Support for healthy breastfeeding mothers with healthy term babies

Evaluating interdisciplinary breastfeeding and lactation knowledge, attitudes and skills: An evaluation of a professional graduate programme for healthcare professionals

Breastfeeding theoretical and skills training is important for health care professionals engaging with the mother infant dyad to increase breastfeeding exclusivity and duration. The aim of this study was to evaluate the knowledge, attitudes and practices (KAPs) of health care professionals following completion of a university professional graduate programme in breastfeeding and lactation. A pre and post-educational study design was used. All students enrolled in a six month programme were invited to complete an online anonymous survey at two time points: January 2023 and July 2023. Ethical approval (LS-C-23-17) was obtained in January 2023. Descriptive statistics were utilised to report percentages and means, and independent T tests were used to report mean differences between variables on knowledge, attitude and practices. All students completed the module. The pre survey participant response rate was n = 55 (92.82%) and the post survey participant response rate n = 33 (60%). Comparison of the pre and post questionnaire report nine statistically significant results following completion of the university breastfeeding and lactation programme. Knowledge scores increased specifically with higher mean knowledge scores for reporting "I am confident with my knowledge about breastfeeding" and statistically significant mean difference of 0.29 following completion of the module (95% CI, 0.13 to 0.45) (t (64) = 3.59, p = 0.001). The programme evaluation identifies the importance of a professional graduate breastfeeding and lactation education programme for interdisciplinary health care professionals increasing knowledge, attitudes and practices and ultimately increasing breastfeeding rates in the short and long term, with improved maternal and child health outcomes.

The effect of telephone-assisted breastfeeding monitoring on physiological jaundice, exclusive breastfeeding in the first six months, development of colic, and breastfeeding self-efficacy: A randomized controlled trial

This randomized controlled study was conducted to evaluate the effects of telephone-assisted breastfeeding monitoring on physiological jaundice, exclusive breastfeeding in the first six months, colic, breastfeeding success, and breastfeeding self-efficacy. Breastfeeding and infant care training were given to pregnant women by video calls (N = 54). Video call counseling was provided to the mothers in the intervention group (n = 27) every day for the first week after discharge and weekly until the 24th week, and the control group (n = 27) was only telephone called in follow-up weeks. The primary variables were exclusive breastfeeding and breastfeeding success, while secondary variables were physiological jaundice, colic, and breastfeeding self-efficacy. The LATCH Breastfeeding Assessment Tool, the Breastfeeding Self-Efficacy Scale, and the Infantile Colic Scale were used. The mean scores of the intervention and control groups were compared using the Mann-Whitney U test and multivariate analysis of variance in repeated measurements. The telephone-assisted breastfeeding monitoring increased exclusive breastfeeding in the first six months. Physiological jaundice was experienced less in infants in the intervention group. There was no difference in terms of infantile colic, breastfeeding success, and breastfeeding self-efficacy between group and group*time interaction, a difference was found in terms of time. The telephone-assisted breastfeeding monitoring can be used to increase exclusive breastfeeding and prevent physiological jaundice (ClinicalTrials.gov Identifier: NCTXXX).

A qualitative study on the perspectives of prenatal breastfeeding educational classes in Ireland: Implications for maternal breastfeeding decisions

BACKGROUND

Breastfeeding, acknowledged for its critical health benefits for both infants and mothers, remains markedly underutilized in Ireland, which reports the lowest breastfeeding rates in Europe. Recent data indicate that fewer than 60% of Irish mothers initiate breastfeeding at birth, with this rate precipitously declining in the subsequent weeks postpartum. Various sociocultural, psychological, and educational elements, such as prenatal breastfeeding education, influence this persistently low prevalence. This descriptive qualitative study explores the perspectives of mothers and healthcare professionals, specifically midwives and lactation consultants, on prenatal breastfeeding education classes in Ireland and how they influence mothers' breastfeeding decisions.

METHODS

A qualitative descriptive methodology was employed, utilizing online semi-structured interviews with midwives, lactation consultants (n = 10), and postnatal mothers (n = 20) from four tertiary hospitals in the Republic of Ireland. The data were subjected to reflexive thematic analysis, adhering to the six-step process of thematic analysis, to extrapolate and analyse the interview transcriptions. NVivo software was used to facilitate this analysis, given its robust capabilities in organizing, coding, and retrieving qualitative data efficiently. Four criteria for qualitative research were also used to enhance analytical rigor.

RESULTS

Prenatal breastfeeding education in Ireland often presents breastfeeding in an idealized way, resulting in a gap between mothers' expectations and their actual experiences. Participants needed practical content that included realistic scenarios and breastfeeding benefits. Additionally, findings indicate a desire for a more interactive and personalized educational model to address expectant mothers' unique needs better. Limitations of the virtual class format were also highlighted, with participants noting the potential for technology to improve engagement and personalization. The data further underscore the need for consistency and accuracy in breastfeeding education, with participants identifying standardized approaches and awareness of socio-cultural dynamics, including partner involvement, as essential elements in effective prenatal breastfeeding education.

CONCLUSION

This study underscores the necessity for a more realistic, interactive, and standardized approach to prenatal breastfeeding education in Ireland. Current classes often set idealized expectations that may leave mothers feeling unprepared for breastfeeding's real-life challenges. Addressing these gaps by integrating practical scenarios, enhancing technological tools for virtual classes, and incorporating socio-cultural considerations could improve breastfeeding education and maternal outcomes. This qualitative descriptive study highlights a disconnect between educational objectives and mothers' actual experiences, advocating for a holistic approach that includes personalized, culturally sensitive support and comprehensive training for healthcare providers.

The Impact of Marriage on Breastfeeding Duration: Examining the Disproportionate Effect of COVID-19 Pandemic on Low-Income Communities

Background

Marriage promotes breastfeeding duration through economic and social supports. The COVID-19 pandemic disproportionately affected marginalized communities and impacted women's employment and interpersonal dynamics. This study examined how marital status affects breastfeeding duration across socioeconomic and racially minoritized groups during COVID-19, aiming to inform social support strategies for vulnerable families in public health crises.

Methods

Data were drawn from the 2017-2021 North Dakota Pregnancy Risk Assessment Monitoring System(weighted n=41433). Breastfeeding duration was self-reported, and 2-, 4-, and 6-month duration variables were calculated. Marital status(married, unmarried) and education ($48,000) and race/ethnicity (White, American Indian, Other) were self-reported. Infant birth date was used to identify pre-COVID(2017-2019) and COVID(2020-2021) births. Logistic regression estimated odds ratios and 95% confidence intervals for the association between marital status and breastfeeding duration outcomes. Models were fit overall, by COVID-19 era and by demographic factors. Lastly, demographic-specific models were further stratified by COVID era. Models were adjusted for maternal health and sociodemographic factors.

Results

Overall, married women consistently had 2-fold higher odds of breastfeeding across all durations during both pre-COVID and COVID eras. Pre-COVID, marriage was a stronger predictor for all breastfeeding durations in low-income women (4-month duration OR4.07,95%CI 2.52,6.58) than for high-income women (4-month duration OR1.76,95%CI 1.06,2.91). Conversely, during COVID, marriage was a stronger predictor of breastfeeding duration for high-income women (4-month duration OR 2.89,95%CI1.47,5.68) than low-income women (4-month duration OR 1.59,95%CI0.80, 3.15). Findings were similar among American Indian women and those with less than high school education, in that both groups lost the benefit of marriage on breastfeeding duration during the COVID-19 pandemic.

Conclusion

Marriage promotes breastfeeding duration, yet the benefit of marriage was reduced for low-socioeconomic and racially minoritized populations during the COVID-19 pandemic. Policies like paid parental leave and enhanced access to lactation consultants could help mitigate disproportionate impacts during public health crises. Continued research examining how major societal disruptions intersect with social determinants to shape breastfeeding outcomes can inform more equitable systems of care.

The need for educational intervention for breastfeeding women and the professional practice of midwives in France to promote breastfeeding: A joint explanatory study

In France, breastfeeding prevalence is high at birth, but its continuation remains low compared with other high-income countries, despite worldwide public health recommendations. Midwives offer parenting classes in an experimental manner without considering the importance of education in their interventions. The objectives of this study were to identify the teaching strategies and learning environments offered by midwives and their effect on women's perception of usefulness and their breastfeeding competence, to assess midwives' perception of usefulness and their pedagogical competencies. A comparative mixed study of 20 hospital midwives and 53 breastfeeding women (at 3 and 30 days postpartum) was conducted between January and August 2022 in two maternity units in France. Comparing the two periods, positive effects were found about breastfeeding women's level of knowledge: usefulness of learning theoretical (p=0.01) and practical (p=0.00) knowledge; and their breastfeeding management: signs of lactation (p=0.00), breast engorgement (p=0.04), and behavior (p=0.04). It positively reinforced the development of self-esteem (p=0.00) and commitment to breastfeeding (p=0.00). Midwives expressed strong motivation to use an appropriate teaching strategy and provide a supportive learning environment for women to improve their educational interventions (mean motivation score 7.7/10). The study results can promote research to examine educational interventions modeled according to the theories in education. Critical realism can be used to evaluate these interventions to elucidate how a program based on educational engineering can contribute to breastfeeding promotion and achieving the 2030 goals of WHO.

CLINICAL TRIAL REGISTRATION

The study was registered on the official website of ClinicalTrials.gov.

IDENTIFIER

ID NCT05271812.

Using Legitimation Code Theory to Underpin the Development of Undergraduate Nursing Students' Breastfeeding Knowledge: A Qualitative Study

AIM

To explore how undergraduate nursing students develop knowledge during a breastfeeding module.

DESIGN

A qualitative study using a single case-study approach.

METHODS

This study was conducted in Australia over 2 years during the period between July 2021 and December 2022. Semi-structured interviews and artefact collection were conducted with a purposive sample of undergraduate nurses (n = 10) who completed a paediatric elective subject that included a breastfeeding module. Thematic and content analysis were used. The specialisation dimension in Legitimation Code Theory (LCT) was used for the content analysis, and students' data was mapped on the specialisation plane.

