IFHs and is a promising intervention warranting further research as to its effect on infant feeding outcomes.

Crucial Contributions : A Biocultural Study of Grandmothering During the Perinatal Period

Maternal grandmothers play a key role in allomaternal care, directly caring for and provisioning their grandchildren as well as helping their daughters with household chores and productive labor. Previous studies have investigated these contributions across a broad time period, from infancy through toddlerhood. Here, we extend and refine the grandmothering literature to investigate the perinatal period as a critical window for grandmaternal contributions. We propose that mother-daughter co-residence during this period affords targeted grandmaternal effort during a period of heightened vulnerability and appreciable impact. We conducted two focus groups and 37 semi-structured interviews with Himba women. Interviews focused on experiences from their first and, if applicable, their most recent birth and included information on social support, domains of teaching and learning, and infant feeding practices. Our qualitative findings reveal three domains in which grandmothers contribute: learning to mother, breastfeeding support, and postnatal health and well-being. We show that informational, emotional, and instrumental support provided to new mothers and their neonates during the perinatal period can aid in the establishment of the mother-infant bond, buffer maternal energy balance, and improve nutritional outcomes for infants. These findings demonstrate that the role of grandmother can be crucial, even when alloparenting is common and breastfeeding is frequent and highly visible. Situated within the broader anthropological and clinical literature, these findings substantiate the claim that humans have evolved in an adaptive sociocultural perinatal complex in which grandmothers provide significant contributions to the health and well-being of their reproductive-age daughters and grandchildren.

The Influence of Breastfeeding Peer Support on Breastfeeding Satisfaction Among Japanese Mothers: A Randomized Controlled Trial

BACKGROUND

Peer support may help mothers to feel satisfied with their breastfeeding and to continue breastfeeding. However, previous researchers have not examined the influence of peer support on the three breastfeeding-satisfaction domains.

RESEARCH AIM

We aimed to examine the influence of telephone-based peer support on the following three domains of breastfeeding satisfaction among Japanese mothers: maternal satisfaction, perceived benefit to the infant, and lifestyle compatibility with breastfeeding.

METHODS

Breastfeeding mothers were recruited at four maternity hospitals in Japan to participate in a randomized controlled trial. Data were collected 1 month and 4 months postpartum. Among all of the participants (N = 114), those in the intervention group (n = 60) received telephone-based peer support until 4 months postpartum, and participants in the control group (n = 54) received conventional support. Breastfeeding satisfaction was measured using the short version of the revised Japanese Maternal Breastfeeding Evaluation Scale. Generalized estimating equations and effect size analyses were used to examine the influence of the intervention.

RESULTS

On the subscale measuring lifestyle compatibility, participants with peer support had a higher score than those without peer support: regression coefficient 1.54 (95% confidence interval [0.03, 3.04]). The effect size was 0.40 standard deviations among participants with low and mid-level scores at baseline.

CONCLUSION

Although peer support did not change maternal satisfaction or perceived benefit to the infant, it did increase lifestyle compatibility with breastfeeding among these Japanese mothers. This is evidence in favor of increasing the use of peer support.

Mothers' experiences of exclusive breastfeeding in a postdischarge home setting

Re‐establishment and maintenance of exclusive breastfeeding (EBF) is recommended by the World Health Organization for the nutritional rehabilitation of malnourished infants under 6 months; however, there is no explicit guidance on how this should be achieved. The IBAMI study—a pilot study conducted in Kilifi, Kenya—implemented these recommendations using an intervention for hospitalized infants and their mothers that included ward‐based breastfeeding peer supporters. This paper explores how the challenges of maintaining EBF are recontextualized after infant hospitalization for malnutrition. Four weeks after discharge, semistructured interviews on experiences of trying to maintain EBF in a postdischarge home setting were conducted with a total of 20 mothers. Although most stated the aspiration of maintaining EBF for 6 months, a range of challenges were reported and not all had successfully maintained EBF post discharge. Reported challenges include the stress of household chores, food insecurity, technical difficulties and social stigma of expressing breast milk, pressure from neighbours and family members to introduce mixed feeding, and needing more community‐based awareness and support. Most of these challenges were specific to the home setting and were not easily surmountable, despite the breastfeeding practices mothers had learned in the ward. Indeed, in some cases, challenges were exacerbated by the overmedicalized nature of the breastfeeding practices taught in the ward. In order to aid the transition from ward to home, there may be a need to further translate ward‐based education and promotional messaging for EBF into a community setting, targeting other caregivers as well.

