Overcoming barriers to breastfeeding continuation and exclusivity

Plasma per- and polyfluoroalkyl substance mixtures during pregnancy and duration of breastfeeding in the New Hampshire birth cohort study

BACKGROUND

Prior studies suggest that prenatal per- and polyfluoroalkyl substances (PFAS) exposures are associated with shorter breastfeeding duration. Studies assessing PFAS mixtures and populations in North America are sparse.

METHODS

We quantified PFAS concentrations in maternal plasma collected during pregnancy in the New Hampshire Birth Cohort Study (2010-2017). Participants completed standardized breastfeeding surveys at regular intervals until weaning (n = 813). We estimated associations between mixtures of 5 PFAS and risk of stopping exclusive breastfeeding before 6 months or any breastfeeding before 12 months using probit Bayesian kernel machine regression. For individual PFAS, we calculated the relative risk and hazard ratio (HR) of stopping breastfeeding using modified Poisson regression and accelerated failure time models respectively.

RESULTS

PFAS mixtures were associated with stopping exclusive breastfeeding before 6 months, primarily driven by perfluorooctanoate (PFOA). We observed statistically significant trends in the association of perfluorohexane sulfonate (PFHxS), PFOA, and perfluorononanoate (PFNA) (p-trends≤0.02) with stopping exclusive breastfeeding. Participants in the highest PFOA quartile had a 28% higher risk of stopping exclusive breastfeeding before 6 months compared to those in the lowest quartile (95% Confidence Interval: 1.04, 1.56). Similar trends were observed for PFHxS and PFNA with exclusive breastfeeding (p-trends≤0.05). PFAS were not associated with stopping any breastfeeding before 12 months.

CONCLUSIONS

In this cohort, we observed that participants with greater overall plasma PFAS concentrations had greater risk of stopping exclusive breastfeeding before 6 months and associations were driven largely by PFOA. These findings further support the growing literature indicating that PFAS may be associated with shorter duration of breastfeeding.

Using the theory of planned behavior model to predict factors influencing breastfeeding behavior among preterm mothers at week 6 postpartum: the mediating effect of breastfeeding intention

Background

Exclusive breastfeeding (EBF) in the first 6 weeks postpartum is key to continued breastfeeding. This study aimed to explore the role of EBF-related predictors (particularly breastfeeding intention) in breastfeeding behavior among preterm mothers at week 6 postpartum based on the theory of planned behavior (TPB).

Methods

A total of 352 mothers of preterm infants were recruited, 340 of whom participated in this study. Prior to discharge, participants completed the Chinese versions of the modified Breastfeeding Attrition Predictive Tool, the Breastfeeding Knowledge Questionnaire (BKQ), the Infant Feeding Intention, and the Edinburgh Postnatal Depression Scale. Responses to the items of the Breastfeeding Behavioral Questionnaire (BBQ) were also collected by telephone at week 6 postpartum. The final analyses included 321 participants who completed the full two-wave data collection.

Results

The fitness indices of the modified TPB model were acceptable. Breastfeeding knowledge and EBF before discharge positively impacted breastfeeding intention, whereas depression had a negative impact. Before discharge, breastfeeding intention fully mediated the impacts of breastfeeding attitude, social and professional support, knowledge, depression, and EBF on breastfeeding behavior and partially mediated the influence of perceived breastfeeding control on breastfeeding behavior.

Conclusion

These findings indicate that TPB accurately predicts breastfeeding behavior among preterm mothers at week 6 postpartum, and breastfeeding intention is key to the above-mentioned EBF-related factors and breastfeeding behavior. The findings underline the need for further longitudinal studies and corresponding interventions for preterm mothers with a high risk of EBF attrition.

A systematic review of qualitative research on barriers and facilitators to exclusive breastfeeding practice in sub-Saharan African countries

BACKGROUND

Studies reporting factors associated with exclusive breastfeeding are mostly quantitative. No study has performed a systematic qualitative summary to document the recurring constraints and facilitators to exclusive breastfeeding in sub-Saharan African countries from breastfeeding mothers' perspective. This study systematically reviews the literature reporting barriers and facilitators to exclusive breastfeeding from the breastfeeding mothers' perspective in sub-Saharan Africa to develop an educational intervention to optimize exclusive breastfeeding.

METHODS

A systematic literature review of qualitative studies such as phenomenological studies, followed by a risk of bias and methodological assessment of the included studies' quality using the Critical Appraisal Skills Programme (CASP) tool was conducted. MEDLINE and Google Scholar were searched from January 1990 to October 2019 to retrieve studies of breastfeeding mothers who had infants aged between 0 and 12 months. Two authors independently carried out the review process and resolved disagreements through consensus. We analyzed the data thematically.