RESULTS

This study reveals how participants developed knowledge by linking personal breastfeeding experiences to theoretical components within the nursing program. Using the LCT dimension of specialisation, this study provides new insights into how participants move through distinct quadrants of the specialisation plane. Learners tour between the knowledge, knower, and elite quadrants of the plane as they integrate their knowledge. The research maps the journey towards becoming the 'right kind of knower' and reveals how personal experience and theoretical knowledge intersect to create disciplinary expertise. This study advances the LCT dimension of specialisation by illustrating the fluid, non-linear nature of knowledge acquisition and knower development.

CONCLUSIONS

This study highlights the value of integrating personal experiences into nursing education, demonstrating how students use these to build knowledge and professional identity. The findings emphasise the dynamic knowledge development process in preparing future healthcare professionals.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Integrating lived experiences and interprofessional education equips nurses to address complex health issues, leading to more effective, personalised care and better health outcomes for breastfeeding mothers and infants. This approach signals a transformative shift in nursing education.

IMPACT

By personalising and contextualising learning, fostering reflective practice, deepening disciplinary knowledge, and promoting a collaborative practice environment, this approach enriches nursing education.

REPORTING METHOD

The consolidated criteria for reporting qualitative research (COREQ).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Internet-based breastfeeding peer support for breastfeeding parents: An integrative review

AIM

To explore what Internet-based breastfeeding peer support offers to breastfeeding parents.

DESIGN

Integrative review.

DATA SOURCES AND REVIEW METHODS

A systematic literature search was conducted in March 2024 using the following electronic databases: CINAHL, The Cochrane Library, PubMed/MEDLINE and PsycINFO. Database searches yielded 717 results. Two researchers removed the duplicates (n = 256) and screened the remaining titles (n = 461), abstracts (n = 197) and full texts (n = 60) independently. Eventually, 19 studies were included in the review. The chosen studies had qualitative (n = 11), quantitative (n = 6), or mixed methods designs (n = 2) and were published between 2015 and 2024. Qualitative content analysis was conducted.

RESULTS

The main categories were supplying support that is responsive to the needs of parents and belonging to a breastfeeding community. The parents looked for and received breastfeeding support, advice, information, emotional support, reassurance and access to shared experiences from various online breastfeeding peer support groups. The support groups helped them in their breastfeeding decisions, thus making a difference in their breastfeeding experience. The support groups created breastfeeding communities for these parents and they were able to bond with others, feel like they belonged and share experiences. Additionally, these breastfeeding communities helped to normalize various breastfeeding practices.

CONCLUSION

Breastfeeding peer support groups can offer parents the support and guidance they seek and a sense that they are part of a breastfeeding community. However, it is vital these groups are efficiently moderated to ensure the advice parents receive is evidence-based and the support is encouraging.

IMPACT

These findings show that well-moderated online breastfeeding peer support can offer parents high-quality support. It is essential for health care professionals to be aware of the various options available in order to recommend high-quality support groups for breastfeeding parents.

REPORTING METHOD

PRISMA.

PATIENT OR PUBLIC CONTRIBUTION

This was an integrative review therefore no patient or public contribution was necessary.

Healthcare providers' hospital breastfeeding practices during the COVID-19 endemic and associated factors in Thailand: a cross-sectional study

BACKGROUND

During COVID-19, healthcare providers were limited in their ability to provide breastfeeding support while women encountered breastfeeding difficulties. Enhancing appropriate breastfeeding care practices among healthcare providers in hospitals may improve the safety of breastfeeding during an endemic. However, little is known about the breastfeeding care practices by healthcare providers and associated factors during the endemic impact.

OBJECTIVE

To investigate the effect of the endemic on breastfeeding care practices by healthcare providers in hospitals and examine their associated factors in Thailand.

METHODS

A descriptive comparative design was conducted through an online survey with 350 healthcare providers across five regions of Thailand between January and March 2022. The convenience sampling was used to recruit healthcare providers who had at least two years of experience supporting breastfeeding practices and were full-time working in the obstetric and pediatric departments of public tertiary hospitals. Analysis of variance and the independent t-test with relevant statistical corrections were utilized for comparisons of associated factors on breastfeeding care practices in healthcare providers.

RESULTS

The mean breastfeeding care practices in hospitals during the COVID-19 endemic by healthcare providers was 39.17 (SD = 4.64, range 23 to 50). Four factors were statistically significant differences in breastfeeding care practices score, including work position (F = 7.03, df = 2.0, p = 0.001), types of COVID-19 vaccination (F = 6.95, df = 2, p = 0.001), education (F = 4.78, df = 2, p = 0.009), and monthly family income (F = 4.25, df = 3, p = 0.006), respectively. In addition, dose of COVID-19 vaccination and types of COVID-19 vaccination were significantly associated with individual breastfeeding support in hospitals (p < 0.05).

CONCLUSIONS

Healthcare providers' breastfeeding care practices in hospitals during the COVID-19 endemic were mostly at a moderate level in the Thai context. Hospital policy for maternal and child health support should strongly recommend the effective and safe practice of breastfeeding to encourage mothers to continue their breastfeeding duration.

Development of a complex intervention to strengthen municipality-based breastfeeding support to reduced social inequity in breastfeeding

BACKGROUND

Breastfeeding is the ideal nutrition for infants and protects infants and mothers from a range of adverse health outcomes during their lifespan. In Denmark, while the breastfeeding initiation rate is high, only 14% of mothers meet the World Health Organization's recommendation of exclusive breastfeeding at six months. Furthermore, a notable social inequity exists among those who achieve this recommendation. Knowledge of effective interventions to reduce breastfeeding inequity is limited. A previous hospital-based intervention succeeded in increasing breastfeeding duration. However, most breastfeeding support is provided in Danish municipalities by health visitors. This called for adapting the intervention to the health visiting program and developing an intensified intervention addressing the social inequity in breastfeeding. This article describes the adaptation and development process of a municipality-based intervention.

METHODS

During a 15-month period in 2020-21, the municipal intervention was iteratively developed using a three-stage framework for developing complex health interventions described by Hawkins et al. The three stages were 1) need assessment and stakeholder consultation, 2) co-production and 3) prototyping. The process was inspired by O'Cathain et al.'s principles for a user-centred, co-created and theory- and evidence-based approach, involving parents and health visitors.

RESULTS

In stage 1, we identified the needs and priorities of the target groups of the intervention. In stage 2, the intervention was developed through action research design and inspired by Duus' 'learning cycles' as the method to enhance motivation and ownership and to strengthen the implementation process by creating a joint room for learning and reflection with health visitors and developers. In stage 3, the intervention was tested for feasibility and usefulness during a 2.5-month period accompanied by monthly dialogue meetings with health visitors and developers. In this period, the intervention was refined based on the gathered experiences and was subsequently prepared for evaluation.

CONCLUSION

The description of the development of this complex intervention, aimed at increasing breastfeeding duration and reducing inequity, offers breastfeeding practitioners and researchers a transparent foundation for continuously improving breastfeeding support and a methodology for complex intervention development.

TRIAL REGISTRATION

Registered at Clinical Trials NCT05311631.

Why do mothers mix milk feed their infants? Results from a systematic review

CONTEXT

Combining or supplementing breastfeeding with formula feeding, also called mixed milk feeding (MMF), is a common infant feeding practice. However, there is no well-established MMF evidence-base for informing and guiding parents. A better understanding of the reasons why mothers practice MMF may facilitate identification of efficient strategies for supporting exclusive breastfeeding, and/or opportunities to prolong breastfeeding, at least partially.

OBJECTIVE

An updated systematic literature review was undertaken with the primary aim of gaining a deeper understanding of the reasons why mothers choose MMF.

DATA SOURCES

Six databases were searched for relevant articles published in English from January 2012 to January 2022.

DATA EXTRACTION

Two reviewers independently performed the screenings and data extraction, and any differences were resolved by a third reviewer. Data from 138 articles were included, 90 of which contained data on MMF reasons/drivers, and 60 contained data on infant age and/or maternal demographic factors associated with MMF.

DATA ANALYSIS

A total of 13 different unique MMF drivers/reasons were identified and categorized according to whether the drivers/reasons related to perceived choice, necessity, or pressure. Risk of bias was evaluated using the Quality Assessment Tool of Diverse Studies and the JBI Systematic Reviews tool. Several different terms were used to describe and classify MMF across the studies. The most commonly reported reasons for MMF were related to a perception of necessity (39% of drivers, eg, concerns about infant's hunger/perceived breast milk insufficiency or breastfeeding difficulties), followed by drivers associated with perceived choice (34%; eg, having more flexibility) and perceived pressure (25%; eg, returning to work or healthcare professionals' advice). This was particularly true for infants aged 3 months or younger.

CONCLUSION

The key global drivers for MMF and their distribution across infant age and regions were identified and described, providing opportunities for the provision of optimal breastfeeding support. A unified definition of MMF is needed in order to enable more comparable and standardized research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022304253.

Inequalities in large-scale breastfeeding programmes in Bangladesh, Burkina Faso and Vietnam

Inequalities in breastfeeding programmes and practices have slowed global progress in providing the life-saving protection of breastfeeding for millions of infants despite well-known life-long impacts. As breastfeeding interventions are scaled up, inequalities in coverage and breastfeeding practices should be tracked, particularly in disadvantaged groups, who are likely to suffer the most serious health and developmental impacts of poor childhood nutrition. The literature provides evidence of inequalities in breastfeeding practices, but research is limited on socioeconomic disparities in the coverage of breastfeeding interventions. This paper (1) compares inequalities in breastfeeding practices in intervention and nonintervention areas and (2) documents inequalities in programme coverage by type of intervention. We disaggregated endline evaluation surveys in Bangladesh, Burkina Faso and Vietnam, where rigorous evaluations had documented significant overall improvements, and analysed whether inequalities in breastfeeding practices and programme coverage differed by treatment areas. We used Erreygers index to quantify inequalities and found that breastfeeding practices were largely pro-poor; intervention coverage was not consistently pro-poor. While counselling coverage often favoured women from the poorest quintile, public education/media coverage consistently favoured better-off women. Inequalities favoured more educated mothers in the coverage of combined interventions. None of the programmes had explicit equality objectives. The results indicate the need for introducing specific actions to reduce inequalities in breastfeeding policies and programmes. This is a priority unfinished agenda for nutrition programming.

