Motivational interviewing improves exclusive breastfeeding in an Australian randomised controlled trial

The Marri Gudjaga project: a study protocol for a randomised control trial using Aboriginal peer support workers to promote breastfeeding of Aboriginal babies

BACKGROUND

Breastfeeding protects against a range of conditions in the infant, including sudden infant death syndrome (SIDS), diarrhoea, respiratory infections and middle ear infections [1, 2]. The World Health Organization (WHO) recommends exclusive breastfeeding until six months of age, with continued breastfeeding recommended for at least two years and other complementary nutritious foods [3]. The 2017-18 National Health Survey (NHS) and 2018-19 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) reported that the proportion of breastfeeding in Aboriginal and Torres Strait Islander infants (0-2 years) were less than half that of non-Indigenous infants (21.2% vs. 45%, respectively)[4]. There is a lack of research on interventions supporting Aboriginal women to breastfeed, identifying an evaluation gap related to peer support interventions to encourage exclusive breastfeeding in Aboriginal women.

METHODS

We will evaluate the effect of scheduled breastfeeding peer support for and by Aboriginal women, on breastfeeding initiation and the prevalence of exclusive breastfeeding. This MRFF (Medical Research Future Fund) funded project is designed as a single-blinded cluster randomised controlled trial recruiting six sites across New South Wales, Australia, with three sites being randomised to employ a peer support worker or undertaking standard care. Forty pregnant women will be recruited each year from each of the six sites and will be surveyed during pregnancy, at six weeks, four and six months postnatally with a single text message at 12 months to ascertain breastfeeding rates. In-depth interviews via an Indigenous style of conversation and storytelling called 'Yarning' will be completed at pre- and post-intervention with five randomly recruited community members and five health professionals at each site" [5]. Yarns will be audio recorded, transcribed, coded and thematic analysis undertaken. Health economic analysis will be completed to assess the health system incremental cost and effects of the breastfeeding intervention relative to usual care.

DISCUSSION

Evidence will be given on the effectiveness of Aboriginal peer support workers to promote the initiation and continuation of breastfeeding of Aboriginal babies. The findings of this study will provide evidence of effectiveness and cost-effectiveness of including peer support workers in postnatal care to promote breastfeeding practices.

TRIAL REGISTRATION

ACTRN12622001208796 The impact of breastfeeding peer support on nutrition of Aboriginal infants.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

1. To describe types of breastfeeding support for healthy breastfeeding mothers with healthy term babies. 2. To examine the effectiveness of different types of breastfeeding support interventions in terms of whether they offered only breastfeeding support or breastfeeding support in combination with a wider maternal and child health intervention ('breastfeeding plus' support).  3. To examine the effectiveness of the following intervention characteristics on breastfeeding support:      a. type of support (e.g. face-to-face, telephone, digital technologies, group or individual support, proactive or reactive);      b. intensity of support (i.e. number of postnatal contacts);      c. person delivering the intervention (e.g. healthcare professional, lay person);     d. to examine whether the impact of support varied between high- and low-and middle-income countries.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes results of searches of CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP)) (11 May 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. Support could be provided face-to-face, over the phone or via digital technologies. All studies had to meet the trustworthiness criteria.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed risk of bias and study trustworthiness.  The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 116 trials of which 103 contribute data to the analyses. In total more than 98,816 mother-infant pairs were included.  Moderate-certainty evidence indicated that 'breastfeeding only' support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at six months (Risk Ratio (RR) 0.93, 95% Confidence Interval (CI) 0.89 to 0.97); stopping exclusive breastfeeding at six months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4-6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4-6 (RR 0.83 95% CI 0.76 to 0.90). Similar findings were reported for the secondary breastfeeding outcomes except for any breastfeeding at two months and 12 months when the evidence was uncertain if 'breastfeeding only' support helped reduce the number of women stopping breastfeeding.  The evidence for 'breastfeeding plus' was less consistent. For primary outcomes there was some evidence that 'breastfeeding plus' support probably reduced the number of women stopping any breastfeeding (RR 0.94, 95% CI 0.91 to 0.97, moderate-certainty evidence) or exclusive breastfeeding at six months (RR 0.79, 95% CI 0.70 to 0.90).  'Breastfeeding plus' interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4-6 weeks, but the evidence is very uncertain (RR 0.73, 95% CI 0.57 to 0.95). The evidence suggests that 'breastfeeding plus' support probably results in little to no difference in the number of women stopping any breastfeeding at 4-6 weeks (RR 0.94, 95% CI 0.82 to 1.08, moderate-certainty evidence). For the secondary outcomes, it was uncertain if 'breastfeeding plus' support helped reduce the number of women stopping any or exclusive breastfeeding at any time points.  There were no consistent findings emerging from the narrative synthesis of the non-breastfeeding outcomes (maternal satisfaction with care, maternal satisfaction with feeding method, infant morbidity, and maternal mental health), except for a possible reduction of diarrhoea in intervention infants.  We considered the overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions and as studies utilised self-report breastfeeding data, there is also a risk of bias in outcome assessment.   We conducted meta-regression to explore substantial heterogeneity for the primary outcomes using the following categories: person providing care; mode of delivery; intensity of support; and income status of country.  It is possible that moderate levels (defined as 4-8 visits) of 'breastfeeding only' support may be associated with a more beneficial effect on exclusive breastfeeding at 4-6 weeks and six months. 'Breastfeeding only' support may also be more effective in reducing women in low- and middle-income countries (LMICs) stopping exclusive breastfeeding at six months compared to women in high-income countries (HICs). However, no other differential effects were found and thus heterogeneity remains largely unexplained. The meta-regression suggested that there were no differential effects regarding person providing support or mode of delivery, however, power was limited.  AUTHORS' CONCLUSIONS: When 'breastfeeding only' support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points.  For 'breastfeeding plus' interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face-to-face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.