RESULTS

After reviewing 92 studies, 20 studies involving 836 participants from 11 countries were eligible. Of the 72 studies excluded, 39 were not conducted in sub-Saharan Africa, and 33 included other participants such as fathers. Three themes emerged as barriers to exclusive breastfeeding (EBF) and five additional themes were identified with facilitators of maternal-infant factors being the most significant in both cases. Maternal employment and knowledge of the benefits of EBF were the most common maternal-infant factors that served as a barrier and a facilitator, respectively. The study's limitations were that the review involved only primary research among breastfeeding mothers living in sub-Saharan Africa and excluded studies not available in the English language. The information synthesized from this review could be used to develop communication strategies employed during individual and group patient education in the hospitals to improve breastfeeding mothers' understanding, acceptance, and practice of exclusive breastfeeding. This review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42020133761.

CONCLUSIONS

This review found that maternal-infant factors have the most significant influence over the practice of exclusive breastfeeding. Therefore, interventions targeted towards maternal-infant factors will improve and optimize exclusive breastfeeding significantly and, ultimately, improve maternal-child health outcomes.

The complex geographies of telelactation and access to community breastfeeding support in the state of Ohio

The availability of breastfeeding support resources, including those provided by Baby-Friendly Hospitals, International Board Certified Lactation Consultants, breastfeeding counselors and educators, and volunteer-based mother-to-mother support organizations, such as La Leche League, are critically important for influencing breastfeeding initiation and continuation for the mother-child dyad. In addition, the emergence of community support options via information and communication technologies such as Skype and Facetime, social media (e.g., Facebook), and telelactation providers are providing mothers with a new range of support options that can help bridge geographic barriers to traditional community support. However, telelactation services that use information and communication technologies to connect breastfeeding mothers to remotely located breastfeeding experts require reliable, affordable, high-quality broadband connections to facilitate interaction between mothers and their support resources. The purpose of this paper is to explore the complex spatial landscape of virtual and face-to-face breastfeeding support options for mothers in the state of Ohio (U.S.), identifying barriers to support. Using a range of spatial and network analytics, the results suggest that a divide is emerging. While urban areas in Ohio benefit from both a density of face-to-face breastfeeding support resources and robust broadband options for engaging in telelactation, many rural areas of the state are lacking access to both. Policy implications and several potential strategies for mitigating these inequities are discussed.

Parity and the Association Between Maternal Sociodemographic Characteristics and Breastfeeding

Objective: Although clinicians recognize the importance of breastfeeding for child health, breastfeeding initiation can be limited by maternal characteristics such as race/ethnicity, age at first birth, and educational attainment. We hypothesized that the strong influence of prior infant feeding experiences on multiparous women's decision to initiate and continue breastfeeding may mean that these maternal characteristics influence breastfeeding more strongly for primiparas than multiparas. Materials and Methods: Using Pregnancy Risk Assessment and Monitoring System (PRAMS) (Phase 8) survey data from 2016 to 2017, we analyzed mothers' responses to the supplemental question about parity, "Before you got pregnant with your new baby, did you ever have any other babies who were born alive?" Study variables were summarized by using weighted means and proportions and compared according to parity by using Wald tests. In the overall cohort, we evaluated the interaction between parity and each covariate by using logistic regression. Results: In our sample (N = 20,694), 40% of respondents were first-time mothers, and 88% had initiated breastfeeding. Primiparas were more likely to breastfeed than multiparas (92% versus 86%; p < 0.001), but they had shorter mean breastfeeding duration. On unadjusted analysis, four covariates were more strongly associated with breastfeeding initiation among primiparas than multiparas (maternal age, educational attainment, receiving breastfeeding information from a nurse or other medical professional, and receiving breastfeeding information from family or friends). Conclusions: Breastfeeding initiation is impacted more strongly by maternal characteristics for primiparas than multiparas.

Weaning Practices of Turkish Mothers: A Mixed-Model Research

Objectives: The aim of this study is to determine the weaning practices of mothers who have children between the ages of 2 and 5 years. Materials and Methods: This study was designed as a cross-sectional descriptive study, which was carried out between September 1, 2019 and October 1, 2019 in a pediatric clinic of a university hospital. For a better understanding, the traditional approaches, qualitative, and quantitative data were collected concurrently and analyzed together using Creswell's concurrent transformative mixed-model research design. Results: Of the 114 participants, the overall mean age was 29.2 ± 4.5 years. The mean breastfeeding duration was 15.3 ± 8.2 months. Sixty five (57.0%) of participants terminated breastfeeding themselves and 55 (85.9%) of them used traditional methods for weaning their children. The traditional methods used for termination of breastfeeding were staining the nipples to make baby startle (16.4%), applying nipples with a bad taste or smell to make baby disgust (40.0%), covering the nipples with various materials (18.2%), using a pacifier or feeding bottle (20.0%), and separation from mother (5.5%). Conclusions: In this study, it was found that most of the Turkish mothers use improper traditional methods for weaning. This study also demonstrated the urgent need to plan effective counseling services to implement natural weaning rather than traditional methods that are unsuitable for weaning.

Factors associated with cessation of exclusive breastfeeding at 1 and 2 months postpartum in Taiwan

Background

Breastfeeding benefits both mothers and infants. Even though Taiwan national policy promotes exclusive breastfeeding (EBF), the rates in Taiwan are below those in other developed countries. This study aimed to investigate factors associated with EBF cessation at 1 and 2 months postpartum.

