Discontinuity of Breastfeeding Care: "There's No Captain of the Ship"

Missed care and equitable breastfeeding support: An integrative review of exposure to in-hospital care by patient characteristics and breastfeeding outcomes

AIM

To synthesize the literature on breastfeeding outcomes associated with exposure to internationally recognized best practices, such as the Baby-Friendly Hospital Initiative, for patients in the United States during the postpartum period, contextualized within the Missed Care Model.

DESIGN

The authors employed Whittemore and Knafl's integrative review framework and the 2020 PRISMA guidelines for data extraction, synthesis, reporting and assessment.

METHODS

Five electronic databases were searched for articles published between 2007 and 2023. Eligible articles reported on exposure to breastfeeding best practices and outcomes or the experiences, views, perceptions and attitudes of parents, nurses or lactation consultants regarding hospital breastfeeding support. Extracted data were compared to identify in-hospital exposure to breastfeeding best practices and breastfeeding outcomes, and differences in exposure and outcomes based on patient and provider characteristics.

RESULTS

Twenty-one quantitative, qualitative and mixed methods articles met inclusion criteria. A higher reported adherence to best practices was associated with greater odds of breastfeeding; some practices demonstrated greater effects overall or for specific groups. Higher exposures to best practices and higher breastfeeding rates were found for non-Hispanic white patients, and those with more education, private insurance and who live in urban areas. Disparities in support and outcomes were related to patients' race/ethnicity, language, weight and age. Qualitative findings reflected missed care concepts, such as internal processes related to habits and group norms, relevant to breastfeeding support.

CONCLUSION

Review findings also include an adapted Missed Care Model specific to breastfeeding support, which can inform future research related to providers' internal processes that may influence breastfeeding or equitable breastfeeding care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Missed care can be influenced by a variety of factors, including providers' internal values and beliefs. Study findings suggest the existence of inequities in breastfeeding care and underscore the need to address and eliminate breastfeeding disparities.

IMPACT

This study addressed how patient exposure to best practices in breastfeeding support relates to breastfeeding outcomes and whether exposure and outcomes differ by patient or provider characteristics, connecting this to the Missed Care in Breastfeeding Support Model. The main findings were that higher reported exposure to best practices in breastfeeding support related to improved breastfeeding outcomes; inequities exist in exposure to best practices; and patients and providers identify the importance of providers' internal processes in the delivery of breastfeeding support, which aligns with the Missed Care in Breastfeeding Support Model. Study findings will have the potential to impact how nurses, lactation consultants and other providers who deliver breastfeeding support in the postpartum hospital setting.

REPORTING METHOD

The authors adhered to relevant 2020 PRISMA reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Low Nirmatrelvir and Ritonavir Exposure through Breastmilk: Analyzing Milk Concentrations and Infant Risk

This research study investigates the intricate relationship among COVID-19, maternal and infant health, and breastfeeding practices, with a specific focus on assessing the transfer of nirmatrelvir and ritonavir into human milk. Our aim is to provide critical insights to those managing COVID-19 treatment in lactating individuals. The InfantRisk Center Human Milk Biorepository contained human milk and corresponding health information for eight mother-infant dyads exposed to standard doses of maternal nirmatrelvir with ritonavir (300 mg nirmatrelvir and 100 mg ritonavir taken orally twice daily for 5 days). The primary outcomes measured were drug levels in milk using liquid chromatography-mass spectrometry and reporting the tolerance of the breastfed infant. Nirmatrelvir with ritonavir was measurable in all participants at a mean concentration of 33.48 ng/mL (ritonavir) and 729 ng/mL (nirmatrelvir). The estimated infant dose via milk was 0.0024 mg/kg/12 h (ritonavir) and 0.054 mg/kg/12 h (nirmatrelvir). The estimated relative infant dose was 0.19% (ritonavir) and 1.43% (nirmatrelvir) well under the standard 10% safety threshold. Among the eight infants exposed in this study, there were no reported adverse events. Nirmatrelvir with ritonavir is the recommended treatment for ambulatory COVID-19 patients with mild-to-moderate COVID-19 infection at high risk for progression to severe disease. Although its use is recommended in lactating women, there are no previous studies on the transfer of nirmatrelvir into human milk. The study findings endorse the current approach of nirmatrelvir/ritonavir use in lactating women and encourage healthcare providers to consider prescribing this treatment irrespective of lactation status when indicated.

Healthcare providers' perceived barriers to providing breastfeeding support in Northwest rural China

BACKGROUND

Healthcare providers play important roles in supporting breastfeeding. Although there has been insufficient actual breastfeeding support from healthcare providers in China, little research has been conducted to understand Chinese healthcare providers' perceived barriers to providing breastfeeding support, especially in rural China. This study aims to identify these perceived barriers to providing breastfeeding support in Northwestern rural China.

METHODS

This study was conducted during the period from March 2018 to December 2018. Forty-one healthcare providers were recruited through purposive sampling in two rural counties in Northwest China that are in close proximity to each other and share similar demographic features. Participants included obstetrician-gynecologists, midwives, nurses, "village doctors", and township and village maternal and child health workers. Qualitative data were collected through one-on-one in-depth semi-structured interviews and focus group discussions. Transcripts were thematically analyzed.

RESULTS

Analysis of interview data resulted in four themes that the participants perceived as barriers to supporting breastfeeding: (1) lack of medical resources, within which inadequate staffing, and lack of financial incentives were discussed, (2) lack of clear and specific responsibility assignment, within which no one takes the lead, and mutual buck-passing were discussed, (3) healthcare providers' lack of relevant expertise, within which lack of knowledge and skills, and low prestige of village healthcare providers were discussed, (4) difficulties in accessing mothers, within which medical equipment shortages reduce services utilization, mothers' housing situation, mothers' mobility, and cultural barriers were discussed.

CONCLUSIONS

The study identified HCPs perceived barriers to providing breastfeeding support. Unique to China's Tri-Level Healthcare System, challenges like staffing and financial incentives are hard to swiftly tackle. Recommendations include mHealth enhancement and clarified responsibilities with incentives and tailored training. Further research is crucial to evaluate these strategies in rural Northwestern China and comparable underdeveloped areas nationwide.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Quasi-realist Synthesis Investigating Professional Breastfeeding Support Failure

Background/Purpose: To conduct a synthesis based on a realist perspective, -investigating how professional breastfeeding support can sometimes be ineffective and/or unsatisfactory from the viewpoint of the mother and fail to address the needs of the breastfeeding dyad. Methods: An innovative, targeted "quasi-realist" -synthesis technique was used to explore the context of the interpersonal relationships through which professional breastfeeding intervention is delivered and identify any unintended mechanisms and/or consequences. Results: Multiple expressions of failed breastfeeding support were revealed which had a negative impact on maternal empowerment, informed decision-making, and breastfeeding self-efficacy. The overarching theme, inadequate breastfeeding information/ support, was elucidated by several subthemes: giving inconsistent/contradictory advice, use of the hands-on approach, provision of insensitive care, and making parents feel scrutinized/judged Mothers who experienced inadequate breastfeeding information/support often resorted to the mechanism of duplicity/evasion and withdrew from seeking or following further professional advice. Finally, unintended consequences of not breastfeeding as recommended included feelings of guilt and a sense of failure This was particularly true for mothers who intended to exclusively breastfeed. Implications for Practice: The findings of this unique synthesis suggest that to sustain breastfeeding support relationships and prevent unintentional consequences of inadequate support, professionals must pay more attention to the manner in which breastfeeding intervention is provided. The findings also suggest that they must strive to provide more consistent, engaging, -sensitive, and nonjudgmental care that better meets the needs of breastfeeding dyads.