A randomised controlled trial evaluating the effect of a brief motivational intervention to promote breastfeeding in postpartum depression

Postpartum depression (PPD) is the most frequent psychiatric complication during the postnatal period. According to existing evidence, an association exists between the development of PPD and the maintenance of breastfeeding. A brief motivational intervention (bMI), based on the motivational interview, seems effective in promoting breastfeeding. The objective of this study was to analyse the impact of a bMI aiming to promote breastfeeding on the development of PPD and explore the mediating/moderating roles of breastfeeding and breastfeeding self-efficacy in the effect of the intervention on developing PPD. Eighty-eight women who gave birth by vaginal delivery and started breastfeeding during the immediate postpartum period were randomly assigned to the intervention group (bMI) or control group (breastfeeding education). Randomisation by minimisation was carried out. The breastfeeding duration was longer in the intervention group (11.06 (± 2.94) weeks vs 9.02 (± 4.44), p = 0.013). The bMI was associated with a lower score on the Edinburgh Postnatal Depression Scale, with a regression β coefficient of - 2.12 (95% CI - 3.82; - 0.41). A part of this effect was mediated by the effect of the intervention on the duration of breastfeeding (mediation/moderation index β = - 0.57 (95% CI - 1.30; - 0.04)). These findings suggest that a bMI aiming to promote breastfeeding has a positive impact preventing PPD mainly due to its effectiveness in increasing the duration of breastfeeding.

The Effect of Maternal Self-Regulated Motivation on Breastfeeding Continuation

OBJECTIVE

Women frequently report breastfeeding problems in the early postpartum period. Women who have self-endorsed beliefs that breastfeeding benefits their babies and themselves are more likely to continue breastfeeding despite breastfeeding barriers. Maternal self-endorsed beliefs is a key component of maternal self-regulated motivation. The present study examined the association between maternal self-regulated motivation, breastfeeding duration and exclusivity in Chinese women.

METHODS

This was a prospective cohort study, of which we recruited participants in postnatal maternity units of publicly funded hospitals in Hong Kong. Postpartum women were asked to fill in the validated breastfeeding self-regulation questionnaire (BSRQ) before hospital discharge and their breastfeeding status was assessed by telephone follow-ups at 6 and 12 weeks postpartum. Multiple logistic regression was used to study the relationship between breastfeeding self-regulated motivation and the duration of breastfeeding at follow-up.

RESULTS

At 6 and 12 weeks postpartum, women who breastfed exclusively scored significantly higher in self-regulated motivation than those who formula-fed. The self-regulated motivation was associated with higher odds of exclusive breastfeeding at 6 weeks and any breastfeeding at 12 weeks postpartum.

CONCLUSIONS FOR PRACTICE

The study found that self-regulated motivation was positively related to breastfeeding duration. Maternal self-regulated motivation toward breastfeeding could be enhanced by the availability of social support and breastfeeding-friendly facilities, resulting in longer breastfeeding duration.

