A randomized controlled community-based trial to improve breastfeeding rates among urban low-income mothers

Cost-benefit analysis of a multicomponent breastfeeding promotion and support intervention in a developing country

BACKGROUND

Studies on breastfeeding promotion and support interventions suggest some economic benefits. This study assessed the direct and indirect costs of a multicomponent breastfeeding promotion and support intervention during the first two years of the infant's life.

METHODS

This is a cost-benefit analysis of data generated from a randomized controlled trial that investigated whether provision of a multicomponent breastfeeding promotion and support intervention to Lebanese mothers in the first six months postpartum would improve breastfeeding rates compared to standard obstetric and pediatric care. Data of 339 participants on sociodemographics, mother and infant health, infant nutrition, direct and indirect costs of the intervention were used to assess the benefit-cost ratio (BCR) of the intervention at one, six, 12, and 24 months as primary outcome. Secondary outcomes included overall costs of infant nutrition and infant-mother dyad health costs during the first two years. Multiple linear regression models explored the effect of the intervention on the overall infant nutrition cost and mother-infant health costs. Similar regression models investigated the association between cost variables and infant nutrition types (exclusive breastfeeding, mixed feeding, artificial milk). Intention to treat analyses were conducted using SPSS (version 24). Statistical significance was set at a p-value below 0.05.

RESULTS

The prevalence of Exclusive/Predominant breastfeeding among participants declined from 51.6% in the first month to 6.6% at the end of second year. The multicomponent breastfeeding intervention incurred 485 USD more in costs than the control group during the first six months but was cost-efficient at one year (incremental net benefits of 374 USD; BCR = 2.44), and two years (incremental net benefits of 472 USD; BCR = 2.82). In adjusted analyses, the intervention was significantly associated with fewer infant illness visits in the first year (p = 0.045). Stratified analyses by the infant nutrition type revealed that infants who were on Exclusive/Predominant, or Any Breastfeeding had significantly more favorable health outcomes at different time points during the first two years (p<0.05) compared to infants receiving Artificial Milk only, with health benefits being highest in the Exclusive/Predominant breastfeeding group. Moreover, Exclusive/Predominant and Any Breastfeeding had significantly lower costs of infant illness visits, hospitalizations, and infant medications during the two years (p<0.05) but had additional cost for maternal non-routine doctor visits due to breastfeeding (all p values <0.05). Whereas the overall cost (direct and indirect) during the first six months was significantly lower for the Exclusive/Predominant breastfeeding infants (p = 0.001), they were similar in infants on Mixed Feeding or Artificial Milk.

CONCLUSIONS

Breastfeeding is associated with significant economic and infant health benefits in the first two years. In the context of the current economic crisis in Lebanon, this study provides further evidence to policymakers on the need to invest in national breastfeeding promotion and support interventions.

Community infant safe sleep and breastfeeding promotion and population level-outcomes: A mixed methods study

PROBLEM

In the U.S., sudden unexpected infant deaths due to accidental suffocation and strangulation in bed are increasing. Though breastfeeding is a protective factor against sudden unexpected infant death, motivations to breastfeed often couple with unsafe infant sleep practices. Racial/ethnic disparities are present in sudden unexpected infant death, accidental suffocation and strangulation in bed, and breastfeeding.

BACKGROUND

Promoting infant safe sleep and breastfeeding through community-level initiatives could address disparities in related outcomes.

AIM

Investigate the relationship between community-level strategies and associated state-level outcomes for infant safe sleep and breastfeeding.

METHODS

We employed an intervention mixed methods framework and exploratory sequential design. The qualitative component entailed a hermeneutical phenomenological framework to analyze key informant interview data from seven U.S. community-level providers participating in a practice improvement initiative. The quantitative component entailed descriptively analyzing infant safe sleep and breastfeeding indicators from the 2019 Pregnancy Risk Assessment Monitoring System and Ohio Pregnancy Assessment Survey. Qualitative and quantitative data were linked through embedded integration.

FINDINGS

We identified two mixed insights: gaps in promotion and outcomes, and persistent disparities between infant safe sleep and breastfeeding promotion and outcomes.

DISCUSSION

Our findings indicate conversational approaches could improve infant safe sleep and breastfeeding promotion, outcomes, and relative disparities. We find that community collaboration is needed to address organizational capacity limitations in promoting infant safe sleep and breastfeeding.

CONCLUSION

Community-level organizations and providers should consider tailoring program offerings and care delivery to include conversational approaches and community collaboration to promote infant safe sleep and breastfeeding and decrease relative disparities in outcomes.

The role of clinic-based breastfeeding peer counseling on breastfeeding rates among low-income patients

BACKGROUND

Despite the benefits of breastfeeding (BF), rates remain lower than public health targets, particularly among low-income Black populations. Community-based breastfeeding peer counselor (BPC) programs have been shown to increase BF. We sought to examine whether implementation of a BPC program in an obstetric clinical setting serving low-income patients was associated with improved BF initiation and exclusivity.

METHODS

This is a quasi-experimental time series study of pregnant and postpartum patients receiving care before and after implementation of a BPC program in a teaching hospital affiliated prenatal clinic. The role of the BPC staff included BF classes, prenatal counseling and postnatal support, including in-hospital assistance and phone triage after discharge. Records were reviewed at each of 3 time points: immediately before the hire of the BPC staff (2008), 1-year post-implementation (2009), and 5 years post-implementation (2014). The primary outcomes were rates of breastfeeding initiation and exclusivity prior to hospital discharge, secondary outcomes included whether infants received all or mostly breastmilk during inpatient admission and by 6 weeks post-delivery. Bivariable and multivariable analyses were utilized as appropriate.

RESULTS

Of 302 patients included, 52.3% identified as non-Hispanic Black and 99% had Medicaid-funded prenatal care. While there was no improvement in rates of BF initiation, exclusive BF during the postpartum hospitalization improved during the 3 distinct time points examined, increasing from 13.7% in 2008 to 32% in 2014 (2009 aOR 2.48, 95%CI 1.13-5.43; 2014 aOR 1.82, 95%CI 1.24-2.65). This finding was driven by improved exclusive BF for patients who identified as Black (9.4% in 2008, 22.9% in 2009, and 37.9% in 2014, p = 0.01).

CONCLUSION

Inpatient BF exclusivity significantly increased with the tenure of a BPC program in a low-income clinical setting. These findings demonstrate that a BPC program can be a particularly effective method to address BF disparities among low-income Black populations.

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.

Cost-benefit analysis of a multicomponent breastfeeding promotion and support intervention in a developing country

Background

Studies evaluating breastfeeding promotion and support interventions suggest some economic benefits. This study assessed the direct and indirect costs of a multicomponent breastfeeding promotion and support intervention during the first two years of the infant's life.

Methods

This is a cost-benefit analysis of data generated from a randomized controlled trial that aimed at investigating whether provision of a multicomponent breastfeeding promotion and support intervention to Lebanese mothers in the first six months postpartum would improve breastfeeding rates compared to standard obstetric and pediatric care. Data on 339 participants included information on maternal socio-demographics and health, infant nutrition and health, and direct and indirect costs of the intervention. The primary outcome was the benefit-cost ratio (BCR) of the intervention at one, six, 12, and 24 months. Secondary outcomes included the overall costs of infant nutrition and infant-mother dyad health costs during the first two years. Multiple linear regression models investigated the effect of the multicomponent intervention (independent variable) on the overall infant nutrition cost and the overall mother-infant health costs (as dependent variables), adjusting for monthly income and number of children (confounders) at different time points in the first two years. Similar regression models investigated the association between infant nutrition type (exclusive breastfeeding, mixed feeding, artificial milk) and infant nutrition costs and infant-mother health costs. Intention to treat analyses were conducted using SPSS (version 24). Statistical significance was set at a p-value below 0.05.