Mixed Messages in Women, Infants, and Children Lactation Support

Objective:

Breastfeeding provides health benefits, but women enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are less likely to breastfeed than those not enrolled. This study aimed to investigate the forms of messaging that occur in WIC lactation support.

Methods:

Ethnographic methods were used over a 3-month period in 2021. Observations were collected at WIC lactation care counseling sessions and were complemented with interviews, observations of other interactions, and archival documents.

Results:

The findings of this study indicate women received mixed messages about breastfeeding, including the advice, personal experience, and policies discussed in lactation counseling.

Conclusions:

This study suggests women’s personal experiences may conflict with the messages they receive from lactation support. Recommendations for lactation support programs and training are discussed.

Creating a Culture of Breastfeeding Support and Continuity of Care in Central Illinois

Central Illinois breastfeeding rates fall short of the recommendation to breastfeed exclusively through 6 months, and Black, low-income, and rural families disproportionately experience low rates. A continuity of care framework, which emphasizes interdisciplinary coordination from the prenatal period through weaning, can support breastfeeding. This case study describes an innovative practice model informed by the Collective Impact Model (CIM) designed to promote breastfeeding continuity of care and community support in Central Illinois. Development and maintenance of the Central Illinois Breastfeeding Professional Network (CIBPN), a network of diverse public health practitioners, leveraged CIM principles. The CIBPN began with influential Breastfeeding Champions, identified through the Illinois State Physical Activity and Nutrition program. Champions convened Central Illinois breastfeeding allies and led the CIBPN to coalesce around a common agenda and engage in mutually reinforcing activities. Linked breastfeeding data for families giving birth at a Central Illinois hospital and receiving postnatal care at a health center were analyzed as a snapshot of CIBPN initiatives. The CIBPN engaged at least 135 practitioners and more than 27 organizations. At least 33 people received advanced breastfeeding training, and many professional development opportunities were offered. Numerous breastfeeding support improvements were made at and between CIBPN sites. Breastfeeding rates at the birthing hospital and health center were stable, including during the COVID-19 pandemic. This article contributes to the practice-based evidence for breastfeeding support by strengthening continuity of care through a successful application of the CIM by public health practitioners.

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

INTRODUCTION

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Barriers to Providing Lactation Services and Support to Families in Appalachia: A Mixed-Methods Study With Lactation Professionals and Supporters

Objectives. To understand the barriers and facilitators that lactation professionals and supporters (LPSs) in the Appalachian region of the United States experience when providing services and support to families. Methods. We used a mixed-methods explanatory sequential design with a survey of LPSs in Appalachia (March‒July 2019), followed by semistructured interviews with LPSs (January‒April 2020). We summarized survey responses descriptively and analyzed interview transcripts thematically. Results. The survey was completed by 89 LPSs in Appalachia. We conducted semistructured interviews with 20 LPSs. Survey participants most commonly identified challenges with other health care providers, hospital practices, and non‒medically indicated supplementation as barriers. Interview participants described challenges with clients' families not supporting breastfeeding, difficulty reaching clients, limited numbers of LPSs, and lack of racial/ethnic diversity among LPSs. LPSs identified the need for training in lactation and substance use, mental health, and birth trauma, and supporting lesbian, gay, bisexual, transgender, queer or questioning, plus (LGBTQ+) families. LPSs described social media and telehealth as both facilitators and barriers. Social support from other LPSs was a facilitator. Conclusions. LPSs in Appalachia face various challenges. Addressing these challenges has the potential to improve the lactation support and services families in Appalachia receive. (Am J Public Health. 2022;112(S8):S797-S806. https://doi.org/10.2105/AJPH.2022.307025).

Understanding the challenges related to breastfeeding education and barriers to curricular change: a systems perspective for transforming health professions education

OBJECTIVES

A majority of women and families wish that their babies be breastfed. However, too many still receive insufficient or inappropriate initial care from health professionals (HPs) who have limited breastfeeding (BF) competencies. We investigated barriers and potential solutions to improve the undergraduate training programs for various HPs.

METHODS

Focus groups were carried out in three universities in Quebec and one in Ontario (Canada), with 30 faculty and program directors from medicine, midwifery, nursing, nutrition, and pharmacy. Discussions were subjected to thematic content analysis, before being validated in a strategic planning workshop with 48 participants from the same disciplines, plus dentistry and chiropractic.

FINDINGS

Substantive improvements of undergraduate training programs for BF could be obtained by addressing challenges related to the insufficient, or lack of, (i) interactions among various HPs, (ii) opportunities for practical learning, (iii) specific standards to guide course content, (iv) real-life experience with counselling, and (v) understanding of the influence of attitudes on professional practice. Several potential solutions were proposed and validated. The re-interpretation of the results in light of various literature led to an emerging framework that takes a systems perspective for enhancing the education of HPs on BF.

CONCLUSIONS

To improve the education of HPs so as to enable them to provide relevant support for future mothers, mothers and their families, solutions need to be carried out to address challenges in the health system, the education system as well as regarding the curricular change process.

Lessons Learned from the Pandemic—We Can Do Better

Many breastfeeding issues can be addressed with postpartum lactation support. However, COVID-19 presented new challenges for the breastfeeding dyad with a disruption in normal healthcare practices. The objective of the study was to examine new mothers’ breastfeeding intentions and practices during the COVID-19 pandemic. A 40-question survey was administered to a convenience sample of 50 new mothers during April–June 2020. Findings revealed most mothers (52%) had the intention to breastfeed for one year or longer. However, at the time of hospital discharge only 34% of mothers were exclusively breastfeeding and 60% of mothers were supplementing with formula within the first four days of life. Recommendations for bridging the gap between the hospital and primary care setting include educating providers and nurses on breastfeeding management practices, increasing hospital lactation support, and using telelactation to provide remote support to mothers.

Mothers’ strategies for creating positive breastfeeding experiences: a critical incident study from Northern Sweden

Background

Positive breastfeeding experiences positively influence subsequent attitudes towards breastfeeding, and increase mothers’ confidence, self-efficacy, motivation and intention to breastfeed. However, the strategies that mothers find useful and effective for creating positive breastfeeding experiences remain largely unknown. The aim of our study was thus to describe experience-based knowledge from mothers about strategies for creating positive breastfeeding experiences.

Methods

The study followed a qualitative design involving the critical incident technique. Data were collected with an online survey containing open-ended questions that was administered to a Sweden-based parenting group on Facebook in September 2018. Ultimately, 340 incidents from 176 women were identified as offering strategies for creating positive breastfeeding experiences. Data from the written replies were extracted as textual units, condensed and categorised until categories were mutually exclusive, which resulted in six categories.

