Breastfeeding duration, costs, and benefits of a support program for low-income breastfeeding women

Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement

Background

Breastfeeding impacts positively on multiple health outcomes, but < 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding.

Objectives

To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS.

Design

Evidence syntheses with stakeholder engagement.

Review methods

Systematic reviews examined effectiveness of breastfeeding support for (1) healthy women and (2) women with long-term conditions using Cochrane Pregnancy and Childbirth Group methods. Mixed-methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women and experiences of receiving/providing support for breastfeeding women with long-term conditions. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following National Institute for Health and Care Excellence guidance. All searches were conducted from May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were 23 stakeholders, 16 parents in the parents' panels, 15 women in the focus groups and 87 stakeholders who attended the workshops.

Results

We found considerably more interventions designed for healthy women (review 1) than aimed at women with long-term conditions (reviews 1 and 4); approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and the impact of support may be different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) and involving these sources in the provision of breastfeeding support for women with long-term conditions. In reviews 3 and 6, there was uncertainty about the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence.

Limitations

There was a lack of evidence for the effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information reported about intervention characteristics.

Conclusions

'Breastfeeding only' support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for 'breastfeeding plus' interventions is less consistent, but these may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and at 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good-quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women's and supporters' needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK.

Future work

Evaluation of breastfeeding support for all women, particularly those at risk of poor breastfeeding outcomes (e.g. long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies.

Study registration

This study is registered as PROSPERO CRD42022337239, CRD42021229769 and CRD42022374509. The reviews of economic evidence were not registered; however, the review protocol can be accessed via the repository held by Queen's University Belfast Research Portal (https://pure.qub.ac.uk/).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130995) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 20. See the NIHR Funding and Awards website for further award information.

Levelling up health in the early years: A cost-analysis of infant feeding and healthcare

BACKGROUND

Although breastfeeding is recommended as the optimal form of nutrition in the first six months, it is not sustained as the predominant mode of feeding infants in Scotland. This study estimated the impact of infant feeding choices on primary and secondary healthcare service costs in a 13-year birth cohort.

METHOD

Using linked administrative datasets, in a retrospective cohort design of 502,948 singletons born in Scotland between 1997 and 2009, we estimated the cost of GP consultations and hospital admissions by area deprivation and mode of infant feeding up to 6-8 weeks for ten common childhood conditions from birth to 27 months. Additionally, we calculated the potential healthcare savings if all infants in the cohort had been exclusively breastfed at 6-8 weeks. Discounting of 1.5% was applied following current health economic conventions and 2009/10 used as the base year.

RESULTS

Over the study period, the estimated cost of hospital admissions in the cohort was £111 million and £2 million for the 2% subset of the cohort with primary care records. Within each quintile of deprivation, exclusively breastfed infants used fewer healthcare services and incurred lower costs compared to infants fed (any) formula milk. At least £10 million of healthcare costs may have been avoided if formula-fed infants had been exclusively breastfed within the first 6-8 weeks of birth.

CONCLUSIONS

This study using a representative birth cohort demonstrates how breastmilk can promote equitable child health by reducing childhood illness and healthcare utilisation in the early years.

Clinically Integrated Breastfeeding Peer Counseling to Promote Breastfeeding Equity

OBJECTIVE

This study aimed to determine whether clinically integrated Breastfeeding Peer Counseling (ci-BPC) added to usual lactation care reduces disparities in breastfeeding intensity and duration for Black and Hispanic/Latine participants.

STUDY DESIGN

This study is a pragmatic, randomized control trial (RCT) of ci-BPC care at two ci-BPC-naïve obstetrical hospital facilities in the greater Chicago area. Participants will include 720 patients delivering at Hospital Site 1 and Hospital Site 2 who will be recruited from eight prenatal care sites during midpregnancy. Participants must be English or Spanish speaking, planning to parent their child, and have no exposure to ci-BPC care prior to enrollment. Randomization will be stratified by race and ethnicity to create three analytic groups: Black, Hispanic/Latine, and other races.

RESULTS

The primary outcome will be breastfeeding duration. Additional outcomes will include the proportion of breastmilk feeds during the delivery admission, at 6-week postdelivery, and at 6-month postdelivery. A process evaluation will be conducted to understand implementation outcomes, facilitators, and barriers to inform replication and scaling of the innovative ci-BPC model.

CONCLUSION

This research will produce findings of relevance to perinatal patients and their families, the vast majority of whom desire to provide breastmilk to their infants and require support to succeed with their feeding goals. As the largest RCT of ci-BPC in the United States to date, this research will improve the quality of evidence available regarding the effectiveness of ci-BPC at reducing disparities. These findings will help patients and stakeholders determine the benefits of accepting and adopting the program and inform policies focused on improving perinatal care and reducing maternal/child health disparities. This study is registered with Clinical Trial (identifier: NCT05441709).

KEY POINTS

· Ci-BPC can promote racial breastfeeding equity.. · Ci-BPC has not been tested as a generalized lactation strategy in prior trials and is underused.. · This RCT will identify if ci-BPC can reduce breastfeeding disparities for Black and Hispanic patients..

Effects of Breastfeeding Peer Counseling on County-Level Breastfeeding Rates Among WIC Participants in Greater Minnesota

OBJECTIVE

U.S. breastfeeding outcomes consistently fall short of public health targets, with lower rates among rural and low-income people, as well as participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The U.S. Department of Agriculture funded a subset of local WIC agencies in Minnesota to implement Breastfeeding Peer Counseling Programs (BFPCs) aimed at improving breastfeeding rates. We examined the impact of BFPCs on breastfeeding rates among WIC participants in Greater Minnesota (outside the Minneapolis-St. Paul metropolitan area).

METHODS

We used data from the Minnesota WIC Information System for the years 2012 through 2019 to estimate the impact of peer counseling on breastfeeding duration using difference-in-differences models. Additionally, we examined results among rural counties and assessed the possibility of spillover effects by stratifying whether a county without BFPCs bordered one with BFPCs.

RESULTS

Availability of BFPCs resulted in a 3.1 to 3.4 percentage-point increase in breastfeeding rates at 3 months and a 3.2 to 3.7 percentage-point increase in breastfeeding rates at 6 months among WIC participants in Greater Minnesota. Among rural counties, results showed a statistically significant 4.1 to 5.2 percentage-point increase in breastfeeding duration rates. Both border and nonborder counties experienced positive impacts of BFPCs on breastfeeding rates, suggesting wide-ranging program spillover effects.