Methods

This study was conducted in a community hospital in southern Taiwan between December 2016 and June 2017. Birth mothers (n = 1077) were interviewed by telephone at 1 and 2 months postpartum to collect information on infant feeding patterns (EBF since birth or not) and reasons for EBF cessation. Multivariate logistic regression models were used to determine risk factors associated with EBF cessation at 1 and 2 months.

Results

At 1 month, 432 participants (40.1%) maintained EBF. Factors associated with cessation were lack of tertiary education, primiparity, perceived low milk quantity, mother/infant separation, medical condition in mother, inconvenience/fatigue due to breastfeeding, and baby-centered factors. At 2 months, 316 participants (29.3%) maintained EBF. Factors associated with cessation were lack of tertiary education, primiparity, perceived low milk quantity, and return to work.

Conclusions

Education level, primiparity, perceived low milk quantity, and return to work are associated with premature cessation of EBF in Taiwan. Strategies about health education, family support, and baby-mother friendly environment can be used to achieve higher EBF rate.

Maternal circadian cortisol mediates the link between prenatal distress and breastfeeding

Breastfeeding is associated with positive maternal and infant outcomes. It is recommended that women exclusively breastfeed for the first 6 months postpartum; however, these recommendations are not met in the majority of women. Psychological distress in pregnancy is associated with lower rates of breastfeeding initiation and duration in the postpartum period. The mechanisms linking maternal distress to breastfeeding are not understood. In this study we examined maternal circadian cortisol as a mechanism linking distress in pregnancy to breastfeeding. This study is a secondary data analysis of 197 pregnant women with singleton pregnancies who were part of a larger study of the effects of maternal mood on fetal and infant development. About 34% of women reported exclusively breastfeeding, 18% reported exclusively formula feeding, and 48% reported mixed feeding. Participants reported on perceived stress, perinatal anxiety and depression, and socioeconomic status during pregnancy. They provided salivary cortisol samples at three times a day for 3 days at 24, 30, and 36 weeks' gestation. Participants who reported lower socioeconomic status in pregnancy were less likely to breastfeed, and lower maternal cortisol awakening responses mediated this association. This area of research may identify foci in the prenatal period that could serve as targets for interventions to increase rates of breastfeeding. Lay summary Pregnant women who reported lower socioeconomic status in pregnancy were less likely to breastfeed. This association was mediated by lower cortisol awakening responses, but not evening cortisol levels, over pregnancy.

Prepregnancy Depression and Breastfeeding Duration: A Look at Maternal Age

Background

In the United States, major depressive disorder affects one in five women aged 20-40 years. During these childbearing years, depression can negatively impact maternal behaviors that are crucial for infant growth and development. This study examined the relationship between prepregnancy depression and breastfeeding duration by maternal age.

Methods

Data from Phase 7 (2012-2013) of the Pregnancy Risk Assessment Monitoring System (N=62,483) were analyzed. Prepregnancy depression was dichotomized while breastfeeding duration was categorized as never breastfed, breastfed 8 weeks or less, and breastfed more than 8 weeks. Maternal age was a significant effect modifier; therefore, results were stratified by maternal age. Multinomial logistic regression was used to obtain odds ratios and 95% confidence intervals (CI).

Results

For women aged 20-24, 25-29, and 30-34 years with prepregnancy depression, the odds of never breastfeeding and breastfeeding 8 weeks or less were significantly higher than in women with no history of prepregnancy depression. Notably, among women aged 25-29 with prepregnancy depression, the odds of never breastfeeding and breastfeeding 8 weeks or less were 93% (adjusted odds ratio (AOR) = 1.93, 95% CI =1.57-2.37) and 65% (AOR = 1.65, 95% CI = 1.37-1.99) higher compared to women with no history of prepregnancy depression, respectively.

Conclusions

Having a history of poor mental health before pregnancy may increase the likelihood of premature breastfeeding cessation. A woman's mental health status before pregnancy should be considered in reproductive and prenatal care models. Efforts should be made to understand challenges women of specific age groups face when trying to breastfeed.

The Effect of Nursing Quality Improvement and Mobile Health Interventions on Infant Sleep Practices: A Randomized Clinical Trial

IMPORTANCE

Inadequate adherence to recommendations known to reduce the risk of sudden unexpected infant death has contributed to a slowing in the decline of these deaths.

OBJECTIVE

To assess the effectiveness of 2 interventions separately and combined to promote infant safe sleep practices compared with control interventions.

DESIGN, SETTING, AND PARTICIPANTS

Four-group cluster randomized clinical trial of mothers of healthy term newborns who were recruited between March 2015 and May 2016 at 16 US hospitals with more than 100 births annually. Data collection ended in October 2016.

INTERVENTIONS

All participants were beneficiaries of a nursing quality improvement campaign in infant safe sleep practices (intervention) or breastfeeding (control), and then received a 60-day mobile health program, in which mothers received frequent emails or text messages containing short videos with educational content about infant safe sleep practices (intervention) or breastfeeding (control) and queries about infant care practices.