Results

Participating women were on average 31.2 years old and the median number of children per participant was two. Mothers’ strategies for creating positive breastfeeding experiences generally included being calm and accepting that initiating breastfeeding takes time and can be difficult initially. Participants described feeling close to the baby by maintaining skin-to-skin contact and being present in the moment by taking time to appreciate the child and the breastfeeding situation, and temporarily forgetting about the world and simply being with the child in the here and now. Participants advocated baby-led breastfeeding and following correct techniques. They also described the importance of keeping an effortless mindset about breastfeeding to prevent perceiving breastfeeding as a compulsion. Mothers described acquiring knowledge about breastfeeding so that they could be prepared if breastfeeding problems occurred and getting support from professionals and family was described as significant for having a positive breastfeeding experience. Caring for oneself and one’s body, with aids if necessary, were described as important strategies, as were having a positive attitude and a strong desire to breastfeed.

Conclusion

Because positive breastfeeding experiences and support are predictors of future breastfeeding initiation and duration, assisting women in creating positive breastfeeding experiences is important. Asking mothers to formulate strategies that they find useful could facilitate breastfeeding by making their approaches more conscious and visible.

Ethical Considerations for Hospital-Based Infant Feeding Support

I applied a systematic ethical decision-making approach to evaluate how health care professionals in hospital settings should provide infant feeding support after childbirth. Human milk is recommended as the optimal source of nutrition for infants because of the health benefits it provides for infants and their lactating parents. However, health consequences of insufficient oral intake in infants and psychological distress in the lactating parent may occur when infant feeding does not go according to plan. Infant feeding support should be provided in a way that is objective, sensitive, individualized, equitable, and supportive of autonomy and avoids harm. I provide recommendations for ethical infant feeding support that can be applied by individual health care professionals and on postpartum units in hospitals.

Explaining variance in breastfeeding intentions and behaviors among a cohort of Midwest mothers using a theory of planned behavior-based structural model

Background

The Theory of Planned Behavior (TPB) has guided the investigation of breastfeeding since the 1980’s, incorporating the major constructs of attitudes, subjective norms/normative beliefs, perceived behavioral control, and intentions. The purpose of this research study was to define a TPB-based structural latent variable model so as to explain variance in breastfeeding intentions and behaviors among a cohort of Midwest breastfeeding mothers.

Methods

The longitudinal descriptive study utilized questionnaire data collected from a convenience sample of 100 women with low-risk pregnancies with the intention to breastfeed at three separate time points (> 30 weeks antepartum, 10 and 60 days postpartum). Data were coded and analyzed using IBM SPSS, SAS and the lavaan package in R.

Results

Participants were predominantly White (94%, n = 94), married (95%, n = 95), college-educated (96%, n = 96), and had previous breastfeeding experience (75%, n = 75). The majority gave birth vaginally (79%, n = 75). Varimax analysis revealed a plurality of factors within each domain. Attempts to fit a structural model, including both hierarchical and bi-factor latent variables, failed, revealing a lack of statistical significance and poor fit statistics.

Conclusion(s)

These findings illustrate the importance of using methods that fit the phenomena explained. Contributors to poor model fit may include outdated tools lacking cultural relevance, a change in social norms, or a failure to capture the possible influence of social media and formula marketing on breastfeeding behaviors. The null finding is a significant finding, indicating the need to revisit and refine the operationalization and conceptual underpinnings of the TPB through qualitative methods such as exploring the lived experiences of breastfeeding women in the Midwest region.

Healthcare provider's experiences of supporting breastfeeding: protocol for a systematic review of qualitative evidence

INTRODUCTION

Breastfeeding provides various health benefits to both mothers and infants. Despite the efforts that have been made, breastfeeding rates remain lower than recommended worldwide. Healthcare providers often fail to provide the support women need due to various reasons such as lack of time and competency, discontinuity of care and so on. Synthesis of the primary qualitative studies exploring healthcare providers' experience with supporting breastfeeding can provide greater insights into their perceived barriers and facilitators and further provide evidence for the implementation of interventions to improve breastfeeding services.

METHODS AND ANALYSIS

Qualitative studies exploring healthcare providers' experiences with breastfeeding services will be searched in the following databases: PubMed, Embase, CINAHL, Scopus, ProQuest, PsycINFO, the Cochrane Library, Web of Science, China Biology Medicine disc, China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, Chinese Wanfang Data, ProQuest Dissertations and Theses, Open Grey collection. Studies reported in English or Chinese and conducted between January 1990 to July 2021 will be included. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research will be used to assess the methodological quality of included studies. The JBI standardised data extraction tools will be used to extract data. The JBI meta-aggregation method will be used to synthesise the data. The synthesised findings will be graded finally according to the ConQual approach to establish confidence. Two authors will independently screen and select the search output, extract data, assess methodological quality and cluster findings. Any disagreements that arise between the two reviewers will be adjudicated by a third reviewer to reach a consensus.

ETHICS AND DISSEMINATION

This review will use published data, so it will not require ethical approval. The findings of this systematic review will be disseminated via an international peer-reviewed journal publication and several scientific conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42021254542.

Increasing Breastfeeding Rates Through Continuity of Care

Background

Continuity of care is important in many aspects of medicine, as evidenced by the patient-centered medical home model. The newborn period is an especially important time for continuity of care, as this time sets the stage for lifelong health. Breastfeeding, which is known for its positive health benefits for both mother and child, is the gold standard for infant feeding. While inpatient lactation support is a common amenity available during hospital admission, support can be more difficult to obtain once a patient is discharged. To help eliminate this barrier, a process was put in place within an Eastern Pennsylvania health network’s seven office locations to standardize outreach to the mother-infant dyad.

Methods

A quality improvement retrospective chart review comparing pre- and post-intervention rates of exclusive and non-exclusive breastfeeding was completed using one health system’s Electronic Health Record (EHR). A referral process was established to capture dyads born within the health network’s hospital who were going to be followed at one of the seven pediatric offices outpatient. Mothers were called and followed to see how they were progressing with their breastfeeding goals. Any problems were addressed by the health network’s International Board-Certified Lactation Consultants (IBCLCs) and Certified Lactation Counselor (CLC).

Results

Lactation rates at the pediatric practice were observed to have increased at both 6 months and 12 months post-intervention compared to pre-intervention.

Conclusion

Proactively scheduling and providing outreach immediately following birth may promote increased breastfeeding rates.

Prenatal Provider Breastfeeding Toolkit: Results of a Pilot to Increase Women's Prenatal Breastfeeding Support, Intentions, and Outcomes

BACKGROUND

Breastfeeding rates for United States women with lower incomes fall below the government's Healthy People 2020 Goals. Breastfeeding recommendations combined with support from providers and peer counselors help women decide to begin and sustain breastfeeding, but peer counselor uptake is low.

RESEARCH AIM

To evaluate changes in referrals to Women, Infants, and Children's Supplemental Nutrition Program peer counselors, reported prenatal provider education and support, and breastfeeding outcomes (intention, initiation, 1-month duration of any and exclusive breastfeeding) after a prenatal breastfeeding promotion intervention.

METHOD

In this pre-post intervention study (2015-2016; upstate New York), providers implemented a Toolkit to discuss infant feeding recommendations and initiate peer counselor referral. We surveyed women pre- and post-implementation (after delivery; 1 month postpartum) about prenatal breastfeeding intentions, provider support, and breastfeeding outcomes. Analyses controlled for secular trends.

