An intervention to extend breastfeeding among black and Latina mothers after delivery

The design and implementation of a multi-center, pragmatic, individual-level randomized controlled trial to evaluate Baby2Home, an mHealth intervention to support new parents

BACKGROUND

Becoming a parent is a transformative experience requiring multiple transitions, including the need to navigate several components of health care, manage any mental health issues, and develop and sustain an approach to infant feeding. Baby2Home (B2H) is a digital intervention built on the collaborative care model (CCM) designed to support families during these transitions to parenthood.

OBJECTIVES

We aim to investigate the effects of B2H on preventive healthcare utilization for the family unit and patient-reported outcomes (PROs) trajectories with a focus on mental health. We also aim to evaluate heterogeneity in treatment effects across social determinants of health including self-reported race and ethnicity and household income. We hypothesize that B2H will lead to optimized healthcare utilization, improved PROs trajectories, and reduced racial, ethnic, and income-based disparities in these outcomes as compared to usual care.

METHODS

B2H is a multi-center, pragmatic, individual-level randomized controlled trial. We will enroll 640 families who will be randomized to: [1] B2H + usual care, or [2] usual care alone. Preventive healthcare utilization is self-reported and confirmed from medical records and includes attendance at the postpartum visit, contraception use, depression screening, vaccine uptake, well-baby visit attendance, and breastfeeding at 6 months. PROs trajectories will be analyzed after collection at 1 month, 2 months, 4 months, 6 months and 12 months. PROs include assessments of stress, depression, anxiety, self-efficacy and relationship health.

IMPLICATIONS

If B2H proves effective, it would provide a scalable digital intervention to improve care for families throughout the transition to new parenthood.

Understanding Symptom Self-Monitoring Needs Among Postpartum Black Patients: Qualitative Interview Study

BACKGROUND

Pregnancy-related death is on the rise in the United States, and there are significant disparities in outcomes for Black patients. Most solutions that address pregnancy-related death are hospital based, which rely on patients recognizing symptoms and seeking care from a health system, an area where many Black patients have reported experiencing bias. There is a need for patient-centered solutions that support and encourage postpartum people to seek care for severe symptoms.

OBJECTIVE

We aimed to determine the design needs for a mobile health (mHealth) patient-reported outcomes and decision-support system to assist Black patients in assessing when to seek medical care for severe postpartum symptoms. These findings may also support different perinatal populations and minoritized groups in other clinical settings.

METHODS

We conducted semistructured interviews with 36 participants-15 (42%) obstetric health professionals, 10 (28%) mental health professionals, and 11 (31%) postpartum Black patients. The interview questions included the following: current practices for symptom monitoring, barriers to and facilitators of effective monitoring, and design requirements for an mHealth system that supports monitoring for severe symptoms. Interviews were audio recorded and transcribed. We analyzed transcripts using directed content analysis and the constant comparative process. We adopted a thematic analysis approach, eliciting themes deductively using conceptual frameworks from health behavior and human information processing, while also allowing new themes to inductively arise from the data. Our team involved multiple coders to promote reliability through a consensus process.

RESULTS

Our findings revealed considerations related to relevant symptom inputs for postpartum support, the drivers that may affect symptom processing, and the design needs for symptom self-monitoring and patient decision-support interventions. First, participants viewed both somatic and psychological symptom inputs as important to capture. Second, self-perception; previous experience; sociocultural, financial, environmental, and health systems-level factors were all perceived to impact how patients processed, made decisions about, and acted upon their symptoms. Third, participants provided recommendations for system design that involved allowing for user control and freedom. They also stressed the importance of careful wording of decision-support messages, such that messages that recommend them to seek care convey urgency but do not provoke anxiety. Alternatively, messages that recommend they may not need care should make the patient feel heard and reassured.

CONCLUSIONS

Future solutions for postpartum symptom monitoring should include both somatic and psychological symptoms, which may require combining existing measures to elicit symptoms in a nuanced manner. Solutions should allow for varied, safe interactions to suit individual needs. While mHealth or other apps may not be able to address all the social or financial needs of a person, they may at least provide information, so that patients can easily access other supportive resources.

Factors associated with the absence of postpartum consultations in a high-risk population

Objective

To assess the rate of missed postpartum appointments at a referral center for high-risk pregnancy and compare puerperal women who did and did not attend these appointments to identify related factors.

Methods

This was a retrospective cross-sectional study with all women scheduled for postpartum consultations at a high-risk obstetrics service in 2018. The variables selected to compare women were personal, obstetric, and perinatal. The variables of interest were obtained from the hospital's electronic medical records. Statistical analyses were performed using the Chi-square, Fisher's exact, or Mann-Whitney tests. For the variable of the interbirth interval, a receiver operating characteristic curve (ROC) was used to best discriminate whether or not patients attended the postpartum consultation. The significance level for the statistical tests was 5%.

Results

A total of 1,629 women scheduled for postpartum consultations in 2018 were included. The rate of missing the postpartum consultation was 34.8%. A shorter interbirth interval (p = 0.039), previous use of psychoactive substances (p = 0.027), current or former smoking (p = 0.003), and multiparity (p < 0.001) were associated with non-attendance.

Conclusion

This study showed a high rate of postpartum appointment non-attendance. This is particularly relevant because it was demonstrated in a high-risk obstetric service linked to clinical severity or social vulnerability cases. This highlights the need for new approaches to puerperal women before hospital discharge and new tools to increase adherence to postpartum consultations, especially for multiparous women.