CONCLUSIONS

BFPCs had a significant positive impact on breastfeeding duration. Findings indicate an opportunity for improving rural breastfeeding rates through increased funding for WIC BFPCs.

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.

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 .

Tailored text messages to improve breastfeeding practices in Yangon, Myanmar: the M528 individually randomized controlled trial

BACKGROUND

Text messages are a feasible delivery channel for breastfeeding promotion, but only a few articles have examined their effectiveness.

OBJECTIVE

To evaluate the impact of mobile phone text messages on breastfeeding practices.

DESIGN

We implemented a 2-arm, parallel, individually randomized controlled trial with 353 pregnant participants at the Central Women's Hospital, Yangon. The intervention group (n = 179) received breastfeeding-promotion text messages, and the control group (n = 174) received other maternal and child health care messages. The primary outcome was the exclusive breastfeeding rate at 1-6 mo postpartum. Secondary outcomes were other breastfeeding indicators, breastfeeding self-efficacy, and child morbidity. Using the intention-to-treat approach, the available outcome data were analyzed with generalized estimation equation Poisson regression models to estimate RR and 95% CIs, adjusted for within-person correlation and time, and tested for treatment group-by-time interactions.

RESULTS

Exclusive breastfeeding prevalence was significantly higher in the intervention than in the control group for the 6 follow-up visits combined (RR: 1.48; 95%CI: 1.35, 1.63; P < 0.001) and at each monthly follow-up visit. At 6 mo, exclusive breastfeeding was 43.4% in the intervention compared with 15.3% in the control group (RR: 2.74; 95%CI: 1.79, 4.19; P < 0.001). Also, at 6 mo, the intervention increased current breastfeeding (RR: 1.17; 95%CI: 1.07, 1.26; P < 0.001) and reduced bottle feeding (RR: 0.30; 95%CI: 0.17, 0.54; P < 0.001). Exclusive breastfeeding was progressively higher in the intervention group than in the control group at each follow-up (P for interaction < 0.001) and similarly for current breastfeeding. The intervention increased the mean breastfeeding self-efficacy score (adjusted mean difference 4.0; 95%CI: 1.36, 6.64; P = 0.030). Over the 6-month follow-up, the intervention significantly reduced diarrhea risk by 55% (RR: 0.45; 95%CI: 0.24, 0.82; P < 0.009).

CONCLUSIONS

Regular, targeted text messages delivered to urban pregnant women and mothers via mobile phones significantly improve breastfeeding practices and reduce infant morbidity during the first 6 mo of life.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615000063516; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367704.

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.

Barriers to breastfeeding are shaped by sociocultural context: an exploratory qualitative study in Bangladesh

Background

Breastfeeding practice is still not optimum in Bangladesh. Understanding barriers to breastfeeding is needed to prevent harmful practices. This study aimed to understand barriers to breastfeeding among infants and young children in Bangladesh.

Methods

This qualitative study was conducted in five rural sub-districts and one urban slum in Bangladesh. We conceptualized that barriers to breastfeeding can be broadly grouped into individual, society, and system level barriers. We conducted in-depth interviews with 33 breastfeeding mothers and 13 grandmothers of breastfed children (total n = 46 interviews). We observed 23 of these infants and young children being breastfed. These data were supplemented by 3 focus group discussions held with the children’s fathers. We managed the data using Atlas.ti software and analyzed the data thematically using an inductive approach.

Results

Important individual-level barriers perceived to influence breastfeeding included misconceptions about the adverse effects of breastfeeding on maternal health, nutrition and physical appearance, and lack of awareness of the value of breastfeeding among family members. Perceived society-level barriers included sociocultural norms, beliefs, and practices such as mother obliged to give more attention on household chores than breastfeeding to become a good housewife and feeding formula milk perceived as a symbol of parents’ financial solvency in the society. System-level barriers included attractive advertisements of breastmilk substitutes, and inadequate facilities and support processes in mothers’ work environments.

Conclusion

A range of barriers at individual, society and system level have important implications for infant and young children’s breastfeeding practices in Bangladesh. Development of interventions that address the range of barriers that many mothers face is essential to support breastfeeding practices. Potential interventions include strengthening information-giving during interaction between mothers and health workers on breastfeeding techniques, and engaging fathers and other “significant others” in counseling on breastfeeding.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41043-022-00312-y.

Examining patterns of postnatal feeding in relation to infant's weight during the first year

BACKGROUND

There is mixed evidence regarding specific infant feeding behaviors and later risk for overweight and obesity. We sought to detect underlying patterns in duration of breastfeeding, introduction of solid foods and sweetened beverages, in order to understand the relation to later weight.

METHODS

Patterns of postnatal feeding were examined among infants enrolled in the Infant Feeding Practices Study II (N = 3033). At monthly intervals, mothers reported on the duration of any and exclusive breastfeeding, age of solid food and sweetened beverage introduction, and reported infant weight at ages 9- and 12-months. Latent profile analysis was used to empirically derive patterns of postnatal feeding and examine associations with weight z-scores at 9 and 12 months.

RESULTS

Two profiles emerged: (1) Short breastfeeding duration and early introduction to solid foods and sweetened beverages (Short BF/Early Introduction; 53%) and (2) longer breastfeeding duration and later introduction to solid foods and sweetened beverages (Longer BF/Later Introduction; 43%). Infants in the Shorter BF/Early Introduction profile had significantly greater weight z-scores at 9 (M = 0.18) and 12 months (M = 0.26), compared to those in the Longer BF/Later Introduction profile (M = -0.21; M = -0.17, respectively).

CONCLUSIONS

Overall, shorter BF duration and earlier food and sweetened beverage introduction is associated with higher weight z-scores at 9 and 12 months. Early intervention should aim to promote breastfeeding and later introduction of solids and discourage consumption of sweetened beverages. These postnatal patterns of feeding behaviors provides important context to inform targeted interventions aimed at reducing risk for later obesity.