Results

The prevalence of Exclusive/Predominant breastfeeding among participants declined from 51.6% in the first month to 6.6% at the end of second year. The multicomponent breastfeeding intervention incurred 485 USD more in costs than the control group during the first six months but was cost-efficient by the end of the first year (incremental net benefits of 374 USD; BCR=2.44), and by the end of the second year (incremental net benefits of 472 USD; BCR=2.82). In adjusted analyses, the intervention was significantly associated with fewer infant illness visits in the first year (p=0.045). Stratified analyses by the type of infant nutrition revealed that infants who were on Exclusive/Predominant, or Any Breastfeeding had significantly more favorable health outcomes at different time points during the first two years (p<0.05) compared to infants receiving Artificial Milk only, with health benefits being highest in the Exclusive/Predominant breastfeeding group. Moreover, Exclusive/Predominant and Any Breastfeeding had significantly lower costs of infant illness visits, hospitalizations, and infant medications during the two years (p<0.05), but had additional cost for maternal non-routine doctor visits due to breastfeeding (all p values <0.05). Whereas the overall cost (direct and indirect) during the first six months was significantly lower for the Exclusive/Predominant breastfeeding infants (p=0.001), they were similar in infants on Mixed Feeding or Artificial Milk.

Conclusions

Breastfeeding is associated with significant economic and infant health benefits in the first two years. In the context of the current economic crisis in Lebanon, this study provides further evidence to policymakers on the need to invest in national breastfeeding promotion and support interventions.

Delivery Strategies for Postpartum Care: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the effects of postpartum health care-delivery strategies on health care utilization and maternal outcomes.

DATA SOURCES

We searched Medline, EMBASE, CENTRAL, CINAHL, and ClinicalTrials.gov for studies in the United States or Canada from inception to November 16, 2022.

METHODS OF STUDY SELECTION

We used duplicate screening for studies comparing health care-delivery strategies for routine postpartum care on health care utilization and maternal outcomes. We selected health care utilization, clinical, and harm outcomes prioritized by stakeholder panels.

TABULATION, INTEGRATION, AND RESULTS

We found 64 eligible studies (50 randomized controlled trials, 14 nonrandomized comparative studies; N=543,480). For general postpartum care, care location (clinic, at home, by telephone) did not affect depression or anxiety symptoms (low strength of evidence), and care integration (by multiple types of health care professionals) did not affect depression symptoms or substance use (low strength of evidence). Providing contraceptive care earlier (compared with later) was associated with greater implant use at 6 months (summary effect size 1.36, 95% CI 1.13-1.64) (moderate strength of evidence). Location of breastfeeding care did not affect hospitalization, other unplanned care utilization, or mental health symptoms (all low strength of evidence). Peer support was associated with higher rates of any or exclusive breastfeeding at 1 month and any breastfeeding at 3-6 months (summary effect size 1.10-1.22) but not other breastfeeding measures (all moderate strength of evidence). Care by a lactation consultant was associated with higher breastfeeding rates at 6 months (summary effect size 1.43, 95% CI 1.07-1.91) but not exclusive breastfeeding (all moderate strength of evidence). Use and nonuse of information technology for breastfeeding care were associated with comparable rates of breastfeeding (moderate strength of evidence). Testing reminders for screening or preventive care were associated with greater adherence to oral glucose tolerance testing but not random glucose or hemoglobin A 1c testing (moderate strength of evidence).

CONCLUSION

Various strategies have been shown to improve some aspects of postpartum care, but future research is needed on the most effective care delivery strategies to improve postpartum health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022309756 .

Community-based approaches to infant safe sleep and breastfeeding promotion: a qualitative study

BACKGROUND

In the U.S., sudden unexpected infant deaths (SUID) due to accidental suffocation and strangulation in bed (ASSB) are increasing, with disparities by race/ethnicity. While breastfeeding is a protective factor against infant mortality, racial/ethnic disparities are present in its uptake, and motivations to breastfeed are also often coupled with non-recommended infant sleep practices that are associated with infant sleep deaths. Combining infant safe sleep (ISS) and breastfeeding promotion on the community level presents opportunities to address racial/ethnic disparities and associated socioeconomic, cultural, and psychosocial influences.

METHODS

We completed a descriptive qualitative hermeneutical phenomenology using thematic analysis of focus group data. We examined the phenomenon of community-level providers promoting ISS and breastfeeding in communities vulnerable to ISS and breastfeeding disparities. We asked eighteen informants participating in a national quality improvement collaborative about i.) areas requiring additional support to meet community needs around ISS and breastfeeding, and ii.) recommendations on tools to improve their work promoting ISS and breastfeeding.

RESULTS

We identified four themes: i.) education and dissemination, ii.) relationship building and social support, iii.) working with clients' personal circumstances and considerations, and iv.) tools and systems.

CONCLUSIONS

Our findings support embedding risk-mitigation approaches in ISS education; relationship building between providers, clients, and peers; and the provision of ISS and breastfeeding supportive material resources with educational opportunities. These findings may be used to inform community-level provider approaches to ISS and breastfeeding promotion.

A systematic literature review of breastfeeding interventions among Black populations using the RE-AIM framework

BACKGROUND

Lactation support resources are less likely to be located in close proximity to where Black families live and there is a systemic racist health care belief that Black women prefer bottle feeding (with infant formula) over breastfeeding. Together, these lead to lower reported breastfeeding rates of Black babies compared to other racial / ethnic groups. It is imperative to have a deeper understanding of the cultural aspects as well as the underlying limitations that prevent Black women / persons from being supported to breastfeed. There is a need to know how effective breastfeeding interventions are in reaching the intended population; how well they work in promoting breastfeeding initiation and continuation; and how successful they are when implemented at the setting and staff level. The purpose of this investigation was to establish the level of internal and external validity that was reported by breastfeeding intervention studies among Black communities.

METHODS

Studies on breastfeeding interventions on Black people that were published between the years 1990 and 2019 were carefully examined through PubMed, EBSCOhost, Web of Science, and OneSearch. A total of 31 studies fulfilled the requirements to be included for this evaluation. In order to extract the information from the articles, the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework extraction tool was utilized.

RESULTS

On average, the proportion of studies that reported across reach, effectiveness, adoption, implementation, and maintenance indicators was 54, 35, 19, 48, and 9%, respectively. Across core RE-AIM indicators only sample size (100%) and breastfeeding outcomes (90%) were reported consistently. External validity indicators related to representativeness of participants (16%) and sites (3%) were rarely reported. Similarly, adherence to intervention protocol, and indicator of internal validity, was reported in a small proportion of articles (19%).

CONCLUSION

This body of literature under-reported on aspects associated to both internal and external validity across all RE-AIM domains. The reporting of the individual level of representativeness; the setting level of representativeness; the intervention's adherence to the protocol; the expenses; and the factors of sustainability would benefit from improvement in future research.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

MAIN RESULTS

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

Breastfeeding Awareness and Empowerment (BAE): A Black Women-Led Approach to Promoting a Multigenerational Culture of Health

1 Background

Critical gaps in the U.S. healthcare system perpetuate adverse reproductive health outcomes for Black people. Grounded in reproductive justice and trauma-informed care, Breastfeeding Awareness and Empowerment (BAE) has developed a program titled BAE Cafe to directly address these gaps by providing community-based lactation and perinatal mental health support. A literature review identified key programmatic gaps, namely, access to knowledge relevant to troubleshooting breastfeeding, peer support, community support and healthcare system support, and system-level factors that impede families and communities from accessing lactation support.

2 Methods

This paper describes BAE Cafe through a group process observation and participant survey.

3 Results

The observation of groups highlighted the core elements of the BAE Cafe model: knowledge, support and mental health support in a peer driven format. Participant survey feedback was overwhelmingly positive and highlighted the critical importance of lactation support for Black women by Black women and BAE's role in participants' decisions to continue breastfeeding.

4 Conclusions

BAE Cafe is a replicable, scalable, peer-driven and low-barrier intervention that has the potential to improve outcomes for Black families. Additional research and investment are now needed to assess large-scale implementation to reduce disparities and address health inequity across different contexts and settings.

How breastfeeding behavior develops in women with gestational diabetes mellitus: A qualitative study based on health belief model in China

BACKGROUND

Gestational diabetes mellitus (GDM) is a condition in which women develop hyperglycemia during pregnancy, and is associated with long-term health burden on both mother and their offspring, such as future type 2 diabetes mellitus (T2DM). Although breastfeeding was expected to mitigate metabolic sequelae for both mothers and their newborns, the prevalence of breastfeeding in GDM mothers are sub-optimal worldwide.