An assets-based intervention before and after birth to improve breastfeeding initiation and continuation: the ABA feasibility RCT

Background

The UK has low levels of breastfeeding initiation and continuation, with evident socioeconomic disparities. To be inclusive, peer-support interventions should be woman-centred rather than breastfeeding-centred. Assets-based approaches to public health focus on the positive capabilities of individuals and communities, rather than their deficits and problems. The Assets-based feeding help Before and After birth (ABA) intervention offers an assets-based approach based on behaviour change theory.

Objective

To investigate the feasibility of delivering the ABA infant feeding intervention in a randomised controlled trial.

Design

This was an individually randomised controlled feasibility trial; women were randomised in a 1 : 1 ratio to either the intervention group or the comparator (usual care) group.

Setting

Two separate English sites were selected because they had an existing breastfeeding peer support service, relatively high levels of socioeconomic disadvantage and low rates of breastfeeding.

Participants

Women aged ≥ 16 years who were pregnant with their first child, irrespective of feeding intention (n = 103), were recruited by researchers in antenatal clinics.

Interventions

Proactive, woman-centred support, using an assets-based approach and including behaviour change techniques, was provided by an infant-feeding helper (a breastfeeding peer supporter trained in the ABA intervention) and delivered through face-to-face contact, telephone conversations and text messages. The intervention commenced at around 30 weeks’ gestation and could continue until 5 months postnatally.

Main outcome measures

The main outcome measures were feasibility of intervention delivery with the requisite intensity and duration; acceptability to women, infant-feeding helpers and maternity services; and feasibility of a future randomised controlled trial. Outcomes included recruitment rates and follow-up rates at 3 days, 8 weeks and 6 months postnatally, and outcomes for a future full trial were collected via participant questionnaires. A mixed-methods process evaluation included qualitative interviews with women, infant-feeding helpers and maternity services; infant-feeding helper logs; and audio-recordings of antenatal contacts to check intervention fidelity.

Results

Of the 135 eligible women approached, 103 (76.3%) agreed to participate. The study was successful in recruiting teenagers (8.7%) and women living in areas of socioeconomic disadvantage (37.3% resided in the most deprived 40% of small areas in England). Postnatal follow-up rates were 68.0%, 85.4% and 80.6% at 3 days, 8 weeks and 6 months, respectively. Feeding status at 8 weeks was obtained for 95.1% of participants. Recruitment took place from February 2017 until August 2017. It was possible to recruit and train existing peer supporters to the infant-feeding helper role. The intervention was delivered to most women with relatively high fidelity. Among the 50 women in the intervention group, 39 received antenatal visits and 40 received postnatal support. Qualitative data showed that the intervention was acceptable. There was no evidence of intervention-related harms.

Limitations

Birth notification delays resulted in delays in the collection of postnatal feeding status data and in the offer of postnatal support. In addition, the intervention needs to better consider all infant-feeding types and did not adequately accommodate women who delivered prematurely.

Conclusion

It is feasible to deliver the intervention and trial.

Future work

The intervention should be tested in a fully powered randomised controlled trial.

Trial registration

Current Controlled Trials ISRCTN14760978.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 7. See the NIHR Journals Library website for further project information.

Marital Adjustment and Prenatal Breastfeeding Efficacy of First Time Mothers in A Low-Income Community in The Philippines

Introduction: All women should be offered support to breastfeed their babies to increase the duration and exclusivity of breastfeeding. This study aims to assess the level of marital satisfaction and its influence to prenatal breastfeeding self-efficacy in   first time mothers during late pregnancy.Methods: A descriptive correlational was conducted among 128 simple randomized prim gravid women who agreed to participate and had prenatal care check-up in the health center at the time of data gathering. The instruments used were 15-item Marital Adjustment Test (MAT) to measure marital adjustment and 14-item Breastfeeding Self efficacy Scale-Short Form (BSES-SF) as a measure of breastfeeding self-efficacy. Pearson’s correlation coefficient was utilized to test the relationships between the sample’s marital adjustment scores to correlate with BFSE of the respondents. Fisher’s t test was utilized to determine the significance of correlations. A p-value of equal to or less than .05 was considered statistically significant.Results: The study revealed that the sampled mothers have a high level of marital adjustment score (112.05± 21.83). Prenatal mothers responded in the study were highly confident and have high self-efficacy in breastfeeding first child currently bearing (4.55±.51). Lastly, it was found that there is no significant correlation between marital adjustment and prenatal breastfeeding self-efficacy (β=-.052, p-value=.280).Conclusion: It was found  that there is a high level of marital adjustment and breastfeeding self-efficacy among sampled mothers. However, there is no significant correlation between marital adjustment and prenatal breastfeeding self-efficacy. The study suggests incorporating co-parenting intervention involving father’s involvement and assistance with breastfeeding when creating interventions in breastfeeding.