Unbiasing costs? An appraisal of economic assessment alongside randomized trials in neonatology

Economic evaluations performed alongside randomized controlled trials benefit from the protections against bias inherent in randomization. In this systematic review, we assessed the frequency and quality of economic assessments alongside randomized controlled trials of interventions in neonates published between 1990 and 2016. Over that period, 58 economic assessments were published, corresponding to approximately 2% of RCTs. We noted significant methodological limitations of these studies, including limitation of included costs to the health sector or payer rather than broader categories such as family or community expenditures (81%), short time horizon for cost measurement (less than one year in 60%), lack of reporting of uncertainty (26%), and infrequent analysis of costs and effects in a single metric (combined in 45%). Strategies for improving the quality and frequency of economic evaluations in neonatology are discussed, including selection of appropriate trials, funding, and peer review.

The Evaluation of Training for Health-Care Professionals and Community Leaders Regarding 6-Month Exclusive Breastfeeding in Northeast Thailand

To address the reduction of the 6-month exclusive breastfeeding (EBF) rate in Northeast Thailand, a 3-year 6-month EBF intervention model was developed using concept mapping. A training for health-care professionals and community leaders was prioritized as the initial intervention. The aim was to assess the feasibility of the training intervention and its potential to improve 6-month EBF knowledge. A pre- and posttest, and an open question were conducted. Data were analyzed using t tests and thematic analysis. For the 17 health-care professionals and community leaders who participated, the mean 6-month EBF knowledge scores improved significantly from 5.28 to 10.21 (p value < .01). It is recommended that this workshop could be duplicated and scaled up in other regions across Thailand to standardize care.

A systematic review of costing studies for implementing and scaling-up breastfeeding interventions: what do we know and what are the gaps?

Despite the well-established evidence that breastfeeding improves maternal and child health outcomes, global rates of exclusive breastfeeding remain low. Cost estimates can inform stakeholders about the financial resources needed to scale up interventions to ultimately improve breastfeeding outcomes in low-, middle- and high-income countries. To inform the development of comprehensive costing frameworks, this systematic review aimed to (1) identify costing studies for implementing or scaling-up breastfeeding interventions, (2) assess the quality of identified costing studies and (3) examine the availability of cost data to identify gaps that need to be addressed through future research. Peer-reviewed and grey literature were systematically searched using a combination of index terms and relevant text words related to cost and the following breastfeeding interventions: breastfeeding counselling, maternity leave, the World Health Organization International Code of Marketing of Breastmilk Substitutes, the Baby-Friendly Hospital Initiative, media promotion, workplace support and pro-breastfeeding social policies. Data were extracted after having established inter-rater reliability among the first two authors. The quality of studies was assessed using an eight-item checklist for key costing study attributes. Forty-five studies met the inclusion criteria, with the majority including costs for breastfeeding counselling and paid maternity leave. Most cost analyses included key costing study attributes; however, major weaknesses among the studies were the lack of clarity on costing perspectives and not accounting for the uncertainty of reported cost estimates. Costing methodologies varied substantially, standardized costing frameworks are needed for reliably estimating the costs of implementing and scaling-up breastfeeding interventions at local-, national- or global-levels.

Interventions to promote exclusive breastfeeding among young mothers: a systematic review and meta-analysis

Background

Exclusive breastfeeding rates in many high-income countries are considerably lower than the World Health Organization recommendations. Younger mothers are less likely than older mothers to exclusively breastfeed or to exclusively breastfeed for a long duration. This systematic review explores interventions to increase the rate of exclusive breastfeeding among young mothers in high-income countries.

Methods

A systematic search of the following databases was completed in August 2020: CINAHL, PubMed, MEDLINE, ProQuest, PsychInfo, Web of Science, Cochrane, Scopus and Embase. A manual search of the reference lists of all the included studies and published systematic reviews was also performed. The Cochrane Collaboration Risk of Bias Tool was used to assess the quality of the included studies. A random effects model meta-analyses was applied. Heterogeneity of outcomes between the studies was assessed using both the χ² test and the I² statistic.

Results

Of 955 records identified in the search, 392 duplicates were removed, and nine studies met the inclusion criteria. Seven studies were randomised controlled trial (RCTs) and two were quasi-experimental in design. Eight were conducted in the United States. The interventions included peer counselling, telephone support, massage, gift packs, financial incentive and antenatal education. Most studies included a combination of strategies, peer counselling being the most common. A meta-analysis of four of nine included studies did not detect a difference in rate of exclusive breastfeeding to 3 months postpartum (RR 1.44; 95% CI 0.82, 2.55; p = 0.204).

This review is limited by the relatively few studies which met the inclusion criteria and the small sample sizes of most included studies. High rates of attrition and formula supplementation among the participants made it difficult to detect a statistically significant effect. Consistency in follow up times would enable more studies to be included in a meta-analysis.

Conclusions

Peer counselling was the most promising strategy associated with higher rates of exclusive breastfeeding. However, further studies are needed to understand the breastfeeding experiences of young mothers. Young mothers should be targeted specifically in intervention studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-020-00340-6.

A scoping review of breastfeeding peer support models applied in hospital settings

BACKGROUND

The 2013 updated guidelines on management of severe acute malnutrition in infants and children recommends the support of exclusive breastfeeding. These guidelines are inconsistently applied in low and middle income countries (LMICs) due to barriers including unclear implementation guides, technical support and epidemiological factors. Peer support strategies have been used to offer psychological support to families with infants in NICU and improve mental health outcomes. Breastfeeding peer supporters (BFPS) have been shown to be effective in improving breastfeeding outcomes in community settings however, their success within hospital settings in LMICs is unknown. We conducted a scoping review to explore implementation of breastfeeding peer support strategies as have been applied to hospitalized infants globally and highlight their implementation strategies in order to guide future research and practice.

METHODS

A scoping review of the literature was conducted using the Arksey and O'Malley framework. A search was conducted in five online databases (PubMed, Cochrane library, Hinari, Google Scholar and Open Grey library). Data were extracted and charted in data extraction tables to capture general characteristics, modes of peer support delivery, implementation details and evaluation procedures.

RESULTS

From the online search 276 articles were identified, however only 18 met the inclusion criteria for the study. The majority of these articles were reports on in-patient breastfeeding peer support interventions applied in Europe and the United States of America and only two were from LMICs. The articles described peer supporters' identification, training (n = 13) and supervision (n = 14). The majority of the BFPS were employed (n = 10) compared to volunteers (n = 3) and support was mainly one-to-one (n = 11) rather than group support. Process and impact evaluation (n = 13) reported positive breastfeeding outcomes associated with breastfeeding peer support.