OBJECTIVE

To explore the experience of disease among mothers with GDM and how they develop feeding behaviors.

METHODS

This study was conducted in three branches of an integrated tertiary hospital in the central area of China. Mothers who were diagnosed with GDM, had no other complications, and gave birth before no more than 6 months were approached based on a purposive sampling. GDM mothers' experience of the disease and breastfeeding were collected via in-depth interviews. A theory-driven thematic analysis based on Health Belief Model (HBM) was applied for data analysis. Inductive reasoning was used to identify emerging themes which were not included in HBM.

RESULTS

16 GDM mothers were included in the current study, with nine using breastfeeding, six mixed feeding and one artificial feeding, respectively. Nine themes were identified, including: 1) GDM diagnosis and severity; 2) information searching and GDM knowledge;3) GDM management; 4) perceived susceptibility of future diabetes;5) perceived severity of future diabetes;6) perceived benefits of breastfeeding;7) perceived barriers of breastfeeding;8) decision making process of feeding and social support. Generally, mothers with GDM lack reliable sources of information, considered the disease as a minor and transient illness during pregnancy, and failed to realize the long-term risk of GDM and the protective effect of breastfeeding to themselves and their babies. They rarely considered GDM in their feeding decision. Instead, the formation of feeding behaviors depends on the balance between the benefits and barriers of breastfeeding as well as the level of social support.

CONCLUSION

To promote breastfeeding, a multi-facet intervention targeted on healthcare providers (HCPs), GDM mothers and their networks was important to help GDM mothers better and correctly understand the disease and breastfeeding, and increase their capacity of breastfeeding.

Subject Matter Experts Identify Health Equity Concerns in Breastfeeding for African American Women

Although the rate of breastfeeding initiation in the United States has continued to rise since 1972, African American mothers continue to experience a significant disparity in initiation. The aim of this study was to explore the perceptions of the facilitators and barriers of breastfeeding initiation among African American mothers from the perspective of subject matter experts (SMEs). This study was part of a larger study that also involved focus group methodology with African American women. The purpose of this article is to describe the opinions, knowledge, and perceptions of SMEs who work with African American mothers. A semistructured interview guide was used to interview 7 SMEs at which point no new themes emerged from the data. SMEs highlighted the significance of modifiable factors in breastfeeding initiation decisions and validated many perceptions of African American mothers. SMEs identified many critical issues foundational to community perspective and shaping future success in raising breastfeeding initiation rates. To increase breastfeeding initiation rates among African American mothers, strategies beyond the individual level are necessary. SMEs recognize the importance of addressing fundamental issues related to historical perspectives, normalization, education, and disparities in breastfeeding as critical.

Impact of breastfeeding interventions among United States minority women on breastfeeding outcomes: a systematic review

BACKGROUND

In the U.S., strong ethnic/racial, socioeconomic, demographic, and geographic breastfeeding (BF) inequities persist, and African American and Hispanic women are less likely to meet their breastfeeding goals compared to White women. This systematic review (SR) was designed to answer the question: What is the impact of breastfeeding interventions targeting ethnic/racial minority women in the U.S. on improving BF initiation, duration and exclusivity rates?

METHODS

The SR was conducted following the Institute of Medicine Guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The study protocol was developed and registered a priori in PROSPERO (ID#CRD42020177764). The electronical databases searched was MEDLINE All (Ovid). Search strategies were led by the team's expert public health librarian using both controlled vocabulary and free text queries and were tested against a validated set of relevant papers included in existing reviews. The GRADE methodology was used to assess the quality of the studies.

RESULTS

We included 60 studies that had randomized (n = 25), observational (n = 24), quasi-experimental (n = 9), or cross-sectional (n = 2) designs. The studies focused on populations that were multi-ethnic/racial (n = 22), only Hispanic (n = 24), only Black (n = 13), and only American Indian (n = 1). The study interventions were classified following the socioecological model: macrosystem/policy level (n = 6); community level (n=51), which included healthcare organizations (n = 34), The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (n = 9), and community organizations/public health institutions (n = 8); and  interpersonal level (n = 3).

CONCLUSIONS

Policy and community level interventions delivered through WIC, healthcare facilities, and community agencies) are likely to improve BF outcomes among women of color. The combination of interventions at different levels of the socioecological model has not been studied among minority women in the U.S. Implementation science research is needed to learn how best to scale up and sustain effective BF interventions, taking into account the needs and wants of minority women. Thus, it is strongly recommended  to conduct large scale implementation research studies addressesing how to strengthen the different health and social environments surrounding women of color in the U.S. to improving their BF outcomes.

Process evaluations of early childhood obesity prevention interventions delivered via telephone or text messages: a systematic review

BACKGROUND

Increasingly, public health interventions are delivered via telephone and/or text messages. Recent systematic reviews of early childhood obesity prevention interventions have not adequately reported on the way interventions are delivered and the experiences/perceptions of stakeholders. We aimed to summarise the literature in early childhood obesity prevention interventions delivered via telephone or text messages for evidence of application of process evaluation primarily to evaluate stakeholders' acceptability of interventions.

METHODS

A systematic search of major electronic databases was carried out using the Population, Intervention, Comparison, Outcomes framework. Studies were included if interventions were delivered via telephone/text messages; aimed at changing caregivers' behaviours to prevent early childhood obesity; with one or more outcomes related to early obesity risk factors such as breastfeeding, solid feeding, tummy time, sleep and settling, physical activity and screen time; published from inception to May 2020. All eligible studies were independently assessed by two reviewers using the Cochrane Collaboration tool for assessing risk of bias. Qualitative studies were assessed using the Consolidated Criteria for Reporting Qualitative Research and Standards for Reporting Qualitative Research tools.

RESULTS

Twenty-four studies were eligible, and the overall risk of bias was low. Eight studies (33%) had evidence of process evaluation that examined participants' perceptions of interventions. Participants appreciated the convenience of receiving interventions via telephone or text messages. 63% of all studies in this review showed improvement in one or more behaviours related to childhood obesity prevention. Participants were likely to modify behaviours if they received information from a credible source such as from health professionals.

CONCLUSION

There is limited reporting of stakeholders' experiences in early obesity prevention studies delivered by telephone or text messages. Only one-third of studies examined participants' acceptability and the potential for delivery of childhood obesity prevention interventions conveniently using this mode of delivery. Interventions delivered remotely via telephone or text messages have the potential to reach equal or a greater number of participants than those delivered via face-to-face methods. Future research should build in process evaluation alongside effectiveness measurements to provide important insight into intervention reach, acceptability and to inform scale up.

TRIAL REGISTRATION

PROSPERO registration: CRD42019108658.

Effects of Telephone and Short Message Service Support on Infant Feeding Practices, "Tummy Time," and Screen Time at 6 and 12 Months of Child Age: A 3-Group Randomized Clinical Trial

Importance

There is limited information as to whether telephone or short message service (SMS) support is effective in improving infant feeding practices and tummy time and reducing screen time.

Objective

To determine the effectiveness of either nurse-led telephone or SMS support in improving infant feeding practices and tummy time and reducing screen time.

Design, Setting, and Participants

This study was part of a 2-year, 3-group parallel, randomized clinical trial conducted from February 23, 2017, to November 30, 2018, among 1155 women in the third trimester of pregnancy in New South Wales, Australia. It reports the main outcomes at 6 and 12 months of child age. All analyses were conducted on an intention-to-treat principle.

Interventions

The intervention consisted of staged information booklets mailed to the intervention groups, each followed by either a nurse-led telephone support session or SMS intervention, antenatally and at 1, 3, 5, 7, and 10 months after birth.

Main Outcomes and Measures

The primary outcomes were infant feeding practices at both 6 and 12 months and tummy time at 6 months. The secondary outcome was screen time at 12 months.