RESULTS

Pre-intervention (n = 71) and post-intervention (n = 70) participants were 49% Black, 61% publicly insured, and 16% uninsured. More post-intervention participants had > 1 Toolkit use (76%), peer counselor program referrals (60.0% post vs. 36.6% pre, p < .01), reported any breastfeeding intention (89% vs. 72%, p = .013), and intended to breastfeed for > 1 year (31% vs. 14%, p = .014). Post-intervention breastfeeding initiation and exclusivity were higher, but not significantly different. Post-intervention participants reported better prenatal breastfeeding support.

CONCLUSIONS

Implementing a prenatal Breastfeeding Toolkit, including facilitating peer counselor referral, was associated with increases in provider counseling, participants' breastfeeding intentions, and uptake of peer counselors. Replicating this approach may reinforce efforts to support breastfeeding in similar practices serving women with lower incomes.

Indução da lactação em mulheres nuligestas: relato de experiência

Resumo Objetivo relatar a experiência de indução da lactação em nuligestas realizada por enfermeira consultora em aleitamento. Método relato de experiência. O processo de indução láctea foi realizado com três mulheres por motivo de gestação em útero de substituição e relacionamento homoafetivo. Resultados todas perceberam o aumento de tamanho e a sensibilidade nas mamas, bem como apresentaram secreção láctea. No entanto, a continuidade da amamentação foi diferenciada entre elas. A primeira não recebeu apoio de profissionais de saúde no contexto de pós-parto hospitalar, nem em casa, e não deu continuidade à amamentação. A segunda recebeu apoio da equipe do hospital e da parceira, amamentando por três meses. A terceira, com o apoio da parceira, amamentou por dois meses, mas interrompeu por sentir-se inibida por familiares. Conclusão e implicações para a prática a técnica de indução é capaz de desencadear a produção láctea. Já o processo de amamentação só se estabeleceu mediante a associação com a rede de apoio, o acolhimento, o incentivo da equipe de saúde e o olhar integral à mulher e sua família. Dessa forma, o cuidado de Enfermagem na indução láctea não deve focar apenas no manejo da indução, mas transcender o aspecto técnico, o que se mostra como fundamental para a proteção, o estabelecimento e a continuidade da amamentação.

Testing the buffering hypothesis: Breastfeeding problems, cessation, and social support in the UK

OBJECTIVES

Physical breastfeeding problems can lead women to terminate breastfeeding earlier than planned. In high-income countries such as the UK, breastfeeding problems have been attributed to the cultural and individual "inexperience" of breastfeeding, ultimately leading to lower breastfeeding rates. Yet, cross-cultural evidence suggests breastfeeding problems still occur in contexts where breastfeeding is common, prolonged, and seen publicly. This suggests breastfeeding problems are not unusual and do not necessarily lead to breastfeeding cessation. As humans evolved to raise children cooperatively, what matters for breastfeeding continuation may be the availability of social support during the postnatal period. Here, we test the hypothesis that social support buffers mothers from the negative impact breastfeeding problems have on duration.

METHODS

We run Cox models on a sample of 565 UK mothers who completed a retrospective online survey about infant feeding and social support in 2017-2018.

RESULTS

Breastfeeding problems were important predictors of cessation; however, the direction of the effect was dependent on the problem type and type of support from a range of supporters. Helpful support for discomfort issues (blocked ducts, too much milk) was significantly associated with reduced hazards of cessation, as predicted. However, helpful support for reported milk insufficiency was assoicated with an increased hazard of cessation.

CONCLUSIONS

Experiencing breastfeeding problems is the norm, but its impact may be mitigated via social support. Working from an interdisciplinary approach, our results highlight that a wide range of supporters who provide different types of support have potential to influence maternal breastfeeding experience.

The risk-risk trade-offs: Understanding factors that influence women's decision to use substances to boost breast milk supply

Galactagogues are foods, herbs or medications thought to support or increase breast milk supply. The use of galactagogues during lactation is becoming increasingly common despite limited evidence regarding effectiveness and safety, and no definitive recommendations for use in clinical practice. The aim of this study is to explore factors influencing women's decisions to use galactagogues during lactation. Twenty-two semi-structured interviews were conducted in October and November 2019 (over the telephone or in person) with participants located in most Australian states and territories, including metro and regional areas. Interviews were audio-recorded, transcribed verbatim and thematically analysed using NVivo. Analysis revealed that following a concern about breast milk supply, the decision to use galactagogues was influenced by three core and interrelated domains: access to and quality of breastfeeding support, maternal agency and determination to provide breast milk. Women revealed many problematic experiences with health care professionals that left them feeling dismissed and confused due to provision of inconsistent and insufficient information that was sometimes at odds with their desire to provide breast milk. In this instance, some women turned to galactagogues to regain agency. A range of broader dimensions influencing decision-making also emerged. These were separated into categories that emphasise distinctions relating to breast milk supply, which included: maternal emotional wellbeing, social norms and pressures, concerns about infant development, maternal physical health and lactation history, as well as those relating specifically to galactagogue use, including: desire for a guaranteed/urgent response, risk-risk trade-off, acceptance and trust, and accessibility and cost. In understanding the complexity of decision-making concerning these substances, we identify opportunities to improve breastfeeding counselling and support. We recommend that support be individually tailored to manage conflicting information, adopt communication styles that encourage trust and processes that enable shared decision-making to enhance or restore maternal agency. There is also considerable need to address evidence gaps regarding the effectiveness and safety of commonly used galactagogues, so that women can be appropriately counselled about potential benefits and harms.

Breastfeeding in the first six months of life for babies seen by Lactation Consulting

OBJECTIVE

to identify breastfeeding patterns, survival of exclusive breastfeeding and factors associated with its interruption, in the first six months of life of babies seen by Lactation Consulting.

METHOD

a prospective cohort, with 231 mother-babies in a Baby-Friendly Hospital. An initial questionnaire was applied after 24 hours of birth, after consulting, as well as a follow-up questionnaire, applied by telephone at 15, 30, 60, 120 and 180 days, with sociodemographic and obstetric variables, maternal habits, father's schooling, birth data and baby feeding. Survival Analysis was carried out.

RESULTS

at 180 days of age, exclusive breastfeeding was 12.7% and the probability was 19.6% in the analysis of the survival curve. The factors associated with its interruption were smoking during pregnancy (HR 1.66; CI 1.05 - 2.61), age ≥ 35 years old (HR 1.73; CI 1.03 - 2.90), difficulty in breastfeeding after hospital discharge (HR 2.09; CI 1.29 - 3.41), search for professional assistance (HR 2.45; CI 1.69 - 3.54) and use of a pacifier (HR 1.76; IC 1.21 - 2.58).

CONCLUSION

lactation consultancy contributed to the improvement of the exclusive breastfeeding rates, although there are opportunities for advances.