MAIN OUTCOMES AND MEASURES

The primary outcome was maternal self-reported adherence to 4 infant safe sleep practices of sleep position (supine), sleep location (room sharing without bed sharing), soft bedding use (none), and pacifier use (any); data were collected by maternal survey when the infant was aged 60 to 240 days.

RESULTS

Of the 1600 mothers who were randomized to 1 of 4 groups (400 per group), 1263 completed the survey (78.9%). The mean (SD) maternal age was 28.1 years (5.8 years) and 32.8% of respondents were non-Hispanic white, 32.3% Hispanic, 27.2% non-Hispanic black, and 7.7% other race/ethnicity. The mean (SD) infant age was 11.2 weeks (4.4 weeks) and 51.2% were female. In the adjusted analyses, mothers receiving the safe sleep mobile health intervention had higher prevalence of placing their infants supine compared with mothers receiving the control mobile health intervention (89.1% vs 80.2%, respectively; adjusted risk difference, 8.9% [95% CI, 5.3%-11.7%]), room sharing without bed sharing (82.8% vs 70.4%; adjusted risk difference, 12.4% [95% CI, 9.3%-15.1%]), no soft bedding use (79.4% vs 67.6%; adjusted risk difference, 11.8% [95% CI, 8.1%-15.2%]), and any pacifier use (68.5% vs 59.8%; adjusted risk difference, 8.7% [95% CI, 3.9%-13.1%]). The independent effect of the nursing quality improvement intervention was not significant for all outcomes. Interactions between the 2 interventions were only significant for the supine sleep position.

CONCLUSIONS AND RELEVANCE

Among mothers of healthy term newborns, a mobile health intervention, but not a nursing quality improvement intervention, improved adherence to infant safe sleep practices compared with control interventions. Whether widespread implementation is feasible or if it reduces sudden and unexpected infant death rates remains to be studied.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01713868.

Comparing maternal breastfeeding self-efficacy during first week and sixth week postpartum

Introduction

The ideal nourishment for the first 12 months of a child’s life comes from breastfeeding its mother’s milk, and maternal self-efficacy is one factor which affects breastfeeding duration. Therefore, the present study aimed to compare the maternal breastfeeding self-efficacy during the first week and sixth-week postpartum.

Methods

This descriptive, analytical study was conducted on 767 women referring to the Family Health Research Center of Rasht in 2014. Mothers were selected through continuous sampling. For data collection, we used demographic questionnaires, and Dennis breastfeeding self-efficacy scale. For data analysis, Chi-square, Mann-Whitney U, Pearson’s correlation coefficient and multiple regression were performed using SPSS version 19.

Results

In this study, most mothers had scores compatible with moderate self-efficacy in the first week, and in the sixth week had high self-efficacy for breastfeeding. There was a significant relationship between breastfeeding self-efficacy (BSE) score and employment status (p<0.0001). Also, we found significant BSE score differences between primiparous and multiparous women (p<0.001).

Conclusion

Results of the study indicate that breastfeeding duration increases the breastfeeding self-efficacy levels. So, Developing and implementing appropriate approaches are needed to improve breastfeeding duration in mothers.

Integrative Review of Breastfeeding Duration and Influencing Factors Among Women Serving Active Duty in the U.S. Military

OBJECTIVE

To determine what is known about breastfeeding duration among active-duty servicewomen and to identify factors related to military employment that facilitate or inhibit breastfeeding.

DATA SOURCES

Literature searches using CINAHL and MEDLINE were conducted with the keywords military and breastfeeding for articles published from January 2000 through May 2016.

STUDY SELECTION

Abstracts and full-text research articles were retrieved and analyzed that met the inclusion criteria: English language, U.S. active-duty military personnel, peer-reviewed, and identified facilitators and/or barriers to breastfeeding.

DATA EXTRACTION

Eight studies were analyzed for quality and content; analysis was guided by Cooper's five stages of review synthesis processes.

DATA SYNTHESIS

Findings indicated that although breastfeeding initiation rates are similar to those for civilians, military women may discontinue sooner. Perception of military work as a barrier is associated with shorter duration, and enlisted personnel were less likely to breastfeed to 12 months than commissioned officers. Military women experienced work-related barriers: lack of proper facilities for pumping, pressures and obligations related to rank, conflicts between mother/soldier demands, physical fitness/weight standards, concerns related to exposure to hazardous material, and prolonged separations from their infants.

CONCLUSION

Most women in the military serve during their childbearing years when they may want to breastfeed. Strategies to promote breastfeeding include advocacy for policy changes, education of servicewomen and supervisors/commanders, and implementation of a breastfeeding class that addresses military-specific factors.

Impact of intervention on breastfeeding outcomes and determinants based on theory of planned behavior

BACKGROUND

Breastfeeding knowledge, attitude, subjective norm, and perceived control are significant determinants of breastfeeding, according to the theory of planned behavior (TPB). However, evidence concerning the effectiveness of the TPB-based intervention in breastfeeding promotion is sparse. Meanwhile, the changes of these determinants with time have not been examined in previous studies.

AIM

To investigate the effectiveness of the TPB-based intervention program in improving exclusive breastfeeding, and the interaction of time and intervention on these determinants of breastfeeding.