Results

Of 1155 mothers, 947 (82%; mean [SD] age, 32.5 [5.0] years) completed follow-up surveys at 6 months; 920 mothers (80%) completed follow-up surveys at 12 months. Compared with the control group, telephone support led to higher odds of appropriate timing of introducing solid foods (adjusted odds ratio [AOR], 1.68 [95% CI, 1.22-2.32]), cup use (AOR, 1.54 [95% CI, 1.12-2.13]), and early-start tummy time (AOR, 1.63 [95% CI, 1.18-2.25]) at 6 months and higher odds of having no screen time (AOR, 1.80 [95% CI, 1.28-2.53]) and no bottle at bedtime (AOR, 1.73 [95% CI, 1.23-2.42]) at 12 months. Use of SMS also led to higher odds than the control group of having no screen time (AOR, 1.28 [95% CI, 1.08-1.52]) and having no bottle at bedtime (AOR, 1.29 [95% CI, 1.10-1.51]) at 12 months. No significant differences were found in breastfeeding rates between the telephone support, SMS support, and control groups.

Conclusions and Relevance

Both the nurse-led telephone support and SMS interventions were effective in reducing screen time and bottle use at bedtime. Telephone support was also effective in promoting the appropriate timing of the introduction of solid foods, early-start tummy time, and cup use.

Trial Registration

http://anzctr.org.au Identifier: ACTRN12616001470482.

A Spatial Analysis of Breastfeeding and Breastfeeding Support in the United States: The Leaders and Laggards Landscape

BACKGROUND

To better track progress in achieving the Healthy People 2020 goals, the Centers for Disease Control and Prevention (CDC) publishes an annual Breastfeeding Report Card (BRC) that represents a compilation of data on breastfeeding practices in all states. With data drawn from the CDC National Immunization Survey, the BRC provides an especially valuable source of information about geographic trends in breastfeeding and related support activities.

RESEARCH AIM

This study aimed to identify important geographic trends in both breastfeeding practices and support structures in the United States, highlighting their spatial disparities.

METHODS

Exploratory spatial data analysis, including local indicators of spatial association, is combined with spatial regression models to highlight geographic variations in breastfeeding practices and support.

RESULTS

Geographic variation in both breastfeeding practices and allied support exists within the United States. Geographic hot spots of breastfeeding are found in the western and northeastern sections of the United States, and cool spots are located primarily in the Southeast. Regression results suggested that unemployment and demographic diversity are negatively associated with breastfeeding rates, whereas higher education and the presence of International Board Certified Lactation Consultants® (IBCLCs®) are positively connected to persistent breastfeeding practices. Further, although the availability of professional support (IBCLC) strengthened nationwide between 2011 and 2016, the availability of mother-to-mother support (La Leche League) softened.

CONCLUSION

Although breastfeeding initiation rates continue to increase in the United States, rates of exclusive breastfeeding at 3 and 6 months remain low, displaying significant geographic variation. The ability to pinpoint lagging regions can help to efficiently allocate additional breastfeeding support resources and interventions.

A systematic review and meta-analysis of interventions incorporating behaviour change techniques to promote breastfeeding among postpartum women

The benefits of exclusive breastfeeding are well documented, yet few women adhere to recommendations. We report the Behaviour Change Techniques (BCTs) within interventions trialled internationally after pregnancy to promote exclusive and mixed breastfeeding as well as evidence of effectiveness. PsycINFO, EMBASE and MEDLINE databases were screened. Twenty-three (n = 23) studies met inclusion criteria. Three authors independently extracted data, coded interventions using the BCT v.1 taxonomy, and assessed study quality. There was a moderate significant effect of the interventions promoting exclusive breastfeeding up to four weeks postpartum (OR 1.77, [95% CI: 1.47-2.13]) but this effect slightly declined beyond thirteen weeks (OR 1.63, [95% CI: 1.07-2.47]). Twenty-nine BCTs were identified within interventions. 'Credible source' and 'instruction on how to perform the behaviour' were the most prevalent and 'social support (unspecified)' contributed to the effectiveness of exclusive breastfeeding interventions five to eight weeks postpartum. Using BCTs with cognitive and behavioural aspects may help women develop coping mechanisms promoting exclusive breastfeeding. Further trials are needed in countries with low breastfeeding rates such as the UK. The use of programme theory during intervention development and clear description of intervention components is recommended. This meta-analysis provides guidance for trials evaluating postpartum breastfeeding interventions.

Effectiveness of educational interventions conducted by telephone to promote breastfeeding: a systematic review of the literature

OBJECTIVE

To assess the effectiveness of telephone educational interventions on the duration and exclusiveness of breastfeeding.

METHOD

A systematic review of the literature was conducted including only Randomized Clinical Trials. The exposure factor was an educational intervention via telephone, and the outcomes were duration and exclusiveness of breastfeeding. Literature in Portuguese, English and Spanish published between 2010 and 2016 were searched for in the Cochrane, Lilacs, Medline and Scopus databases. The articles were analyzed through a results synthesis.

RESULTS

241 articles were identified, of which 231 did not meet the inclusion criteria. Therefore, only 10 articles were reviewed. Four studies showed no efficacy related to breastfeeding. Regarding common characteristics, these studies were performed in short periods and in pairs. The others revealed efficacy regarding duration and/or exclusiveness of breastfeeding. The latter were mostly studies with long-term interventions and carried out by nurse lactation consultants.

CONCLUSION

The evidence demonstrates that the telephone is a viable technology for promoting breastfeeding, representing an alternative for the health units and health professionals that can contribute to mother-baby care.

Integrative Literature Review of Factors Related to Breastfeeding in African American Women: Evidence for a Potential Paradigm Shift

BACKGROUND

Human milk has widespread health benefits for infants, mothers, and society. However, not all populations of women, particularly African American women, engage in human milk feeding at high rates. Research aim: The purpose of this integrative literature review is twofold: (a) to examine factors that influence low rates of human milk feeding among African American women and (b) to introduce a need for a methodological paradigm shift to develop culturally relevant and effective interventions.

METHODS

The authors searched four electronic social science databases for peer-reviewed journal articles pertaining to human milk among African American women published from 1990 to 2015. Both coauthors independently assessed these articles using thematic analysis and validation. The database search yielded 47 peer-reviewed articles.

RESULTS

Three main themes emerged explaining the human milk feeding disparity: (a) the social characteristics of women likely not to feed human milk (e.g., low socioeconomic status, single); (b) women's perceptions of human milk feeding; and (c) the quality of human milk feeding information provided by health care providers (i.e., limited human milk information).

CONCLUSION

Current literature does include sociohistorical factors that have shaped current norms. Adding sociohistorical frameworks, paying particular attention to the embodied experience of historical trauma, could lead to the development of new evidence-based, culturally sensitive interventions to enhance human milk feeding in the African American community.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

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

OBJECTIVES

To describe forms of breastfeeding support which have been evaluated in controlled studies, the timing of the interventions and the settings in which they have been used.To examine the effectiveness of different modes of offering similar supportive interventions (for example, whether the support offered was proactive or reactive, face-to-face or over the telephone), and whether interventions containing both antenatal and postnatal elements were more effective than those taking place in the postnatal period alone.To examine the effectiveness of different care providers and (where information was available) training.To explore the interaction between background breastfeeding rates and effectiveness of support.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 100 trials involving more than 83,246 mother-infant pairs of which 73 studies contribute data (58 individually-randomised trials and 15 cluster-randomised trials). We considered that the overall risk of bias of trials included in the review was mixed. Of the 31 new studies included in this update, 21 provided data for one or more of the primary outcomes. The total number of mother-infant pairs in the 73 studies that contributed data to this review is 74,656 (this total was 56,451 in the previous version of this review). The 73 studies were conducted in 29 countries. Results of the analyses continue to confirm that all forms of extra support analyzed together showed a decrease in cessation of 'any breastfeeding', which includes partial and exclusive breastfeeding (average risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.88 to 0.95; moderate-quality evidence, 51 studies) and for stopping breastfeeding before four to six weeks (average RR 0.87, 95% CI 0.80 to 0.95; moderate-quality evidence, 33 studies). All forms of extra support together also showed a decrease in cessation of exclusive breastfeeding at six months (average RR 0.88, 95% CI 0.85 to 0.92; moderate-quality evidence, 46 studies) and at four to six weeks (average RR 0.79, 95% CI 0.71 to 0.89; moderate quality, 32 studies). We downgraded evidence to moderate-quality due to very high heterogeneity.We investigated substantial heterogeneity for all four outcomes with subgroup analyses for the following covariates: who delivered care, type of support, timing of support, background breastfeeding rate and number of postnatal contacts. Covariates were not able to explain heterogeneity in general. Though the interaction tests were significant for some analyses, we advise caution in the interpretation of results for subgroups due to the heterogeneity. Extra support by both lay and professionals had a positive impact on breastfeeding outcomes. Several factors may have also improved results for women practising exclusive breastfeeding, such as interventions delivered with a face-to-face component, high background initiation rates of breastfeeding, lay support, and a specific schedule of four to eight contacts. However, because within-group heterogeneity remained high for all of these analyses, we advise caution when making specific conclusions based on subgroup results. We noted no evidence for subgroup differences for the any breastfeeding outcomes.