Breastfeeding Practices in Patients with Heart Disease Stratified by Area Deprivation Index

Objective: We sought to evaluate breastfeeding (BF) practices in patients with maternal cardiac disease (MCD) stratified by area deprivation index (ADI) to identity communities at risk. Study Design: Retrospective cohort of patients managed by the University of Alabama at Birmingham (UAB) Cardio-Obstetrics Program. Patients were included if they had ≥1 prenatal visit with the Cardio-Obstetrics team, delivered at UAB, and had a street address on file. The primary outcome was BF rate at hospital discharge. Secondary outcomes included BF intent on admission and BF at the postpartum (PP) visit. ADI reports socioeconomic disadvantage at the census tract level; 1 = least deprived and 100 = most deprived. Baseline characteristics and BF rates were compared by ADI categories: Low (ADI 1-33), medium (ADI 34-66), and high (ADI 67-100). Results: One hundred and forty-eight patients were included: 14 (10%) low, 42 (28%) medium, and 92 (62%) high ADI. Patients in the high ADI category were younger relative to those in the medium or low ADI (26 versus 28 versus 32 years; p < 0.01) and less likely to be married or living with a partner (30.4% versus 58.5% versus 71.4%; p < 0.01), There was no difference in BF intent between the lowest, medium, and highest ADI categories (85.7% versus 85.4% versus 81.6%; p = 0.38) or BF rates at hospital discharge (100% versus 92.7% versus 85.6%, p = 0.23). However, there was a significant difference in BF rates at the PP visit (90% versus 63.0% versus 38.6%; p < 0.01) even after controlling for differences in baseline characteristics (odds ratio = 0.11 (95% confidence interval [0.01-0.93]), p = 0.043). Conclusions: There was an association between living in a resource-poor community and early cessation of BF in our population of patients with MCD. Community-based interventions targeting mothers with heart disease living in high ADI communities may help these individuals achieve higher BF rates.

Postnatal Care: A Comparative Review of Guidelines

Importance

Postnatal care refers to the ongoing health care provision of both the mother and her offspring and contributes to the timely identification and effective management of complications in the postpartum period, to secure maternal and infant short- and long-term well-being.

Objective

The aim of this study was to review and compare the most recently published influential guidelines on postnatal care practices.

Evidence Acquisition

A comparative review of guidelines from the American College of Obstetricians and Gynecologists, the World Health Organization, the National Institute for Health and Care Excellence, and the Public Health Agency of Canada regarding postnatal care was conducted.

Results

There is a consensus among the reviewed guidelines regarding the importance of health care provision in the postpartum period, including home visits and midwifery services, the use of telemedicine for the facilitation of communication with the patient, and the appropriate preparation for discharge, as well as the discharge criteria. All medical societies also agree on the clinical aspects that should be evaluated at each postnatal visit, although discrepancies exist with regard to the contact schedule. In addition, there is consistency regarding the management of postpartum infections, perineal pain, fecal and urinary incontinence, and physical activity guidance. Mental health issues should be addressed at each postnatal visit, according to all guidelines, but there is disagreement regarding routine screening for depression. As for the optimal interpregnancy interval, the American College of Obstetricians and Gynecologists recommends avoiding pregnancy for at least 6 months postpartum, whereas the National Institute for Health and Care Excellence recommends a 12-month interval. There is no common pathway regarding the recommended contraceptive methods, the nutrition guidance, and the postpartum management of pregnancy complications. Of note, the World Health Organization alone provides recommendations concerning the prevention of specific infections during the postnatal period.

Conclusions

Postnatal care remains a relatively underserved aspect of maternity care, although the puerperium is a critical period for the establishment of motherhood and the transition to primary care. Thus, the development of consistent international protocols for the optimal care and support of women during the postnatal period seems of insurmountable importance to safely guide clinical practice and subsequently reduce maternal and neonatal morbidity.

Evidence-based labor management: postpartum care after vaginal delivery (part 6)