METHODS

285 primiparous mothers were included, with 157 mothers in the experimental group and 128 mothers in the control group. The experimental group received the TPB-based intervention program delivered during 6 weeks postpartum, while both the experimental and control groups received the standard obstetric care.

FINDINGS

Scores of breastfeeding knowledge, attitude and breastfeeding control increased with time from baseline to 6 weeks postpartum, while breastfeeding subjective norm decreased at 6 weeks both in the experimental and the control groups. Besides, scores of the four determinants were significantly higher in the experimental group than these in the control group at 3days and 6 weeks, except for breastfeeding control at 6 weeks, which resulted in the higher exclusive breastfeeding rates at 3days and 6 weeks in the experimental group than the control group.

DISCUSSION AND CONCLUSIONS

The TPB-based intervention was effective in promoting exclusive breastfeeding during 6 weeks postpartum. Future interventions are recommended to adjust intervention strategies with time, and give more focus on providing continued breastfeeding support after discharge.

Maternal serum perfluoroalkyl substances during pregnancy and duration of breastfeeding

BACKGROUND

Perfluoroalkyl substances (PFAS) may affect breast development and decrease duration of breastfeeding, thus interfering with the health benefits of breastfeeding. We investigated the association between maternal PFAS exposure and breastfeeding duration.

METHODS

We measured PFAS concentrations in maternal serum collected during pregnancy in 2003-2006. After delivery, women (n=336) completed standardized breastfeeding surveys every 3 months until ending breastfeeding or 36 months postpartum. We estimated relative risks (RRs) for ending any breastfeeding within 3-6 months postpartum by Poisson regression, adjusted for relevant confounding factors.

RESULTS

Women in the 4th quartile of perfluorooctanoic acid (PFOA) serum concentration had 1.77 times the risk of ending any breastfeeding by 3 months (95% confidence interval (CI): 1.23, 2.54; p-trend=0.003) and 1.41 times the risk of ending any breastfeeding by 6 months (95%CI: 1.06, 1.87; p-trend=0.038), compared with women in the first quartile. Women in the 4th quartile of perfluorooctane sulfonic acid serum concentration had a marginally increased risk of discontinuing any breastfeeding by 3 months (RR=1.32; 95%CI: 0.97, 1.79; p-trend=0.065).

CONCLUSIONS

Maternal serum PFOA concentrations were inversely related to duration of any breastfeeding in this cohort, even after controlling for prior breastfeeding. These findings suggest that PFOA exposure may adversely affect breastfeeding duration and highlight the need to consider the potential adverse effects of maternal environmental chemical exposure on breastfeeding.

Associations between perceived value of exclusive breastfeeding among pregnant women in the United States and exclusive breastfeeding to three and six months postpartum: a prospective study

BACKGROUND

Successful breastfeeding often starts with prenatally established intention. Yet, few mothers with the intention to exclusively breastfeed achieve their intended breastfeeding duration goal. This study examined the degree to which having a strong value of exclusive breastfeeding is associated with exclusive breastfeeding duration for at least 3 and 6 months postpartum among women who reported prenatal intention to exclusively breastfeed.

METHODS

Data were from the Infant Feeding Practices Study II, a longitudinal US national survey that followed maternal-infant dyads from pregnancy to 1 year postpartum. Bivariate and multivariate regression examined the degree to which strong maternal value of exclusive breastfeeding predicted exclusive breastfeeding duration.

RESULTS

Of the 1799 women who prenatally intended to exclusively breastfeed within the first few weeks postpartum, 34 and 9 % exclusively breastfed for at least 3 months and 6 months, respectively. Thirty-six percent of women reported strongly valuing exclusive breastfeeding out of which 46 % exclusively breastfeed to three months. In adjusted results, women who reported that they strongly value exclusive breastfeeding had more than twice the odds of exclusive breastfeeding for at least 3 months (Adjusted Odds Ratio [AOR] 2.29; 95 % confidence interval [CI] 1.84, 2.85) and for 6 months (AOR 2.49; 95 % CI 1.76, 3.53) compared to those who did not strongly value exclusive breastfeeding.

CONCLUSION

Valuing the benefits of exclusive breastfeeding during pregnancy is a strong independent predictor of actual exclusive breastfeeding duration. A minority of pregnant women strongly value exclusive breastfeeding and are able to exclusively breastfeed to 3 months even among women with established prenatal intention to exclusively breastfeed. Prenatal maternal education and environmental lactation support that extends into the postnatal period can promote longer duration of exclusive breastfeeding.