Telelactation with a Mobile App: User Profile and Most Common Queries

Background: Mobile applications related to health issues are currently expanding. Different uses of new technologies have produced positive results regarding breastfeeding support. Breastfeeding applications are increasing. Objective: We conducted a descriptive analysis of a mobile application for breastfeeding (LactApp) to study the user profile and the most frequent queries. Materials and Methods: This was a retrospective, comparative, and descriptive ecological time-series study of LactApp from 2016 to 2019. Google Analytics and the app itself were used for data collection. The data were analyzed in Excel, and for the time series, Prais-Winsten autoregressions were applied based on the Durbin-Watson method in Stata. Results: A total of 115,830 users and 71,780 infants were registered in the application. A total of 1.91% of these users obtained the medical version. The application was used for both queries and surveys and for users to interact through chat. A total of 30.17% of the responses were related with "baby's sleep" (8.94%), 8.91% were related to "preservation of milk," 6.16% were related to "breastfeeding crisis," and 6.15% were related to "physiological evolution of breastfeeding," all with an increasing trend. Conclusion: LactApp is a resource for breastfeeding that is widely downloaded and used by a substantial number of individuals. The most recurring topics were baby's sleep, milk extraction and preservation, breastfeeding crisis and physiological evolution of breastfeeding.

Description of an mHealth tool for breastfeeding support: LactApp. Analysis of how lactating mothers seek support at critical breastfeeding points and according to their infant's age

Interventions in mHealth have had positive effects on establishing and maintaining breastfeeding, but we still do not know what content women consult when downloading a breastfeeding mobile application. We conducted an observational, descriptive, and retrospective study using the data recorded by LactApp in 2019. The most frequently consulted topics were those related to breastfeeding technique, infant sleep, human milk management and storage, breastfeeding myths, breastfeeding stages, complementary feeding, infant care, and returning to work. Our study results suggest that LactApp's support seems to develop with mothers' needs according to their infant's development stage. The first breastfeeding days include more physiological answers. Between 15 days and 3 months, mothers look for support in topics like breastfeeding crisis/complications and returning to work. At 3 months to 1 year, answers are related to complementary feeding and weaning. When the user's infant is 1 year of age, mothers seek support for weaning, weaning management, and tandem breastfeeding.

Breastfeeding support at an Australian Breastfeeding Association drop-in service: a descriptive survey

Background

In Australia, during the early establishment phase of breastfeeding, women can access telephone peer support counselling provided by the Australian Breastfeeding Association (ABA) however options for face-to-face peer support are limited. The known factors which improve ongoing and exclusive breastfeeding include face-to-face support, peer and/or professional support, and trained personnel. This study aimed to examine women’s experiences of accessing one breastfeeding drop-in peer support service provided by trained peer support volunteer counsellors from the ABA.

Methods

Women who accessed the service were invited, in 2014, to participate in an anonymous online survey which collected both quantitative and qualitative data. Participants were asked about their experiences of breastfeeding support, as well as their experiences of the drop-in service. In total, 53 women completed the online survey, and subsequent analysis generated descriptive statistics and qualitative themes.

Results

Responses to the survey revealed that women attended the drop-in service with infants ranging in age from less than 1 week through to 12 months of age. Most women reported attending with infants aged 0–8 weeks of age (72%). The predominant presenting problems identified were sore/damaged nipples, difficulties with infant latching to the breast, or concerns about using nipple shields. Analysis of the open text qualitative responses revealed one overarching theme ‘Support to continue breastfeeding’ and four subthemes: ‘feeling listened to and not judged’; ‘emotional support and confidence building’; ‘the importance of face-to-face, practical support’; and ‘the need for ongoing, free access’.

Discussion

In this study many women were seeking support for ongoing breastfeeding difficulties. Health professionals who had limited breastfeeding knowledge and skills were identified as most unhelpful in providing support with ongoing breastfeeding difficulties. Women valued having access to trained peer counsellors, who had the capacity to provide non-judgemental, face-to-face support; who could sit through a feed; in a space that was ‘safe’; and who could enhance a woman’s confidence with breastfeeding over the course of her full breastfeeding journey.

Conclusions

Reactive peer support, provided in response to need, at an Australian Breastfeeding Association drop-in service, was described by participants as pivotal to enabling their ongoing breastfeeding.

Nursing student's knowledge about breastfeeding: Design and validation of the AprendeLact questionnaire

BACKGROUND

Breastfeeding is the best source of food that a mother can offer her child during the first months of life because it provides numerous benefits for both mother and baby. Despite breastfeeding being an innate act, it requires qualified health professionals for advice and support.

OBJECTIVES AND PARTICIPANTS

To design and validate a questionnaire to evaluate nursing student breastfeeding knowledge.

METHODS AND DESIGN

Cross-sectional study. Construction and validation of the questionnaire (content validity, test-retest reliability and internal consistency). Descriptive and bivariate analyses of socio-demographic variables and the questionnaire results.

RESULTS

Optimum results were obtained in terms of internal consistency (KR-20 = 0.9) and test-retest reliability (ICC = 0.925) with a samples of 144 participants (mean age of 22.69 years). Statistical significance were observed among the questionnaire score and academic year, clinical practice, type of breastfeeding in childhood, knowing about support groups and participating in a breastfeeding workshop or course.

CONCLUSION

A questionnaire on breastfeeding knowledge was validated. Nursing students progressively acquire breastfeeding skills as they advance in their undergraduate studies.

Vulnerable mothers' experiences breastfeeding with an enhanced community lactation support program

The Canada Prenatal Nutrition Program (CPNP) provides a variety of health and nutrition supports to vulnerable mothers and strongly promotes breastfeeding but does not have a formal framework for postnatal lactation support. Breastfeeding duration and exclusivity rates in Canada fall well below global recommendations, particularly among socially and economically vulnerable women. We aimed to explore CPNP participant experiences with breastfeeding and with a novel community lactation support program in Toronto, Canada that included access to certified lactation consultants and an electric breast pump, if needed. Four semistructured focus groups and 21 individual interviews (n = 46 women) were conducted between September and December 2017. Data were analysed using inductive thematic analysis. Study participants reported a strong desire to breastfeed but a lack of preparation for breastfeeding-associated challenges. Three main challenges were identified by study participants: physical (e.g., pain and low milk supply), practical (e.g., cost of breastfeeding support and maternal time pressures), and breastfeeding self-efficacy (e.g., concern about milk supply and conflicting information). Mothers reported that the free lactation support helped to address breastfeeding challenges. In their view, the key element of success with the new program was the in-home visit by the lactation consultant, who was highly skilled and provided care in a non-judgmental manner. They reported this support would have been otherwise unavailable due to cost or travel logistics. This study suggests value in exploring the addition of postnatal lactation support to the well-established national CPNP as a means to improve breastfeeding duration and exclusivity among vulnerable women.

How much can Mexican healthcare providers learn about breastfeeding through a semi-virtual training? A propensity score matching analysis

Background

Mexico has shown a worrisome decrease in breastfeeding indicators, especially in the lowest socioeconomic level. Improving breastfeeding protection, promotion, and support services through workforce development is a key area of intervention. The objective of this study is to assess the influence on breastfeeding knowledge and abilities of a semi-virtual training for primary healthcare providers assisting beneficiaries of PROSPERA in Mexico, which is one of the largest conditional cash-transfer programs in the world.

Methods

Two independent cross-sectional samples of healthcare providers were drawn at baseline and post-intervention in three states of Mexico. Baseline data were collected among primary physicians, registered nurses and nurse technicians (i.e. unit of analysis) on July 2016 (n = 529) and post-training between March and April 2017 (n = 211). A 19-item telephone questionnaire assessed providers’ general knowledge about breastfeeding, breastfeeding benefits and clinical aspects of breastfeeding, clinical ability to solve problems and abilities to overcome breastfeeding challenges. The effects of the training were assessed through a propensity score matching (PSM) stratified by types of providers (i.e. physicians, registered nurses, nurse technicians).