In the setting of postpartum care after vaginal delivery, rooming-in is associated with a higher rate of exclusive breastfeeding rate at hospital discharge, but there is insufficient evidence to support or refute rooming-in to increase breastfeeding at 6 months. Education and support for breastfeeding are valuable interventions to promote initiation of breastfeeding whether it is offered by a healthcare professional, nonhealthcare professional, or peer. A combined intervention, a professional provider-led intervention, having a protocol available for the provider training program, and implementation during both the prenatal and postnatal periods increased the rate of exclusive breastfeeding for 6 months. There is no single effective treatment for breast engorgement. Breast massage, continuing breastfeeding, and pain relief are recommended by national guidelines. Nonsteroidal anti-inflammatory drugs and acetaminophen are better than placebo for relief of pain caused by uterine cramping and perineal trauma; acetaminophen is effective in breastfeeding individuals who underwent episiotomy; and local cooling pain relievers have been shown to reduce perineal pain for 24 to 72 hours, compared with no treatment. There is insufficient evidence to assess the safety and efficacy of postpartum routine universal thromboprophylaxis after vaginal delivery. Anti-D immune globulin administration is recommended in Rhesus-negative individuals who have given birth to a Rhesus-positive infant. There is very low-quality evidence that a universal complete blood count is useful in reducing the risk of receiving blood products. In the absence of any postpartum complication, there is insufficient evidence to recommend a routine postpartum ultrasound. Measles, mumps, and rubella combination; varicella; human papillomavirus; and tetanus, diphtheria, and pertussis vaccines should be administered in nonimmune individuals in the postpartum period. Smallpox and yellow fever vaccines should be avoided. Individuals undergoing postplacental placement are more likely to use an intrauterine device at 6 months than those advised to follow-up for placement during outpatient postpartum care. An implant is safe and effective for immediate postpartum contraception. There is insufficient evidence to support or refute the routine administration of micronutrient supplements in breastfeeding women. Placentophagia does not provide any benefits and exposes mothers and offspring to infectious risks. Therefore, it should be discouraged. Because of the low level of evidence, there is insufficient data to assess the efficacy of home visits in the postpartum period. There is insufficient evidence to recommend when to resume daily activities, and individuals should be counseled to return to prepregnancy level of activity or exercise when comfortable. Sexual activity, housework exercise, driving, climbing stairs, and lifting weights should be resumed as soon as postpartum individuals want. A behavioral educational intervention reduces depression symptoms and increases breastfeeding duration. Physical activity after delivery is protective against postpartum mood disorders. There is no strong evidence that supports early discharge after vaginal delivery compared with standard discharge (ie, ≥48 hours).

Race/ethnicity-specific associations between breastfeeding information source and breastfeeding rates among U.S. women

BACKGROUND

Despite evidence of the impact of breastfeeding information on breastfeeding rates, it is unknown if information sources and impact vary by race/ethnicity, thus this study assessed race/ethnicity-specific associations between breastfeeding information sources and breastfeeding.

METHODS

We used data from the 2016-2019 Pregnancy Risk Assessment Monitoring System. Race/ethnicity-stratified multinomial logistic regression was used to estimate associations between information source (e.g., family/friends) and breastfeeding rates (0 weeks/none, < 10 weeks, or ≥ 10 weeks; < 10 weeks and ≥ 10 weeks = any breastfeeding). All analyses were weighted to be nationally representative.

RESULTS

Among 5,945,018 women (weighted), 88% reported initiating breastfeeding (≥ 10 weeks = 70%). Information from family/friends (< 10 weeks: aORs = 1.58-2.14; ≥ 10 weeks: aORs = 1.63-2.64) and breastfeeding support groups (< 10 weeks: aORs = 1.31-1.76; ≥ 10 weeks: aORs = 1.42-2.77) were consistently associated with breastfeeding and duration across most racial/ethnic groups; effects were consistently smaller among Alaska Native, Black, and Hispanic women (vs White women). Over half of American Indian and one-quarter of Black women reported not breastfeeding/stopping breastfeeding due to return to school/work concerns.

CONCLUSIONS

Associations between breastfeeding information source and breastfeeding rates vary across race/ethnicity. Culturally tailored breastfeeding information and support from family/friends and support groups could help reduce breastfeeding disparities. Additional measures are needed to address disparities related to concerns about return to work/school.

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.

Remote provision of breastfeeding support and education: Systematic review and meta-analysis

The Covid-19 pandemic has led to a substantial increase in remotely provided maternity care services, including breastfeeding support. It is, therefore, important to understand whether breastfeeding support provided remotely is an effective method of support. To determine if breastfeeding support provided remotely is an effective method of support. A systematic review and meta-analysis were conducted. Twenty-nine studies were included in the review and 26 contributed data to the meta-analysis. Remotely provided breastfeeding support significantly reduced the risk of women stopping exclusive breastfeeding at 3 months by 25% (risk ratio [RR]: 0.75, 95% confidence interval [CI]: 0.63, 0.90). There was no significant difference in the number of women stopping any breastfeeding at 4-8 weeks (RR: 1.10, 95% CI: 0.74, 1.64), 3 months (RR: 0.89, 95% CI: 0.71, 1.11), or 6 months (RR: 0.91, 95% CI: 0.81, 1.03) or the number of women stopping exclusive breastfeeding at 4-8 weeks (RR: 0.86, 95% CI: 0.70, 1.07) or 6 months (RR: 0.93, 95% CI: 0.85, 1.0). There was substantial heterogeneity of interventions in terms of mode of delivery, intensity, and providers. This demonstrates that remote interventions can be effective for improving exclusive breastfeeding at 3 months but the certainty of the evidence is low. Improvements in exclusive breastfeeding at 4-8 weeks and 6 months were only found when studies at high risk of bias were excluded. They are also less likely to be effective for improving any breastfeeding. Remote provision of breastfeeding support and education could be provided when it is not possible to provide face-to-face care.

Consensus Bundle on Postpartum Care Basics: From Birth to the Comprehensive Postpartum Visit

In the weeks after childbirth, a woman navigates multiple challenges. She must recover from birth, learn to care for herself and her newborn, and cope with fatigue and postpartum mood changes as well as chronic health conditions. Alongside these common morbidities, the number of maternal deaths in the United States continues to increase, and unacceptable racial inequities persist. One third of pregnancy-related deaths occur between 1 week and 1 year after delivery, with a growing proportion of these deaths due to cardiovascular disease; one fifth occur between 7 and 42 days postpartum. In addition, pregnancy-associated deaths due to self-harm or substance misuse are increasing at an alarming rate. Rising maternal mortality and morbidity rates, coupled with significant disparities in outcomes, highlight the need for tailored interventions to improve safety and well-being of families during the fourth trimester of pregnancy, which includes the period from birth to the comprehensive postpartum visit. Targeted support for growing families during this transition can improve health and well-being across generations.

