A Comparison of Breastfeeding Rates in an Urban Birth Cohort Among Women Delivering Infants at Hospitals That Employ and Do Not Employ Lactation Consultants

Changes in Breastfeeding Exclusivity and Satisfaction During the COVID-19 Pandemic

BACKGROUND

Because of its many benefits, exclusive breastfeeding for 6 months is a common public health goal. However, only 44% of infants aged 0-6 months are exclusively breastfed worldwide and, in the United States, only 26% of infants are exclusively breastfed for 6 months. The restrictions imposed during the COVID-19 pandemic may have reduced these rates even further.

RESEARCH AIM

To examine the differences in breastfeeding exclusivity and satisfaction before and during the COVID-19 pandemic.

METHODS

A cross-sectional, two-group survey design was used. Parents (N = 110) of infants born April 1 to December 31, 2019 (pre-pandemic; n = 69), or April 1 to December 31, 2020 (during the pandemic; n = 41), who received lactation support services from an urban academic breastfeeding clinic were surveyed.

RESULTS

Respondents who gave birth in 2020 (pandemic year) were no less likely to exclusively breastfeed for the first 6 months of their infant's life compared to respondents who gave birth in 2019 (pre-pandemic year). After multivariable logistic regression, the odds of high breastfeeding satisfaction were 73% lower in respondents with infants born in 2020 than in respondents with infants born in 2019 (OR = 0.27, 95% CI [0.08, 0.89]). The strongest contributor to high breastfeeding satisfaction was a prenatal breastfeeding visit with an International Board Certified Lactation Consultant.

CONCLUSIONS

Future research is needed to identify the specific pandemic-related factors that led to the difference in breastfeeding satisfaction between the two groups and to confirm the impact of prenatal International Board Certified Lactation Consultant visits on breastfeeding satisfaction.

Factors affecting breastfeeding in women with epilepsy

OBJECTIVE

This study aimed to compare rates of breastfeeding initiation and maintenance in women with epilepsy (WWE) with those of the general population and to identify factors affecting breastfeeding patterns in WWE.

METHODS

We retrospectively reviewed data for the following variables in pregnant WWE (n = 102) and healthy women without epilepsy (n = 112): demographic characteristics (age, race, ethnicity), epilepsy type (focal or generalized onset), antiseizure medication(s), psychiatric comorbidities, postpartum seizure control, breastfeeding counseling, and lactation consultation. Fisher exact test and logistic regression analyses were performed to compare the rates of breastfeeding initiation and continuation in pregnant WWE with those of healthy pregnant women and to determine factors associated with rates of breastfeeding initiation and maintenance.

RESULTS

The rate of breastfeeding initiation in WWE was significantly lower than in healthy women without epilepsy (50.9% vs. 87.6%), and WWE were less likely to maintain breastfeeding at 6 weeks (38.2%) and 3 months (36%) postpartum. Nearly half (53%) of WWE received antepartum breastfeeding counseling by their neurologists, and these women had higher odds of breastfeeding initiation and continuation (odds ratio [OR] = 2.53, 95% confidence interval [CI] = 1.14-5.72, p = .02). Postpartum consultation with a board-certified lactation consultant was associated with higher odds of breastfeeding continuation at 6 weeks (OR = 5.43, 95% CI = 1.39-27.23, p = .02) and at 3 months (OR = 4.9, 95% CI = 1.34-20.87, p = .019). Women taking levetiracetam were more likely to initiate and continue breastfeeding than those taking lamotrigine (OR = 6.22, 95% CI = 2.15-20.20, p = .001).

SIGNIFICANCE

The initiation rate and duration of breastfeeding were significantly lower in WWE than in healthy women without epilepsy and were significantly associated with several factors. Identification of potential barriers to breastfeeding in WWE may lead to development of intervention strategies that can improve breastfeeding rates in WWE to maximize positive health outcomes for WWE and their infants.