CONCLUSION

Breastfeeding peer support strategies are applied in different hospital settings and can be used to improve breastfeeding outcomes. However, to achieve integration, scalability and comparability of impact and outcomes, there is a need to standardize training, develop consistent implementation and supervision plans of in-patient peer supporters' strategies. Further research to assess sustainability and evaluate cost-effectiveness of in-patient breastfeeding peer support strategies will improve uptake and scalability of these potentially lifesaving interventions.

"Real-world" effect of a peer counselor on breastfeeding outcomes in an urban prenatal clinic in the United States

BACKGROUND

One approach for improving breastfeeding support and alleviating breastfeeding disparities is the implementation of a clinic-based peer counselor. Our objective was to assess the "real life" effects of an autonomous peer counselor who provides tailored support to low-income, minority women based on individual needs rather than a pre-determined research protocol.

METHODS

This is a secondary analysis of a prospective cohort study of women receiving publicly funded prenatal care during the 6 months before and after introduction of a peer counselor in a single prenatal clinic. The peer counselor provided one-on-one antenatal and postpartum lactation support. Electronic medical record and survey data were collected. The primary outcome was breastfeeding continuation at 6 weeks postpartum. Secondary outcomes included breastfeeding comfort, confidence, and training satisfaction, any breastfeeding, and total breastfeeding duration. Bivariable and multivariable analyses were performed.

RESULTS

Peer counselor exposure was not associated with the primary outcome of continued breastfeeding at 6 weeks (55.6% with peer counselor versus 49.1% without; aOR 1.26, 95% CI 0.69-2.31). However, women with peer counselor exposure were more likely to be satisfied with breastfeeding training at the time of delivery (98.2% vs. 83.6%, p = 0.006) and were more likely to have performed any breastfeeding (89.8% vs. 78.9%, p = 0.04), which remained significant on multivariable analysis (aOR 2.85, 95% CI 1.11-7.32).

CONCLUSIONS

Peer counselor interventions are a promising approach to increase breastfeeding initiation. Further research is required to inform the most efficacious approach while also allowing peer counselors to operate independently and in line with the specific needs of their clients.

Grading the evidence to identify strategies to modify risk for necrotizing enterocolitis

Although risk for necrotizing enterocolitis (NEC) is often presented from the perspective of a premature infant's vulnerability to nonmodifiable risk factors, in this paper we describe the evidence and present recommendations to manage modifiable risks that are amenable to clinical actions. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, we present recommendations in the context of their supporting evidence in a way that balances risks (e.g. potential harm, cost) and benefits. Across the prenatal, intrapartum, early and late clinical course, strategies to limit NEC risk in premature infants are presented. Our goal is to summarize modifiable NEC risk factors, grade the evidence to offer quality improvement (QI) targets for healthcare teams and offer a patient-family advocate's perspective on how to engage parents to recognize and reduce NEC risk.

The effect of breastfeeding training on exclusive breastfeeding: a randomized controlled trial

INTRODUCTION

Although exclusive breastfeeding is very beneficial for children's and mothers' health, a limited number of infants are exclusively breastfed for 6 months.

AIM

This randomized controlled intervention study aims to determine the effect of breastfeeding training on mothers' knowledge, behaviors, and exclusive breastfeeding for 6 months.

MATERIALS AND METHODS

The participants were selected randomly for training (n = 60) and control groups (n = 60) among the pregnant women admitted to the obstetrics and gynecology polyclinics of a baby-friendly hospital. The training group received breastfeeding training during the prenatal and postnatal periods. The data were collected using a questionnaire during admission and at the postpartum 1st and 24th weeks through face-to-face interviews. The study was completed with 34 and 30 mother-infant pairs in the training and control groups, respectively. Analyzed using the chi-square, Student t, Mann-Whitney U, and Wilcoxon t-tests.

RESULTS

The difference between the number of correct answers in pre- and posttest was higher in the training group (four questions) than in the control group (two questions) (p < .001). The number of mothers exclusively breastfeeding for 6 months was significantly higher in the training group (26.5%) than in the control group (3.3%) (p = .015). The median of the exclusive breastfeeding period was longer in the training group (5 months) than in the control group (4 months) (p = .013).

CONCLUSION

Training and supporting pregnant women and breastfeeding mothers on breastfeeding increased their knowledge, the period of exclusive breastfeeding, and the rate of 6-month exclusive breastfeeding.

Multilevel Factors Influencing Young Mothers' Breastfeeding: A Qualitative CBPR Study

BACKGROUND

Young mothers (age 14-24 years), who are often low income, are less likely than other mothers to breastfeed for 6 months. They also are more likely to be diagnosed with aggressive forms of breast cancer; breastfeeding significantly reduces this risk. While adolescent breastfeeding has been investigated from the perspective of the individual, the social ecological model recognizes the influence of factors at multiple levels.

RESEARCH AIM

The aim was to identify social and structural barriers to and motivators of breastfeeding that young mothers may encounter.

METHODS

Using a cross-sectional prospective qualitative design with a community-based participatory research approach, we sought to identify influential factors at each social ecological level: individual, relationship, community, and societal/structural. We used purposeful sampling, and enlisted snowball sampling. We interviewed stakeholder experts ( n = 9) and dyads ( n = 6) consisting of a young mother and her decision-making partner. Groups of young mothers ( n = 6 groups) collectively created community maps while discussing their feelings about infant feeding in different locations. Using collaborative data analysis, we identified themes and categorized barriers and facilitators according to the social ecological levels.

RESULTS

Four meta-themes emerged: roles, place, stigma, and support. While some barriers and facilitators were similar to those experienced by mothers of all ages, participants reported multiple overlapping stigmas, requiring more support.

CONCLUSION

Young mothers who decide to breastfeed encounter barriers at multiple levels. Policies and programs aiming to increase breastfeeding rates in this group must address these barriers and enlist identified facilitators.

Greater Breastfeeding in Early Infancy Is Associated with Slower Weight Gain among High Birth Weight Infants

OBJECTIVE

To examine whether feeding patterns from birth to age 6 months modify the association between birth weight and weight at 7-12 months of age.