AUTHORS' CONCLUSIONS

When breastfeeding support is offered to women, the duration and exclusivity of breastfeeding is increased. Characteristics of effective support include: that it is offered as standard by trained personnel during antenatal or postnatal care, that it includes ongoing scheduled visits so that women can predict when support will be available, and that it is tailored to the setting and the needs of the population group. Support is likely to be more effective in settings with high initiation rates. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed with women practising exclusive breastfeeding.

Workplace Lactation Support in Milwaukee County 5 Years After the Affordable Care Act

BACKGROUND

Workplace lactation support has become increasingly important because returning to work is associated with discontinuing breastfeeding and women in the workforce are increasing. Research aim: This study examined workplace lactation support among Milwaukee County businesses 5 years after implementation of the Affordable Care Act's Break Time for Nursing Mothers provision.

METHODS

A cross-sectional survey of Milwaukee County businesses was conducted in the summer of 2015 that inquired about workplace policies, lactation spaces, and other lactation resources offered. Business supports were stratified based on employer sizes: large (> 500 employees), medium (50-499 employees), and small (20-49 employees). A lactation amenity score was calculated for each business based on lactation resources available.

RESULTS

Three hundred surveys were distributed and 71 businesses voluntarily completed the survey. Small employers were excluded from statistical analysis due to fewer responses ( n = 8). Overall, 87.3% ( n = 55) of respondents reported providing access to a multiuser space for lactation and 65.1% ( n = 41) reported providing a designated lactation space. Large employers ( n = 30) were more likely than medium employers ( n = 33) to provide a designated lactation space for breastfeeding or expressing (86.7% vs. 45.5%, p < .001). Large employers' mean amenity score was significantly higher than that of medium employers (3.37 vs. 2.57, p = .014), and they were also more likely to offer additional supports including access to a lactation consultant, classes, and materials (46.7% vs. 12.1%, p < .01).

CONCLUSION

Large employers provide more lactation support than medium employers in Milwaukee County. All employers, regardless of size, need to increase additional lactation support for women in the workplace.

Breastfeeding Problems and Interventions for Underserved Populations

Objective: This study focused on promoting breastfeeding. A group of 32 underserved postpartum women in a Baby-Friendly hospital presented with 10 pre-existing breastfeeding risk factors. Ten interventions and increased time of interventions were implemented during their 2- to 3-day hospital stay. The LATCH scores were increased, and the hospital’s exclusive breastfeeding rate was 83%.

Method: This study was a retrospective chart review.

Results: The breastfeeding nursing intervention characteristics have a strong relationship with the LATCH scores. The increased LATCH scores related with increased nursing breastfeeding intervention characteristics.

Conclusion: Identifying the breastfeeding problems and implementing proper interventions increased breastfeeding rate.

Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis

AIM

To provide comprehensive evidence of the effect of interventions on early initiation, exclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health systems and services (ii) Home and family environment (iii) Community environment (iv) Work environment (v) Policy environment or a combination of any of above.

METHODS

Of 23977 titles identified through a systematic literature search in PUBMED, Cochrane and CABI, 195 articles relevant to our objective, were included. We reported the pooled relative risk and corresponding 95% confidence intervals as our outcome estimate. In cases of high heterogeneity, we explored its causes by subgroup analysis and meta-regression and applied random effects model.

RESULTS

Intervention delivery in combination of settings seemed to have higher improvements in breastfeeding rates. Greatest improvements in early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding rates, were seen when counselling or education were provided concurrently in home and community, health systems and community, health systems and home settings, respectively. Baby friendly hospital support at health system was the most effective intervention to improve rates of any breastfeeding.

CONCLUSION

To promote breastfeeding, interventions should be delivered in a combination of settings by involving health systems, home and family and the community environment concurrently.

Reactions of Low-Income African American Women to Breastfeeding Peer Counselors

OBJECTIVE

To examine the influence of breastfeeding peer counseling on the breastfeeding experiences of African American mothers who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

DESIGN

Qualitative study using focus groups.

SETTING

Two WIC clinics in Southeast Wisconsin were used for recruitment and data collection.

PARTICIPANTS

A convenience sample of nine African American mothers participated in one of two focus groups.

METHODS

The women responded to a series of open-ended questions about their breastfeeding experiences and the effect of breastfeeding peer counselors (BPCs). Content and thematic analyses were used to analyze patterns related to the influence of BPCs on breastfeeding.

RESULTS

Four themes were categorized: Educating With Truth, Validating for Confidence, Countering Others' Negativity, and Supporting With Solutions. Mothers in this study expressed positive reactions to educational, emotional, and social support from BPCs. The mothers noted that the contact they had with BPCs had a direct positive influence on their breastfeeding experiences. However, the contact from BPCs varied between the two WIC clinics.

CONCLUSION

The findings demonstrate the positive effects of BPCs on breastfeeding experiences among African American WIC participants. Findings from this study can guide future explorations using BPCs. Interventions are needed to develop standardized guidelines to bring about homogeneity of, better access to, and greater use of BPCs.

Overcoming Workplace Barriers: A Focus Group Study Exploring African American Mothers' Needs for Workplace Breastfeeding Support

BACKGROUND

Persistent racial disparities in breastfeeding show that African American women breastfeed at the lowest rates. Return to work is a critical breastfeeding barrier for African American women who return to work sooner than other ethnic groups and more often encounter unsupportive work environments. They also face psychosocial burdens that make breastfeeding at work uniquely challenging. Participants share personal struggles with combining paid employment and breastfeeding and suggest workplace and personal support strategies that they believe will help continue breastfeeding after a return to work.

OBJECTIVE

To explore current perspectives on ways to support African American mothers' workplace breastfeeding behavior.

METHODS

Pregnant African American women (n = 8), African American mothers of infants (n = 21), and lactation support providers (n = 9) participated in 1 of 6 focus groups in the Greater Detroit area. Each focus group audiotape was transcribed verbatim. Thematic analysis was used to inductively analyze focus group transcripts and field notes. Focus groups explored thoughts, perceptions, and behavior on interventions to support African American women's breastfeeding.

RESULTS

Participants indicate that they generally believed breastfeeding was a healthy option for the baby; however, paid employment is a critical barrier to successful breastfeeding for which mothers receive little help. Participants felt breastfeeding interventions that support working African American mothers should include education and training for health care professionals, regulation and enforcement of workplace breastfeeding support policies, and support from peers who act as breastfeeding role models.

CONCLUSION

Culturally appropriate interventions are needed to support breastfeeding among working African American women.

The Positive Effect of a Group Intervention to Reduce Postpartum Depression on Breastfeeding Outcomes in Low-Income Women

This study examined, as a secondary analysis, whether a group interpersonal psychotherapy (IPT) intervention focused on preventing postpartum depression by strengthening social support and building interpersonal skills during the transition to motherhood positively affected breastfeeding outcomes among low-income women. The intervention-Reach Out, Stand strong, Essentials for new mothers (ROSE)-taught participants the importance of self-care and assertive help seeking to be better able to sustain breastfeeding practices. Ninety-nine pregnant women were randomized to ROSE plus standard care or to standard care alone. Though women in both conditions had similar breastfeeding initiation rates, women in ROSE had longer breastfeeding duration (median days breastfed: 54 vs. 21). Results suggest ROSE may positively affect breastfeeding.