Racial Disparities in Sustaining Breastfeeding in a Baby-Friendly Designated Southeastern United States Hospital: An Opportunity to Investigate Systemic Racism

Background: Racial disparities in breastfeeding rates persist in the United States with Black women having the lowest rates of initiation and continuation. A literature review attributes this to many factors-historical roles, cultural norms, lack of social support, and systemic racism in the health care and lactation support system. The Baby-Friendly Hospital Initiative (BFHI) is an evidence-based program to increase breastfeeding through standardized protocols, and, in a Southeastern U.S. academic center, it was associated with increased breastfeeding, but the effect on racial disparities in breastfeeding was unknown. Methods: Through an institutional Perinatal Information Systems database, breastfeeding rates were compared before and after BFHI implementation. Breastfeeding initiation, sustained breastfeeding 24-hours before discharge, and patient demographics were assessed. Results: After BFHI implementation, mothers were overall 1.17 (95% confidence interval: 1.13-1.19) times more likely to initiate breastfeeding. For Black mothers, breastfeeding initiation increased significantly from 52% to 66%, but they were significantly less likely to sustain in-hospital breastfeeding compared to nonBlack mothers (69.4% versus 84.6%, p < 0.0001). Several demographic and medical comorbidities were significantly associated with failure to sustain breastfeeding to hospital discharge. When controlling for these factors, the racial disparity persisted. Conclusions: Since BFHI implementation, the racial gap in breastfeeding initiation decreased, but a significant disparity remained for sustained in-hospital breastfeeding. This study highlights the success of the BFHI program, but in the context of the current literature, also reveals the need for further work to ensure interventions are culturally competent and delivered equitably to support sustained breastfeeding for Black women.

Neonatal Intensive Care Unit-Specific Lactation Support and Mother's Own Breast Milk Availability for Very Low Birth-Weight Infants

BACKGROUND

Mother's own milk (MOM) is the preferred nutrition for premature infants, particularly for the very low birth-weight (VLBW) cohort. Benefits are well documented; yet, numerous barriers exist for provision of MOM in the neonatal intensive care unit (NICU). Lactation consultants (LCs) can optimize breastfeeding support for NICU mothers; however, understanding of the impact of NICU-dedicated LCs is limited.

PURPOSE

Evaluate the effectiveness of NICU-dedicated LCs in improving breastfeeding outcomes and MOM provision in VLBW infants.

METHODS

A retrospective chart review of 167 VLBW infants comparing breastfeeding outcomes between 2 NICUs, one with NICU-dedicated LCs (hospital A; n = 48) and one without (hospital B; n = 119). Primary outcome measures included feeding percentages of MOM received by infants at 3 intervals, throughout hospitalization, and number of direct breastfeeding events. Secondary outcome measures included number of days to first enteral feed, days to reach full feeds, days of nil per os, days on total parenteral nutrition, and length of stay.

FINDINGS

Neonatal intensive care unit-specific lactation support increased the number of direct breastfeeding events on day of discharge (P = .048). No statistical significance was found at each of the 3 time intervals, or throughout hospitalization (week 1: P = .18; midpoint: P = .40; discharge: P = .16; total hospitalization: P = .19). No statistical significance was demonstrated in secondary outcome measures (days to first enteral feed: P = .22; days to full feeds: P = .25; nil per os days: P = .27; total parenteral nutrition days: P = .34; length of stay: P = .01). Length of stay not found to be significant after correcting for confounding variables.

IMPLICATION FOR PRACTICE

Increased direct breastfeeding events on day of discharge with exposure to NICU-dedicated LCs in the VLBW population.

IMPLICATION FOR RESEARCH

Prospective studies regarding NICU-specific lactation support with larger samples are warranted.

What Is the Impact of NICU-Dedicated Lactation Consultants? An Evidence-Based Practice Brief

BACKGROUND

Benefits of exclusive human milk diets for preterm and low birth-weight infants are well established. Despite known benefits, supporting mothers in the provision of mother's own milk for high-risk infants is challenging. Lactation support in the neonatal intensive care unit (NICU) is highly variable. Lactations consultants (LCs) are often shared between postpartum units and the NICU, potentially increasing LC workload with less time spent with high-risk mothers. Furthermore, less than half of NICUs in the United States staff an international board-certified lactation consultant. Limited understanding exists regarding impacts of NICU-specific lactation support on breastfeeding outcomes.

PURPOSE

The purpose of this evidence-based practice brief is to synthesize the literature on the impact of NICU-specific lactation support, LCs who work exclusively in the NICU, and provide guidance about how NICU staffing with LCs solely focused on supporting mothers of high-risk infants impacts breastfeeding outcomes for low birth-weight infants.