STUDY DESIGN

Longitudinal mixed models were used to examine feeding trajectories across categories of birth weight and weight at 7-12 months of age in 1799 mother-infant dyads enrolled in the Infant Feeding Practices Study II. The percentage of breast milk received and the average daily formula consumption were calculated from birth to 6 months of age. Birth weights were classified as high (≥4000 g) and normal (≥2500 g and <4000 g). Weights at 7-12 months of age were categorized as high (z score >1) or normal (z score ≤1). A secondary analysis was performed using categories defined by birth weight adjusted for gestational age percentiles (>90% and 10th-90th percentile).

RESULTS

High birth weight (HBW) infants with high weights at 7-12 months of age demonstrated a rapid decline in the percentage of breast milk feedings compared with HBW infants with normal weights at 7-12 months of age. Normal birth weight infants with high weights at 7-12 months of age received a lower percentage of breast milk and had greater absolute intakes of formula than those with normal weights at 7-12 months of age; these associations did not vary over time. Results were similar when infants were categorized by birth weight percentiles.

CONCLUSIONS

A lower proportion of breast milk feedings was associated with excess weight at 7-12 months of age in HBW infants. These findings suggest an initial target for obesity prevention programs focusing on the first 6 months after birth.

Pilot evaluation of HEAL - A natural experiment to promote obesity prevention behaviors among low-income pregnant women

Instituting interventions during the prenatal period is optimal for early obesity prevention in the child. Healthy Eating Active Living (HEAL) is a six-week, multi-component program to promote breastfeeding, healthy dietary habits, cooking skills and physical activity among Medicaid-eligible pregnant-women in Texas. HEAL is integrated into the healthcare system and offered as a standard-of-care for eligible patients.

METHODS

Preliminary evaluation of this natural experiment conducted from March 2015 through October 2016 informs the initial feasibility, acceptability and effects of the program on participant diet, home nutrition environment, physical activity, and breastfeeding self-efficacy and intentions measured using self-report surveys. Analysis of covariance (ANCOVA) was conducted to evaluate pre- and post-intervention changes, controlling for participants' ethnicity, age, and income level. Interaction effects of session attendance on the outcomes were further assessed.

RESULTS

Of the 329 women who enrolled in HEAL, 210 women completed the pre-post assessment (64% retention rate). Pre-to-post intervention, there were significant increases in availability and intake of fruits and vegetables, self-efficacy towards consuming more fruits and vegetables, and cooking frequency and skills (p < 0.05), and decreased frequency of eating heat and serve foods (p < 0.05). Significant improvements in physical activity, duration of breastfeeding, perceived benefits and intentions to breastfeed were also observed (p < 0.05). Higher attendance of HEAL sessions was associated with better outcomes. Process evaluation demonstrated 95% fidelity of program implementation.

CONCLUSION

HEAL operationalizes clinic-community linkages and shows promise in improving behaviors during pregnancy. Future research warrants the use of a stringent study design with a control group to determine program efficacy.

The Mother-Infant Study Cohort (MISC): Methodology, challenges, and baseline characteristics

BACKGROUND

The United Arab Emirates (UAE) exhibits alarming high prevalence of Non-Communicable Diseases (NCDs) and their risk factors. Emerging evidence highlighted the role of maternal and early child nutrition in preventing later-onset NCDs. The objectives of this article are to describe the design and methodology of the first Mother and Infant Study Cohort (MISC) in UAE; present the baseline demographic characteristics of the study participants; and discuss the challenges of the cohort and their respective responding strategies.

METHODS

The MISC is an ongoing two-year prospective cohort study which recruited Arab pregnant women in their third trimester from prenatal clinics in Dubai, Sharjah and Ajman. Participants will be interviewed six times (once during pregnancy, at delivery, and at 2, 6, 12 and 24months postpartum). Perinatal information is obtained from hospital records. Collected data include socio-demographic characteristics, lifestyle, dietary intake and anthropometry; infant feeding practices, cognitive development; along with maternal and infant blood profile and breast milk profile.

RESULTS

The preliminary results reported that 256 completed baseline assessment (mean age: 30.5±6.0 years; 76.6% multiparous; about 60% were either overweight or obese before pregnancy). The prevalence of gestational diabetes was 19.2%. Upon delivery, 208 women-infant pairs were retained (mean gestational age: 38.5±1.5 weeks; 33.3% caesarean section delivery; 5.3% low birthweight; 5.7% macrosomic deliveries). Besides participant retention, the main encountered challenges pertained to cultural complexity, underestimation the necessary start-up time, staff, and costs, and biochemical data collection.

CONCLUSIONS

Despite numerous methodological, logistical and sociocultural challenges, satisfactory follow-up rates are recorded. Strategies addressing challenges are documented, providing information for planning and implementing future birth cohort studies locally and internationally.

Lactation Support Services and Breastfeeding Initiation: Evidence from the Affordable Care Act

OBJECTIVE

Despite substantial evidence of the benefits of breastfeeding for both mothers and children, rates of sustained breastfeeding in the United States are quite low. This study examined whether mandated coverage of lactation support services under the Affordable Care Act (ACA) affects breastfeeding behavior.

DATA SOURCE

We studied the census of U.S. births included in the National Vital Statistics System from 2009 to 2014.

STUDY DESIGN

We used regression-adjusted difference-in-differences (DD) to examine changes in breastfeeding rates for privately insured mothers relative to those covered by Medicaid. We adjusted for several health and sociodemographic measures. We also examined the extent to which the effect varied across vulnerable populations-by race/ethnicity, maternal education, WIC status, and mode of delivery.

PRINCIPAL FINDINGS

Results suggest that the ACA mandate increased the probability of breastfeeding initiation by 2.5 percentage points, which translates into about 47,000 more infants for whom breastfeeding was initiated in 2014. We find larger effects for black, less educated, and unmarried mothers.

CONCLUSIONS

The Affordable Care Act-mandated coverage of lactation services increased breastfeeding initiation among privately insured mothers relative to mothers covered by Medicaid. The magnitude of the effect size varied with some evidence of certain groups being more likely to increase breastfeeding rates.