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.

Individual breastfeeding support with contingent incentives for low-income mothers in the USA: the 'BOOST (Breastfeeding Onset & Onward with Support Tools)' randomised controlled trial protocol

INTRODUCTION

National breastfeeding rates have improved in recent years, however, disparities exist by socioeconomic and psychosocial factors. Suboptimal breastfeeding overburdens the society by increasing healthcare costs. Existing breastfeeding supports including education and peer support have not been sufficient in sustaining breastfeeding rates especially among low-income women. The preliminary outcomes of contingent incentives for breastfeeding in addition to existing support show promising effects in sustaining breastfeeding among mothers in the Special Supplemental Nutrition Programme for women, infants and children (WIC).

METHODS AND ANALYSIS

This trial uses a parallel randomised controlled trial. This trial is conducted at two sites in separate states in the USA. Mothers who were enrolled in WIC and initiated breastfeeding are eligible. Participants (n=168) are randomised into one of the two study groups: (1) standard care control (SC) group consisting of WIC breastfeeding services plus home-based individual support or (2) SC plus breastfeeding incentives (SC +BFI) contingent on demonstrating successful breastfeeding. All participants receive standard breastfeeding services from WIC, home-based individual support and assessments. Participants in SC receive financial compensation based on the number of completed monthly home visits, paid in a lump sum at the end of the 6-month intervention period. Participants in SC +BFI receive an escalating magnitude of financial incentives contingent on observed breastfeeding, paid monthly during the intervention period, as well as bonus incentives for selecting full breastfeeding food packages at WIC. The primary hypothesis is that monthly incentives contingent on breastfeeding in SC +BFI will significantly increase rates of any breastfeeding compared with SC. The primary outcome is the rate of any breastfeeding over 12 months. Randomisation is completed in an automated electronic system. Staff conducting home visits for support and assessments are blinded to study groups.

ETHICS AND DISSEMINATION

The Advarra Institutional Review Board has approved the study protocol (Pro00033168). Findings will be disseminated to our participants, scientific communities, public health officials and any other interested community members.

TRIAL REGISTRATION NUMBER

NCT03964454.

The effectiveness on health education to prevent nipple trauma from breastfeeding: a systematic review

Abstract Objectives: to analyze the effectiveness on health education to prevent nipple trauma in breastfeeding compared to other interventions. Methods: systematic literature review was carried out in January 2019, according to PRISMA recommendations. The searches were conducted in Cinahl, PubMed, Web of Science, Scopus, and in the references cited in the selected articles. The studies were assessed for quality and level of evidence according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Results: twelve studies were selected, all conducted at the maternities. The interventions were classified in two categories: health education on breastfeeding and the use of nipple covers. Health education on breastfeeding presents a moderate level of evidence on the prevention of nipple trauma. There is a moderate to high level of evidence on the positive effects of guaiazulene, gel or peppermint water applied in the postpartum period to prevent nipple trauma. Conclusion: health education on breastfeeding with clinical demonstration is an important strategy to prevent nipple trauma and requires more than one educational approach. The use of nipple covers requires some consideration, since they must be removed prior to breastfeeding. All interventions were conducted in the postpartum period, which points out for the necessity of clinical research to prevent nipple trauma in prenatal care.

Las Dos Cosas Versus Exclusive Breastfeeding: A Culturally and Linguistically Exploratory Intervention Study in Hispanic Mothers Living in Kentucky

INTRODUCTION

Formula supplementation among infants of breastfeeding Hispanic immigrants is common practice known as las dos cosas. The purpose of this study was to assess the feasibility, effectiveness, and acceptability of a culturally and linguistically diverse intervention to promote exclusive breastfeeding (EBF) for the first 6 months.

METHODS

A sample of 39 Hispanic pregnant women was recruited and randomly assigned to intervention (n = 20) and control groups (n = 19). The intervention included a peer counselor and professional support, and mothers were followed from pregnancy to 6 months after birth.

RESULTS

After the study, women assigned to the intervention group were over three times more likely to EBF their baby through all four postpartum assessed time points (odds ratio = 3.1, 95% confidence interval: 1.1-8.7).

DISCUSSION

This culturally and linguistically diverse intervention contributed to increased EBF duration and decreased formula supplementation in Hispanic mothers up to 6 months postpartum.

Maternal Behavioral Health: Fertile Ground for Behavior Analysis

The World Health Organization has identified four behavioral health priorities as risk factors for noncommunicable diseases in maternal populations: tobacco use, harmful alcohol use, poor nutrition, and lack of physical activity. These risk factors also significantly affect pregnant and immediately postpartum mothers, doubling the health risk and economic burden by adversely affecting maternal and birth or infant outcomes. Psychosocial and behavioral interventions are ideal for pregnant and immediately postpartum women as opposed to pharmacotherapy. Among other behavioral interventions, the use of incentives based on the principles of reinforcement has been a successful yet controversial way to change health behaviors. Implementing an incentive-based intervention in maternal health often brings up social validity concerns. The existing guideline on how to develop and conduct research in incentive-based interventions for maternal health lacks enough information on the specific variables to control for to maintain the intervention's effectiveness. This article outlines some of the critical variables in implementing an effective behavior-analytic intervention and addressing social validity concerns to change maternal behaviors in a sustainable manner, along with specific research topics needed in the field to prevent adverse maternal, birth, and infant outcomes.