SEARCH STRATEGY

CINAHL PLUS, PubMed, Cochrane Library, and OVID databases were searched using key words and restricted to English language.

FINDINGS

During hospitalization, NICUs staffed with dedicated board-certified LCs have increased potential to yield improved breastfeeding rates through hospital discharge, increased proportion of infants who receive mother's own milk, and increased duration of breastfeeding or human milk expression through hospital discharge.

IMPLICATIONS FOR PRACTICE

Human milk nutrition is related to improved outcomes for high-risk infants. Neonatal intensive care unit-specific lactation support can potentially optimize maternal breastfeeding practices and improve outcomes for high-risk infants.

IMPLICATIONS FOR RESEARCH

There is a need for further studies pertaining to NICU-specific lactation consultants and influences on breastfeeding outcomes.

The effect of maternity practices on exclusive breastfeeding rates in U.S. hospitals

The Baby-friendly Hospital Initiative (BFHI) includes a set of 10 evidenced-based maternity practices that when used together have been shown to improve breastfeeding outcomes. In 2007, the Centers for Disease Control and Prevention launched the Maternity Practices in Infant Nutrition and Care (mPINC) survey to assess and monitor these and other evidenced-based maternity practices. The purpose of this study was to explore individual maternity practices measured in the 2013 mPINC survey, along with hospital demographic information, and their relationships with exclusive breastfeeding (EBF) rates, using a sample of United States (U.S.) hospitals. We obtained mPINC survey data from 69 BFHI hospitals and 654 non-BFHI hospitals in the U.S., and EBF rates from The Joint Commission, a leading hospital accreditation agency. On the basis of linear regression analysis, we found that most maternity practices studied were significantly associated with EBF rates (max adjusted R2  = 14.9%). We found a parsimonious model with an adjusted R2 of 47.3%. This study supports the need for a systematic approach in providing breastfeeding support as no one maternity care practice was able to explain the variability in EBF rates as well as a collection of maternity care practices.

Effect of Dedicated Lactation Support Services on Breastfeeding Outcomes in Extremely-Low-Birth-Weight Neonates

BACKGROUND

Breastfeeding is associated with major benefits for high-risk infants born prematurely, yet this population faces significant challenges to breastfeeding. Lactation services provide successful interventions, yet the impact of lactation services on breastfeeding outcomes in preterm infants is understudied. Research aim: The provision of full-time lactation support in the neonatal intensive care unit (NICU) will improve quantitative breastfeeding measures in premature infants.

METHODS

A longitudinal retrospective nonexperimental design was used. Data were collected from medical records of breastfeeding outcomes in patients 30 weeks' gestational age and under admitted to a level IV regional NICU over three epochs of varying levels of lactation services, from none to full time. Demographic, medical, and breastfeeding data were collected. Data analysis was performed using standard statistical tests and hierarchical regression analysis.

RESULTS

A significant increase in the number of lactation consults was observed across epochs, and the number of infants who received human milk via feeding at the breast, as the first oral feeding, increased across epochs. After controlling for covariates, the odds of infants receiving any human milk compared with exclusive formula feeding increased across epochs.

CONCLUSION

The provision of full-time dedicated NICU lactation support is associated with an increase in breastfeeding outcome measures for high-risk preterm infants.

Factors associated with delayed initiation of breastfeeding: a survey in Northern Uganda

Background: Initiation of breastfeeding later than 1 hour after birth is associated with increased neonatal morbidity and mortality.

Objective: To determine the prevalence and factors associated with delayed initiation of breastfeeding.

Methods: We conducted a survey in 2016 of 930 children under the age of 2 years in Lira district, northern Uganda. Mothers of the children were interviewed and data was collected on mobile phones using Open Data Kit software (https://opendatakit.org). Multivariable logistic regression was used to determine factors associated with delayed initiation of breastfeeding.

Results: Almost half [48.2%, 95% confidence interval (CI) (44.3–52.1)] of the mothers delayed initiation of breastfeeding. Factors significantly associated with delayed initiation of breastfeeding in multivariable analysis included caesarean delivery [Adjusted Odds Ratio (AOR) 11.10 95% CI (3.73–33.04)], discarding initial breast milk [AOR 2.02 95% CI (1.41–2.88)], home delivery [AOR 1.43 95% CI (1.04–1.97)] and mother being responsible for initiating breastfeeding as compared to a health worker or relative [AOR 1.73 95% CI (1.33–2.26)]. Mothers having a secondary education were less likely [AOR 0.54 95% CI (0.30–0.96)] to delay initiation of breastfeeding as compared to those with no education.