African American Women's Breastfeeding Experiences: Cultural, Personal, and Political Voices

The low rate of breastfeeding among African American women in the United States is a poorly understood, persistent disparity. Our purpose in this study was to gain an understanding of how African American women experience breastfeeding in the context of their day-to-day lives. The Sequential-Consensual Qualitative Design (SCQD), a 3-stage qualitative methodology aimed at exploring the cultural, personal, and political context of phenomena, was used to explore the experiences of African American women who felt successful with breastfeeding. An integration of qualitative content analysis and Black feminist theory was used to analyze the data. Themes that emerged from Stage-2 data analysis included self-determination, spirituality and breastfeeding, and empowerment. In Stage 3 of the study, participant recommendations regarding breastfeeding promotion and support initiatives for African American breastfeeding were categorized into three themes, including engaging spheres of influence, sparking breastfeeding activism, and addressing images of the sexual breast vs. the nurturing breast.

Breastfeeding among adolescent mothers: a systematic review of interventions from high-income countries

Despite growing evidence of the benefits of breastfeeding, rates of breastfeeding remain disproportionately low among adolescent mothers compared with older mothers in the United States. Current interventions primarily target adult women, and little evidence is available for breastfeeding promotion among young women. Accordingly, we aim to review interventions designed to improve breastfeeding rates among adolescents to make recommendations for future research and practice. We searched MEDLINE and PsycINFO for articles that evaluated interventions aiming to improve rates of breastfeeding initiation, duration, or exclusivity among adolescents. Inclusion criteria included interventions targeting pregnant or postpartum adolescents (mean/median age <22 years) that were conducted in high-income settings. Six interventions met our inclusion criteria; of these, 4 interventions aimed to increase breastfeeding initiation, 5 aimed to increase breastfeeding duration, and 4 aimed to increase breastfeeding exclusivity. Interventions included school-based programs, home visits, and telephone support that were implemented by a combination of peer counselors, nurse clinicians, doulas, and lactation consultants. Only 1 intervention, a combination of education and counseling provided by a lactation consultant-peer counselor team, significantly improved both breastfeeding initiation and duration. Other results were mixed, and studies were subject to several methodological limitations. We recommend that more interventions should be developed and evaluated. In addition, interventions should be less resource intensive, be more theoretically driven, and specifically include mothers and partners of adolescents to successfully promote breastfeeding among adolescent mothers.

WIC peer counselors' perceptions of breastfeeding in African American women with lower incomes

BACKGROUND

African American women have the lowest breastfeeding rates among all racial/ethnic groups in the United States. Peer counseling is an effective intervention in improving breastfeeding in this population. However, little is known on peer counselors' perceptions of breastfeeding in African American women.

OBJECTIVE

As part of a larger qualitative study, the goal of this study was to understand the contextual factors influencing breastfeeding decisions of low-income African American women from the perspective of breastfeeding peer counselors (PCs).

METHODS

Three focus groups were conducted with 23 PCs from the Women, Infants, and Children program in a southeastern state. All focus group discussions were audio-recorded, professionally transcribed, and analyzed using thematic analysis. Bronfenbrenner's socioecological model was used to group categories into themes.

RESULTS

Of the sample, 47.8% were African American, 78.2% were married, and 56.5% had some college education. Five main themes emerged to describe factors at multiple levels influencing breastfeeding in PCs' low-income African American clients: individual, microsystem, exosystem, macrosystem, and chronosystem. Novel findings included (1) having breast pumps may give African American women a "sense of security," (2) cultural pressures to be a "strong black woman" can impede breastfeeding support, and (3) breastfeeding "generational gaps" have resulted from American "slavery" and when formula was "a sign of wealth."

CONCLUSION

As PCs described, low-income African American women's breastfeeding decisions are affected by numerous contextual factors. Findings from this study suggest a need to broaden the public health approach to breastfeeding promotion in this population by moving beyond individual characteristics to examining historical and sociocultural factors underlying breastfeeding practices in African American women.

Enhancing breastfeeding rates among African American women: a systematic review of current psychosocial interventions

The goals of this article are to provide a review of key interventions and strategies that impact initiation and duration of breastfeeding with particular focus on low-income African American mothers' maternal psychological vulnerabilities during the early postpartum period using a social ecological perspective as a guiding framework. Although modest gains have been achieved in breastfeeding initiation rates in the United States, a projected gap remains between infant feeding practices and national Healthy People breastfeeding goals set for 2020, particularly among African Americans. These disparities raise concerns that socially disadvantaged mothers and babies may be at increased risk for poor postnatal outcomes because of poorer mental health and increased vulnerability to chronic health conditions. Breastfeeding can be a protective factor, strengthening the relationship between mother and baby and increasing infant health and resilience. Evidence suggests that no single intervention can sufficiently address the multiple breastfeeding barriers faced by mothers. Effective intervention strategies require a multilevel approach. A social ecological perspective highlights that individual knowledge, behavior, and attitudes are shaped by interactions between the individual woman, her friends and family, and her wider historical, social, political, economic, institutional, and community contexts, and therefore effective breastfeeding interventions must reflect all these aspects. Current breastfeeding interventions are disjointed and inadequately meet all African American women's social and psychological breastfeeding needs. Poor outcomes indicate a need for an integrative approach to address the complexity of interrelated breastfeeding barriers mothers' experience across layers of the social ecological system.

Effect of primary care intervention on breastfeeding duration and intensity

OBJECTIVES

We determined the effectiveness of primary care-based, and pre- and postnatal interventions to increase breastfeeding.

METHODS

We conducted 2 trials at obstetrics and gynecology practices in the Bronx, New York, from 2008 to 2011. The Provider Approaches to Improved Rates of Infant Nutrition & Growth Study (PAIRINGS) had 2 arms: usual care versus pre- and postnatal visits with a lactation consultant (LC) and electronically prompted guidance from prenatal care providers (EP). The Best Infant Nutrition for Good Outcomes (BINGO) study had 4 arms: usual care, LC alone, EP alone, or LC+EP.

RESULTS

In BINGO at 3 months, high intensity was greater for the LC+EP (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.08, 6.84) and LC (OR = 3.22; 95% CI = 1.14, 9.09) groups versus usual care, but not for the EP group alone. In PAIRINGS at 3 months, intervention rates exceeded usual care (OR = 2.86; 95% CI = 1.21, 6.76); the number needed to treat to prevent 1 dyad from nonexclusive breastfeeding at 3 months was 10.3 (95% CI = 5.6, 50.7).

CONCLUSIONS

LCs integrated into routine care alone and combined with EP guidance from prenatal care providers increased breastfeeding intensity at 3 months postpartum.

Breastfeeding promotion interventions and breastfeeding practices: a systematic review

Introduction

Exclusive Breastfeeding (EBF) rates remain low in both low-income and high-income countries despite World Health Organization recommendations for EBF till 6 months. Breastfeeding has been shown to have a protective effect against gastrointestinal infections, among other benefits. Large-scale interventions focusing on educating mothers about breastfeeding have the potential to increase breastfeeding prevalence, especially EBF, up to recommended standards and also to decrease infant morbidity.

Methods

A systematic literature search was conducted for RCTs and quasi-experimental studies comparing breastfeeding education or support to routine care. The effect of interventions was observed for exclusive, predominant, partial and no breastfeeding rates. The time intervals of interest were day 1, <1 month, and 1 to 5 months. Outcome-specific evidence was graded according to the Child Health Epidemiology Reference Group (CHERG) rules using the adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria and recommendations were made from studies in developing countries for inclusion into the Lives Saved Tool (LiST) model.

Results

After reviewing 4600 abstracts, 372 studies were selected for full text screening and 110 of these studies were finally included. Statistically significant increases in EBF rates as a result of breastfeeding promotion interventions were observed: 43% at day 1, 30% at <1 month, and 90% at 1-5 months. Rates of ‘no breastfeeding’ reduced by 32% at 1 day, 30% at <1 month, and 18% at 1-5 months. The effect of interventions on the rates of predominant and partial breastfeeding were non-significant.