Effectiveness of community-based peer support for mothers to improve their breastfeeding practices: A systematic review and meta-analysis

Breastfeeding is associated with reduced mortality in children aged less than 5 years. We conducted a systematic review and meta-analysis (registered as PROSPERO 2015: CRD42015019105) to examine the effectiveness of community-based peer support for mothers on their breastfeeding practices as compared to mothers who have not received such a support.

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.

A systematic review of economic evaluations of CHW interventions aimed at improving child health outcomes

Evidence of the cost-effectiveness of community health worker interventions is pertinent for decision-makers and programme planners who are turning to community services in order to strengthen health systems in the context of the momentum generated by strategies to support universal health care, the post-2015 Sustainable Development Goal agenda.We conducted a systematic review of published economic evaluation studies of community health worker interventions aimed at improving child health outcomes. Four public health and economic evaluation databases were searched for studies that met the inclusion criteria: National Health Service Economic Evaluation Database (NHS EED), Cochrane, Paediatric Economic Evaluation Database (PEED), and PubMed. The search strategy was tailored to each database.The 19 studies that met the inclusion criteria were conducted in either high income countries (HIC), low- income countries (LIC) and/or middle-income countries (MIC). The economic evaluations covered a wide range of interventions. Studies were grouped together by intended outcome or objective of each study. The data varied in quality. We found evidence of cost-effectiveness of community health worker (CHW) interventions in reducing malaria and asthma, decreasing mortality of neonates and children, improving maternal health, increasing exclusive breastfeeding and improving malnutrition, and positively impacting physical health and psychomotor development amongst children.Studies measured varied outcomes, due to the heterogeneous nature of studies included; a meta-analysis was not conducted. Outcomes included disease- or condition -specific outcomes, morbidity, mortality, and generic measures (e.g. disability-adjusted life years (DALYs)). Nonetheless, all 19 interventions were found to be either cost-effective or highly cost-effective at a threshold specific to their respective countries.There is a growing body of economic evaluation literature on cost-effectiveness of CHW interventions. However, this is largely for small scale and vertical programmes. There is a need for economic evaluations of larger and integrated CHW programmes in order to achieve the post-2015 Sustainable Development Goal agenda so that appropriate resources can be allocated to this subset of human resources for health. This is the first systematic review to assess the cost-effectiveness of community health workers in delivering child health interventions.

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.

Does breast-feeding reduce offspring junk food consumption during childhood? Examinations by socio-economic status and race/ethnicity

Objective

To examine whether breast-feeding duration and socio-economic status (SES) interact to predict junk food consumption among offspring and whether the interaction differs across racial/ethnic groups.

Design

Survey research using a longitudinal panel design. Hierarchical linear regression was used to analyse the data.

Setting

In-home interviews with the child’s parents over a 5-year period across the USA.

Subjects

Approximately 10 000 American children from the Early Childhood Longitudinal Study: Birth Cohort (ECLS-B).

Results

The findings revealed that longer breast-feeding durations correspond to lower levels of junk food consumption, but that this relationship emerges consistently only among low-SES blacks.

Conclusions

Efforts to promote breast-feeding among low-SES black women may have the added benefit of reducing their children’s junk food intake, and may thereby promote their general health and well-being. Future research should seek to explore the mechanisms by which breast-feeding might benefit the dietary habits of low-SES black children.

Breastfeeding Supports and Services in Rural Hawaii: Perspectives of Community Healthcare Workers

Background. In the state of Hawaii, breastfeeding initiation rates are higher than the national average but fall below target rates for duration. Accessing breastfeeding support services is challenging for mothers living in rural areas of the state. Healthcare workers (HCWs) working with mothers and infants are in a key position to encourage and support breastfeeding efforts. The purpose of this study is to gain a better understanding of a Hawaiian community's (specifically Hilo, Hawai‘i) breastfeeding service and support issues. Method. The qualitative study design utilized was a focused ethnography. This approach was used to gather data from participant HCWs (N = 23) about their individual or shared experience(s) about the breastfeeding supports and services available in their community. An iterative process of coding and categorizing the data followed by conceptual abstraction into patterns was completed. Results. Three patterns emerged from the qualitative interviews: Operating within Constraints of the Particular Environment, Coexisting Messages, and Process Interrupted. Participants identified a number of gaps in breastfeeding services available to their clients including the lack of available lactation consultants and the inconsistent communication between hospital and community providers. A number of implications for practice and further research were suggested within the results and are discussed.

Breastfeeding booklet and proactive phone calls for increasing exclusive breastfeeding rates: RCT protocol

Breastfeeding is associated with infant and maternal health benefits and considerable potential savings to health services. Despite this, only 37% of infants globally are exclusively breastfed for 6 months. Interventions are needed to improve breastfeeding rates. The aim of this study is to determine whether written breastfeeding information in pregnancy and proactive breastfeeding-focused support phone calls, provided by a health professional educated in breastfeeding management, increase exclusive breastfeeding rates at 3 months compared with general birth-related information with proactive support calls or standard care. This is a single-centre, randomised, controlled, three-arm, superiority study with blind outcome assessment. Eligible participants will include primigravidae with singleton pregnancies who speak Croatian, attending six primary care obstetric practices. We estimate a total sample size of 459, with computer generated stratified randomisation of 153 women per arm. Participants in the intervention and active control groups will receive booklets in pregnancy, phone calls 2 weeks later, and 2, 6 and 10 weeks after birth. The primary outcome will be the proportion of women exclusively breastfeeding at 3 months. Secondary outcomes will compare: infant feeding practices and attitudes, social support, breastfeeding difficulties, breastfeeding self efficacy and utilisation of breastfeeding support services. Follow-up at 6 months will compare exclusive and any breastfeeding and utilised support services. Analysis will be by intention to treat. This trial will contribute to future evidence syntheses identifying the most effective forms of breastfeeding support.

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.

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.

"Be positive as well as realistic": a qualitative description analysis of information gaps experienced by breastfeeding mothers

Background

Early breastfeeding cessation is common in many regions of the world despite high breastfeeding initiation rates and strong evidence of the health benefits to both mother and infant. This research investigated mothers’ perceived breastfeeding information needs in order to increase our understanding of this phenomenon.