Conclusion: About half the mothers delayed initiation of breastfeeding until after 1 hour after birth. Programs to promote, protect and support breastfeeding in this post conflict region are urgently needed.

"Why Even Bother; They Are Not Going to Do It?" The Structural Roots of Racism and Discrimination in Lactation Care

Through semi-structured interviews with 36 International Board Certified Lactation Consultants (IBCLCs) who assist mothers with breastfeeding, this study takes a systematic look at breastfeeding disparities. Specifically, this study documents race-based discrimination against patients in the course of lactation care and links the implicit bias literature to breastfeeding disparities. IBCLCs report instances of race-based discrimination against patients such as unequal care provided to patients of color and overt racist remarks said in front of or behind patient's backs. This study connects patient discrimination in lactation to institutional inequality and offers suggestions to address these inequities.

Differences in Breastfeeding Among Medicaid and Commercially Insured Patients: A Retrospective Cohort Study

BACKGROUND

While breastfeeding rates have been increasing in the United States, they remain below targets set by multiple public health organizations. Lower rates are associated with certain demographic groups. We performed a retrospective chart review to examine rates of breastfeeding at the time of postpartum follow-up in a mixed-race urban cohort.

OBJECTIVE

This study was conducted to examine the proportion of women who were breastfeeding at 6-8 weeks postpartum and to determine if these proportions differed by race and insurance status.

MATERIALS AND METHODS

We identified women who delivered singleton term infants at an urban university hospital between July and December 2013. Self-reported breastfeeding status at 6-8 weeks postpartum was abstracted for all women who completed postpartum follow-up visits. Data were analyzed with logistic regression to compare rates of any or exclusive breastfeeding between women with Medicaid and private insurance.

RESULTS

Charts of 656 women were reviewed; 405 women completed postpartum follow-up within 8 weeks. The Medicaid population had significantly lower rates of breastfeeding even after accounting for interaction and confounding by demographic factors (any breastfeeding odd ratio [OR] 0.53, confidence interval [CI] 0.04-0.31; exclusive breastfeeding OR 0.48, CI 0.33-0.85). When stratified by race, white women on Medicaid had the lowest probability of breastfeeding of all groups (p < 0.01).

CONCLUSIONS

Among patients delivering at an urban academic hospital, women on Medicaid were significantly less likely to breastfeed than those with private insurance. The greatest differential by insurance was seen among white women. Efforts to improve breastfeeding should focus on low-income women of all races.

Factors Influencing International Board Certified Lactation Consultants to Continue Advancing Practice Beyond Certification: A Multinational Study

Background:

Certification as a lactation consultant is based on practitioners having achieved a standard of knowledge indicative of their competence to practice by passing a psychometric examination. The underpinning principle of recertification programs is to support clinicians to become lifelong learners by progressively enhancing and advancing their knowledge and skills in line with contemporary evidence. The aim of this study was to investigate the factors that influence International Board Certified Lactation Consultants (IBCLCs) to advance their practice.

Method:

A mixed-methods study was conducted in two phases. Phase 1 included focus groups, interviews, and participants’ demographic data. Phase 2 comprised of an online questionnaire to IBCLCs. This approach was designed to provide a comprehensive qualitative understanding of the IBCLCs’ experiences, which was then triangulated with quantitative data from a significantly larger population of IBCLCs in Phase 2.

Results:

The findings are described in themes and subthemes. Participants in phase 2 (n = 3,946) reported being intrinsically motivated (93.3%, n = 3,631) and committed to providing evidence-based guidance and optimal care to support breastfeeding mothers. They identified various sources of continuing education, although attendance at conferences, peer support, and reflective sessions were the most common approaches to enhancing knowledge. They recognized that it was through extension of knowledge that they were able to advance their practice.

Conclusion:

This article identifies strategies that the managers, educators, and certification bodies can adopt to support the IBCLCs in continuing to advance their practice, which will ultimately improve breastfeeding outcomes for mothers.