"Motivate to Lactate": Utilizing Motivational Interviewing to Improve Breastfeeding Rates

Promotion of exclusive breastfeeding is a nationwide initiative that has been incorporated into health-care facilities. Staff educators for women's and children's services should consider using motivational interviewing techniques to engage patients in a conversation about breastfeeding. Motivational interviewing has been linked with many positive outcomes in patient-centered care. This research article reveals the staffs' positive perception of adopting these techniques into daily practice and their thoughts on the potential patient outcomes.

Characteristics and experiences of peer counsellors in urban Dhaka: a structured interview study

Background

Interventions to promote breastfeeding are the cornerstone of efforts to reduce childhood illness and death from undernutrition. Evidence suggests that one of the most effective strategies to increase breastfeeding is through peer counsellors. However, the experiences of peer counsellors has not been studied in depth. This study aimed to collect and report the experiences of peer counsellors participating in an intervention study to improve breastfeeding in urban Dhaka, Bangladesh.

Methods

Peer counsellors underwent a 10 day training course in May 2013 which included practical sessions on position and attachment and common difficulties with breastfeeding. Home visits were conducted with new mothers and performance of peer counsellors was monitored by senior breastfeeding counsellors. The number of supervised home visits needed to achieve a satisfactory level of competency was recorded. Demographic data were collected and a structured interview was performed in the first six months of the project (May-September 2013). One structured interview per peer counsellor was conducted by the project manager at the project site office to gain understanding of their experiences in counselling mothers. The interview included some open-ended questions on specific aspects of the training that they found useful, challenges faced, and whether they developed close friendships with the mothers that they were counselling.

Results

Seventeen peer counsellors with an average age of 31 years (SD 6.8) and at least six years of schooling participated in the study. All peer counsellors were satisfied with their role and with the training that they received, and most felt that they were able to deal with common breastfeeding problems. The peer counsellors reported that building a personal rapport and establishing a peer-to-peer relationship was most important in supporting mothers to breastfeed. Common challenges included interruption of sessions by relatives/children, as well as mothers being too busy for the visits.

Conclusion

In future peer counselling for breastfeeding projects, more focus could be placed on the communications aspects of the training, especially in how to deal with non-supportive family members and managing interruptions effectively, as well as how to motivate and engage busy new mothers.

Prevalence of exclusive breastfeeding practice in the first six months of life and its determinants in Iran: a systematic review and meta-analysis

Background

Exclusive breastfeeding (EBF) in the first 6 months of life is the best and most complete option for an infant, in that supplies the vitamins and minerals the baby needs. Several studies in Iran have been conducted concerning the prevalence of EBF. The aim of this study was to determine the prevalence of EBF in the first 6 months of life and associated factors in Iran synthesizing published studies.

Methods

We searched PubMed/MEDLINE, Embase, Scopus, ISI/Web of Science, the Cochrane Library, Directory of Open Access Journals Directory (DOAJ) and Google Scholar as well as Iranian databases (Barakathns, MagIran and the Scientific Information Database or SID) up to November 2018. The Newcastle-Ottawa Scale was used to assess the quality of studies. Analyses were performed by pooling together studies using DerSimonian-Laird random-effects model with 95% confidence interval. To test for heterogeneity, I² test was used. The Egger’s regression test and funnel plot were used to evaluate the publication bias. The strength of EBF determinants was assessed computing the Odds-ratios (OR) using the Mantel–Haenszel method.

Results

In the initial search 725 records were found. Finally, 32 studies were selected based on inclusion/exclusion criteria. The sample size of studies varied between 50 and 63,071 subjects. The overall prevalence of EBF in Iran was 53% (CI 95%; 44–62). The OR for breastfeeding education received before pregnancy was 1.13 (0.94–1.36), for mother’s job 1.01 (0.81–1.27), for education level 1.12 (0.89–1.42), for type of delivery 1.16 (0.98–1.37), and for gender of child 1.03 (0.83–1.28).

Conclusion

In Iran health policy- and decision-makers should try to take interventions that encourage mothers to use their milk to breastfeed the infants.