Pragmatic Trial to Evaluate the Effect of a Promotora Telephone Intervention on the Duration of Breastfeeding

OBJECTIVE

To evaluate the effectiveness of a telephone intervention delivered by promotoras (lay health care workers) to increase the duration of exclusive breastfeeding (EBF) in Hispanic women at 12 weeks postpartum. Secondary objectives were to assess breastfeeding duration (BFD) and to evaluate background variables that may be associated with EBF and BFD.

DESIGN

Pragmatic trial.

SETTING

Two obstetric clinics affiliated with a community medical center in Southern California.

PARTICIPANTS

We recruited 61 participants from the two clinics. Participants were 18 to 45 years old and planned to breastfeed their infants. Women who showed interest in the study were sequentially divided into an intervention (n = 31) or a control group (n = 30).

METHODS

The intervention consisted of telephone support for breastfeeding provided by certified and trained promotoras.

RESULTS

Fourteen out of 31 (45%) participants in the intervention group continued to practice EBF compared with 4 out of 30 (13%) in the control group (odds ratio = 3.39, p = .04). Breastfeeding duration in days was significantly longer for the participants in the intervention group (F =1/59 = 29.88, p < .01). The positive predictors of EBF at 12 weeks after birth were prior breastfeeding experience, perceived breastfeeding support, promotora telephone support, and higher scores on the acculturation scale. Positive predictors of BFD were breastfeeding support, promotora telephone support, and higher scores on breastfeeding self-efficacy. A negative predictor was lower household income.

CONCLUSION

Our results indicate that a telephone support intervention delivered by promotoras may increase the rates of EBF by threefold at 12 weeks after birth.

Delivery and Payment Redesign to Reduce Disparities in High Risk Postpartum Care

Purpose This paper describes the implementation of an innovative program that aims to improve postpartum care through a set of coordinated delivery and payment system changes designed to use postpartum care as an opportunity to impact the current and future health of vulnerable women and reduce disparities in health outcomes among minority women. Description A large health care system, a Medicaid managed care organization, and a multidisciplinary team of experts in obstetrics, health economics, and health disparities designed an intervention to improve postpartum care for women identified as high-risk. The program includes a social work/care management component and a payment system redesign with a cost-sharing arrangement between the health system and the Medicaid managed care plan to cover the cost of staff, clinician education, performance feedback, and clinic/clinician financial incentives. The goal is to enroll 510 high-risk postpartum mothers. Assessment The primary outcome of interest is a timely postpartum visit in accordance with NCQA healthcare effectiveness data and information set guidelines. Secondary outcomes include care process measures for women with specific high-risk conditions, emergency room visits, postpartum readmissions, depression screens, and health care costs. Conclusion Our evidence-based program focuses on an important area of maternal health, targets racial/ethnic disparities in postpartum care, utilizes an innovative payment reform strategy, and brings together insurers, researchers, clinicians, and policy experts to work together to foster health and wellness for postpartum women and reduce disparities.

Stigma and Postpartum Depression Treatment Acceptability Among Black and White Women in the First Six-Months Postpartum

Objective To measure stigma associated with four types of postpartum depression therapies and to estimate the association between stigma and the acceptance of these therapies for black and white postpartum mothers. Methods Using data from two postpartum depression randomized trials, this study included 481 black and white women who gave birth in a large urban hospital and answered a series of questions at 6-months postpartum. Survey items included socio demographic and clinical factors, attitudes about postpartum depression therapies and stigma. The associations between race, stigma, and treatment acceptability were examined using bivariate and multivariate analyses. Results Black postpartum mothers were less likely than whites to accept prescription medication (64 vs. 81%, p = 0.0001) and mental health counseling (87 vs. 93%, p = 0.001) and more likely to accept spiritual counseling (70 vs. 52%, p = 0.0002). Women who endorsed stigma about receipt of postpartum depression therapies versus those who did not were less likely to accept prescription medication, mental health and spiritual counseling for postpartum depression. Overall black mothers were less likely to report stigma associated with postpartum depression therapies. In adjusted models, black women versus white women remained less likely to accept prescription medication for postpartum depression (OR = 0.42, 95% CI 0.24-0.72) and stigma did not explain this difference. Conclusions Although treatment stigma is associated with lower postpartum depression treatment acceptance, stigma does not explain the lower levels of postpartum depression treatment acceptance among black women. More research is needed to understand treatment barriers for postpartum depression, especially among black women.

Racial and ethnic disparities in U.S. breastfeeding and implications for maternal and child health outcomes

Marked racial and ethnic disparities exist in infant feeding in the United States. Based on a review of recent literature, this article examines current discrepancies between the 2020 Healthy People breastfeeding goals and current breastfeeding rates among women from different ethnic groups in the United States. We discuss maternal and child health outcomes associated with breastfeeding, and we review potential causes of racial and ethnic disparities in breastfeeding outcomes in the United States, especially among non-Hispanic Black, American Indian/Alaska Native, and Hispanic/Latina populations. We conclude with an overview of best practices in interventions aimed to increase U.S. breastfeeding rates, such as adoption of the baby friendly hospital initiative (BHFI) and programs that utilize peer counseling strategies to increase breastfeeding promotion and support.