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.

The Impact of Hospital Resources and Availability of Professional Lactation Support on Maternity Care: Results of Breastfeeding Surveys 2009-2014

BACKGROUND

Breastfeeding provides maternal and infant health benefits. Maternity care practices encompassed in the 10 Steps to Successful Breastfeeding are positively associated with improved breastfeeding outcomes. This study assessed changes in maternity care practices and lactation support.

MATERIALS AND METHODS

In 2009, 2011, and 2014, New York (NY) hospitals providing maternity care services were surveyed to assess the implementation of 9 of the 10 Steps to Successful Breastfeeding, professional lactation support, distribution of formula and discharge packs, and patient and hospital barriers to breastfeeding success. Generalized estimating equations were used to evaluate changes over time.

RESULTS

Surveys were completed by 138/138 (2009), 128/129 (2011), and 125/125 (2014) NY hospitals. During this time period, the percent of hospitals reporting implementation of Steps 2, 4, 6, or 9 increased, and the mean number of 9 steps implemented increased from 4.3 to 5.3. Hospitals distributing formula samples at discharge to breastfeeding mothers decreased significantly from 39 (32%) to 3 (2%). Professional lactation staffing ratios (N/1,000 births) of both International Board Certified Lactation Consultants and Certified Lactation Counselors increased between 2009 and 2011, but then decreased between 2011 and 2014. Reported barriers to breastfeeding support changed, with reductions in mixed messages from staff, but increases in lack of financial resources for breastfeeding support, inadequate prenatal education, mothers not being prepared, and family not being receptive to breastfeeding.

CONCLUSIONS

Between 2009 and 2014, NY hospitals reported increased barriers and a reduction in professional lactation support, which may have contributed to the limited improvements in breastfeeding support.

Community Rates of Breastfeeding Initiation

BACKGROUND

Breastfeeding initiation rates vary considerably across racial and ethnic groups, maternal age, and education level, yet there are limited data concerning the influence of geography on community rates of breastfeeding initiation.

OBJECTIVE

This study aimed to describe how community rates of breastfeeding initiation vary in geographic space, highlighting "hot spots" and "cool spots" of initiation and exploring the potential connections between race, socioeconomic status, and urbanization levels on these patterns.

METHODS

Birth certificate data from the Kentucky Department of Health for 2004-2010 were combined with county-level geographic base files, Census 2010 demographic and socioeconomic data, and Rural-Urban Continuum Codes to conduct a spatial statistical analysis of community rates of breastfeeding initiation.

RESULTS

Between 2004 and 2010, the average rate of breastfeeding initiation for Kentucky increased from 43.84% to 49.22%. Simultaneously, the number of counties identified as breastfeeding initiation hot spots also increased, displaying a systematic geographic pattern in doing so. Cool spots of breastfeeding initiation persisted in rural, Appalachian Kentucky. Spatial regression results suggested that unemployment, income, race, education, location, and the availability of International Board Certified Lactation Consultants are connected to breastfeeding initiation.

CONCLUSION

Not only do spatial analytics facilitate the identification of breastfeeding initiation hot spots and cool spots, but they can be used to better understand the landscape of breastfeeding initiation and help target breastfeeding education and/or support efforts.

Health Professionals' Attitudes and Beliefs About Breastfeeding

The aim of this descriptive study was to investigate how health-care providers perceived their role in breastfeeding and maternal support. Data was collected via interviews of 53 health-care professionals that provided care to breastfeeding women. The emerging themes included (a) understanding the benefits of breastfeeding: often lacking current knowledge, (b) lacking consistency: gaps between knowledge of benefits and actual clinical practice, (c) not knowing how to help: lack of assessment and therapeutic skills, and (d) understanding the barriers to breastfeeding: how health-care providers can make a difference. Data analysis suggests inconsistencies between the health-care provider's perceived support and behaviors, lack of knowledge, and significant lack of skill in the assessment and management of breastfeeding couples.

Medicaid IBCLC Service Coverage following the Affordable Care Act and the Center for Medicare and Medicaid Services Update

BACKGROUND

International Board Certified Lactation Consultants (IBCLCs) are associated with increased rates and duration of breastfeeding. Recent US legislation offers opportunities for private and public insurers to include IBCLC services as a covered benefit.