Trends and disparities in ever-breastfeeding practice and early breastfeeding initiation in Ethiopia: a 20-year trend analysis from EDHS datasets

BACKGROUND

Ethiopia has had a long-standing national commitment to improving child health for the last five decades. However, evidence on trends of ever-breastfeeding and early initiation remained fragmented, and there existed a paucity of holistic evidence on the extent of the impacts of the policy and the associated factors. This study examined trends, disparities, and factors influencing ever-breastfed and early initiation in the last twenty years.

METHODS

The Ethiopian Demographic and Health Surveys (EDHS 2000-2019) datasets were used and extracted for children aged 0-23 months and their mothers. Data analyses were performed using SPSS version 25. Trend and time-series analysis was used to visualize changes over time. Multivariable logistic regression was used to identify associated factors.

RESULTS

Prevalence of ever-breastfeeding declined from 99.4% in 2000, to 84.01% in 2019; and early initiation showed inconsistency, increasing from 48.55% in 2000 to 69.57% in 2016 and remained unchanged (69.78%) in 2019. Maternal age, religion, and maternal healthcare utilization significantly influenced early initiation (p < 0.001). Both ever-breastfeeding and early initiation varied across regional states (< 0.001). Disparities in breastfeeding and early initiation were observed across socio-cultural settings and regional states (p < 0.05).

CONCLUSION

The prevalence of ever-breastfeeding declined nationwide between 2000 and 2019, which was not uniform and early initiation showed inconsistency across socio-cultural settings and regional states. These findings highlight the need to revisit current policies and interventions. Further research is crucial to inform the development of regionally tailored and culturally sensitive strategies that promote equitable and sustained breastfeeding improvement across Ethiopia.

Perceived Pressures and Mental Health of Breastfeeding Mothers: A Qualitative Descriptive Study

When a mother is supported to breastfeed, the benefits for her mental health are significant. However, if pressured or unsupported, the opposite is true. This research examines mothers' breastfeeding experiences, exploring how perceived pressure can impact perinatal mental health. A sample of 501 respondents to a research questionnaire was explored using Reflexive Thematic Analysis. Three main themes identified were perceived pressure to breastfeed, perceived pressure not to breastfeed and mental health impact. The main findings were that mothers received conflicting advice from healthcare professionals, and pressures to feed in a certain way came from their support networks, as well as from their internal beliefs. Perceived pressures negatively impacted maternal mental health, while positive breastfeeding experiences benefitted mental health outcomes.

Breastfeeding experiences of women with perinatal mental health problems: a systematic review and thematic synthesis

BACKGROUND

Despite its known benefits, breastfeeding rates among mothers with perinatal mental health conditions are staggeringly low. Systematic evidence on experiences of breastfeeding among women with perinatal mental health conditions is limited. This systematic review was designed to synthesise existing literature on breastfeeding experiences of women with a wide range of perinatal mental health conditions.

METHODS

A systematic search of five databases was carried out considering published qualitative research between 2003 and November 2021. Two reviewers conducted study selection, data extraction and critical appraisal of included studies independently and data were synthesised thematically.

RESULTS

Seventeen articles were included in this review. These included a variety of perinatal mental health conditions (e.g., postnatal depression, post-traumatic stress disorders, previous severe mental illnesses, eating disorders and obsessive-compulsive disorders). The emerging themes and subthemes included: (1) Vulnerabilities: Expectations versus reality; Self-perception as a mother; Isolation. (2) Positive outcomes: Bonding and closeness; Sense of achievement. (3) Challenges: Striving for control; Inconsistent advice and lack of support; Concerns over medication safety; and Perceived impact on milk quality and supply.

CONCLUSIONS

Positive breastfeeding experiences of mothers with perinatal mental health conditions can mediate positive outcomes such as enhanced mother/infant bonding, increased self-esteem, and a perceived potential for healing. Alternatively, a lack of consistent support and advice from healthcare professionals, particularly around health concerns and medication safety, can lead to feelings of confusion, negatively impact breastfeeding choices, and potentially aggravate perinatal mental health symptoms. Appropriate support, adequate breastfeeding education, and clear advice, particularly around medication safety, are required to improve breastfeeding experiences for women with varied perinatal mental health conditions.

Health professional competency building for the Baby-Friendly Hospital Initiative in Malawi

Health professional competency building is one of nine national responsibilities (to achieve universal coverage and sustainability) described in the 2018 World Health Organization (WHO)/United Nations Children's Fund (UNICEF) implementation guidance for the Baby-Friendly Hospital Initiative (BFHI). With stagnating rates of exclusive breastfeeding worldwide, skilled breastfeeding support as a standard of newborn care is critical to the establishment of lactation and exclusive breastfeeding. Few studies exist on how low-income countries are integrating BFHI into their standards of care. This qualitative case study describes Malawi's experience. We interviewed 48 key informants and conducted a desk review of the literature on BFHI programming, national plans, policies and other related documents. We explored the findings using the seven key domains and 16 competencies to implement the Ten Steps to successful breastfeeding from the WHO and UNICEF Competency Verification Toolkit. The study found that although the focus of the guidance is on preservice training, continuing education and in-service training remain important. To achieve universal coverage for health professional competency, Malawi uses preservice, in-service and refresher training. However, their main limitations to aligning with the new guidance are a lack of preservice BFHI- and breastfeeding-specific curricula, experienced lecturers and sufficient time to dedicate to practical skill development. Conducted during the coronavirus disease 2019 pandemic, this study confirmed disruptions to BFHI training and service delivery, while also documenting Malawi's resilient attempts to mitigate impacts on breastfeeding support through mentoring and coaching. Opportunities exist for strengthening and scaling up, including engaging preservice training institutions and standardizing mentoring, coaching and competency verification.

Feasibility and acceptability of integrating a multicomponent breastfeeding promotion intervention into routine health services in private health facilities in Lagos State, Nigeria: A mixed methods process evaluation

Most health care providers in Lagos State, Nigeria are private and are not required to offer breastfeeding counseling to women. From May 2019-April 2020, Alive & Thrive implemented a multicomponent breastfeeding promotion intervention in private health facilities in Lagos that included training and support to implement the Baby-Friendly Hospital Initiative and provide breastfeeding counseling and support to pregnant women and lactating mothers in person and on WhatsApp. We conducted a mixed methods process evaluation in 10 intervention and 10 comparison private health facilities to examine the feasibility and acceptability of integrating the intervention into routine health services. We conducted in-depth interviews with 20 health facility owners/managers and providers, 179 structured observations of health providers during service provision to pregnant and lactating women and 179 exit interviews with pregnant and lactating women. The in-depth interviews were transcribed and analyzed thematically. The structured observations and exit interviews were summarized using descriptive and inferential statistics. The in-depth interviews indicated that almost all health facility owners/managers and providers at the intervention health facilities had generally positive experiences with the intervention. However, the health providers reported implementation barriers including increased workload, use of personal time for counseling on WhatsApp, and some mothers' lack of access to WhatsApp support groups. Observations suggested that more breastfeeding counseling occurred at intervention compared with comparison health facilities. Third trimester exit interviews showed that 86% of women in the intervention health facilities were very confident they could carry out the breastfeeding advice they received, compared to 47% in the comparison health facilities. Our research suggests that provision of breastfeeding counseling and support through private health facilities is feasible and acceptable, but service delivery challenges must be considered for successful scale-up.

Teleintervention's effects on breastfeeding in low-income women in high income countries: a systematic review and meta-analysis

BACKGROUND

Many mothers in high-income countries (HIC) do not breastfeed to the World Health Organisation's recommendation of two years. This is particularly true for low-income women (LIW). They often face additional socio-structural barriers that encourage early discontinuation and are inadequately supported by current healthcare interventions. Teleinterventions are flexible and widely used following the global pandemic and increase maternal autonomy over intervention delivery. They show promise in improving other maternal conditions in LIW, including postpartum depression. Teleinterventions can increase breastfeeding rates in the wider maternal population, however their efficacy for this underserved population has not yet been systematically assessed. This meta-analysis aimed to identify if teleinterventions increase 'exclusive' or 'any' breastfeeding by LIW in HIC at 1-, 3-4, and 6-months postpartum.

METHODS

We searched five online databases for randomised controlled trials assessing breastfeeding teleinterventions for LIW in HIC. Risk ratios (RR) were used to calculate the average effect of teleinterventions on 'any' and 'exclusive' breastfeeding at at 1-, 3-4, and 6-months postpartum using random effects meta-analysis. Study bias was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB2), and outcome quality was evaluated against GRADE criteria.

RESULTS

Nine studies met inclusion criteria: six providing telephone calls, two text messages and one an online support group. All the studies were conducted in the United States, with small sample sizes and a high risk of bias. Pooled results indicate teleinterventions modestly increase 'any' and 'exclusive' breastfeeding at all time points, with a statistically significant increase in 'exclusive' breastfeeding after 3-4 months (RR 1.12, 95% CI [1.00,1.25]). At 3-4 months teleinterventions providing peer support were more effective than educational teleinterventions at promoting any and exclusive breastfeeding. Evidence for all outcomes were rated 'low' or 'very low' quality using the GRADE tool, mainly due to high attrition and low power.

CONCLUSIONS

Despite insufficient high-quality research into breastfeeding teleinterventions for LIW, our results suggest teleinterventions may improve exclusive and any breastfeeding. Given breastfeeding is particularly low in LIW population from HIC, our findings are promising and require further exploration by larger, methodologically sound trials in other HIC.

Does planning to mixed feed undermine breastfeeding?