Human Milk for the Term Newborn

Human milk provides optimal nutrition for term newborns, but the prevalence of its use is below target, and risks have been identified. Infants of black mothers as well as term newborns admitted to the neonatal intensive care unit are at risk for not receiving human milk. To improve human milk intake, multiple individual-level interventions have been shown to be effective, but some popular system-level interventions are ineffective or harmful. Expressed milk and donor milk may be less beneficial than direct breastfeeding. Nuanced public policies can help support lactation while promoting individual choice and equity.

Breastfeeding counseling based on formative research at primary healthcare Services in Mexico

BACKGROUND

Breastfeeding rates in Mexico are far from World Health Organization (WHO) recommendations with 28.8% of Exclusive Breastfeeding (EBF) under 6 months of age, according to the 2018 National Health and Nutrition Survey. Formative research has shown that culturally appropriate counseling is an effective breastfeeding intervention. The objective of the current study was to evaluate the effect of interpersonal counseling on EBF in a primary healthcare center in Tijuana, México.

METHODS

This was a randomized controlled trial pilot with a sample of mothers with infants under 4 months of age from a primary care center. Participants were randomized into two groups: 1) Control group, received counseling on immunizations and standard infant feeding information, and 2) Intervention group, receiving breastfeeding counseling using a socio-ecological framework. Changes in breastfeeding attitudes, self-efficacy and EBF were evaluated at 2 months post-intervention.

RESULTS

A total of 80 mothers completed the 2 month follow up assessment (40 in each group). The mean age at baseline was 26.4 years for mothers and 1.4 months for infants. There was a 30% increase in EBF at 2 months follow up in the intervention group and 15% decrease in the control group post-intervention. We observed a significant improvement in breastfeeding attitudes (P = 0.0001), self-efficacy (P = 0.046) and EBF (P = 0.0001) in the intervention group. Reported obstacles were discomfort of breastfeeding in public (23%), infant dissatisfaction (23%), pain (19%), insufficient milk supply (15%) and returning to work (8%).

CONCLUSIONS

Breastfeeding counseling based on previous formative research improved breastfeeding attitudes, self-efficacy and practices in this population. These findings suggest that the promotion of breastfeeding utilizing a socio-ecological framework may improve breastfeeding rates by addressing the needs of women within their varying sociocultural contexts.

TRIAL REGISTRATION

ACTRN: ACTRN12621000915853 . Retrospectively registered.

Effect of a brief motivational intervention in the immediate postpartum period on breastfeeding self-efficacy: Randomized controlled trial

Brief motivational intervention (bMI) is a therapeutic approach that encourages self-efficacy and may have a positive effect on breastfeeding self-efficacy (BSE). The purpose of this study was to analyze the effectiveness of a bMI in increasing BSE in women who started breastfeeding in the immediate postpartum period and to explore the roles of general self-efficacy and other baseline variables in this relationship. A randomized, parallel-group clinical trial was carried out. A bMI was compared with an educational session on breastfeeding. Changes in BSE and its dimensions and the interaction and mediation/moderation of general self-efficacy and other variables were analyzed. BSE increased in the bMI group from a mean baseline score of 59.14 (±9.35) to 64.62 (±7.91) at 1st month (p < 0.001). An interaction was found in that only women with higher education had an improvement in BSE during the follow-up period that was attributable to the bMI (mean difference between the bMI and the attention control group: 18.25 (95% confidence interval: 5.86-30.19; p = 0.006). This interaction was not found for the changes produced in the intrapersonal thoughts dimension of BSE, whose scores were higher in the bMI group at 3 and 6 months. General self-efficacy exerted a moderating effect on the association of bMI with BSE change. The effect of bMI was no longer significant when the general self-efficacy score was above 84. Thus, bMI is effective in increasing BSE. This effectiveness was limited by the mother's educational level and moderated by baseline general self-efficacy.

Path Model Validation of Breastfeeding Intention Among Pregnant Women

OBJECTIVE

To validate a blended health belief model and integrated behavioral model of selected modifiable psychosocial constructs during pregnancy to seek the best-fit path model for breastfeeding intention.

DESIGN

A nonexperimental, cross-sectional study.

SETTING

A virtual online market research sample aggregator.