Household food insecurity, maternal nutritional status, and infant feeding practices among HIV-infected Ugandan women receiving combination antiretroviral therapy

Household food insecurity (HHFI) may be a barrier to both optimal maternal nutritional status and infant feeding practices, but few studies have tested this relationship quantitatively, and never among HIV-infected individuals. We therefore described the prevalence of HHFI and explored if it was associated with poorer maternal nutritional status, shorter duration of exclusive breastfeeding (EBF) and fewer animal-source complementary foods. We assessed these outcomes using bivariate and multivariate analyses among 178 HIV-infected pregnant and breastfeeding (BF) women receiving combination antiretroviral therapy in the PROMOTE trial (NCT00993031), a prospective, longitudinal cohort study in Tororo, Uganda. HHFI was common; the prevalence of severe, moderate, and little to no household hunger was 7.3, 39.9, and 52.8 %, respectively. Poor maternal nutritional status was common and women in households experiencing moderate to severe household hunger (MSHH) had statistically significantly lower body mass index (BMIs) at enrollment (21.3 vs. 22.5, p < 0.01) and prior to delivery (22.6 vs. 23.8, p < 0.01). BMI across time during pregnancy, but not gestational weight gain, was significantly lower for MSHH [adjusted beta (95 % CI) -0.79 (-1.56, -0.02), p = 0.04; -2.06 (-4.31, 0.19), p = 0.07], respectively. The prevalence (95 % CI) of EBF at 6 months was 67.2 % (59.7-73.5 %), and the proportion of women BF at 12 months was 80.4 % (73.3-85.7 %). MSHH was not associated with prevalence of EBF at 6 months or BF at 12 months. However, among those women still EBF at 4 months (81.4 % of population), those experiencing MSHH were significantly more likely to cease EBF between 4 and 6 months (aHR 2.38, 95 % CI 1.02-5.58). The prevalence of HHFI, maternal malnutrition, and suboptimal infant feeding practices are high and the causal relationships among these phenomena must be further explored.

Variation in the association between socioeconomic status and breastfeeding practices by immigration status in Taiwan: a population based birth cohort study

BACKGROUND

The relationship between socioeconomic status (SES) and breastfeeding has been extensively discussed in the literature. However, there is some evidence that this relationship can differ with immigration status. To date the majority of research investigating the relationships among SES, breastfeeding and immigration status has been conducted in Europe and the United States with a lack of similar research from Asia. Therefore, the aim of this study was to describe differences in breastfeeding practices between native-born Taiwanese mothers and immigrant mothers in Taiwan and to investigate any differences in the relationship between SES and breastfeeding practices by immigration status.

METHODS

Data analyzed came from the Taiwan Birth Cohort Study, the first longitudinal study of babies in Taiwan with a nationally representative sample born in 2005. In the present study, we included 21,217 mothers or primary caregivers who completed interview surveys when their child was 6 months old. Socioeconomic status was measured by the education level of mothers and fathers, and the couple's monthly income. Data analysis involved multiple logistic regression. Control variables included residential area, mother's employment status, age of the father and mother, and sex of the infant.

RESULTS

The proportion of immigrant mothers predominantly breastfeeding for 4 and for 6 months (Mainland Chinese mothers: 18.25 %, 36.29 %; Southeast Asian mothers: 10.71 %, 24.85 %) was significantly higher than that observed in their Taiwan-born counterparts (7.03 %, 16.22 %). Analysis stratified by immigration status showed that a higher level of parental education was associated with a greater likelihood of predominantly breastfeeding in Taiwanese mothers. However, no statistically significant relationship was observed between education and predominantly breastfeeding in immigrant mothers. Higher monthly income was also significantly associated with a greater likelihood of predominantly breastfeeding in Taiwanese mothers. However, there was no significant linear relationship between monthly income and predominantly breastfeeding in immigrant women.

CONCLUSION

The relationship between SES and breastfeeding is different in immigrant mothers and native-born Taiwanese mothers. Taiwanese policy should continue to encourage breastfeeding in immigrant mothers. However, greater attention should be placed on Taiwanese mothers from a low SES background.

Factors influencing breastfeeding exclusivity during the first 6 months of life in developing countries: a quantitative and qualitative systematic review

Breastfeeding is the most advantageous feeding option for infants, and epidemiological studies provide evidence for its promotion. The objective of this review was to comprehensively delineate the barriers and facilitators of exclusive breastfeeding of infants aged 0-6 months old by mothers in developing countries. A search of CINAHL, MEDLINE and PsycINFO was carried out to retrieve studies from January 2001 to January 2014. Using our inclusion criteria, we selected studies that described barriers and facilitators of exclusive breastfeeding. Qualitative and quantitative studies were considered. Twenty-five studies involving 11 025 participants from 19 countries were included. Barriers and facilitators of exclusive/full breastfeeding were identified, analysed tabulated and summarised in this review. Maternal employment was the most frequently cited barrier to exclusive breastfeeding. Maternal perceptions of insufficient breast milk supply was pervasive among studies while medical barriers related to illness of mothers and/or infants as well as breast problems, rather than health care providers. Socio-cultural factors such as maternal and significant other's beliefs about infant nutrition also often constitute strong barriers to exclusive breastfeeding. Despite these barriers, mothers in developing countries often possess certain personal characteristics and develop strategic plans to enhance their success at breastfeeding. Health care providers should be informed about the determinants of exclusive breastfeeding and provide practical anticipatory guidance targeted at overcoming these barriers. In so doing, health care providers in developing countries can contribute to improving maternal and child health outcomes.