Continued breastfeeding is important for infants' health, but it is unclear whether mixed feeding increases the risk of breastfeeding cessation. We aimed to explore associations of mixed feeding and lactation problems with early cessation of breastfeeding. We analysed data from mothers who completed the Scottish National Maternal and Infant Feeding Survey and had previously breastfed their infants. At age 8-12 weeks, mothers (N = 1974) reported their feeding history and intentions, lactation problems and reasons for giving formula milk. The main outcome measure was cessation of breastfeeding before 6-8 weeks and time to cessation. By 6 weeks, 65% had mixed fed at some point, 32% had ceased breastfeeding, 22% were currently mixed feeding and 46% were exclusively breastfeeding. Lactation problems before 2 weeks were common (65%), and strongly associated with stopping breastfeeding (relative risk [RR]: 3.23, 95% confidence interval [CI]: 2.0-5.3) and with mixed feeding (RR: 3.14, 95% CI: 2.5-4.0). However, even after adjustment for breastfeeding problems mothers who planned to mixed feed (RR: 3.39, 95% CI: 2.4-4.9) and those who introduced formula for practicalities (RR: 3.21, 95% CI: 2.3-4.4) were more likely to stop breastfeeding. These variables also predicted later lactation insufficiency (planned mixed feeding RR: 1.39, 95% CI: 1.0-2.0; formula for practicalities RR: 1.76, 95% CI: 1.3-2.3). Mothers who received specialist lactation support were less likely to cease breastfeeding (RR: 0.63, 95% CI: 0.5-0.9) but nonspecialist input was unrelated to risk of cessation (RR: 1.06, 95% CI: 0.2-4.9). In conclusion, choosing to mix feed an infant is strongly associated with stopping breastfeeding, even in the absence of lactation problems.

What makes a city 'breastfeeding-friendly'? A scoping review of indicators of a breastfeeding-friendly city

A breastfeeding-friendly city is one where there is an enabling environment to support breastfeeding throughout the first 2 years or more of a child's life. Indicators of a breastfeeding-friendly city have yet to be identified. What are the indicators or criteria used to define breastfeeding friendliness in a geographic area such as a city and the settings within, which we have classified as community, healthcare and workplace? Three major databases and grey literature were searched. Records were screened to identify publications describing criteria such as indicators or descriptions of a breastfeeding-friendly setting, defined as 'criteria-sets'. These criteria-sets were then categorized and summarized by settings. The search up to 2 September 2021 found 119 criteria-sets from a range of settings: geographic locations (n = 33), community entities (n = 24), healthcare facilities (n = 28), workplaces (n = 28) and others (n = 6). Overall, 15 community, 22 healthcare and 9 workplace related criteria were extracted from the criteria-sets. Criteria that were consistently present in all settings were policy, training & education, skilled breastfeeding support and physical infrastructure. Some criteria-sets of geographic locations contained criteria only from a single setting (e.g., the presence of breastfeeding-friendly cafes). Criteria-sets were present for all settings as defined in this review, but few were actual indicators. Specifically, there were no existing indicators of a breastfeeding-friendly city. Several common components of the criteria-sets were identified, and these could be used in developing indicators of a breastfeeding-friendly city. Future studies should determine which of these are important and how each can be measured.

Partners with a Highly Favorable Attitude Toward Breastfeeding Contribute to Promoting Initiation and Length of Breastfeeding for More than 5 Months in a Population-Based Canadian Study

Introduction: Promoting maternal breastfeeding for at least 6 months is important to improve children physical health during infancy and neurodevelopmental outcomes in childhood. For this guideline to be followed, it is paramount to identify what factors best support the initiation and length of breastfeeding. This study estimates the contribution of various child- and parent-level factors, as well as the sociodemographic context in predicting maternal breastfeeding initiation and duration. Methods: This study draws on data from the Quebec Longitudinal Study of Child Development. Mothers who never breastfed when the infant was 5 months old (n = 630, 28.3%) were compared to mothers who breastfed for less than 5 months (n = 844, 38.0%) and mothers breastfeeding for more than 5 months (n = 749, 33.7%), using multivariable multinomial regression models. Results: Mothers with a partner showing a positive attitude toward breastfeeding were up to 13 times more likely to breastfeed their infant for more than 5 months. The positive attitude of partners toward breastfeeding was the strongest predictor of breastfeeding duration, followed by the maternal educational attainment and timing she returns to work. Most prenatal and perinatal child-level factors and the sociodemographic context predicted breastfeeding duration, but to a lesser extent. Discussion: This finding underscores the role of the partner's attitude in promoting initiation and length of breastfeeding. As such, educational campaigns and health practitioners could target both the mother and their partner in promoting breastfeeding.

Early feeding and nutritional status of Portuguese children in the first 36 months of life: EPACI Portugal 2012-a national representative cross-sectional study

Background

Early feeding practices have a critical role in the future not only in health but also in modulating eating habits. This study aimed to assess breastfeeding and complementary feeding practices and the nutritional status of Portuguese toddlers aged 0-36 months.

Methods

EPACI Portugal 2012 is a cross-sectional study of a national representative sample. Trained interviewers collected data about early feeding practices and anthropometrics. Body mass index was classified according to World Health Organization criteria. Frequencies and survival analysis were used to characterize variables.

Results

More than 90% of children were initiated breastfeeding, around 20% were exclusively breastfed for six months, and about 20% were breastfed at 12 months while complementary feeding was taking place. Exclusive breastfeeding was determined by maternal prepregnancy body mass index (HR 1.01; 95% CI 1.00, 1.03, P=.03) and low birth weight (HR 1.61; IC 95% 1.21, 2.15, P=.001) of the infants. About 90% were initiated complementary feeding between four and six months, and almost 10% were introduced to cow's milk before 12 months. In the second year of life, 83.2% and 61.6% of toddlers have already consumed nectars and sweet desserts, respectively. About one-third of Portuguese toddlers showed a body mass index z-score >1, and 6.6% were overweight/obese (z-score >2). No association was found between the duration of breastfeeding or timing of complementary feeding and the body mass index z-score in children.

Conclusions

Despite the low prevalence of exclusive breastfeeding at six months, Portuguese infants effectively comply with dietary recommendations during the first year of life. The transition to the family diet must be carefully made. There is a high prevalence of Portuguese toddlers at least at overweight risk. The duration of breastfeeding or timing of complementary feeding was not associated with the expression of overweight/obesity.

[Sense of coherence in breastfeeding women: A scoping review]

BACKGROUND

The establishment of breastfeeding may sometimes be stressful. We aimed to analyze the sense of coherence in lactating women to determine the general resistance resources during lactation and the professional interventions that promote a high sense of coherence.

METHODS

A search of studies in English, Spanish, or Portuguese on lactating women's sense of coherence was carried out in PubMed, PsycINFO, ScienceDirect, and CINAH databases published between May and November 2022. Study quality and risk of bias were examined according to ICROMS and STROBE criteria.

RESULTS

We identified 316 studies, of which eight -all of adequate quality- were included, three qualitative and five quantitative. A high level of maternal sense of coherence was related to longer duration, self-efficacy, attachment, and enjoyment of the breastfeeding experience. The main general resistance resources were to receive social support, particularly from partners, mothers, and health professionals. The interventions that favored the sense of coherence were mainly those related to a close, empathic, personalized, comprehensive, and family-centered professional support.

CONCLUSIONS

The detection of the level of sense of coherence in lactating mothers may help identify women with a higher risk of weaning and establish professional intervention strategies that improve the breastfeeding experience.

Barriers to promoting breastfeeding in primary health care in Mexico: a qualitative perspective

Objective

This article aimed to identify the main barriers related to promoting and counseling breastfeeding (BF) at the Primary Health Care (PHC) in Mexico.

Methodology

A qualitative study with a phenomenological approach was carried out in 88 health centers of the Ministry of Health in the states of Chihuahua, Oaxaca, Chiapas, Veracruz, Mexico, and Yucatan. From September to November 2021, we interviewed 88 key health professionals (HPs) (physicians, nurses, nutritionists, and others) from the PHC of the Ministry of Health in Mexico and 80 parents of children under 5 years old. In addition, nine focus groups were conducted with parents and caregivers. The data obtained were triangulated with information from focus groups and semi-structured interviews.

Results

Of the total interviews, 43.2% (n = 38) were nurses, 29.5% (n = 26) were physicians, 19.3% (n = 17) were nutritionists, and the rest were other health professionals. In the group of users, 97.6% (n = 121) were women. We identified contextual barriers, such as the lack of well-trained health professionals and the scarcest nutrition professionals, as material resources in the health units, without mentioning the low user attendance at their control consultations. Furthermore, we identified barriers related to the orientation and promotion of breastfeeding in health units, including a lack of specific strategies, ineffective communication, and the recommendations of commercial milk formulas.

Conclusion

The results presented reflect the reality of Mexico in relation to BF, making it urgent to take immediate action to improve the quality of nutritional care related to the promotion and orientation of BF at the PHC.

Differences in Diagnosis and Treatment of Nipple Conditions of Reproductive-Age Women at a Tertiary Health System

Background: Nipple-areolar complex (NAC) conditions affect reproductive-age women, yet it is not known how care of NAC complaints is distributed among medical specialties. There is a need to characterize all NAC conditions, including their treatment and the care team involved in their clinical management, of nonlactating and lactating patients to determine care gaps. Materials and Methods: This was a retrospective cohort study of reproductive-age females who presented to a large tertiary health system with an NAC complaint between 2015 and 2020. Data about the symptoms, diagnosis, specialty providing care, diagnostic considerations, and treatments were collected. Results: Nipple pain, dermatitis, and thrush were the most common diagnoses among 407 encounters (215 patients). Lactating patients represented half (204, 50%) of the study sample. Benign breast conditions like obstructed ductal openings, accessory nipples, nipple growth, inverted nipples, and chronic and bacterial infections represented a third of all encounters. Primary care physicians (167, 41%) and obstetricians (105, 26%) provided most of the care and referred a third and quarter of patients, respectively, to another provider. Conclusion: The care of patients with NAC complaints is not limited to obstetricians. Internal medicine, family medicine, emergency medicine, and obstetrician-gynecology, dermatology, and surgery resident physicians should receive training in benign breast conditions and clinical lactation.

Effectiveness and cost-effectiveness of Assets-based feeding help Before and After birth (ABA-feed) for improving breastfeeding initiation and continuation: protocol for a multicentre randomised controlled trial (Version 3.0)

INTRODUCTION

Breastfeeding has health benefits for infants and mothers, yet the UK has low rates with marked social inequalities. The Assets-based feeding help Before and After birth (ABA) feasibility study demonstrated the acceptability of a proactive, assets-based, woman-centred peer support intervention, inclusive of all feeding types, to mothers, peer supporters and maternity services. The ABA-feed study aims to assess the clinical and cost-effectiveness of the ABA-feed intervention compared with usual care in first-time mothers in a full trial.