OBJECTIVE

To explore US states' Medicaid coverage of IBCLC services following January 2014 legislative expansions of coverage for preventive health services.

METHODS

To assess IBCLC reimbursement practices, 20 states, stratified by Medicaid expansion (yes/no) and 3-month exclusive breastfeeding rates, were selected to participate. An electronic survey was sent to Medicaid and Maternal Health Directors, breastfeeding coordinators, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) coordinators between July and December 2014. Email follow-ups clarified missing or ambiguous responses.

RESULTS

Of the 15 states responding, 9 had Medicaid expansion. None of the states permitted IBCLCs to bill for services autonomously. In 9 states, IBCLC services were covered with some type of stipulation, for example, billing under a physician. Of the 9 states with IBCLC coverage, 7 had accepted Medicaid expansion. States with higher rates of exclusive breastfeeding were also more likely to provide IBCLC coverage.

CONCLUSION

Recent legislative changes to public and private insurance that could expand coverage of IBCLCs have not yielded appreciable changes, particularly in states without Medicaid expansion. There is a need for research on the effects of adopting expanded coverage for IBCLCs and advocacy to do so.

An IBCLC in the Maternity Ward of a Mother and Child Hospital: A Pre- and Post-Intervention Study

Published evidence on the impact of the integration of International Board Certified Lactation Consultants (IBCLCs) for breastfeeding promotion is growing, but still relatively limited. Our study aims at evaluating the effects of adding an IBCLC for breastfeeding support in a mother and child hospital environment. We conducted a prospective study in the maternity ward of our maternal and child health Institute, recruiting 402 mothers of healthy term newborns soon after birth. The 18-month intervention of the IBCLC (Phase II) was preceded (Phase I) by data collection on breastfeeding rates and factors related to breastfeeding, both at hospital discharge and two weeks later. Data collection was replicated just before the end of the intervention (Phase III). In Phase III, a significantly higher percentage of mothers: (a) received help to breastfeed, and also received correct information on breastfeeding and community support, (b) started breastfeeding within two hours from delivery, (c) reported a good experience with the hospital staff. Moreover, the frequency of sore and/or cracked nipples was significantly lower in Phase III. However, no difference was found in exclusive breastfeeding rates at hospital discharge or at two weeks after birth.

Impact of peer counselors on breastfeeding outcomes in a nondelivery NICU setting

PURPOSE

Although the independent effects of lactation consultants and peer counselors have been shown to improve breastfeeding outcomes, the joint effects have yet to be considered, particularly in the neonatal intensive care unit (NICU) in nondelivery hospitals. Therefore, the objective of this study was to assess the effect of lactation staff type on breastfeeding outcomes during hospital stay after the addition of peer counselors to a NICU lactation program.

SUBJECTS

A total of 596 mother-infant pairs admitted to Nationwide Children's Hospital, Columbus, Ohio, pre- and postlactation program expansion.

DESIGN

A descriptive pre-/posttest study as conducted.

MAIN OUTCOME MEASURES

Differences in provision of any maternal breast milk, exclusive breast milk, or direct breastfeeding during NICU stay and at discharge were evaluated pre and postprogram implementation. Logistic regression was used to determine associations between lactation staff type and each outcome during hospital stay.

RESULTS

Infants receiving any breast milk during NICU stay increased from baseline to postprogram year 1 (63% vs 73%; P= 0.03). Direct breastfeeding increased from baseline to postprogram year 4 (42% vs 53%; P= 0.03). Mothers seen by only peer counselors were less likely to provide any breast milk at discharge, provide exclusive breast milk during stay or discharge, to be direct breastfeeding during stay or at discharge compared with mothers seen by both peer counselors and lactation consultants.

CONCLUSIONS

NICU lactation programs should consider including both peer counselors and lactation consultants to improve breastfeeding outcomes during hospital stay.

Initiation of complementary feeding and duration of total breastfeeding: unlimited access to lactation consultants versus routine care at the well-baby clinics

INTRODUCTION

Breastfeeding has several advantages for both mother and child. Lactation consultants may promote prolonged breastfeeding, but little is known about their impact on the initiation of complementary feeding.