Methods

Surveys were distributed by public health nurses in a health region in Western Canada to mothers who had initiated breastfeeding and whose infants were six to eleven months old to learn more about their infant feeding experiences during the birth to six month period. Two open-ended survey questions asked: (1) What support or advice did you receive that helped you with feeding your baby?” and (2) “What support or information on feeding your baby would you have found helpful but did not receive?” A total of 191 eligible mothers submitted a survey (response rate 35%) between January and October 2012. Qualitative description was used in analyzing the responses of the women who provided comments for the open-ended questions.

Results

While many mothers felt their information needs were met, others outlined important content areas where more information and guidance was desired. These areas included milk supply management, frequency/duration of feeds, proper latch and feeding positions, nipple care, expression/pumping, other nutrition sources, and realistic information regarding common breastfeeding concerns.

Conclusions

The results suggest that several of the information gaps highlighted by respondents in this study closely align with commonly cited reasons for breastfeeding cessation including perceived insufficient milk supply, latching difficulties and nipple discomfort. The findings emphasize the need for lactation support with systematic measures to ensure breastfeeding mothers are universally provided with information on these key content areas. Lactation supports should reinforce critical information and seek feedback to ascertain that mothers have clearly understood the information provided. Ensuring mothers receive and understand key breastfeeding information is a modifiable factor in efforts to increase breastfeeding duration rates.

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.

Using qualitative comparative analysis (QCA) in systematic reviews of complex interventions: a worked example

BACKGROUND

Systematic reviews that address policy and practice questions in relation to complex interventions frequently need not only to assess the efficacy of a given intervention but to identify which intervention - and which intervention components - might be most effective in particular situations. Here, intervention replication is rare, and commonly used synthesis methods are less useful when the focus of analysis is the identification of those components of an intervention that are critical to its success.

METHODS

Having identified initial theories of change in a previous analysis, we explore the potential of qualitative comparative analysis (QCA) to assist with complex syntheses through a worked example. Developed originally in the area of political science and historical sociology, a QCA aims to identify those configurations of participant, intervention and contextual characteristics that may be associated with a given outcome. Analysing studies in these terms facilitates the identification of necessary and sufficient conditions for the outcome to be obtained. Since QCA is predicated on the assumption that multiple pathways might lead to the same outcome and does not assume a linear additive model in terms of changes to a particular condition (that is, it can cope with 'tipping points' in complex interventions), it appears not to suffer from some of the limitations of the statistical methods often used in meta-analysis.

RESULTS

The worked example shows how the QCA reveals that our initial theories of change were unable to distinguish between 'effective' and 'highly effective' interventions. Through the iterative QCA process, other intervention characteristics are identified that better explain the observed results.

CONCLUSIONS

QCA is a promising alternative (or adjunct), particularly to the standard fall-back of a 'narrative synthesis' when a quantitative synthesis is impossible, and should be considered when reviews are broad and heterogeneity is significant. There are very few examples of its use with systematic review data at present, and further methodological work is needed to establish optimal conditions for its use and to document process, practice, and reporting standards.

Ringing Up about Breastfeeding: a randomised controlled trial exploring early telephone peer support for breastfeeding (RUBY) - trial protocol

BACKGROUND

The risks of not breastfeeding for mother and infant are well established, yet in Australia, although most women initiate breastfeeding many discontinue breastfeeding altogether and few women exclusively breastfeed to six months as recommended by the World Health Organization and Australian health authorities. We aim to determine whether proactive telephone peer support during the postnatal period increases the proportion of infants who are breastfed at six months, replicating a trial previously found to be effective in Canada.

DESIGN/METHODS

A two arm randomised controlled trial will be conducted, recruiting primiparous women who have recently given birth to a live baby, are proficient in English and are breastfeeding or intending to breastfeed. Women will be recruited in the postnatal wards of three hospitals in Melbourne, Australia and will be randomised to peer support or to 'usual' care. All women recruited to the trial will receive usual hospital postnatal care and infant feeding support. For the intervention group, peers will make two telephone calls within the first ten days postpartum, then weekly telephone calls until week twelve, with continued contact until six months postpartum. Primary aim: to determine whether postnatal telephone peer support increases the proportion of infants who are breastfed for at least six months.

HYPOTHESIS

that telephone peer support in the postnatal period will increase the proportion of infants receiving any breast milk at six months by 10% compared with usual care (from 46% to 56%).Outcome data will be analysed by intention to treat. A supplementary multivariate analysis will be undertaken if there are any baseline differences in the characteristics of women in the two groups which might be associated with the primary outcomes.

DISCUSSION

The costs and health burdens of not breastfeeding fall disproportionately and increasingly on disadvantaged groups. We have therefore deliberately chosen trial sites which have a high proportion of women from disadvantaged backgrounds. This will be the first Australian randomised controlled trial to test the effectiveness and cost effectiveness of proactive peer telephone support for breastfeeding.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12612001024831.

The 'active ingredients' for successful community engagement with disadvantaged expectant and new mothers: a qualitative comparative analysis

AIMS

To explore which conditions of community engagement are implicated in effective interventions targeting disadvantaged pregnant women and new mothers.

BACKGROUND

Adaptive experiences during pregnancy and the early years are key to reducing health inequalities in women and children worldwide. Public health nurses, health visitors and community midwives are well placed to address such disadvantage, often using community engagement strategies. Such interventions are complex; however, and we need to better understand which aspects of community engagement are aligned with effectiveness.

DESIGN

Qualitative comparative analysis conducted in 2013, of trials data included in a recently published systematic review.

METHODS

Two reviewers agreed on relevant conditions from 24 maternity or early years intervention studies examining four models of community engagement. Effect size estimates were converted into 'fuzzy' effectiveness categories and truth tables were constructed. Using fsQCA software, Boolean minimization identified solution sets. Random effects multiple regression and fsQCA were conducted to rule out risk of methodological bias.

RESULTS/FINDINGS

Studies focused on antenatal, immunization, breastfeeding and early professional intervention outcomes. Peer delivery (consistency 0·83; unique coverage 0·63); and mother-professional collaboration (consistency 0·833; unique coverage 0·21) were moderately aligned with effective interventions. Community-identified health need plus consultation/collaboration in intervention design and leading on delivery were weakly aligned with 'not effective' interventions (consistency 0·78; unique coverage 0·29).

CONCLUSIONS

For disadvantaged new and expectant mothers, peer or collaborative delivery models could be used in interventions. A need exists to design and test community engagement interventions in other areas of maternity and early years care and to further evaluate models of empowerment.