METHODS AND ANALYSIS

A multicentre randomised controlled trial with economic evaluation to explore clinical and cost-effectiveness, and embedded process evaluation to explore differences in implementation between sites. We aim to recruit 2730 primiparous women, regardless of feeding intention. Women will be recruited at 17 sites from antenatal clinics and various remote methods including social media and invitations from midwives and health visitors. Women will be randomised at a ratio of 1.43:1 to receive either ABA-feed intervention or usual care. A train the trainer model will be used to train local Infant Feeding Coordinators to train existing peer supporters to become 'infant feeding helpers' in the ABA-feed intervention. Infant feeding outcomes will be collected at 3 days, and 8, 16 and 24 weeks postbirth. The primary outcome will be any breastfeeding at 8 weeks postbirth. Secondary outcomes will include breastfeeding initiation, any and exclusive breastfeeding, formula feeding practices, anxiety, social support and healthcare utilisation. All analyses will be based on the intention-to-treat principle.

ETHICS AND DISSEMINATION

The study protocol has been approved by the East of Scotland Research Ethics Committee. Trial results will be available through open-access publication in a peer-reviewed journal and presented at relevant meetings and conferences.

TRIAL REGISTRATION NUMBER

ISRCTN17395671.

Associations between maternal health literacy, neonatal health and breastfeeding outcomes in the early postpartum period

INTRODUCTION

Maternal health literacy is a social skill that is relevant to successful postnatal newborn adaptation, neonatal feeding, and neonatal health outcomes, given the importance of maternal health literacy in newborn healthcare. The study aims to identify and assess the associations between maternal health literacy, neonatal health, and breastfeeding outcomes during the early postpartum period.

METHODS

Five hundred women who gave birth to full-term newborns at Vilnius University Hospital were invited to the study from 1 May to 30 September 2022. The 47 questions of the European Health Literacy Questionnaire (HLS-EU-Q47) were used to assess maternal health literacy on days 2 and 3 after birth. Each subject's health literacy indices were divided into four categories: inadequate, problematic, sufficient, and excellent. The neonatal health indicators were birth weight and height, along with the APGAR score and the outcomes of feeding either exclusively with breast milk or with adapted formula in addition to breastfeeding.

RESULTS

Most women who participated in the survey had insufficient or problematic health literacy (69%). The study showed that women's higher health literacy is associated with a lower risk of obesity, a healthier diet, regular physical activity, and a higher birth weight and height of their newborns (p<0.05). Mothers with inadequate/problematic health literacy were more likely to feed their newborns with adapted formula in addition to breastfeeding.

CONCLUSIONS

Women's health literacy is a factor that affects women's healthy lifestyle choices before and during pregnancy and is significant for newborns' health indicators.

The prevalence of breastfeeding aversion response in Australia: A national cross-sectional survey

Some women who breastfeed will experience complex ongoing difficulties, such as breastfeeding aversion response (BAR). This recently named breastfeeding challenge is defined as feelings of aversion while breastfeeding for the entire time that the child is latched. This study provides the first prevalence data for the experience of BAR in Australian breastfeeding women. A national online survey investigated the breastfeeding experience of Australian women including data on (1) participant demographics, (2) breastfeeding experience with up to four children, (3) breastfeeding challenges and prevalence of BAR, and (4) the value of available breastfeeding support. This study found that of the Australian breastfeeding women who participated (n = 5511), just over one in five self-identified as having experienced a BAR (n = 1227, 22.6%). Most reported experiencing some breastfeeding challenges, with only 4.5% (n = 247) having had no breastfeeding complications. Importantly, despite these difficulties, 86.9% of the total women in this study rated their overall breastfeeding experience as good (n = 2052, 37.6%), or very good (n = 2690, 49.3%), and 82.5% of those who experience BAR as good (n = 471, 38.7%) or very good (n = 533, 43.8%). BAR reporting was decreased in higher education and income groups. Women who are breastfeeding for the first time are more likely to encounter difficulties with breastfeeding such as BAR. Complications with breastfeeding are pervasive, but women who can overcome breastfeeding issues often report a positive overall breastfeeding experience.

Trends of breastfeeding indicators in Brazil from 1996 to 2019 and the gaps to achieve the WHO/UNICEF 2030 targets

BACKGROUND

The comprehension of breastfeeding patterns and trends through comparable indicators is essential to plan and implement public health policies.

OBJECTIVE

To evaluate the trends of breastfeeding indicators in Brazil from 1996 to 2019 and estimate the gap to achieve the WHO/UNICEF 2030 targets in children under 5 years.

METHODS

Microdata from two National Surveys on Demography and Health of Women and Children (PNDS-1996 and PNDS-2006) and the Brazilian National Survey on Child Nutrition-2019 were used. The indicators of early initiation of breastfeeding (EIBF), exclusive breastfeeding of infants 0-5 months of age (EBF<6 mo), continued breastfeeding at 1 year of age (CBF1yr) and CBF at 2 years of age (CBF2yr) were analysed using prevalence and 95% CI. The average annual variation and years to achieve the WHO/UNICEF 2030 targets were calculated for Brazil and the macroregions. Statistical analyses considered the survey's complex sample design for each database.

RESULTS

EIBF increased from 36.3% (95% CI 33.6% to 39.0%) in 1996 to 60.9% (95% CI 56.5% to 65.3%) in 2006 (statistically significant) and 62.5% (95% CI 58.3% to 66.6%) in 2019. EBF<6 mo increased from 26.9% (95% CI 21.3% to 31.9%) in 1996 to 39.0% (95% CI 31.0% to 47.1%) in 2006 and 45.8% (95% CI 40.9% to 50.7%) in 2019 (significant increases for 1996-2019 for Brazil, Northeast and Midwest regions). CBF1yr rose from 36.6% (95% CI 30.8% to 42.4%) in 1996 to 48.7% (95% CI 38.3% to 59.0%) in 2006, and 52.1% (95% CI 45.4% to 58.9%) in 2019. CBF2yr increased from 24.7% (95% CI 19.5% to 29.9%) in 1996 to 24.6% (95% CI 15.7% to 33.5%) in 2006 and 35.5% (95% CI 30.4% to 40.6%) in 2019 (significant increase for 1996-2019). The South and Southeast regions need to double the 2019 prevalence to reach the target for the CBF1yr and CBF2yr; the Northeast and North need to increase 60% the current prevalence for the indicator of EBF<6 mo.

CONCLUSION

A substantial improvement in breastfeeding indicators occurred in Brazil from 1996 to 2019, although at an insufficient rate to achieve the WHO/UNICEF 2030 targets.

Infant feeding practices and autism spectrum disorder in US children aged 2-5 years: the national survey of children's health (NSCH) 2016-2020

OBJECTIVE

To investigate the relationship between infant feeding practices and autism spectrum disorder (ASD) among children aged 2-5 years in the United States (US).

METHODS

Data from the 2016-2020 National Survey of Children's Health, a nationally representative cross-sectional survey, were utilized for this study. Questionnaires were administered to parents of children aged 2-5 years to gather information on ASD diagnosis, infant feeding practices, and demographic factors (e.g., child sex, ethnic group, and maternal age at birth). Logistic regression with sample weights was employed to assess the association between infant feeding practices and ASD, while controlling for demographic variables. Polynomial regression models were used to examine trends in exclusive breastfeeding and ever breastfeeding rates among children with and without ASD.

RESULTS

A total of 35,050 children aged 2-5 years were analyzed, including 616 diagnosed with ASD, after excluding participants with missing information on breastfeeding and ASD diagnosis. Of these children with ASD, 76.6% (n = 472) had a breastfeeding history, with 67.5% (n = 416) engaged in partial breastfeeding and 9.1% (n = 56) exclusively breastfed. Adjusted odds ratios for each additional month of breastfeeding compared to never being breastfed were 0.98 (95% CI, 0.96-1.01). The adjusted odds ratios for breastfeeding durations of > 0-6 months, > 6-12 months, > 12-24 months, and > 24 months were 0.81 (95% CI, 0.50-1.31), 0.65 (95% CI, 0.36-1.18), 0.81 (95% CI, 0.44-1.49), and 0.48 (95% CI, 0.23-1.01), respectively. Compared to children who were never breastfed, the adjusted odds ratio for children who were ever breastfed was 0.74 (95% CI, 0.47-1.18). Among children with ASD, the proportion of ever breastfeeding declined from 82.0% in 2017 to 64.3% in 2020, while exclusive breastfeeding decreased from 12.0% in 2016 to 4.2% in 2020.

CONCLUSIONS AND RELEVANCE

Although no significant association was found between infant feeding practices and ASD among US children aged 2-5 years, the rates of breastfeeding, particularly exclusive breastfeeding, were suboptimal among children with ASD. This highlights the need for specific policies and practices to promote and support breastfeeding among parents of children with ASD or those at high risk of having a child with ASD.

Is proactive telephone-based breastfeeding peer support a cost-effective intervention? A within-trial cost-effectiveness analysis of the 'Ringing Up about Breastfeeding earlY' (RUBY) randomised controlled trial

OBJECTIVE

The 'Ringing Up about Breastfeeding earlY' (RUBY) randomised controlled trial showed increased breastfeeding at 6 months in participants who received the proactive telephone-based peer support breastfeeding intervention compared with participants allocated to receive standard care and supports. The present study aimed to evaluate if the intervention was cost-effective.

DESIGN

A within-trial cost-effectiveness analysis.

SETTING

Three metropolitan maternity services in Melbourne, Victoria, Australia.

PARTICIPANTS

First time mothers intending to breastfeed their infant (1152) and peer volunteers (246).

INTERVENTION

The intervention comprised proactive telephone-based support from a peer volunteer from early postpartum up to 6 months. Participants were allocated to usual care (n=578) or the intervention (n=574).

MAIN OUTCOME MEASURES

Costs during a 6-month follow-up period including individual healthcare, breastfeeding support and intervention costs in all participants, and an incremental cost-effectiveness ratio.