Conclusion

Breastfeeding education and/or support increased EBF rates and decreased no breastfeeding rates at birth, <1 month and 1-5 months. Combined individual and group counseling appeared to be superior to individual or group counseling alone. Interventions in developing countries had a greater impact than those in developed countries.

WIC (The Special Supplemental Nutrition Program for Women, Infants, and Children): policy versus practice regarding breastfeeding

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides foods, education, and referrals to participants who are considered to be at nutritional risk. The outreach of the program is impressive, and nearly 9.17 million people participated in the program in 2010. WIC participation is associated with many positive outcomes, including improved birthweights and childhood dietary practices. Despite these benefits, WIC mothers experience lower breastfeeding rates when compared with demographically similar women who do not participate in the WIC program. According to WIC, "A breastfeeding mother and her infant shall be placed in the highest priority level." Despite this statement and others that support breastfeeding, WIC allocates only 0.6% of its budget toward breastfeeding initiatives. Formula expenses accounted for 11.6% ($850 million) of WIC's 2009 expenses. The inconsistency between WIC's policies that encourage breastfeeding vs. practices that favor formula begs further examination. Research shows consistent success with peer counseling programs among WIC participants; however, little money is budgeted for these programs. Rebates included, WIC spends 25 times more on formula than on breastfeeding initiatives. The American Academy of Nursing Expert Panel on Breastfeeding is calling for a re-evaluation of how these taxpayer dollars are spent. Additionally, the American Academy of Nursing recommends a shift from formula bargaining to an investment in structured peer counseling programs. All WIC programs should offer peer counseling support services that encourage breastfeeding and meet the needs of the families they serve.

African American women and breastfeeding: an integrative literature review

The purpose of this article is to present a review of literature regarding factors that influence breastfeeding intentions, initiation, and duration in the African American population. Research related to health disparities experienced by African Americans in the United States, as well as research regarding the protective benefits of breastfeeding for those specific health disparities, are also presented. Community and institutional interventions and promotional campaigns aimed at increasing initiation and duration of breastfeeding in the African American population are discussed. Future research regarding African American women's breastfeeding experiences using Black feminist thought as a theoretical foundation is recommended.

Breastfeeding promotion interventions and breastfeeding practices: a systematic review

INTRODUCTION

Exclusive Breastfeeding (EBF) rates remain low in both low-income and high-income countries despite World Health Organization recommendations for EBF till 6 months. Breastfeeding has been shown to have a protective effect against gastrointestinal infections, among other benefits. Large-scale interventions focusing on educating mothers about breastfeeding have the potential to increase breastfeeding prevalence, especially EBF, up to recommended standards and also to decrease infant morbidity.

METHODS

A systematic literature search was conducted for RCTs and quasi-experimental studies comparing breastfeeding education or support to routine care. The effect of interventions was observed for exclusive, predominant, partial and no breastfeeding rates. The time intervals of interest were day 1, <1 month, and 1 to 5 months. Outcome-specific evidence was graded according to the Child Health Epidemiology Reference Group (CHERG) rules using the adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria and recommendations were made from studies in developing countries for inclusion into the Lives Saved Tool (LiST) model.

RESULTS

After reviewing 4600 abstracts, 372 studies were selected for full text screening and 110 of these studies were finally included. Statistically significant increases in EBF rates as a result of breastfeeding promotion interventions were observed: 43% at day 1, 30% at <1 month, and 90% at 1-5 months. Rates of 'no breastfeeding' reduced by 32% at 1 day, 30% at <1 month, and 18% at 1-5 months. The effect of interventions on the rates of predominant and partial breastfeeding were non-significant.

CONCLUSION

Breastfeeding education and/or support increased EBF rates and decreased no breastfeeding rates at birth, <1 month and 1-5 months. Combined individual and group counseling appeared to be superior to individual or group counseling alone. Interventions in developing countries had a greater impact than those in developed countries.

Development and validation of a scale measuring satisfaction with maternal and newborn health care following childbirth

To demonstrate the validity and internal consistency of a multi-item scale measuring women's satisfaction with health care received in the weeks following childbirth for both themselves and their newborns. Data are from 1,154 women delivering healthy singletons or twins recruited for a randomized trial. Satisfaction with care items were selected from prior research, including the previously validated Primary Care Satisfaction Survey for Women (PCSSW) and studies of postpartum care. After randomly splitting the sample (1:1) for cross-validation purposes, Exploratory (EFA) and Confirmatory factor analysis (CFA) on ordinal data using the WLSMV estimator available in the MPLUS statistical modeling program were conducted. A CFA was also conducted on available data at 2 weeks and 2 months after discharge in order to examine internal consistency at follow-up. A one factor model with 11 items was selected, with the main factor explaining 83% of total 11-item variation in the overall sample. The Cronbach's alpha for the final 11-item scale at baseline and follow-up time periods was 0.96. High correlations with overall trust in provider (Spearman rho = 0.78) and quality of healthcare (0.75) supported convergent validity. The baseline mean score was 47.9 with a standard deviation of 7.13 and a possible range of 11 (low) to 55 (high satisfaction). This validated scale is a new tool for measuring satisfaction with health care received during the postpartum period for mothers and their newborns. This tool will be useful in studies assessing quality of care and the outcomes of postpartum health care interventions, and it is the first tool to focus on care for the mother-baby unit.

Maternal experience of interactions with providers among mothers with milk supply concern

BACKGROUND

Milk supply concern is the most common reason given by mothers for discontinuing breastfeeding. OBJECTIVES. To describe maternal experiences of interactions with health care providers related to milk supply.

PATIENTS AND METHODS

Ten focus groups (N = 56 participants) were conducted among mothers who had had milk supply concern in the first month after birth. Group sessions were audio-recorded, transcribed, coded, and analyzed to identify themes. Results. Interactions regarding milk supply concern evoked strong emotions, including gratitude, guilt, disappointment, and fear, and measurement of infant weight was frequently reported as a trigger for these emotions. Some mothers reported that experiencing "pressure" and "guilt" when providers emphasized exclusive breastfeeding led to suboptimal breastfeeding choices.

CONCLUSIONS

Interactions with providers about milk supply concern evoke strong emotions among mothers. Providers should be aware that how they communicate routine advice regarding infant weight and formula may have unintended consequences, including discontinuation of breastfeeding.

Recruiting and retaining low-income, multi-ethnic women into randomized controlled trials: successful strategies and staffing

Developing effective recruitment and retention strategies in populations with traditionally high attrition rates is critical to the success of Randomized Controlled Trials (RCTs). Data on successful participation of women from low-income, minority populations in RCTs of behavioral interventions are limited. This is problematic given the multiplicity of Healthy People 2020 goals that target health disparities in these populations. This paper reports successful recruitment and retention methods from two separately funded NIH clinical trials of primary care-based prenatal interventions to increase breastfeeding among ethnically diverse, low-income women in urban medical centers in the Bronx, NY. It also presents the required staff effort necessary to conduct such a successful RCT, in terms of full-time equivalents (FTEs). Results include timely recruitment of 941 participants over 29 months, with 98.1% completing >¯¯1 follow-up interview. A recruitment and retention plan that maximized study staff access and availability to the participant, as well as strong study staff rapport with participants, addressed previously reported barriers in this population, optimizing follow-up rates. A qualitative assessment of the participants' study experience suggesting that high retention was due to strong rapport with participants, short interviews requiring little time commitment, and participants' perception of the study as informative, provides further evidence of our approach's effectiveness. Logistical protocol procedures and staff management strategies relating to successful recruitment/retention are provided to propose a practical, cost-effective and translational recruitment-retention plan for other researchers to adopt.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

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

OBJECTIVES

To assess the effectiveness of support for breastfeeding mothers.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (3 October 2011).

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Of the 67 studies that we assessed as eligible for inclusion, 52 contributed outcome data to the review (56,451 mother-infant pairs) from 21 countries. All forms of extra support analysed together showed an increase in duration of 'any breastfeeding' (includes partial and exclusive breastfeeding) (risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.88 to 0.96). All forms of extra support together also had a positive effect on duration of exclusive breastfeeding (RR at six months 0.86, 95% CI 0.82 to 0.91; RR at four to six weeks 0.74, 95% CI 0.61 to 0.89). Extra support by both lay and professionals had a positive impact on breastfeeding outcomes. Maternal satisfaction was poorly reported.