Results

The PSM analysis showed significant improvements among all providers in the general knowledge about breastfeeding (around 20 percentage points [pp]) and knowledge about breastfeeding benefits (approximately 50 pp). In addition, physicians improved their knowledge about clinical aspects of breastfeeding (7 pp), while registered nurses improved in their ability to solve breastfeeding problems (14 pp) and in helping mothers overcome breastfeeding challenges (12 pp).

Conclusions

Promoting a breastfeeding enabling environment in Mexico to improve breastfeeding rates will require improving the knowledge and skills of healthcare providers. While a semi-virtual training showed large improvements in knowledge, developing skills among providers may require a more intensive approach.

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

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

Too Old to Be Breastfed? Examination of Pre-Healthcare Professionals' Beliefs About, and Emotional and Behavioral Responses toward Extended Breastfeeding

While breastfeeding seems to be widely accepted in the United States, extended breastfeeding (defined as breastfeeding beyond 12 months of age) tends to be stigmatized. Healthcare professionals are assumed to play a significant role in supporting women who desire to practice extended breastfeeding; however, how healthcare professionals react to extended breastfeeding has not been well understood. This research surveyed 116 healthcare students, who majored in nursing and human medicine, and examined their perceived advantages and disadvantages, emotional responses to, and advice that they would provide to future mothers regarding extended breastfeeding. The results indicated that students responded predominantly with negative emotions and neutral responses to extended breastfeeding, with a small number of participants responding with positive emotions. Many participants believed that it would bring benefits to the child and that it would be burdensome to the mother. Participants displayed a variety of behavioral responses when asked about advice that they would provide to future mothers with whom they will interact in a clinical setting. Practical implications are discussed.

Main Barriers to Optimal Breastfeeding Practices in Armenia: A Qualitative Study

BACKGROUND

In 2015, the median duration of exclusive breastfeeding was 2.2 months in Armenia, and only 15% of 4-5-month-old children were exclusively breastfed, indicating an issue with breastfeeding knowledge and practices.

RESEARCH AIM

To identify the main barriers to optimal breastfeeding practices in Armenia.

METHODS

We used qualitative research methods via focus group discussions and in-depth interviews with four groups of providers from different levels of care, and mothers of young children, from Yerevan city and two provinces, Lori and Shirak. Overall, eight in-depth interviews and 13 focus group discussions were conducted with a total of 99 participants. Qualitative content analysis was applied, with elements of both inductive and deductive approaches.

RESULTS

We identified two main categories of barriers to optimal breastfeeding-systemic barriers and knowledge deficiencies. The main themes within systemic barriers were lack of skilled breastfeeding support services and low motivation of providers-mainly related to inadequate recognition of their role in breastfeeding counseling and low remuneration. The main knowledge-related barriers were insufficient counseling of mothers, lack of reliable information sources about infant feeding, and misconceptions among both mothers and providers.

CONCLUSION

Optimal breastfeeding is crucial for the best start to an infant's life; however, there were a number of barriers to optimal breastfeeding practices in Armenia. Our findings and recommendations could help policymakers apply effective strategies for improving breastfeeding rates in Armenia. Considering the similar historical backgrounds of the post-Soviet countries, our findings could also be applicable to other Commonwealth of Independent States countries.

Prenatal Provider Support for Breastfeeding: Changes in Attitudes, Practices and Recommendations Over 22 Years

BACKGROUND

Prenatal care providers play a central role in breastfeeding outcomes. A survey on obstetricians' support of breastfeeding was conducted in 1993 in Monroe County, NY. Since the landscape of prenatal care and breastfeeding support has changed significantly in the past 2 decades, we repeated and extended this survey in 2015.

RESEARCH AIM

To determine changes in breastfeeding support by prenatal care providers over a 20 year period.

METHODS

We sent a 46-item on-line or paper questionnaire to all categories of prenatal care providers identified by an online search. A breastfeeding support score was created based on the prior survey, with a maximum score of 3. One point was awarded for: (1) personally discussing breastfeeding; (2) generally suggesting breastfeeding; and (3) commonly receiving questions from patients. Data were analyzed using Chi-square.

RESULTS

We had 164 participants (response rate 80%). More current participants, compared to 1993, reported discussing (97% vs. 86%, p < .001) and recommending (93% vs. 80%, p = .001) breastfeeding. Only 10% of 2015 participants gave infant formula samples, compared with 34% in 1993 (p < .0001). Improvement in the support score was seen, with 98% of current participants having high scores compared to 87% in 1993 (p < .001). Similar numbers reported receiving breastfeeding education, though more reported that the education was inadequate (54% vs. 19%, p < .0001).

CONCLUSION

Breastfeeding support improved significantly over time, even though breastfeeding education has not improved in quality or quantity. Improving education of prenatal care providers may help future providers be more prepared to support breastfeeding.

Infant feeding among women with a history of breast cancer

PURPOSE

Health professional organizations recommend exclusive breastfeeding for 6 months, but there are mothers, such as those with a history of breast cancer, who are unable to exclusively provide their milk for their infants. Minimal research has been published on mothers' experience with lactation, breastfeeding, and bottle-feeding after breast cancer. This study explored mothers' perspectives of infant feeding after a history of breast cancer.

METHODS

Qualitative interviews were completed with 20 mothers who had experience with infant feeding after breast cancer, including exclusive breastfeeding, partial provision of human milk with formula supplementation, and exclusive formula feeding.

RESULTS

Mothers shared their perceptions, barriers, and experiences of infant feeding. Four themes were identified: miracle of motherhood after breast cancer, medical misinformation or no available information contributing to the exacerbation of mothers' worries, post-breast-cancer feeding challenges, and desire for infant-feeding support rather than pressure.

CONCLUSIONS

Mothers who have had breast cancer and have since given birth face specific challenges to infant feeding which are compounded by limited resources and knowledge among healthcare providers. Findings of the study highlight the importance of healthcare professionals becoming more educated to provide adequate support and evidence-based information on lactation and infant feeding for women with a history of breast cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Understanding the experiences of women who have given birth after breast cancer can help women in similar situations know that they are not alone, identify resources, access peer support, and seek evidence-based infant feeding advice from healthcare providers involved in their care.

Outpatient Breastfeeding Champion Program: Breastfeeding Support in Primary Care

Background: Breastfeeding support offered by trained professionals can increase breastfeeding success. The Outpatient Breastfeeding Champion (OBC) program creates a network of Breastfeeding Champions (typically nurses) who are trained to identify and resolve common breastfeeding issues and refer to lactation professionals as needed. The objective of this study was to evaluate the impact the OBC program on nurses' attitudes toward breastfeeding and self-confidence in providing breastfeeding care. Materials and Methods: The OBC program was implemented in 11 medical offices within a health care system. Nurses were surveyed before (n = 9) and immediately after (n = 9) participating in OBC training sessions, and 6 months following the implementation of the OBC training (n = 15). Data were collected on their breastfeeding attitude and self-confidence in providing breastfeeding care, and the responses at the different time points were compared using Wilcoxon Rank-Sum tests. Results: Nurses' attitudes toward breastfeeding (p = 0.049) and self-confidence in managing breastfeeding position and attachment (p = 0.09) were higher immediately after completion of the OBC training than they were before training. There was no significant difference in either response between immediately after completion and 6 months following training. Conclusion: This study presents a model of breastfeeding care that extends the reach of an International Board Certified Lactation Consultant to improve breastfeeding support in the primary care setting. Nurses' more positive breastfeeding attitudes and self-confidence in providing breastfeeding care following training suggest that the use of a breastfeeding training program may improve the breastfeeding support provided by nurses, which could be sustained over time.