RESULTS

Costs per mother supported were valued at $263.75 (or $90.33 excluding costs of donated volunteer time). There was no difference between the two arms in costs for infant and mothers in healthcare and breastfeeding support costs. These figures result in an incremental cost-effectiveness ratio of $4146 ($1393 if volunteer time excluded) per additional mother breast feeding at 6 months.

CONCLUSION

Considering the significant improvement in breastfeeding outcomes, this intervention is potentially cost-effective. These findings, along with the high value placed on the intervention by women and peer volunteers provides robust evidence to upscale the implementation of this intervention.

TRIAL REGISTRATION NUMBER

ACTRN12612001024831.

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

PURPOSE

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05432700.

The Marri Gudjaga project: a study protocol for a randomised control trial using Aboriginal peer support workers to promote breastfeeding of Aboriginal babies

BACKGROUND

Breastfeeding protects against a range of conditions in the infant, including sudden infant death syndrome (SIDS), diarrhoea, respiratory infections and middle ear infections [1, 2]. The World Health Organization (WHO) recommends exclusive breastfeeding until six months of age, with continued breastfeeding recommended for at least two years and other complementary nutritious foods [3]. The 2017-18 National Health Survey (NHS) and 2018-19 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) reported that the proportion of breastfeeding in Aboriginal and Torres Strait Islander infants (0-2 years) were less than half that of non-Indigenous infants (21.2% vs. 45%, respectively)[4]. There is a lack of research on interventions supporting Aboriginal women to breastfeed, identifying an evaluation gap related to peer support interventions to encourage exclusive breastfeeding in Aboriginal women.

METHODS

We will evaluate the effect of scheduled breastfeeding peer support for and by Aboriginal women, on breastfeeding initiation and the prevalence of exclusive breastfeeding. This MRFF (Medical Research Future Fund) funded project is designed as a single-blinded cluster randomised controlled trial recruiting six sites across New South Wales, Australia, with three sites being randomised to employ a peer support worker or undertaking standard care. Forty pregnant women will be recruited each year from each of the six sites and will be surveyed during pregnancy, at six weeks, four and six months postnatally with a single text message at 12 months to ascertain breastfeeding rates. In-depth interviews via an Indigenous style of conversation and storytelling called 'Yarning' will be completed at pre- and post-intervention with five randomly recruited community members and five health professionals at each site" [5]. Yarns will be audio recorded, transcribed, coded and thematic analysis undertaken. Health economic analysis will be completed to assess the health system incremental cost and effects of the breastfeeding intervention relative to usual care.

DISCUSSION

Evidence will be given on the effectiveness of Aboriginal peer support workers to promote the initiation and continuation of breastfeeding of Aboriginal babies. The findings of this study will provide evidence of effectiveness and cost-effectiveness of including peer support workers in postnatal care to promote breastfeeding practices.

TRIAL REGISTRATION

ACTRN12622001208796 The impact of breastfeeding peer support on nutrition of Aboriginal infants.

Breastfeeding practices in Northeast China in 2008 and 2018: cross-sectional surveys to explore determinants over a decade

BACKGROUND

This study was conducted to investigate the prevalence and determinants of breastfeeding in 2008 and 2018, respectively, in Northeast China, where health service efficiency is at the lowest national level and regional data on breastfeeding are lacking. The influence of early initiation of breastfeeding on later feeding practices was specifically explored.

METHODS

Data from the China National Health Service Survey in Jilin Province in 2008 (n = 490) and 2018 (n = 491) were analysed. Multistage stratified random cluster sampling procedures were used to recruit the participants. Data collection was conducted in the selected villages and communities in Jilin. Early initiation of breastfeeding was defined as the proportion of children born in the last 24 months who were put to the breast within one hour after birth in both the 2008 and 2018 surveys. Exclusive breastfeeding was defined as the proportion of infants 0-5 months of age who were fed exclusively with breast milk in the 2008 survey; while defined as the proportion of infants 6-60 months of age who had been fed exclusively with breast milk within the first six months of life in the 2018 survey.

RESULTS

The prevalence of early initiation of breastfeeding (27.6% in 2008 and 26.1% in 2018) and exclusive breastfeeding during the first six months (< 50%) were low in two surveys. Logistic regression revealed that exclusively breastfeeding at six months was positively associated with early initiation of breastfeeding (OR 2.65; 95% confidence interval (CI) 1.65, 4.26) and negatively associated with caesarean section (OR 0.65; 95% CI 0.43, 0.98) in 2018. Continued breastfeeding at one year and timely introduction of complementary foods were associated with maternal residence and place of delivery, respectively, in 2018. Early initiation of breastfeeding was associated with mode and place of delivery in 2018 but residence in 2008.

CONCLUSION

Breastfeeding practices in Northeast China are far from optimal. The negative effect of caesarean section and positive effect of early initiation of breastfeeding on exclusive breastfeeding suggest that an institution-based approach should not be substituted by the community-based one in the formulation of breastfeeding strategies in China.

Breastfeeding support provided by lactation consultants in high-income countries for improved breastfeeding rates, self-efficacy, and infant growth: a systematic review and meta-analysis protocol

BACKGROUND

It is well established that breast milk offers numerous health benefits for mother and child. Mothers are recommended to exclusively breastfeed their child until 6 months of age, with continued breastfeeding up to 1-2 years of age or beyond. Yet, these recommendations are met less than half of the time in high-income countries. Lactation consultants specialize in supporting mothers with breastfeeding and are a promising approach to improving breastfeeding rates. For lactation consultant interventions to be implemented widely as part of public health policy, a better understanding of their effect on breastfeeding rates and important health outcomes is needed.

METHODS

The overall aim of this systematic review is to evaluate the effect of lactation consultant interventions provided to women, compared to usual care, on breastfeeding rates (primary outcome), maternal breastfeeding self-efficacy, and infant growth. A search strategy has been developed to identify randomized controlled trials published in any language between 1985 and April 2023 in CENTRAL, MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science. We will also perform a search of the grey literature and reference lists of relevant studies and reviews. Two reviewers will independently extract data on study design, baseline characteristics, details of the interventions employed, and primary and secondary outcomes using a pre-piloted standardized data extraction form. Risk of bias and quality of evidence assessment will be done independently and in duplicate using the Cochrane Risk of Bias tool and GRADE approach, respectively. Where possible, meta-analysis using random-effects models will be performed, otherwise a qualitative summary will be provided. We will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

DISCUSSION

This review will fill an important gap in the lactation support literature. The findings will be of importance to policymakers who seek to implement interventions to improve breastfeeding rates.

TRIAL REGISTRATION

This review has been registered in the PROSPERO database (ID: CRD42022326597).

Weekly Proactive Telephone Breastfeeding Standard Care by Lactation Consultants in the First Month Postpartum Prolongs Breastfeeding for Up to 6 Months

Many mothers, especially those with co-morbidities, do not achieve exclusive breastfeeding (EBF) for the first 6 months, with the loss of multiple health benefits including enhanced infant nutrition. We wished to evaluate whether proactive lactation consultant telephone advice in the first month postpartum improved breastfeeding rates for up to 6 months. A prospective cohort observational study was performed. Mother groupings included the following: Control (CG, n = 379)-standard postnatal care; Exposure (EG, n = 386)-standard postnatal care delivered by lactation consultant telephone contact for the first 3 weeks postpartum and then follow-up calls at 1, 3 and 6 months postpartum to ascertain breastfeeding status. Sore nipples (24%) and fussy/unsettled behaviour (14-19%) were common EG concerns. EG EBF rates were higher at 1 month (65% vs. 53%; p < 0.001), 3 months (57% vs. 49%; p = 0.041) and 6 months (45 vs. 33%; p < 0.001). EG EBF rates across the 6 months were higher for infants admitted to the NNU (52.9% vs. 37.5%, p = 0.003), obese mothers (58.3% vs. 37.2%, p < 0.001), mothers with depression (60.8% vs. 43.4%, p = 0.036) and all birth modes. Proactive early lactation advice significantly prolongs EBF and consequently enhances infant nutrition overall, including for mothers at risk of early breastfeeding cessation.

Lessons from digital technology-enabled health interventions implemented during the coronavirus pandemic to improve maternal and birth outcomes: a global scoping review

BACKGROUND

Timely access to essential obstetric and gynecologic healthcare is an effective method for improving maternal and neonatal outcomes; however, the COVID-19 pandemic impacted pregnancy care globally. In this global scoping review, we select and investigate peer-reviewed empirical studies related to mHealth and telehealth implemented during the pandemic to support pregnancy care and to improve birth outcomes.

METHODS

We searched MEDLINE and PubMed, Scopus, CINAHL and Web of Science for this Review because they include peer-reviewed literature in the disciplines of behavioral sciences, medicine, clinical sciences, health-care systems, and psychology. Because our investigative searches reviewed that there is considerable 'grey literature' in this area; we did not restrict our review to any study design, methods, or place of publication. In this Review, peer-reviewed preprints were comparable to published peer-reviewed articles, with relevant articles screened accordingly.

RESULTS

The search identified 1851 peer reviewed articles, and after removal of duplicates, using inclusion and exclusion criteria, only 22 studies were eligible for inclusion in the review published from January 2020 to May 2022. mHealth interventions accounted for 72.7% (16 of 22 studies) and only 27.3% (6 of 22 studies) were telehealth studies. There were only 3 example studies that integrated digital technologies into healthcare systems and only 3 studies that developed and evaluated the feasibility of mobile apps. Experimental studies accounted 68.8% of mHealth studies and only 33.3% studies of telehealth studies. Key functionalities of the pregnancy apps and telehealth platforms focused on mental and physical wellness, health promotion, patient tracking, health education, and parenting support. Implemented interventions ranged from breastfeeding and selfcare to behavioral health. Facilitators of uptake included perceived benefits, user satisfaction and convenience. Mobile apps and short messaging services were the primary technologies employed in the implemented mHealth interventions.