PARTICIPANTS

Women (N = 300) between 18 and 45 years of age in their second or third trimesters of pregnancy participated in the study in February 2018.

METHODS

Based on the health belief model and the integrated behavioral model, we proposed a theoretical framework, including self-efficacy for breastfeeding, knowledge, perceived benefits, perceived barriers, attitude toward breastfeeding, patient-provider interaction, and motivation to breastfeed, to predict breastfeeding intention. We administered a 98-item questionnaire modified from preexisting instruments. We conducted descriptive, bivariate, and regression analyses to help with the formation of the path model.

RESULTS

The best-fit path model with all significant paths and effect directions showed that intention to breastfeed is directly influenced by motivation to breastfeed, attitudes toward breastfeeding, and self-efficacy for breastfeeding, which together accounted for 56% (R²) of the variance in intention. We also identified indirect effects from knowledge about breastfeeding, patient-provider interaction, perceived benefits, and perceived barriers and their interrelationships with effect directions.

CONCLUSION

Through our findings, we contribute to the emerging body of evidence that shows the significant variables and their effect directions for breastfeeding intention. Incorporating these findings may provide support and evidence for clinical and community interventions focusing on modifiable psychosocial constructs during pregnancy to promote breastfeeding and further investigations using health behavior theories.

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

Background

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

Methods

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

Results

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

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

Conclusions

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

Supplementary Information

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

The Effect of Motivational Interviewing on Self-Efficacy and Continuation of Exclusive Breastfeeding Rates: A Quasi-Experimental Study

Background: Self-efficacy is a decisive psychological and motivational factor in maintaining exclusive breastfeeding (EBF). The aim of this study was to explore the impact of motivational interviewing (MI) on EBF self-efficacy and EBF in primiparous women. Materials and Methods: This quasi-experimental study was conducted on 140 primiparous women admitted to a number of comprehensive health centers in Zahedan in 2019. The health centers were determined through multistage random sampling, and the subjects were selected from each center using convenience sampling. The selected women were equally divided into the intervention and control groups. The two groups took the pretest by filling out a demographic questionnaire and a breastfeeding self-efficacy questionnaire. The intervention group attended four 45- to 60-minute MI sessions on breastfeeding. The EBF continuation sheet and the breastfeeding self-efficacy questionnaire were filled out 6 months postpartum. Data were analyzed in SPSS 22 using paired t-test, independent t-test, chi-square test, and covariance analysis. Results: Based on the results, the mean and standard deviation of the number of EBF days were significantly higher in the intervention group (137.68 ± 65.50) compared with that of the control group (99.51 ± 80.62). In addition, the mean score of breastfeeding self-efficacy after MI was significantly different between the two groups (p = 0.0001). Conclusion: Because of the significantly positive impact of MI on enhancing EBF self-efficacy and continuation, it is recommended to integrate this counseling strategy into the care programs designed for women in pregnancy and even postpartum period.

"Motivate to Lactate": Utilizing Motivational Interviewing to Improve Breastfeeding Rates

Promotion of exclusive breastfeeding is a nationwide initiative that has been incorporated into health-care facilities. Staff educators for women's and children's services should consider using motivational interviewing techniques to engage patients in a conversation about breastfeeding. Motivational interviewing has been linked with many positive outcomes in patient-centered care. This research article reveals the staffs' positive perception of adopting these techniques into daily practice and their thoughts on the potential patient outcomes.

Randomized Controlled Trial of Motivational Interviewing to Support Breastfeeding Among Appalachian Women

OBJECTIVE

To determine the effectiveness of a single session of prenatal motivational interviewing (MI) to enhance breastfeeding outcomes.

DESIGN

A randomized controlled trial with two groups (MI and psychoeducation) with repeated measures: preintervention, postintervention, and at 1 month postpartum.

SETTING

The intervention was conducted at a university-associated clinic, community locations, and participants' homes. Postpartum follow-up was conducted by telephone.

PARTICIPANTS

A total of 81 women with low-risk pregnancies enrolled at 28 to 39 weeks gestation who lived in Appalachia.

METHODS

Participants were randomly assigned to MI or psychoeducation on infant development. Pre- and postintervention outcome measures included intention to breastfeed, confidence in and importance of breastfeeding plan, and breastfeeding attitudes. At 1 month postpartum, participants completed a telephone interview to assess actual breastfeeding initiation, exclusivity, and plans to continue breastfeeding.