Using the behaviour change wheel to explore infant feeding peer support provision; insights from a North West UK evaluation

Background

Breastfeeding peer support is advocated in national and international guidelines, but the evidence base is mixed. In the UK, breastfeeding peer support was found to be ineffective in randomised controlled trials, while women report positive impacts on breastfeeding experiences in qualitative studies. A key criticism levied against breastfeeding peer support is the lack of theory underpinning intervention design. Here we use the Behaviour Change Wheel to structure the analysis of evaluation data from an infant feeding peer support service in one area in North West England. We aimed to provide theoretically informed insights into how peer support can be operationalised to influence women's breastfeeding experiences.

Methods

A 2 year mixed-methods evaluation (2014-2016) comprised surveys and interviews (individual or group) with peer supporters, health and community professionals, project leads and women, and routinely collected infant feeding data. We used the three layers (policies, intervention functions and behaviour-related components) of the Behaviour Change Wheel to structure and interpret the data.

Results

Overall data comprised 23 interviews (n = 14 - individual; n = 9 - group) and 409 completed surveys. The findings are presented in three sections. First, the 'policies' (outer) layer of the Behaviour Change Wheel provides insights into the existing context, infrastructure and resources that underpinned peer support delivery. Then the second (intervention functions) and inner (behaviour components) layers of the Behaviour Change Wheel are used to present three themes, 'developing capabilities for infant feeding', 'motivating guidance and support' and 'opportunities for support'. These findings highlight that a peer support service delivered in a context of effective interdisciplinary partnerships, Baby Friendly Initiative accreditation, and flexible service planning, with peer support provided via different types of instrumental, social, practical and emotional support was perceived to be highly beneficial on women's breastfeeding experiences. In the final section key challenges faced by the service are outlined.

Conclusion

While gaps and areas for development were highlighted, the service enhanced women's capabilities, motivations and opportunities for breastfeeding. These theoretically informed insights into an organic and responsive peer support service help build the evidence base for breastfeeding peer support and to identify positive delivery features for future testing.

The Use of and Experiences With Telelactation Among Rural Breastfeeding Mothers: Secondary Analysis of a Randomized Controlled Trial

Background

Telelactation services connect breastfeeding mothers to remotely located lactation consultants through audio-visual technology and can increase access to professional breastfeeding support in rural areas.

Objective

The objective of this study was to identify maternal characteristics associated with the demand for and use of telelactation and to describe visit characteristics.

Methods

We conducted a descriptive study within the context of a randomized controlled trial. Participant survey data and vendor electronic medical record data were used to assess video call characteristics like timing, duration, topics discussed, and participant satisfaction. Recruitment occurred from 2016-2018 at a rural critical access hospital in Pennsylvania. The 102 women enrolled in the study were given access to unlimited, on-demand video calls with lactation consultants through a mobile phone app and were tracked for 12 weeks following their postpartum hospitalization.

Results

A total of 94 participants out of 102 recruits (92%) participated in the final, 12-week survey assessment were included in the analysis. Of those, 47 (50%) participants reported participating in one or more video calls, and 31 (33%) completed one or more calls that included a substantive discussion of a breastfeeding challenge. Participants who used telelactation (21/31, 68%; P=.02) were more likely to be working at 12 weeks postpartum compared to others (26/63, 41%), were less likely (12/31, 39%; P=.02) to have prior breastfeeding experience on average compared to nonusers (41/63, 65%), and were less likely to have breastfed exclusively (16/31, 52%; P<.001) prior to hospital discharge compared to mothers who didn’t use telelactation services (51/63, 81%). Most video calls (58/83, 70%) occurred during the infant’s first month of life and 41% (34/83) occurred outside of business hours. The most common challenges discussed included: breast pain, soreness, and infection (25/83, 30%), use of nipple shields (21/83, 25%), and latch or positioning (17/83, 24%). Most telelactation users (43/47, 91%) expressed satisfaction with the help received.

Conclusions

Telelactation is an innovation in the delivery of professional breastfeeding support. This research documents both demand for and positive experiences with telelactation in an underserved population.