Maternity care hospital trends in providing postdischarge breastfeeding supports to new mothers-United States, 2007-2015

BACKGROUND

Hospitals that provide maternity care can play an important role in providing or directing mothers to postdischarge breastfeeding support, which improves breastfeeding duration especially when providing multiple support modes. This study described 2007-2015 national trends in postdischarge breastfeeding supports among United States maternity care hospitals.

METHODS

Data were from the Maternity Practices in Infant Nutrition and Care survey, a biennial census of maternity care hospitals in the United States and territories. Hospitals reported whether they provided nine support types, which we categorized into three support modes: physical contact (eg, return visits), active reaching out (eg, telephone calls), and referrals (eg, to lactation consultants). We calculated prevalence of each support type, each support mode, and providing all three support modes for each survey year and examined trends over 2007-2015. For 2015, we assessed differences by hospital- and area-level characteristics.

RESULTS

Prevalence of providing all three support modes increased from 24% (2007) to 31% (2015). Nearly all (99%) hospitals provided referrals in each survey year. Fewer offered physical contact and active reaching out. However, from 2007 to 2015, the prevalence of physical contact increased from 39% to 46%; active reaching out increased from 54% to 64%. In 2015, smaller and rural hospitals were more likely to provide all three discharge supports.

CONCLUSIONS

Prevalence of offering referrals was high, but there is room for improvement in providing physical contact and active reaching out to ensure multiple modes of support are available to help mothers reach their breastfeeding goals.

Experiences and Perspectives About Breastfeeding in "Public": A Qualitative Exploration Among Normal-Weight and Obese Mothers

BACKGROUND

Women face societal and cultural barriers to breastfeeding. These challenges have been investigated in international studies and U.S. public opinion polls; however, mothers' experiences with breastfeeding in public in the United States remain unexplored. Research aim: The aim of this study was to describe the experiences of obese and normal-weight women with breastfeeding in public in central New York.

METHODS

Pregnant women ( N = 26) in central New York who intended to breastfeed and were either normal weight or obese were enrolled during their third trimester. A longitudinal, qualitative study was conducted to obtain information about women's experiences from birth through 3 to 6 months postpartum. Interviews were audio recorded, transcribed, and verified for accuracy. Transcripts were analyzed iteratively using conventional content analysis.

RESULTS

The concept of "public" was situational rather than a set of physical places; women experienced challenges while breastfeeding around others in private locations that were indistinguishable from those they encountered in places typically considered public. Women experienced social and physical awkwardness including perceived lack of acceptability, fear of confrontation, exposure, and positioning difficulties. They used strategies to reduce awkwardness, for example, being "discreet" and minimizing breastfeeding around other people. Obese women experienced similar challenges but to a greater degree than normal-weight women.

CONCLUSION

"Breastfeeding around others" described mother's experiences more accurately than "breastfeeding in public" and was experienced as awkward both socially and physically, particularly by obese women. Strategies are needed to normalize breastfeeding in the United States and to prepare mothers for the challenges of breastfeeding around others.

Lactation Consultants' Perceived Barriers to Providing Professional Breastfeeding Support

BACKGROUND

Addressing suboptimal breastfeeding initiation and duration rates is a priority in the United States. To address challenges to improving these rates, the voices of the providers who work with breastfeeding mothers should be heard. Research aim: The purpose of this study was to explore lactation consultants' perceived barriers to managing early breastfeeding problems.

METHODS

This qualitative study was conducted with a grounded theory methodological approach. In-depth interviews were conducted with 30 International Board Certified Lactation Consultants across Florida. Lactation consultants were from a range of practice settings, including hospitals, Special Supplemental Nutrition Program for Women, Infants, and Children clinics, private practice, and pediatric offices. Data were digitally recorded, transcribed, and analyzed in Atlas.ti.

RESULTS

A range of barriers was identified and grouped into the following categories/themes: indirect barriers (social norms, knowledge, attitudes); direct occupational barriers (institutional constraints, lack of coordination, poor service delivery); and direct individual barriers (social support, mother's self-efficacy). A model was developed illustrating the factors that influence the role enactment of lactation consultants in managing breastfeeding problems.

CONCLUSION

Inadequate support for addressing early breastfeeding challenges is compounded by a lack of collaboration among various healthcare providers and the family. Findings provide insight into the professional management issues of early breastfeeding problems faced by lactation consultants. Team-based, interprofessional approaches to breastfeeding support for mothers and their families are needed; improving interdisciplinary collaboration could lead to better integration of lactation consultants who are educated and experienced in providing lactation support and management of breastfeeding problems.

Statewide Breastfeeding Hotline Use Among Tennessee WIC Participants

OBJECTIVE

To examine the use of the Tennessee Breastfeeding Hotline (TBH), a 24 h/d, 7-d/wk telephonic lactation support program, based on Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation.

METHODS

Self-reported quantitative data were collected during the initial call. Data collected included caller type, maternal and infant characteristics, breastfeeding (BF) status, and primary reason for contacting the TBH.

RESULTS

A total of 366 participants in WIC and 1,354 participants not enrolled in WIC received services through the TBH. Significant differences existed for maternal age, race, ethnicity, infant age, preterm delivery, caller type, and exclusive BF (P < .05). Among participants in WIC, lactation professionals primarily addressed concerns related to lactation and milk expression.

CONCLUSIONS AND IMPLICATIONS

The TBH is a resource to address BF concerns, particularly among women who may face barriers to seeking professional lactation advice. Special Supplemental Nutrition Program for Women, Infants, and Children agencies might consider implementing initiatives outside their standard scope of clinic practice to address participants' needs for BF support.

Low milk supply and the pediatrician

PURPOSE OF REVIEW

Human milk is the optimal food for human infants, and provides many diverse and well described benefits for both mother and infant. Low milk supply, whether perceived or actual, is one of the most common reasons why mothers stop breastfeeding. Breastfeeding mothers often seek out the guidance and support of their pediatrician in evaluating and resolving milk production concerns.

RECENT FINDINGS

Recent evidence supports the importance of breastfeeding for maternal and child health in both developing and developed countries. Lack of knowledge regarding optimal breastfeeding management accounts for the large majority of low milk supply concerns, but there is emerging evidence that impaired glucose tolerance may contribute to intrinsic low milk supply.

SUMMARY

Breastfeeding mother-infant dyads should be followed closely until lactation is well established and the infant is gaining well. Further research is needed to understand the physiologic contributors to low milk supply and to guide evidence-based interventions to optimize maternal success in reaching breastfeeding goals, particularly for women of poorer metabolic health.