AUTHORS' CONCLUSIONS

All women should be offered support to breastfeed their babies to increase the duration and exclusivity of breastfeeding. Support is likely to be more effective in settings with high initiation rates, so efforts to increase the uptake of breastfeeding should be in place. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed. Support that is only offered reactively, in which women are expected to initiate the contact, is unlikely to be effective; women should be offered ongoing visits on a scheduled basis so they can predict that support will be available. Support should be tailored to the needs of the setting and the population group.

The effect of early postpartum home visits by health visitors: a natural experiment

OBJECTIVE

The purpose of this study was to assess if the absence of early home visits influenced the mothers' breastfeeding duration and use of medical services.

DESIGN

Data from mothers who had given birth during a strike period were compared with data from a reference period with usual work practice.

SAMPLE

The study included 3,834 newborn and 375 health visitors, 75 of whom worked during the strike period.

INTERVENTION

All families were offered nonstandardized home visits after discharge in the reference period. During the strike, the service was based on individual risk assessment.

RESULTS

Overall, no difference in breastfeeding duration between the two periods was seen, but unvisited mothers in the strike period had shorter durations of full breastfeeding than a comparable group of mothers in the reference period (p < .005). Moreover, mothers in the strike period reported a significantly higher use of medical services. The mothers' needs for postnatal visits differed depending on parity: primiparae underlined uncertainty, multiparae underlined previous breastfeeding experience. Mothers had missed out on guidance on all areas of the health visitors' service.

CONCLUSION

Nonstandardized home visits by health visitors were associated with a longer breastfeeding duration. The postnatal visits depended on parity and unmet needs increased the use of medical services.

Breastfeeding among minority women: moving from risk factors to interventions

The gap between current breastfeeding practices and the Healthy People 2020 breastfeeding goals is widest for black women compared with all other ethnic groups. Also of concern, Hispanic and black women have the highest rates of formula supplementation of breast-fed infants before 2 d of life. These disparities must be addressed through the scale-up of effective interventions. The objective of this critical review is to identify and evaluate U.S.-based randomized trials evaluating breastfeeding interventions targeting minorities and highlight promising public health approaches for minimizing breastfeeding disparities. Through PubMed searches, we identified 22 relevant publications evaluating 18 interventions targeting minorities (peer counseling [n = 4], professional support [n = 4], a breastfeeding team [peer + professional support, n = 3], breastfeeding-specific clinic appointments [n = 2], group prenatal education [n = 3], and enhanced breastfeeding programs [n = 2]). Peer counseling interventions (alone or in combination with a health professional), breastfeeding-specific clinic appointments, group prenatal education, and hospital/Special Supplemental Nutrition Program for Women, Infants, and Children enhancements were all found to greatly improve breastfeeding initiation, duration, or exclusivity. Postpartum professional support delivered by nurses was found to be the least effective intervention type. Beyond improving breastfeeding outcomes, 6 interventions resulted in reductions in infant morbidity or health care use. Future research should include further evaluations of successful interventions, with an emphasis on determining the optimal timeframe for the provision of support, the effect of educating women's family members, and the impact on infant health care use and cost-effectiveness.

Process evaluation for the FEeding Support Team (FEST) randomised controlled feasibility trial of proactive and reactive telephone support for breastfeeding women living in disadvantaged areas

OBJECTIVE

To assess the feasibility, acceptability and fidelity of a feeding team intervention with an embedded randomised controlled trial of team-initiated (proactive) and woman-initiated (reactive) telephone support after hospital discharge.

DESIGN

Participatory approach to the design and implementation of a pilot trial embedded within a before-and-after study, with mixed-method process evaluation.

SETTING

A postnatal ward in Scotland.

SAMPLE

Women initiating breast feeding and living in disadvantaged areas.

METHODS

Quantitative data: telephone call log and workload diaries. Qualitative data: interviews with women (n=40) with follow-up (n=11) and staff (n=17); ward observations 2 weeks before and after the intervention; recorded telephone calls (n=16) and steering group meetings (n=9); trial case notes (n=69); open question in a telephone interview (n=372). The Framework approach to analysis was applied to mixed-method data.

MAIN OUTCOME MEASURES

Quantitative: telephone call characteristics (number, frequency, duration); workload activity. Qualitative: experiences and perspectives of women and staff.

RESULTS

A median of eight proactive calls per woman (n=35) with a median duration of 5 min occurred in the 14 days following hospital discharge. Only one of 34 control women initiated a call to the feeding team, with women undervaluing their own needs compared to others, and breast feeding as a reason to call. Proactive calls providing continuity of care increased women's confidence and were highly valued. Data demonstrated intervention fidelity for woman-centred care; however, observing an entire breast feed was not well implemented due to short hospital stays, ward routines and staff-team-woman communication issues. Staff pragmatically recognised that dedicated feeding teams help meet women's breastfeeding support needs in the context of overstretched and variable postnatal services.

CONCLUSIONS

Implementing and integrating the FEeding Support Team (FEST) trial within routine postnatal care was feasible and acceptable to women and staff from a research and practice perspective and shows promise for addressing health inequalities.

TRIAL REGISTRATION

ISRCTN27207603. The study protocol and final report is available on request.

Costs related to promoting breastfeeding among urban low-income women

OBJECTIVE

To describe the costs of providing support to breastfeeding low-income women and compares costs to cost offsets of the intervention.

DESIGN

Secondary analysis of data from a randomized controlled trial of an intervention to promote breastfeeding among low-income women with full-term infants.

SETTING

A university hospital and a community hospital in Baltimore, Maryland.

PARTICIPANTS

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) eligible breastfeeding women (N = 328) were randomized to usual care or the community health nurse/peer counselor intervention.

METHODS

The researchers collected and described personnel and mileage costs over the entire duration of the intervention (24 weeks). Researchers also compared (using t tests) change in resources associated with breastfeeding including the number of clinic visits, hospital nights, emergency room visits, prescriptions, and formula feedings per day up to 12 weeks.

RESULTS

The cost of the personnel and travel required for the intervention was $296 per woman. The use of medical care and number of formula feedings per day were similar for the intervention and usual care groups. When differences in use of medical care and formula feeding were statistically significant, the intervention group used fewer resources.

CONCLUSION

Support for breastfeeding by community health nurses and peer counselors is partially offset by reducing medical care utilization and formula feeding costs.

Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries

Background

Given the recognized benefits of breastfeeding for the health of the mother and infants, the World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for the first six months of life. However, the prevalence of EBF is low globally in many of the developing and developed countries around the world. There is much interest in the effectiveness of breastfeeding promotion interventions on breastfeeding rates in early infancy.

Methods

A systematic literature was conducted to identify all studies that evaluated the impact of breastfeeding promotional strategies on any breastfeeding and EBF rates at 4-6 weeks and at 6 months. Data were abstracted into a standard excel sheet by two authors. Meta-analyses were performed with different sub-group analyses. The overall evidence were graded according to the Child Health Epidemiology Reference Group (CHERG) rules using the adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria and recommendations made from developing country studies for inclusion into the Live Saved Tool (LiST) model.

Results

After reviewing 968 abstracts, 268 studies were selected for potential inclusion, of which 53 randomized and quasi-randomized controlled trials were selected for full abstraction. Thirty two studies gave the outcome of EBF at 4-6 weeks postpartum. There was a statistically significant 43% increase in this outcome, with 89% and 20% significant increases in developing and developed countries respectively. Fifteen studies reported EBF outcomes at 6 months. There was an overall 137% increase, with a significant 6 times increase in EBF in developing countries, compared to 1.3 folds increase in developed country studies. Further sub-group analyses proved that prenatal counseling had a significant impact on breastfeeding outcomes at 4-6 weeks, while both prenatal and postnatal counseling were important for EBF at 6 months.

Conclusion

Breastfeeding promotion interventions increased exclusive and any breastfeeding rates at 4-6 weeks and at 6 months. A relatively greater impact of these interventions was seen in developing countries with 1.89 and 6 folds increase in EBF rates at 4-6 weeks and at 6 months respectively.