SUBJECTS AND METHODS

Dietary intake during the initial complementary feeding period from 5 to 6 months was collected on mother-infant pairs who had unlimited access to lactation consultants along with those mother-infant pairs who received routine care at the well-baby clinics. The total duration of breastfeeding in each study population was also recorded, and total breastfeeding durations of infants receiving complementary foods from 4 months and those exclusively breastfed for 6 months in each of the two study populations were compared.

RESULTS

Higher proportion of infants of mothers with unlimited access to lactation consultants were fed vegetable and vegetable purées (p=0.05) and more than one food type (p=0.05) at 5 months. Furthermore, a lower percentage of them had three meals per day at 6 months (p=0.001) compared with those receiving routine care at the well-baby clinics. Infants exclusively breastfed for 6 months all had similar duration of total breastfeeding.

CONCLUSIONS

Mother-infant pairs with unlimited access to lactation consultant had slower introduction of complementary foods at the initial complementary feeding period, according to number of infant's meals at 6 months of age. Furthermore, those exclusively breastfed for 6 months had more prolonged breastfeeding compared with mothers who began complementary feeding at 4 months regardless of exposure to lactation consultants.

Effect of primary care intervention on breastfeeding duration and intensity

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Women's perceptions of breastfeeding barriers in early postpartum period: a qualitative analysis nested in two randomized controlled trials

OBJECTIVES

This study examined women's perceptions of early infant feeding experiences and identified early postpartum barriers to successful breastfeeding.

SUBJECTS AND METHODS

We conducted semistructured exit interviews at 6 months postpartum with a subsample of participants (n=67) enrolled in two randomized controlled trials of breastfeeding promotion. Study arms included (1) routine pre- and postnatal visits with an International Board Certified Lactation Consultant (IBCLC) (LC group), (2) electronically prompted guidance from prenatal care providers (EP group), (3) EP+LC combined, and (4) standard of care (control group). Interview transcripts were coded using grounded theory and analyzed in MAXqda. Code matrices were used to identify early postpartum breastfeeding barriers and were further examined in relation to treatment group using a mixed methods analysis.

RESULTS

The majority of the participants reported experiencing at least one barrier to breastfeeding. Barriers to breastfeeding were more commonly reported in the early postpartum than late postpartum period. The most common barrier during the early postpartum period was the perception of inadequate milk supply ("lactational") (n=18), followed by problems with latch, medical problems that were perceived as precluding breastfeeding, and medical staff and hospital practices. Participants frequently reported that the IBCLCs assisted them in anticipating, managing, and overcoming these barriers.

CONCLUSIONS

Our findings underscore the importance of integrating IBCLCs into routine pre- and postpartum care because they provide critical support that effectively addresses early postpartum barriers to breastfeeding.

Recognition of International Board Certified Lactation Consultants by health insurance providers in the United States: results of a national survey of lactation consultants

BACKGROUND

Insurance coverage for lactation management is proposed by the United States Affordable Care Act. International Board Certified Lactation Consultants (IBCLCs) are key providers of lactation services. In order to inform national discussion, this study examines the scope of insurance reimbursement of IBCLC services.

OBJECTIVES

An email survey of US IBCLCs (N = 10 495) in March 2011 was used to explore frequencies of (1) submission--how often lactation consults were submitted to insurance providers for reimbursement and (2) recognition--the proportion of submitted charges recognized by insurance providers.

METHODS

Results (N = 2045) were analyzed to describe patterns of submission and recognition by IBCLC work setting, job classification, and reimbursement strategy.

RESULTS

Many survey respondents did not know their submission (41%) or recognition (57%) levels. Multiple strategies were used for reimbursement of IBCLC services with large variations in recognition between strategies. Overall, less than 15% reported high levels of submissions to insurance providers. Moreover, of submitted encounters, only 4% were consistently recognized by insurance providers. Inpatient hospital IBCLCs were least likely to have consults recognized (3%), and private community IBCLCs were most frequently recognized (32%). Compared with using IBCLC credentials for submitting an encounter, using another clinical license was the most successful strategy for achieving recognition of IBCLC consults (crude risk ratio, 1.44; 95% confidence interval, 1.04-2.01; P = .02).

CONCLUSION

IBCLCs provide key care to a vulnerable population. However, we found that these services are not consistently reimbursed. IBCLCs poorly communicate their health care activities to insurance providers, but insurance providers also inconsistently recognize and reimburse IBCLC care.