The fourth trimester: a critical transition period with unmet maternal health needs

After childbirth, most American women are not scheduled for follow-up care for 6 weeks, and this visit is poorly attended. Many new mothers feel unprepared for the common health issues they encounter and are uncertain of whom to contact. To improve care, the 4^th Trimester Project is bringing together mothers, health care providers, and other stakeholders to explore what families need most from birth to 12 weeks postpartum. Eighty-seven individuals convened in March 2016 in Chapel Hill, NC. Four major topic areas emerged: (1) the intense focus on women's health prenatally is unbalanced by infrequent and late postpartum care; (2) medical practice guidelines often do not align with women's experiences and constraints; (3) validation of women as experts of their infants and elevating their strengths as mothers is necessary to achieve health goals; and (4) mothers need comprehensive care, which is difficult to provide because of numerous system constraints. Considerations for improving postpartum services include enabling more convenient care for families that is holistic, culturally appropriate, conversation based, and equitable. Maternal health issues in the fourth trimester intersect and can compound one another. Enhanced collaboration among health care providers may improve the focus of clinical interactions to address the interrelated health issues most important to women.

The Effects of Different Breastfeeding Training Techniques Given for Primiparous Mothers Before Discharge on the Incidence of Cracked Nipples

OBJECTIVE

This research investigated the effects of different breastfeeding training techniques for primiparous mothers before discharge on the incidence of cracked nipples.

MATERIALS AND METHODS

This was a controlled intervention study that was carried out between 2015 and 2016 on 90 mothers living in İzmir. The mothers were divided into three groups: the demonstration-based training group, brochure group, and routine care-receiving group. The mothers in the "brochure group" were provided with breastfeeding training brochures. Mothers in the demonstration-based training group received one-to-one training using designed doll and puppet tools.

RESULTS

The rate of cracked nipples at age 2 weeks was 63.3% in the routine care-receiving group, 56.7% in the brochure group, and 20% in the demonstration-based training group. At the end of the fourth week, the rate was 30% in the routine care-receiving group and less than 10% in the other two groups (p < 0.005). The LATCH scores were higher in the demonstration-based training group than in the other two groups (p < 0.05). There was no significant difference between the groups in the percentage of exclusive breastfeeding.

CONCLUSION

The results documented that breastfeeding training based on one-to-one demonstration utilizing specially designed audiovisual tools was more effective than the other two methods in the prevention of nipple cracks.

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.

Incentive-based Intervention to Maintain Breastfeeding Among Low-income Puerto Rican Mothers

BACKGROUND AND OBJECTIVE

Despite maternal and child health benefits, breastfeeding rates are relatively low among low-income Puerto Rican mothers. This study examined the hypothesis that monthly financial incentives would significantly increase the proportion of breastfeeding mothers at 6 months postpartum compared with Supplemental Nutrition Program for Women, Infants, and Children (WIC) services only among Puerto Rican mothers.

METHODS

A randomized, 2-arm parallel-group design, from February 2015 through February 2016. Half of the randomized participants received monthly financial incentives contingent on observed breastfeeding for 6 months (Incentive), and the other half received usual WIC services only (Control). Thirty-six self-identified Puerto Rican women who initiated breastfeeding were enrolled. Monthly cash incentives were contingent on observed breastfeeding increasing the amount given at each month from $20 to $70 for a total possible of $270.

RESULTS

The intent-to-treat analysis showed significantly higher percentages of breastfeeding mothers in the incentive group at each time point compared with those in the control group (89% vs 44%, P = .01 at 1 month; 89% vs 17%, P < .001 at 3 months; 72% vs 0%, P < .001 at 6 months). No significant differences were detected at any time point between study groups for self-reported exclusive breastfeeding rate and infant outcomes (ie, weight, emergency department visits).

CONCLUSIONS

Contingent cash incentives significantly increased breastfeeding through 6-month postpartum among WIC-enrolled Puerto Rican mothers; however, no significant differences between the study groups were observed on exclusive breastfeeding rate and infant outcomes. Larger-scale studies are warranted to examine efficacy, implementation potential, and cost-effectiveness.

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.

Antenatal breastfeeding education for increasing breastfeeding duration

BACKGROUND

Breast milk is well recognised as the best food source for infants. The impact of antenatal breastfeeding (BF) education on the duration of BF has not been evaluated.

OBJECTIVES

To assess the effectiveness of antenatal breastfeeding (BF) education for increasing BF initiation and duration.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register on 1 March 2016, CENTRAL (The Cochrane Library, 2016, Issue 3), MEDLINE (1966 to 1 March 2016) and Scopus (January 1985 to 1 March 2016). We contacted experts and searched reference lists of retrieved articles.