CONCLUSION

Although our Review emphasizes a lack of studies on mHealth interventions and data from pregnant women during the COVID-19 crisis, the review shows that implementation of digital health interventions during emergencies are inevitable given their potential for supporting pregnancy care. There is also a need for more randomized clinical trials and longitudinal studies to better understand the effectiveness and feasibility of implementing such interventions during disease outbreaks and emergencies.

Does benefits-of-breastfeeding language or risks-of-formula-feeding language promote more-positive attitudes toward breastfeeding among midwives and nurses?

BACKGROUND

Midwives and nurses are crucial in breastfeeding support. Few studies have explored appropriate language for nursing education on breastfeeding. We assessed the impact of the language used on breastfeeding attitudes among midwives and nurses.

METHODS

A quasi-experimental study was conducted online in Japan among 174 midwives and nurses who had work experience in obstetrics or pediatrics. Participants were allocated to three groups to receive different text messages as the intervention (the benefit of breastfeeding for Group 1; the risk of formula feeding for Group 2; the importance of childcare for Group 3 as the comparison). The Japanese version of the Iowa Infant Feeding Attitude Scale (IIFAS-J) was used to assess breastfeeding attitudes before and after reading the texts. Also, participant reactions to the text were assessed by their responses to three statements. ANOVA, the chi-square test, and the t-test were used for outcome assessments.

RESULTS

The post-test IIFAS-J score was significantly higher than the pre-test score only for Group 1 (p <  0.01). The percentage of participants who agreed with the content of the text was 70.7% in Group 1 and 48.3% in Group 2. The percentage of participants who reported discomfort with the text was 34.5% in Group 1 and 55.2% in Group 2. No significant difference among groups existed regarding interest in the text. In all three groups, participants who agreed with the text had a higher post-test IIFAS-J score than those who disagreed with the text (6.85 points higher, p <  0.01 in Group 1; 7.19 points higher, p <  0.01 in Group 2; 8.00 points higher, p <  0.02 in Group 3). Discomfort with the text and interest in the text were associated with a significantly higher post-test IIFAS-J score in Group 1 and Group 2 but not in Group 3.

CONCLUSIONS

"Benefits of breastfeeding" language, which conveys the information in a positive manner, appears to be more appropriate than "risks of infant formula" language for creating a positive attitude toward breastfeeding in nursing education.

TRIAL REGISTRATION

This study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000023322). Registered 05/08/2016.

"Breast is best"… until they say so

In this autoethnographic article, I discuss the consequences of being exposed to two competing breastfeeding discourses during my first mothering experience-the "self-regulated dyad" and the "externally regulated dyad" discourse. The former represents the ideal scenario and the evidence-based practices recommended by the World Health Organization (i.e., breastfeeding on demand, internally regulated by the dyad). The externally regulated discourse refers to the standardized health interventions that take over when difficulties arise (e.g., weight gain deviations and latching issues). Building on Kugelmann's critique about our blind reliance on "standardized health," existing evidence, and my breastfeeding journey, I argue that unqualified and unindividualized breastfeeding interventions are highly counterproductive. To illustrate these points, I discuss the implications of the polarized interpretation of pain and the limited dyadically focused support. I then move on to analyze how ambivalent social positioning around breastfeeding impacts our experience. In particular, I found that I was highly regarded as a "good, responsible mum" up till my baby was 6 months, and how breastfeeding became increasingly challenged by others when my daughter was approaching her first birthday. Here, I discuss how performing attachment mothering identity work allowed me to navigate these challenges. Against this backdrop, I reflect upon feminist ambivalent positionings on breastfeeding and the complexity of balancing the promotion of women's hard-earned rights while supporting them to engage in whatever baby-feeding choice they feel appropriate. I conclude that unless we acknowledge the physical and social complexities of the process, and our healthcare systems seriously invest in allocating human resources and training them appropriately, breastfeeding rates may continue to suffer and women continue to interiorize it as their own failure.

Effectiveness of a community-based support programme to reduce social inequality in exclusive breastfeeding: study protocol for a cluster-randomised trial

BACKGROUND

Breastmilk is the ideal nutrition for infants, and breastfeeding protects infants and mothers from a range of adverse health outcomes. In Denmark, most mothers initiate breastfeeding but many cease within the first months resulting in just 14% reaching the World Health Organization recommendation of six months of exclusive breastfeeding. Furthermore, the low breastfeeding proportion at six months is characterised by a marked social inequality. A previous intervention tested in a hospital setting succeeded in increasing the proportion of mothers breastfeeding exclusively at six months. However, most breastfeeding support is provided within the Danish municipality-based health visiting programme. Therefore, the intervention was adapted to fit the health visiting programme and implemented in 21 Danish municipalities. This article reports the study protocol, which will be used to evaluate the adapted intervention.

METHODS

The intervention is tested in a cluster-randomised trial at the municipal level. A comprehensive evaluation approach is taken. The effectiveness of the intervention will be evaluated using survey and register data. Primary outcomes are the proportion of women who breastfeed exclusively at four months postpartum and duration of exclusive breastfeeding measured as a continuous outcome. A process evaluation will be completed to evaluate the implementation of the intervention; a realist evaluation will provide an understanding of the mechanisms of change characterising the intervention. Finally, a health economic evaluation will assess the cost-effectiveness and cost-utility of this complex intervention.

DISCUSSION

This study protocol reports on the design and evaluation of the Breastfeeding Trial - a cluster-randomised trial implemented within the Danish Municipal Health Visiting Programme from April 2022 to October 2023. The purpose of the programme is to streamline breastfeeding support provided across healthcare sectors. The evaluation approach is comprehensive using a multitude of data to analyse the effect of the intervention and inform future efforts to improve breastfeeding for all.

TRIAL REGISTRATION

Prospectively registered with Clinical Trials NCT05311631 https://clinicaltrials.gov/ct2/show/NCT05311631.

Emotional and informational social support from health visitors and breastfeeding outcomes in the UK

BACKGROUND

Shorter breastfeeding duration is associated with detrimental consequences for infant health/development and maternal health. Previous studies suggest social support is essential in maintaining breast/chest-feeding and helping to improve general infant feeding experiences. Public health bodies therefore work to support breastfeeding in the UK, yet UK breastfeeding rates continue to be one of the lowest globally. With this, a better understanding of the effectiveness and quality of infant feeding support is required. In the UK, health visitors (community public health nurses specialising in working with families with a child aged 0-5 years) have been positioned as one of the key providers of breast/chest-feeding support. Research evidence suggests that both inadequate informational support and poor/negative emotional support can lead to poor breastfeeding experiences and early breastfeeding cessation. Thus, this study tests the hypothesis that emotional support from health visitors moderates the relationship between informational support and breastfeeding duration/infant feeding experience among UK mothers.

METHODS

We ran cox and binary logistic regression models on data from 565 UK mothers, collected as part of a 2017-2018 retrospective online survey on social support and infant feeding.

RESULTS

Informational support, compared to emotional support, was a less important predictor of both breastfeeding duration and experience. Supportive emotional support with unhelpful or absent informational support was associated with the lowest hazard of breastfeeding cessation before 3 months. Results for breastfeeding experience followed similar trends, where positive experience was associated with supportive emotional and unhelpful informational support. Negative experiences were less consistent; however, a higher probability of negative experience was found when both types of support were reported as unsupportive.

CONCLUSIONS

Our findings point to the importance of health visitors providing emotional support to bolster the continuation of breastfeeding and encourage a positive subjective experience of infant feeding. The emphasis of emotional support in our results encourages increased allocation of resources and training opportunities to ensure health visitors are able to provide enhanced emotional support. Lowering health visitors caseloads to allow for personalised care is just one actionable example that may improve breastfeeding outcomes in the UK.

Breastfeeding in Canada: predictors of initiation, exclusivity, and continuation from the 2017-2018 Canadian Community Health Survey

Human milk is the ideal source of nutrition for infants; however, adherence to breastfeeding recommendations is suboptimal and availability of Canadian breastfeeding data are limited. Using the 2017-2018 Canadian Community Health Survey Public Use Microdata File (Maternal Experiences Module, n = 5558, weighted n = 1 669 462) we computed breastfeeding indicators and explored sociodemographic, health, and geographical predictors of breastfeeding with univariate logistic regression models. Nationally, of all participants who gave birth in the preceding 5 years, 91% initiated breastfeeding, 43% exclusively breastfed to ≥5 months and 35% to ≥6 months, 56% reported any breastfeeding at ≥6 months, and 31% reported breastfeeding at ≥12 months. Breastfeeding cessation was most commonly attributed to insufficient milk supply (25%), but reasons differed significantly by breastfeeding duration. Breastfeeding initiation, exclusivity for ≥5 months, and extended breastfeeding ≥12 months all differed by geographic region, and by most sociodemographic and health characteristics. Positive breastfeeding outcomes were highest in British Columbia, and lowest in Quebec and the Atlantic region, and generally higher if caregivers had recently immigrated to Canada, were married, were >30 years of age, were not White, were nonsmoking, had completed postsecondary education, and had an annual household income >$40 000. These disparities indicate the need for tailored, equitable approaches to breastfeeding support, and continued regional monitoring of breastfeeding outcomes.

Impact of the Thompson method on breastfeeding exclusivity and duration: Multi-method design

BACKGROUND

How hospital clinicians facilitate breastfeeding in the first 48-72 h is critical to breastfeeding exclusivity and duration. Mothers who discharge hospital directly breastfeeding are more likely to continue exclusively breastfeeding at 3-months.

OBJECTIVE

To assess the impact of facility-wide implementation of a physiological breastfeeding method (the Thompson method) on direct breastfeeding at hospital discharge and exclusive breastfeeding at 3-months of age.

DESIGN

Multi-method design using interrupted time series analysis and surveys.

SETTING(S)

An Australian tertiary maternity hospital.

PARTICIPANTS

13,667 mother-baby pairs (interrupted time series analysis) and 495 postnatal mothers (surveys).

METHODS

The Thompson method includes cradle position and hold, alignment of mouth-to-nipple, baby-led connection and seal, maternal fine-tuning for symmetry, and leisurely duration. We used a large pre-post implementation dataset and conducted interrupted time series analysis using a 24-month baseline period (January 2016 - December 2017); and a 15-month post-implementation period (April 2018 - June 2019). We recruited a sub-sample of women to complete surveys at hospital discharge and 3-months postpartum. Surveys were primarily used to measure impact of Thompson method on exclusive breastfeeding at 3-months, compared with a baseline survey conducted in same setting.