Defining lactation acuity to improve patient safety and outcomes

While substantial evidence exists identifying risks factors associated with premature weaning from breastfeeding, there are no previously published definitions of patient acuity in the lactation field. This article defines evidence-based levels of lactation acuity based on maternal and infant characteristics. Patient acuity, matching severity of illness to intensity of care required, is an important determinant of patient safety and outcomes. It is often used as part of a patient classification system to determine staffing needs and acceptable workloads in health care settings. As acuity increases, more resources, including more skilled clinicians, are needed to provide optimal care. Developing an evidence-based definition of lactation acuity can help to standardize terminology, more effectively distribute health care staff resources, encourage research to verify the validity and reliability of lactation acuity, and potentially improve breastfeeding initiation and duration rates.

Lactation rounds: a system to improve hospital productivity

Currently, there are no national guidelines on appropriate staffing for hospital lactation, and a central goal in today's health care climate is to provide optimal patient care while making the best use of available resources. This article describes a successful effort to improve patient care, lactation productivity, and employee satisfaction through a system of lactation rounds at Oklahoma University Medical Center (OUMC). Outcomes included more accurate data collection and distribution of resources for patient care, increased lactation service productivity, and increased employee satisfaction.

Evaluation of a breastfeeding assessment score in a diverse population

A previous study performed in a predominately suburban population developed a breastfeeding assessment score (BAS) that was designed to predict, prior to hospital discharge, those mothers who would discontinue breastfeeding within the first 10 days of age. The purpose of the present study was to assess the BAS in a more diverse population. Patients were solicited from 3 urban hospitals serving patients primarily supported by public funding. Results of the present study with 1182 mother-infant pairs confirmed that 5 variables scored on a 0-2 scale (maternal age, previous breastfeeding experience, latching difficulty, breastfeeding interval, number bottles) remained highly significant for predicting discontinuation of breastfeeding. The data also demonstrate that the BAS is inversely related to the risk of cessation of breastfeeding at 7 to 10 days of age. Those at an early risk of cessation of breastfeeding, identified by the BAS, may benefit from early identification and a lactation consultation.

Breastfeeding status on US birth certificates: where do we go from here?

OBJECTIVES

The objectives of this study were to assess the extent to which states collected breastfeeding data on the birth certificate, to verify the wording of the breastfeeding questions used, and to develop recommendations for future revisions of the breastfeeding question asked on the US Standard Certificate of Live Birth.

METHODS

Registrars of vital statistics in US states and territories were contacted via telephone with e-mail follow-up between April 2006 and May 2008 to determine whether their state/territory collected breastfeeding data on its birth certificate. Responses were categorized as follows: (1) breastfeeding data currently collected; (2) breastfeeding data not currently collected but implementation date set; or (3) breastfeeding data not currently collected and no implementation plans.

RESULTS

In May 2008, 56.6% (30 of 53) of US states and territories were collecting data on breastfeeding status at hospital discharge on their birth certificate. The questions used to collect breastfeeding data, however, had not been standardized. Approximately one quarter (12 of 53) reported that they were not yet collecting breastfeeding data on their birth certificate but that an implementation date had been set. Approximately one fifth (11 of 53) indicated that their state birth certificate did not plan to collect breastfeeding data by January 2010.

CONCLUSIONS

A total of 79% of the registrars reported that breastfeeding data were collected on the birth certificate or that the process would begin within the next 2 years. Future revisions to the Standard Certificate of Live Birth breastfeeding question should assess breastfeeding exclusivity. The revision process should include feedback from health professionals who collect these data, pretesting of the revised question for feasibility, and extensive training before data collection.

Breast-feeding: good starts, good outcomes

Meeting national breast-feeding objectives and mothers' personal breast-feeding goals depends on a number of factors, including the provision of current, consistent, and timely help with breast-feeding. Nurses are in a prime position to guide mothers during their hospital stay and provide community follow-up postdischarge. Mothers and infants need to acquire a set of breast-feeding skills prior to hospital discharge so that a mother goes home confident that she can adequately nourish her infant, initiate and maintain an abundant milk supply, avoid problems, and address them if they occur. This article describes strategies for optimizing breast-feeding during the first 48 hours and delineates what mothers need to know before they leave the hospital.