RESULTS

At 1 month postpartum, women in the MI group were more likely to report any current breastfeeding than women in the psychoeducation group, regardless of parity, χ²(1, N = 79) = 4.30, p = .040, Φ = .233. At the postintervention time point, the MI intervention had a significant effect on improving attitudes about breastfeeding among primiparous women only (p < .05).

CONCLUSION

One session of MI was effective to promote breastfeeding at 1 month postpartum and to enhance positive attitudes toward breastfeeding among primiparous women in Appalachia.

A novel peer-support intervention using motivational interviewing for breastfeeding maintenance: a UK feasibility study

BACKGROUND

In total, 81% of women in the UK start breastfeeding, but fewer than half continue beyond 6 weeks. Peer support in the early postnatal period may encourage women to breastfeed for longer.

OBJECTIVE

To develop a breastfeeding peer-support intervention based on motivational interviewing (MI) for breastfeeding maintenance and to test the feasibility of delivering it to mothers in areas with high levels of social deprivation.

DESIGN

Intervention development and a non-randomised multisite feasibility study.

SETTING

Community maternity services in three areas with high levels of social deprivation and low breastfeeding initiation rates in England and Wales.

PARTICIPANTS

Pregnant women considering breastfeeding. Women who did not plan to breastfeed, who had a clinical reason that precluded breastfeeding continuation or who were unable to consent were excluded.

INTERVENTION

The intervention Mam-Kind was informed by a survey of infant feeding co-ordinators, rapid literature review, focus groups with service users and peer supporters and interviews with health-care professionals and a Stakeholder Advisory Group. It consisted of face-to-face contact at 48 hours after birth and proactive one-to-one peer support from the Mam-Kind buddy for 2 weeks, followed by mother-led contact for a further 2-6 weeks.

MAIN OUTCOME MEASURES

Recruitment and retention of Mam-Kind buddies, uptake of Mam-Kind by participants, feasibility of delivering Mam-Kind as specified and of data collection methods, and acceptability of Mam-Kind to mothers, buddies and health-care professionals.

RESULTS

Nine buddies were recruited to deliver Mam-Kind to 70 participants (61% of eligible women who expressed an interest in taking part in the study). Participants were aged between 19 and 41 years and 94% of participants were white. Intervention uptake was 75% and did not vary according to age or parity. Most contacts (79%) were initiated by the buddy, demonstrating the intended proactive nature of the intervention and 73% (n = 51) of participants received a contact within 48 hours. Follow-up data were available for 78% of participants at 10 days and 64% at 8 weeks. Data collection methods were judged feasible and acceptable. Data completeness was > 80% for almost all variables. Interviews with participants, buddies and health service professionals showed that the intervention was acceptable. Buddies delivered the intervention content with fidelity (93% of intervention objectives were met), and, in some cases, developed certain MI skills to a competency level. However, they reported difficulties in changing from an information-giving role to a collaborative approach. These findings were used to refine the training and intervention specification to emphasise the focus of the intervention on providing mother-centric support. Health-care professionals were satisfied that the intervention could be integrated with existing services.

CONCLUSIONS

The Mam-Kind intervention was acceptable and feasible to deliver within NHS maternity services and should be tested for effectiveness in a multicentre randomised controlled trial. The feasibility study highlighted the need to strengthen strategies for birth notification and retention of participants, and provided some insights on how this could be achieved in a full trial.

LIMITATIONS

The response rate to the survey of infant feeding co-ordinators was low (19.5%). In addition, the women who were recruited may not be representative of the study sites.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Effective Communication Strategies for Nurses to Discuss Infant Feeding with New Mothers During Postpartum Hospitalization

During prenatal care and postpartum hospitalization, nurses have an important role in assisting new mothers to make informed decisions about feeding their newborn infants. There is overwhelming evidence that breastfeeding is beneficial for most new mothers and babies; therefore, perinatal nurses encourage breastfeeding. Newborn infant feeding conversations with women who have chosen to formula feed may be complicated and may cause tension in the nurse-patient relationship. Despite this potential difficulty, these conversations are essential to establish a feeding plan for the newborn infant and to promote healthy outcomes for mothers and babies. Tools are offered for nurses to guide conversations about infant feeding choices and to help to ensure that all mothers receive support and encouragement on their feeding choice.

Promote Breastfeeding in the Outpatient Setting: It's Easy!