SELECTION CRITERIA

All identified published, unpublished and ongoing randomised controlled trials (RCTs) assessing the effect of formal antenatal BF education or comparing two different methods of formal antenatal BF education, on the duration of BF. We included RCTs that only included antenatal interventions and excluded those that combined antenatal and intrapartum or postpartum BF education components. Cluster-randomised trials were included in this review. Quasi-randomised trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We assessed all potential studies identified as a result of the search strategy. Two review authors extracted data from each included study using the agreed form and assessed risk of bias. We resolved discrepancies through discussion. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review update includes 24 studies (10,056 women). Twenty studies (9789 women) contribute data to analyses. Most studies took place in high-income countries such as the USA, UK, Canada and Australia. In the first five comparisons, we display the included trials according to type of intervention without pooling data. For the 'Summary of findings' we pooled data for a summary effect.Five included studies were cluster-randomised trials: all of these adjusted data and reported adjustments as odds ratios (OR). We have analysed the data using the generic inverse variance method and presented results as odds ratios, because we were unable to derive a cluster-adjusted risk ratio from the published cluster-trial. We acknowledge that the use of odds ratio prevents the pooling of these cluster trials in our main analyses. One method of BF education with standard (routine) careThere were no group differences for duration of any BF in days or weeks. There was no evidence that interventions improved the proportion of women with any BF or exclusive BF at three or six months. Single trials of different interventions were unable to show that education improved initiation of BF, apart from one small trial at high risk of attrition bias. Many trial results marginally favoured the intervention but had wide confidence intervals crossing the line of no effect. BF complications such as mastitis and other BF problems were similar in treatment arms in single trials reporting these outcomes. Multiple methods of BF education versus standard careFor all trials included in this comparison we have presented the cluster-adjusted odds ratios as reported in trial publications. One three-arm study found the intervention of BF booklet plus video plus Lactation Consultant versus standard care improved the proportion of women exclusively BF at three months (OR 2.60, 95% CI 1.25 to 5.40; women = 159) and marginally at six months (OR 2.40, 95% CI 1.00 to 5.76; women = 175). For the same trial, an intervention arm without a lactation consultant but with the BF booklet and video did not have the same effect on proportion of women exclusively BF at three months (OR 1.80, 95% CI 0.80 to 4.05; women = 159) or six months (OR 0.90, 95% CI 0.30 to 2.70; women = 184). One study compared monthly BF sessions and weekly cell phone message versus standard care and reported improvements in the proportion of women exclusively BF at both three and six months (three months OR 1.80, 95% CI 1.10 to 2.95; women = 390; six months OR 2.40, 95% CI 1.40 to 4.11; women = 390). One study found monthly BF sessions and weekly cell phone messages improved initiation of BF over standard care (OR 2.61, 95% CI 1.61 to 4.24; women = 380). BF education session versus standard care, pooled analyses for 'Summary of findings' (SoF)This comparison does not include cluster-randomised trials reporting adjusted odds ratios. We did not downgrade any evidence for trials' lack of blinding; no trial had adequate blinding of staff and participants. The SoF table presents risk ratios for all outcomes analysed. For proportion of women exclusively BF there is no evidence that antenatal BF education improved BF at three months (RR 1.06, 95% CI 0.90 to 1.25; women = 822; studies = 3; moderate quality evidence) or at six months (RR 1.07, 95% CI 0.87 to 1.30; women = 2161; studies = 4; moderate quality evidence). For proportion of women with any BF there were no group differences in BF at three (average RR 0.98, 95% CI 0.82 to 1.18; women = 654; studies = 2; I² = 60%; low-quality evidence) or six months (average RR 1.05, 95% CI 0.90 to 1.23; women = 1636; studies = 4; I² = 61%; high-quality evidence). There was no evidence that antenatal BF education could improve initiation of BF (average RR 1.01, 95% CI 0.94 to 1.09; women = 3505; studies = 8; I² = 69%; high-quality evidence). Where we downgraded evidence this was due to small sample size or wide confidence intervals crossing the line of no effect, or both.There was insufficient data for subgroup analysis of mother's occupation or education.

AUTHORS' CONCLUSIONS

There was no conclusive evidence supporting any antenatal BF education for improving initiation of BF, proportion of women giving any BF or exclusively BF at three or six months or the duration of BF. There is an urgent need to conduct a high-quality, randomised controlled study to evaluate the effectiveness and adverse effects of antenatal BF education, especially in low- and middle-income countries. Evidence in this review is primarily relevant to high-income settings.

Suicidal Ideation During the Postpartum Period

OBJECTIVE

To examine the association between suicidal ideation (SI), 3 weeks, 3 months, and 6 months postpartum with demographic, psychosocial, clinical factors, and depressive/anxiety symptoms (measured 24-48 hours after delivery), among a cohort of postpartum women.

METHODS

This study included 1,073 mothers who gave birth in a large tertiary New York City hospital (2009-2010). Later, self-report SI was assessed using the suicide measure from the Edinburgh Postnatal Depression Scale and from the Patient Health Questionnaire.

RESULTS

Two percent of participants presented with SI during the first 6 months postpartum. In bivariate analyses, race/ethnicity, nativity, insurance, and language were significantly correlated with SI 3 weeks, 3 months, and 6 months postpartum. Screening positive for depression (p = 0.0245) and anxiety (0.0454), assessed 1-2 days postpartum, was significantly correlated with later SI in bivariate analyses, as were antepartum complications (p = 0.001), depressive history (0.001), and self-efficacy (0.045). In adjusted models, antepartum complications (OR = 4.681, 95% CI = 1.99-10.99) and depressive history (OR-3.780, 95% CI = 1.514-9.441) were significantly associated with later postpartum SI. Heightened self-efficacy reduced the odds of later SI (p = 0.050).

CONCLUSION

Findings suggest that SI among a relatively healthy group of new mothers occurs with some frequency. Mothers with a history of depression and antepartum complications may be at increased risk.