Interventions designed to promote exclusive breastfeeding in high-income countries: a systematic review

BACKGROUND

Worldwide, women fail to reach the recommended exclusive breastfeeding target of 6 months postpartum. The objective of this study was to present a conceptual and methodological synthesis of interventions designed to promote exclusive breastfeeding to 6 months in high-income countries.

MATERIALS AND METHODS

A systematic search of leading databases was conducted for scholarly peer-reviewed randomized trials published between January 2000 and June 2013. Seventeen articles were identified as relevant; all were published in English and assessed exclusive breastfeeding with a follow-up period extending beyond 4 months postpartum. Articles were analyzed for overall quality of evidence, regarding duration of exclusive breastfeeding, using the Grading and Recommendations Assessment, Development, and Evaluation approach.

RESULTS

A significant increase in the duration of exclusive breastfeeding was found in eight of the 17 studies, with most interventions using supportive or educational approaches. Interventions in pregnancy focused on educating mothers on the benefits of exclusive breastfeeding. Fifteen interventions took place, at least in part, in the postnatal period and provided educational and emotional support to mothers. Of the eight successful interventions, five took part in the postnatal period in the mothers' own homes. The quality of the evidence for duration of exclusive breastfeeding was moderate.

CONCLUSIONS

The most successful interventions were conducted in the postnatal period and over a long period of time; however, the findings were inconsistent. No study assessed intervention fidelity, and only two studies noted maternal body mass index, a variable known to affect exclusive breastfeeding rates. Further research is needed to provide a robust evidence base to inform future interventions.

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

OBJECTIVE

The purpose of this study was to compare breastfeeding duration in mothers after delivery who were assigned randomly to a behavioral educational intervention vs enhanced usual care.

STUDY DESIGN

We conducted a randomized trial. Self-identified black and Latina mothers early after delivery were assigned randomly to receive a behavioral educational intervention or enhanced usual care. The 2-step intervention aimed to prepare and educate mothers about postpartum symptoms and experiences (including tips on breastfeeding and breast/nipple pain) and to bolster social support and self-management skills. Enhanced usual care participants received a list of community resources and received a 2-week control call. Intention-to-treat analyses examined breastfeeding duration (measured in weeks) for up to 6 months of observation. This study was registered with clinicaltrial.gov (NCT01312883).

RESULTS

Five hundred forty mothers were assigned randomly to the intervention (n = 270) vs control subjects (n = 270). Mean age was 28 years (range, 18-46 years); 62% of the women were Latina, and 38% were black. Baseline sociodemographic, clinical, psychosocial, and breastfeeding characteristics were similar among intervention vs control subjects. Mothers in the intervention arm breastfed for a longer duration than did the control subjects (median, 12.0 vs 6.5 weeks, respectively; P = .02) Mothers in the intervention arm were less likely to quit breastfeeding over the first 6 months after delivery (hazard ratio, 0.79; 95% confidence interval, 0.65-0.97).

CONCLUSION

A behavioral educational intervention increased breastfeeding duration among low-income, self-identified black and Latina mothers during the 6-month postpartum period.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

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.

Telephone support for women during pregnancy and the first six weeks postpartum

BACKGROUND

Telephone communication is increasingly being accepted as a useful form of support within health care. There is some evidence that telephone support may be of benefit in specific areas of maternity care such as to support breastfeeding and for women at risk of depression. There is a plethora of telephone-based interventions currently being used in maternity care. It is therefore timely to examine which interventions may be of benefit, which are ineffective, and which may be harmful.

OBJECTIVES

To assess the effects of telephone support during pregnancy and the first six weeks post birth, compared with routine care, on maternal and infant outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 January 2013) and reference lists of all retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials, comparing telephone support with routine care or with another supportive intervention aimed at pregnant women and women in the first six weeks post birth.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed studies identified by the search strategy, carried out data extraction and assessed risk of bias. Data were entered by one review author and checked by a second. Where necessary, we contacted trial authors for further information on methods or results.

MAIN RESULTS

We have included data from 27 randomised trials involving 12,256 women. All of the trials examined telephone support versus usual care (no additional telephone support). We did not identify any trials comparing different modes of telephone support (for example, text messaging versus one-to-one calls). All but one of the trials were carried out in high-resource settings. The majority of studies examined support provided via telephone conversations between women and health professionals although a small number of trials included telephone support from peers. In two trials women received automated text messages. Many of the interventions aimed to address specific health problems and collected data on behavioural outcomes such as smoking cessation and relapse (seven trials) or breastfeeding continuation (seven trials). Other studies examined support interventions aimed at women at high risk of postnatal depression (two trials) or preterm birth (two trials); the rest of the interventions were designed to offer women more general support and advice.For most of our pre-specified outcomes few studies contributed data, and many of the results described in the review are based on findings from only one or two studies. Overall, results were inconsistent and inconclusive although there was some evidence that telephone support may be a promising intervention. Results suggest that telephone support may increase women's overall satisfaction with their care during pregnancy and the postnatal period, although results for both periods were derived from only two studies. There was no consistent evidence confirming that telephone support reduces maternal anxiety during pregnancy or after the birth of the baby, although results on anxiety outcomes were not easy to interpret as data were collected at different time points using a variety of measurement tools. There was evidence from two trials that women at high risk of depression who received support had lower mean depression scores in the postnatal period, although there was no clear evidence that women who received support were less likely to have a diagnosis of depression. Results from trials offering breastfeeding telephone support were also inconsistent, although the evidence suggests that telephone support may increase the duration of breastfeeding. There was no strong evidence that women receiving telephone support were less likely to be smoking at the end of pregnancy or during the postnatal period.For infant outcomes, such as preterm birth and infant birthweight, overall, there was little evidence. Where evidence was available, there were no clear differences between groups. Results from two trials suggest that babies whose mothers received support may have been less likely to have been admitted to a neonatal intensive care unit (NICU), although it is not easy to understand the mechanisms underpinning this finding.

AUTHORS' CONCLUSIONS

Despite some encouraging findings, there is insufficient evidence to recommend routine telephone support for women accessing maternity services, as the evidence from included trials is neither strong nor consistent. Although benefits were found in terms of reduced depression scores, breastfeeding duration and increased overall satisfaction, the current trials do not provide strong enough evidence to warrant investment in resources.