Maternal anxiety and breastfeeding: findings from the MAVAN (Maternal Adversity, Vulnerability and Neurodevelopment) Study

BACKGROUND

Maternal anxiety and depression may impair maternal intention, motivation, and self-efficacy in multiple domains associated with child health including breastfeeding.

OBJECTIVE

We tested the hypothesis that mothers who experience substantial anxiety during pregnancy or the postpartum period are at increased risk for reduced initiation, exclusivity, and continuation of breastfeeding.

METHODS

We obtained data on 255 Canadian pregnant women from the Maternal Adversity, Vulnerability and Neurodevelopment (MAVAN) study recruited between June 2004 and February 2009. We utilized data collected from 18 to 23 weeks gestation through 12 months postpartum. Multivariate logistic regression was used to assess whether scores on the Hamilton Anxiety Scale (HAM-A) and State-Trait Anxiety Inventory (STAI) were associated with initiation, exclusivity, and continuation of breastfeeding.

RESULTS

Prenatal anxiety was not associated with breastfeeding outcomes. In adjusted models, a single point increase in HAM-A scores at 3 months postpartum was associated with an 11% reduction in the odds of exclusive breastfeeding at 6 months (adjusted odds ratio [aOR] = 0.89; 95% CI, 0.80-0.99). A single point increase in STAI State and STAI Trait scores at 3 months postpartum was associated with a 4% (aOR = 0.96; 95% CI, 0.92-0.99) and 7% (aOR = 0.93; 95% CI, 0.86-1.00) reduction, respectively, in the odds of any breastfeeding at 12 months.

CONCLUSION

Our findings suggest a relationship between maternal anxiety and reduced exclusivity and continuation of breastfeeding. Maternal anxiety should be actively monitored and managed appropriately in the postpartum period to support optimal breastfeeding practices.

A comparative analysis of early child health and development services and outcomes in countries with different redistributive policies

Background

The social environment is a fundamental determinant of early child development and, in turn, early child development is a determinant of health, well-being, and learning skills across the life course. Redistributive policies aimed at reducing social inequalities, such as a welfare state and labour market policies, have shown a positive association with selected health indicators. In this study, we investigated the influence of redistributive policies specifically on the social environment of early child development in five countries with different political traditions. The objective of this analysis was to highlight similarities and differences in social and health services between the countries and their associations with other health outcomes that can inform better global early child development policies and improve early child health and development.

Methods

Four social determinants of early child development were selected to provide a cross-section of key time periods in a child’s life from prenatal to kindergarten. They included: 1) prenatal care, 2) maternal leave, 3) child health care, and 4) child care and early childhood education. We searched international databases and reports (e.g. Organization for Economic Cooperation and Development, World Bank, and UNICEF) to obtain information about early child development policies, services and outcomes.

Results

Although a comparative analysis cannot claim causation, our analysis suggests that redistributive policies aimed at reducing social inequalities are associated with a positive influence on the social determinants of early child development. Generous redistributive policies are associated with a higher maternal leave allowance and pay and more preventive child healthcare visits. A decreasing trend in infant mortality, low birth weight rate, and under five mortality rate were observed with an increase in redistributive policies. No clear influence of redistributive policies was observed on breastfeeding and immunization rates. In the analysis of child care and early education, the lack of uniform measures of early child development outcomes was apparent.

Conclusions

This paper provides further support for an association between redistributive policies and early child health and development outcomes, along with the organization of early child health and development services.

Relationship between intention to supplement with infant formula and breastfeeding duration

OBJECTIVES

According to Health Canada and the Canadian Paediatric Society, infants should be exclusively breastfed for the first six months with continued breastfeeding for two years and beyond. This study examined the relationship between a mother's intention to supplement with infant formula and the risk of discontinuing breastfeeding during the 12 months postpartum.

METHODS

Surveys were administered to a cohort of mothers at 6 weeks, 6 months and 12 months postpartum as part of York Region's Infant Feeding Survey. Those who initiated breastfeeding were included in the analysis (n=345). The relationship between a mother's prenatal intention to supplement with infant formula and breastfeeding duration was examined using Cox proportional hazards regression controlling for mother's age, prenatal education, immigration status, parity, household income, mother's ethnicity and education.

RESULTS

Nearly one third of mothers intended to supplement with infant formula. Of those mothers, 69% actually supplemented their baby with infant formula within 12 months postpartum. Intention to supplement was found to be associated with shorter breastfeeding duration (HR=2.64, 95% CI 1.83-3.81). First-time mothers experienced shorter breastfeeding duration compared to experienced mothers (HR=2.13, 95% CI 1.39-3.27). Mothers who identified as European experienced shorter breastfeeding duration compared to East, Southeast or South Asian mothers (HR=1.79, 95% CI 1.05-3.06).

CONCLUSIONS

Continued breastfeeding is not only beneficial for the infant, but it also has important benefits for the mother. The analysis indicates that a mother's prenatal intent to supplement may be associated with shorter breastfeeding duration. Further research is required to confirm these findings and to address the underlying assumptions and limitations.