Trial Registration

ClinicalTrials.gov NCT02870413; https://clinicaltrials.gov/ct2/show/NCT02870413

Improving exclusive breastfeeding in low and middle-income countries: A systematic review

Exclusive breastfeeding (EBF) rates until 6 months in most low and middle income countries (LMICs) are well below the 90% World Health Organization benchmark. This systematic review sought to provide evidence on effectiveness of various interventions on EBF until 6 months in LMICs, compared with standard care. Experimental and observational studies with concurrent comparator promoting EBF, conducted in LMICs with high country rates of breastfeeding initiation, were included. Studies were identified from a systematic review and PUBMED, Cochrane, and CABI databases. Study selection, data abstraction, and quality assessment were carried out independently and in duplicate. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated for individual studies and pooled. High heterogeneity was explored through prespecified subgroup analyses for the primary outcome (EBF until 6 months) by context and by intervention for the randomized controlled trials. Prediction intervals were calculated for each effect estimate. Sixty-seven studies with 79 comparisons from 30 LMICs were included. At 6 months, intervention group infants were more likely to be exclusively breastfed than controls (RR = 2.19, 95% CI [1.73, 2.77]; I2 78.4%; 25 randomized controlled trials). Larger effects were obtained from interventions delivered by a combination of professional and laypersons (RR 3.90, 95% CI [1.25, 12.21]; I2 46.7%), in interventions spanning antenatal and post-natal periods (RR 2.40, 95% CI [1.70, 3.38]; I2 83.6%), and when intensity was between four to eight contacts/sessions (RR 3.20, 95% CI [2.30, 4.45]; I2 53.8%). Almost every intervention conducted in LMICs increased EBF rates; choice of intervention should therefore be driven by feasibility of delivery in the local context to reduce infant mortality.

A multi-component intervention to support breastfeeding in Lebanon: A randomized clinical trial

Background

Effective evidence-based breastfeeding support interventions can bolster breastfeeding practices. This study investigated the effect of a multi-component breastfeeding support intervention delivered in hospital and home settings on six-month exclusive breastfeeding (EBF) relative to standard care.

Methods

This is a parallel group, randomized clinical trial, in which 362 healthy pregnant women with singleton pregnancy were randomly allocated to a multi-component intervention that included antenatal breastfeeding education, professional, and peer support, delivered in hospital and home settings for six months (experimental, n = 174), or to standard care (control, n = 188). The primary outcome was six-month EBF rate. Secondary outcomes were exclusive and any breastfeeding rates at one and three months, maternal breastfeeding knowledge, attitude, and behavior at six months, and satisfaction with the intervention.

Results

The crude six-month EBF rate was similar in both groups (35.2% vs. 28.1% in the experimental and control groups, respectively, p = 0·16). In adjusted analysis, six-month exclusivity was twice as likely in the experimental group relative to standard care (OR = 2.02; 95%CI: 1.20 to 3.39); whereas the odds for any breastfeeding were similar. Participants compliant with all three components were six times more likely to practice EBF for six months relative to standard care (OR = 6.63; 95% CI: 3.03 to 14.51). Breastfeeding knowledge of the experimental group, at six months, was significantly improved compared to the control. No changes were observed in breastfeeding attitude or behavior.

Conclusions

Combining education with peer and professional breastfeeding support improved six-month breastfeeding exclusivity and knowledge.

It's okay to breastfeed in public but…

Background

Decisions about infant feeding are embedded and are continuously made within a woman's social and cultural context. Despite the benefits of breastfeeding to both women and infants, and government policies and laws to protect and promote breastfeeding, breastfeeding in public remains a controversial issue. The purpose of this paper is to present findings from an Australian study that explored the perceptions and beliefs held by first time expectant mothers and their family and social networks towards breastfeeding in public.

Methods

This study collected data through fifteen family conversations to explore the views and beliefs of first time mothers and those in her social network towards breastfeeding. Breastfeeding in public was discussed in nine of the family conversations with 50 individual people contributing. We used a process of a descriptive contextual analysis drawing out specific elements of the family conversations to identify an underlying ideology around breastfeeding in public within these groups.

Results

The analysis focused on four key elements of the conversations. These included the descriptions of the event, the actions, the locations and feelings of the dominant players. Descriptions of the event outlined different beliefs and feelings related to breastfeeding in public and whether it should occur at all. Suggestions for not breastfeeding in public were timing your outings so feeding could take place at home, expressing breastmilk or using the dummy. When breastfeeding in public was considered acceptable, there were requisite social norms. Breastfeeding in public requires women to be discrete and covered-up, so as not to expose her breast. She is also required to feed in an appropriate place to avoid discomforting others, guard against judgement, and to protect herself from the unwanted male gaze.

Conclusions

Our findings suggest that controversy remains as to whether breastfeeding should occur in public at all. Even where breastfeeding in public is seen as a woman's choice, there are social rules that govern how it should be undertaken to make it an 'appropriate' activity. As a result, women need to take responsibility for others feelings, minimise the discomfort of others and 'keep themselves safe' if and when they breastfeed in public spaces.