RESULTS

Following implementation of the Thompson method, the declining trend in direct breastfeeding at hospital discharge was significantly averted by 0.39% each month relative to baseline (95% CI: 0.03% to 0.76%; p = 0.037). While the 3-month exclusive breastfeeding rate in the Thompson group was 3 percentage points higher than the baseline group; this result did not reach statistical significance. However, a subgroup analysis of women who discharged hospital exclusively breastfeeding revealed the relative odds of exclusive breastfeeding at 3-months in the Thompson group was 0.25 (95% CI: 0.17 to 0.38; p < 0.001), significantly better than the baseline group (Z = 3.23, p < 0.01) where the relative odds was only 0.07 (95% CI: 0.03 to 0.19; p < 0.001).

CONCLUSIONS

Implementation of the Thompson method for well mother-baby pairs improved direct breastfeeding trends at hospital discharge. For women who discharged hospital exclusively breastfeeding, exposure to the Thompson method reduced the risk of exclusive breastfeeding discontinuation by 3-months. The positive impact of the method was potentially confounded by partial implementation and a parallel rise in birth interventions which undermine breastfeeding. We recommend strategies to strengthen clinician buy-in to the method, and future research using a cluster randomised trial design.

TWEETABLE ABSTRACT

Facility-wide implementation of the Thompson method improves direct breastfeeding at hospital discharge and predicts breastfeeding exclusivity at 3-months.

Easier, but not easy: Testing a grounded theory of breastfeeding experiences among women with larger birthweight infants

OBJECTIVE

Grounded Theory has previously been used to explore breastfeeding practices amongst average birthweight infants and these working hypotheses can be 'tested' in new contexts. A pre-existing Grounded Theory was applied to the context of women who gave birth to larger birthweight infants (≥4,000 g) to understand whether perceptions and practices of infant feeding were distinct.

DESIGN

A nested qualitative study analysed data from N = 10 women with a larger birthweight infant (≥4,000 g). Face-to-face, semi-structured interviews were audio-recorded and transcribed verbatim. Grounded Theory methodology was used to analyse data.

RESULTS

A pre-existing Grounded Theory of breastfeeding experiences derived from women with average birthweight infants did not hold true among women with larger birthweight infants. An alternative Grounded Theory was therefore proposed comprised of three discrete themes: Infant Ability to Breastfeed; Attenuating Maternal Concerns; and Reality of Breastfeeding.

CONCLUSIONS

Larger infant birthweight is potentially a protective factor against breastfeeding latch and lactation difficulties. It is associated with alleviating maternal concerns, helping to reduce disparities between expectations of breastfeeding and reality, but does not alleviate the demands breastfeeding places on women. Healthcare professionals help to attenuate women's concerns, however the support needs for women with larger birthweight infants may not differ from existing care recommendations.

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

Background

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

Methods

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

Result

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

Conclusion

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

Systematic review registration

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

Rates of and factors associated with exclusive and any breastfeeding at six months in Canada: an analysis of population-based cross-sectional data

BACKGROUND

Breastfeeding has many health, economic and environmental benefits for both the infant and pregnant individual. Due to these benefits, the World Health Organization and Health Canada recommend exclusive breastfeeding for the first six months of life. The purpose of this study is to examine the prevalence of exclusive and any breastfeeding in Canada for at least six months, and factors associated with breastfeeding cessation prior to six months.

METHODS

We performed a secondary analysis of breastfeeding-related questions asked on the cross-sectional 2017-2018 Canadian Community Health Survey. Our sample comprised 5,392 females aged 15-55 who had given birth in the five years preceding the survey. Descriptive statistics were carried out to assess the proportion of females exclusively breastfeeding and doing any breastfeeding for at least six months by demographic and behavioural factors. We also assessed, by baby's age, trends in the introduction of solids and liquids, breastfeeding cessation and the reasons females stopped breastfeeding. Multivariate log binominal regression was used to examine the association between breastfeeding at six months and selected maternal characteristics hypothesized a priori to be associated with breastfeeding behaviour.

RESULTS

Overall, for at least six months, 35.6% (95% confidence interval (CI): 33.3%-37.8%) of females breastfed exclusively and 62.2% (95% CI: 60.0%-64.4%) did any breastfeeding. The largest decline in exclusive breastfeeding occurred in the first month. Factors most strongly associated with breastfeeding for at least six months were having a bachelor's or higher degree, having a normal body mass index, being married and daily co-sleeping. Insufficient milk supply was given as the most common reason for breastfeeding cessation irrespective of when females stopped breastfeeding.

CONCLUSION

Six-month exclusive breastfeeding rates in Canada remain below targets set by the World Health Assembly. Continued efforts, including investment in monitoring of breastfeeding rates, are needed to promote and support exclusive breastfeeding, especially among females vulnerable to early cessation.

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

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

Interventions to support the re-establishment of breastfeeding and their application in humanitarian settings: A systematic review

In 1998, the World Health Organisation (WHO) published general guidelines proposing essential measures to achieve relactation. Yet, increased knowledge about the practical set-up of relactation support interventions in different contexts is needed, especially in humanitarian settings, where nonbreastfed infants are particularly at risk. This study aimed to compile and assess the characteristics, outcomes and factors influencing the implementation of relactation support interventions reported since the latest WHO recommendations. We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, undertaking a search from Medline, Embase, PubMed Central, Web of Science, Global Health and CINAHL electronic databases. Studies published in English and Spanish, reporting characteristics and outcomes of relactation support provided to non-(breastfeeding) BF mothers with infants aged less than 6 months were included. Data were analysed by narrative synthesis and the Johanna Briggs Institute Critical Appraisal Tools were used for quality assessment. Overall, 16 studies met the inclusion criteria. Most were observational and conducted in middle-income countries, only one focused on humanitarian settings. Studies reported inpatient and community-based interventions, which generally followed WHO recommendations for relactation. In 13 out of 16 studies, over 80% of mothers restarted BF after receiving relactation support. Enabling factors included younger infant age, shorter lactation gap, mother's strong motivation, family support, and continuous skilled support. Although current literature suggests that intensive relactation support can contribute to re-establish BF, its application and effectiveness in humanitarian settings remain uncertain. Further research is needed to explore the effectiveness, feasibility and acceptability of different approaches to relactation support, especially in humanitarian settings.

Factors Associated with the Duration of Breastfeeding: The Practices of Mexican Mothers in a Megacity and in the Agricultural Town

BACKGROUND

Breast milk is irreplaceable for healthy development. In Mexico, by 2019, the prevalence of exclusive breastfeeding (EBF) was low and the use of breastmilk substitutes (BMSs) was high.

OBJECTIVE

The aim of this work was to evaluate the maternal and child characteristics related to breastfeeding (BF) duration and to the introduction of BMSs for residents of Mexico City (CdMX) and an agricultural town in Morelos.

METHODS

A cross-sectional study was conducted with 160 mother-child binomials (0-15 months of age) from the megacity CdMX and the agricultural town.

OUTCOMES

EBF and total breastfeeding (TBF) duration, age of transition to BMSs, and the introduction of complementary feeding (CF) were assessed. Associations with maternal and infant factors were assessed using Cox models.

RESULTS

The prevalence of EBF in the joint samples at 5.9 months was 32.6% and 5.8% at 6 months. EBF was favored under the following conditions: living in CdMX, receiving prenatal care, no newborn hospitalization, and breastmilk provided as first food at birth. TBF was prolonged under the following conditions: older mother, female children, rooming-in care during puerperium, receiving BF upon discharge after birth, cohabiting with extended family, and having no siblings. The introduction of BMSs predominated under the following conditions: living in an agricultural town, BMSs given after birth before discharge, younger mother, worker mother, and lack of prenatal care. The early introduction of CF (before the fourth month) was 2% for CdMX and 14% for the agricultural town.

CONCLUSIONS

The agricultural population had a higher risk of the premature interruption of EBF/TBF and the early introduction of BMSs and CF. Protective factors were family-friendly environments and being born in a baby-friendly hospital.

Feeding Patterns of Healthy Term Newborns in the First 5 Days-The Glucose in Well Babies Study (GLOW)

BACKGROUND

The feeding patterns of healthy newborns have been poorly described.

RESEARCH AIM

To determine the feeding patterns of healthy term newborns soon after birth, and if these differed with sex, gestation, and mode of birth.

METHODS

This study was a prospective, longitudinal observational cohort study. Term, appropriately grown newborns (N = 66) were fed according to maternal choice and details were recorded. Data were analyzed using generalized Poisson regression for feeding frequencies, and mixed model regression of log-transformed data for durations.

RESULTS

The participants completing the study had a M = 3589 g (SD = 348 g) birthweight, with a gestation age of M = 40.1 (1.2) weeks. All participants were breastfed; 23 (35%) also received expressed human milk and 10 (15%) received formula. Participants had fewer feeding sessions on Day 1, (M = 7.3 [1.9] sessions/day) increasing to (M = 9.4 [2.4] sessions/day) by Day 3, then reducing to (M = 9.0 [2.2] sessions/day) on Day 5, p < .001. The overall duration of breastfeeding sessions varied widely (Mdn = 29 [range = 1-447] min). Feed frequency but not duration was higher in males than females (M = 8.9, SE = 0.2 vs. 8.1, 02, sessions/day, p = .03), in newborns born ≥ 40 weeks' gestation (M = 8.9, SE = 0.3 vs. 8.2, 02, sessions/day, p = .04), and in newborns born by Caesarean section (M = 9.4, SE = 0.3 vs. 8.4, 02, sessions/day, for vaginal birth, p = .003).

CONCLUSION

Feeding patterns of healthy term newborns vary widely, but frequency increases during the first 3 days, and is greater in males, newborns born late term, and born by Caesarean section.

CLINICAL TRIAL REGISTRATION

The Australian and New Zealand Clinical Trials Registry Ref: ACTRN12615000986572. The study protocol is available online: http://hdl.handle.net/2292/32066.