An Assessment of the Breastfeeding Practices and Infant Feeding Pattern among Mothers in Mauritius

Proper breastfeeding practices are effective ways for reducing childhood morbidity and mortality. While many mothers understand the importance of breastfeeding, others are less knowledgeable on the benefits of breastfeeding and weaning. The aim in here is to assess breastfeeding pattern, infant formula feeding pattern, and weaning introduction in Mauritius and to investigate the factors that influence infant nutrition. 500 mothers were interviewed using a questionnaire which was designed to elicit information on infant feeding practices. Statistical analyses were done using SPSS (version 13.0), whereby chi-square tests were used to evaluate relationships between different selected variables. The prevalence of breastfeeding practice in Mauritius has risen from 72% in 1991 to 93.4% as found in this study, while only 17.9% breastfed their children exclusively for the first 6 months, and the mean duration of EBF (exclusive breastfeeding) is 2.10 months. Complementary feeding was more commonly initiated around 4-6 months (75.2%). Despite the fact that 60.6% of mothers initiate breastfeeding and 26.1% of mothers are found to breastfeed up to 2 years, the practice of EBF for the first 6 months is low (17.9%). Factors found to influence infant feeding practices are type of delivery, parity, alcohol consumption, occupation, education, and breast problems.

Establishing successful breastfeeding in the newborn period

The first days after delivery of a newborn infant are critical for breastfeeding establishment. Successful initiation and continuation-especially of exclusive breastfeeding-have become public health priorities, but it is fraught with many individual- and systems-level barriers. In this article, we review how hospital newborn services can be constructed or restructured to support the breastfeeding mother-infant dyad so that they can achieve high levels of breastfeeding success. Important positive and negative factors from the prenatal period, and the preparation for hospital discharge are also discussed.

Breastfeeding and infant temperament at age three months

Background & Methods

To examine the relationship between breastfeeding and maternally-rated infant temperament at age 3 months, 316 infants in the prospective Cambridge Baby Growth Study, UK had infant temperament assessed at age 3 months by mothers using the Revised Infant Behavior Questionnaire, which produces scores for three main dimensions of temperament derived from 14 subscales. Infant temperament scores were related to mode of infant milk feeding at age 3 months (breast only; formula milk only; or mixed) with adjustment for infant's age at assessment and an index of deprivation.

Results

Infant temperament dimension scores differed across the three infant feeding groups, but appeared to be comparable between exclusive breast-fed and mixed-fed infants. Compared to formula milk-fed infants, exclusive breast-fed and mixed-fed infants were rated as having lower impulsivity and positive responses to stimulation (adjusted mean [95% CI] “Surgency/Extraversion” in formula-fed vs. mixed-fed vs. breast-fed groups: 4.3 [4.2–4.5] vs. 4.0 [3.8–4.1] vs. 4.0 [3.9–4.1]; p-heterogeneity = 0.0006), lower ability to regulate their own emotions (“Orienting/Regulation”: 5.1 [5.0–5.2], vs. 4.9 [4.8–5.1] vs. 4.9 [4.8–5.0]; p = 0.01), and higher emotional instability (“Negative affectivity”: 2.8 [2.6–2.9] vs. 3.0 [2.8–3.1] vs. 3.0 [2.9–3.1]; p = 0.03).

Conclusions

Breast and mixed-fed infants were rated by their mothers as having more challenging temperaments in all three dimensions; particular subscales included greater distress, less smiling, laughing, and vocalisation, and lower soothability. Increased awareness of the behavioural dynamics of breastfeeding, a better expectation of normal infant temperament and support to cope with difficult infant temperament could potentially help to promote successful breastfeeding.

The impact of peer support training on mothers' attitudes towards and knowledge of breastfeeding

While the benefits of breastfeeding are well established, few Scottish women exclusively breastfeed, as recommended nationally and internationally. Breastfeeding peer support can help mothers to breastfeed for longer, but the training peer supporters receive is variable and few studies have measured the effectiveness of peer supporter training. This study aimed to compare mothers' attitudes towards and knowledge of breastfeeding before and after undertaking Breastfeeding Network (BfN) peer supporter training. This study used a quasi-experimental design to investigate levels of breastfeeding knowledge and attitudes in 28 women, immediately before and after the BfN peer supporter (Helper) training programme. Data were collected using the Infant Feeding Questionnaire. Mothers had high baseline scores for attitude (88.8%) and knowledge (76.4%). After training 78% of mothers improved their attitude scores. The mean difference in attitude scores was 4.9%, which was statistically significant (t = 4.44, P < 0.001). Ninety-six per cent of mothers had increased their knowledge scores. The mean difference in knowledge scores was 10.4%, which was statistically significant (t = 6.25, P < 0.001). This study provides evidence that the BfN's accredited peer support training can improve both breastfeeding knowledge and attitudes of breastfeeding mothers. Peer supporters who have undertaken this training are therefore suitably qualified to provide mothers with the support and information required to make informed choices in breastfeeding and to contribute to effective support and promotion of breastfeeding as suggested in the National Institute for Health and Clinical Excellence guideline on maternal and infant nutrition (PH11) and Scottish Government's Maternal and Infant Nutrition: A Framework for Action (2011).