Invisible seams: Preventing childhood obesity through an improved obstetrics-pediatrics care continuum

Progress in altering the current obesity epidemic among children and adolescents remains elusive. Evidence continues to underscore the challenges of altering weight status as children age. Further, weight loss interventions among children and adults alike tend to demonstrate efficacy in the short-term, however individuals tend to slowly revert back to their original weight status over time. New understanding of obesity's early origins suggests the need to rethink current approaches, particularly within healthcare. Instead of a predominant focus on "mid-flight course corrections," healthcare should consider the "take-off" time period for health trajectories. This means improved support and promotion of healthy behaviors before and after birth, and with both the mother and infant. To meet the challenge, greater continuity will be required across obstetrics and pediatrics, which often operate independently, focused on different clinical outcomes. Likewise, there is an urgent need to remedy a significant skills gap within both practices. Through its connection with almost every new mother, healthcare plays a unique and vital role in maternal and child health outcomes. A more seamless obstetrics-pediatrics care continuum could better address the early origins of obesity, factors that we are coming to learn have life-long consequences.

Medical Directors of Breastfeeding Programs at Academic Medical Centers: Duties and Challenges

INTRODUCTION

An emerging trend in Academic Medical Centers (AMCs) is to coordinate breastfeeding care, research, and trainee education through "medical director" positions. Little is known about their duties, supports, and challenges.

OBJECTIVE

To determine the duties and challenges of directors of breastfeeding medicine in AMCs.

METHODS

A survey was distributed four times over a 3-month period to three listservs with a total of 860 members. Physicians directing breastfeeding programs or services at AMCs were included. Participants were asked about details of their employment, time distribution of the position, their role in education, billing practices, and major hurdles.

RESULTS

Thirty-two physicians responded to the survey: 25 from the United States, and seven international. Only 22% of respondents had formal job descriptions and only 31% reported being paid for their breastfeeding work. Most positions were created in the past 10 years (75%), were housed in Departments of Pediatrics (75%), and provided clinical services for breastfeeding in inpatient and outpatient settings. Ninety-one percent of respondents educated trainees and provided oversight of lactation consultants. Major hurdles included difficulties with billing for services, lack of protected time and personal reimbursement, lack of formal structure and job descriptions, and lack of buy-in at the institutional and sometimes governmental levels.

CONCLUSIONS

Medical Directors of Breastfeeding Services may be increasingly prevalent in AMCs and are engaged in inpatient and outpatient clinical work, trainee education, and lactation consultant oversight. Both financial and structural hurdles were reported by those holding these positions.

Comparison of Support for Breastfeeding Beyond 12 Months of Age from Conventional and Alternative Pediatric Primary Care Providers

OBJECTIVE

Conventional medicine pediatric care providers (e.g., pediatricians) have been shown to be influential in women's decisions to initiate and sustain breastfeeding. Alternative pediatric care providers (e.g., naturopaths and chiropractors) may also provide breastfeeding support, but this has not been the subject of prior research. Our objective was to compare breastfeeding mothers' perceptions of support from these two provider types in a large sample of women who breastfed for more than 12 months.

METHODS

We conducted a cross-sectional study of 49,091 U.S. women through online questionnaire distributed through peer breastfeeding groups. We used log-binomial regression to compare those who used an alternative pediatric healthcare provider to care for their child to those who used a conventional provider on perceptions of support and key factors influencing the decision to breastfeed for more than 12 months.

RESULTS

Those who used an alternative provider were more likely to discuss breastfeeding (Adj RR = 1.25, 95% CI 1.17-1.33), feel comfortable discussing breastfeeding (Adj RR = 1.17; 95% CI 1.15-1.19), and feel supported by the provider (Adj RR = 1.25; 95% CI 1.23-1.28). However, providers' recommendations were not important factors in these women's decision to breastfeed beyond 12 months of age.

CONCLUSIONS

Mothers who used an alternative care provider as their child's primary source of healthcare rated the provider's breastfeeding support more favorable than those who used a conventional provider (usually a pediatrician). Improving breastfeeding support may be one way to retain families in conventional pediatric primary care, and thereby, ensure children receive comprehensive, evidence-based care.

Towards integrated care in breastfeeding support: a cross-sectional survey of practitioners' perspectives

Background

Integrated care is defined as concerted action of healthcare providers ensuring continuity of care within a patient-centered approach, thus contributing to healthcare efficiency and quality. Apart from the WHO/UNICEF Baby-Friendly Initiatives, integrated care has been poorly explored within the context of breastfeeding support. The aim of this study was to investigate the experience of breastfeeding support practitioners, identifying barriers and facilitators towards integrated care.

Methods

A 62-item survey was conducted among 900 participants at 3 international breastfeeding conferences. Analysis included uni-and bivariate descriptive statistics, categorizing of mutually exclusive response groups and thematic networks analysis of responses to 18 open-ended items.

Results

Three-hundred-and-one participants (33 % response), from 34 predominantly industrialized countries (98 %) on nearly all continents, responded to the survey. Norwegian residents alone, felt sufficiently supported in providing breastfeeding support by other healthcare providers, the work environment, society, the media and their National Breastfeeding Committee (P < 0.05). Out of 11 suggested measures for effective breastfeeding promotion, 96 % of respondents ranked integrated care as the most important. The largest response group identified in open-ended items, as a major barrier to integrated care in breastfeeding support, was “lacking or failing health promotion strategies” (n = 454), followed by “a lack of vertically integrated care” (n =268), described mainly as unsatisfactory cooperation within healthcare. This inconsistency of care also impairs “shared decision-making” on infant feeding for parents, including accessibility of information and support (n = 265). Among other measures, 29 % of respondents recommended incentivizing integrated breastfeeding support within healthcare. Two figures, based on open-ended response evaluations, illustrate participants’ ideas of the National Breastfeeding Committees’ role in coordinating policies and protagonists towards integrated breastfeeding support, and a family-centered model of integrated care to facilitate successful breastfeeding.

Conclusions

According to practitioners in breastfeeding support, integrated care is essential for successful breastfeeding. Quality and accessibility of breastfeeding support should be motivated by healthcare system incentives, to counter the reported lack of consistency of care within and beyond healthcare. To effectively integrate a continuum of breastfeeding support into healthcare and society, a policy consensus and strong political action are indispensable, with coordination by an empowered National Breastfeeding Committee.

Electronic supplementary material

The online version of this article (doi:10.1186/s13006-016-0072-y) contains supplementary material, which is available to authorized users.

Problems With Breastfeeding/Breast Milk Feeding Reported by Women Participating in a Workplace Lactation Program

Purpose: The purpose of this study, which was part of a larger study, was to explore the problems with breastfeeding and/or breast milk expression experienced by women participating in a workplace lactation program at a large public sector employer.

Methods: A cross-sectional mailed survey approach was used. The sample (n = 128) consisted of women who had used at least one component of the lactation program in the past 3 years and who were still employed at the same organization.

Findings: Women who reported having a problem with breastfeeding during the first 2 weeks of their baby’s life or after they returned to work or if they had problems expressing milk all had a shorter mean duration of any breastfeeding/breast milk feeding. However, in this study, the mean duration of breastfeeding/breast milk feeding for all respondents was 10.4 months, and 57% of respondents were exclusively feeding breast milk for milk feedings at 6 months.

Conclusions: It is common for women to experience problems in breastfeeding during the first 2 weeks after their baby’s birth and when they return to work. There is some evidence that participation in a workplace lactation program supported a longer duration of breastfeeding in spite of problems experienced by the women. More research is needed.