Maternal depressive symptoms and parenting practices 3-months postpartum

Using data from two postpartum depression randomized trials, we examined the association between postpartum depressive symptoms and parenting practices among a diverse group of mothers. We examined the association between safety practices (back sleep position, car seat use, smoke alarm), feeding practices (breastfeeding, infant intake of cereal, juice, water), and health care practices (routine well child and Emergency Room (ER) visits) with 3-month postpartum depressive symptoms assessed using the Edinburgh Depression Scale (EPDS ≥10). Fifty-one percent of mothers were black or Latina, 33 % had Medicaid, and 30 % were foreign born. Depressed mothers were less likely to have their infant use back sleep position (60 vs. 79 %, p < .001), always use a car seat (67 vs. 84 %, p < .001), more likely to feed their infants water, juice, or cereal (36 vs. 25 %, p = .04 respectively), and to bring their babies for ER visits (26 vs. 16 %, p = .03) as compared with non-depressed mothers. In multivariable model, depressed mothers remained less likely to have their infant use the back sleep position, to use a car seat, and to have a working smoke alarm in the home. Findings suggest the need to intervene early among mothers with depressive symptoms and reinforce positive parenting practices.

Clinical Interventions to Promote Breastfeeding by Latinas: A Meta-analysis

CONTEXT

Breastfeeding duration and exclusivity among Latinas fall below recommended levels, indicating a need for targeted interventions. The effectiveness of clinical breastfeeding interventions for Latinas remains unclear.

OBJECTIVE

To systematically review the documented effectiveness of clinical breastfeeding interventions on any and exclusive breastfeeding among Latinas.

DATA SOURCES

English-language publications in Medline, CINAHL, and Embase were searched through May 28, 2015.

STUDY SELECTION

Fourteen prospective, controlled studies describing 17 interventions met inclusion criteria.

DATA EXTRACTION

Extracted study characteristics include study design, population characteristics, intervention components, timing and intensity of delivery, provider type, control procedures, and outcome measures.

RESULTS

Random-effects meta-analyses estimated risk differences (RDs) between breastfeeding mothers in intervention and control arms of each study and 95% prediction intervals (PIs) within which 95% of intervals cover the true value estimated by a future study. Interventions increased any breastfeeding at 1 to 3 and 4 to 6 months (RD 0.04 [95% PI -0.15 to 0.23] and 0.08 [-0.08 to 0.25], respectively) and exclusive breastfeeding at 1 to 3 and 4 to 6 months (0.04 [-0.09 to 0.18] and 0.01 [-0.01 to 0.02]). Funnel plot asymmetry suggested publication bias for initiation and 1- to 3-month any breastfeeding. Estimates were slightly larger among interventions with prenatal and postpartum components, 3 to 6 patient contacts, and delivery by an International Board Certified Lactation Consultant or lay provider.

LIMITATIONS

The published evidence for Latinas is limited, and studies have varying methodologic rigor.

CONCLUSIONS

Breastfeeding interventions targeting Latinas increased any and exclusive breastfeeding compared with usual care.

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.

ABM Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Setting, Revision 2015

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

'This little piranha': a qualitative analysis of the language used by health professionals and mothers to describe infant behaviour during breastfeeding

Exclusive breastfeeding for the first 6 months of life offers the recommended best start in the life for a newborn baby. Yet, in Australia only a small number of babies receive breast milk exclusively for the first 6 months. Reasons for the introduction of formula milk are multi-factorial including access to appropriate support and the woman's experience of breastfeeding. The language and practices of health professionals can impact upon how a woman feels about breastfeeding and her breastfeeding body. One aspect of breastfeeding support that has had scarce attention in the literature is the language used by health professionals to describe the behaviour of the breastfeeding infant during the early establishment phase of breastfeeding. This paper reveals some of the ways in which midwives, lactation consultants and breastfeeding women describe the newborn baby during the first week after birth. The study was conducted at two maternity units in New South Wales. Interactions between midwives and breastfeeding women were observed and audio recorded on the post-natal ward and in women's homes, in the first week after birth. The transcribed data were analysed using discourse analysis searching for recurring words, themes and metaphors used in descriptions of the breastfeeding baby. Repeated negative references to infant personality and unfavourable interpretations of infant behaviour influenced how women perceived their infant. The findings revealed that positive language and interpretations of infant breastfeeding behaviour emerged from more relationship-based communication.

Racial and ethnic disparities in breastfeeding

This article's aim is to review the literature on racial and ethnic disparities in breastfeeding rates and practices, address barriers to breastfeeding among minority women, conduct a systematic review of breastfeeding interventions, and provide obstetrician-gynecologists with recommendations on how they can help increase rates among minority women. In order to do so, the literature of racial and ethnic disparities in breastfeeding rates and barriers among minority women was reviewed, and a systematic review of breastfeeding interventions among minority women on PubMed and MEDLINE was conducted. Racial and ethnic minority women continue to have lower breastfeeding rates than white women and are not close to meeting the Healthy People 2020 goals. Minority women report many barriers to breastfeeding. Major efforts are still needed to improve breastfeeding initiation and duration rates among minority women in the United States. Obstetrician-gynecologists have a unique opportunity to promote and support breastfeeding through their clinical practices and public policy, and their efforts can have a meaningful impact on the future health of the mother and child.