The numerous benefits for both mother and baby of breastfeeding are evidence-based and well-defined. Breastmilk is the physiologic norm for infant nutrition, offering multiple health benefits and protections for mothers and babies. Although major medical and health organizations, which represent the health of women and children, such as the American Academy of Pediatrics (AAP), American College of Obstetrics and Gynecology (ACOG), American Academy of Family Practice (AAFP), Centers for Disease Control (CDC), UNICEF, the World Health Organization (WHO) and the National Public Health Service (NPHS), all recommend exclusive breastfeeding, few women meet the recommended goals for duration and exclusivity, despite high initiation rates. This article will discuss the barriers women face when breastfeeding. Strategies will be discussed on how physicians and health care providers can assist and advocate for their mothers while helping to improve the health of women and children. Physicians/pediatricians can support women and design interventions that can help patients' mothers overcome these challenges.

Interventions Designed to Promote Exclusive Breastfeeding in High-Income Countries: A Systematic Review Update

BACKGROUND

Worldwide, women seldom reach the recommended target of exclusive breastfeeding up to 6 months postpartum. The aim of the current study was to update a previously published review that presented a conceptual and methodological synthesis of interventions designed to promote exclusive breastfeeding up to 6 months in high-income countries.

MATERIALS AND METHODS

A systematic search of leading databases was conducted for scholarly, peer-reviewed, randomized controlled trials published from June 2013 to December 2016. Twelve new articles were identified as relevant; all were published in English and assessed exclusive breastfeeding with a follow-up period extending beyond 4 months postpartum. Articles were analyzed for overall quality of evidence in regard to duration of exclusive breastfeeding, using the Grading and Recommendations Assessment, Development, and Evaluation approach.

RESULTS

A significant increase in the duration of exclusive breastfeeding was found in 4 of the 12 studies. All four successful interventions had long-duration postpartum programs, implemented by telephone, text message, or through a website. Some of the successful interventions also included prenatal education or in-hospital breastfeeding support.

CONCLUSIONS

Results from this review update correspond closely with previous findings, in that all of the successful interventions had lengthy postnatal support or an education component. More studies assessed intervention fidelity than in the previous review; however, there was little discussion of maternal body-mass index. While a pattern of successful interventions is beginning to emerge, further research is needed to provide a robust evidence base to inform future interventions, particularly with overweight and obese women.

The Effect of a Breastfeeding Motivation Program Maintained During Pregnancy on Supporting Breastfeeding: A Randomized Controlled Trial

BACKGROUND

Exclusive breastfeeding is the recommended breastfeeding method for infants during the first 6 postnatal months.

OBJECTIVE

This study aimed to increase breastfeeding duration and frequency using a breastfeeding motivation program (BMP), which was structurally based on Pender's Health Promotion Model (HPM) and administered during pregnancy and the postnatal period. The study was also designed to determine the BMP effectiveness in supporting exclusive breastfeeding.

MATERIALS AND METHODS

The sample of this randomized controlled trial included 100 pregnant women (50 in the BMP, 50 in the control group) who applied to the pregnancy preparation course in a state hospital located in Usak, western Turkey. Participants in the study were allocated into either the BMP group or control group through systematic sampling and randomization. The BMP was structured based on the HPM and was carried out with the BMP study group four times: during the antenatal period, on the first postnatal day, between the fourth and sixth postnatal weeks, and during the fourth postnatal month. Data were analyzed using the descriptive statistical test, Pearson's chi-square test, independent samples t test, and ANOVA.

RESULTS

The mothers in the BMP group started breastfeeding earlier than the mothers in the control group (97.1%) and had fewer problems with their first breastfeeding experience. The average score of perceived self-efficacy in breastfeeding and the rate of first breastfeeding experience (70.6%) were higher in the BMP group by a statistically significant amount.

CONCLUSION

BMP for breastfeeding, structurally based on Pender's HPM, can help in supporting and maintaining exclusive breastfeeding.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

To describe forms of breastfeeding support which have been evaluated in controlled studies, the timing of the interventions and the settings in which they have been used.To examine the effectiveness of different modes of offering similar supportive interventions (for example, whether the support offered was proactive or reactive, face-to-face or over the telephone), and whether interventions containing both antenatal and postnatal elements were more effective than those taking place in the postnatal period alone.To examine the effectiveness of different care providers and (where information was available) training.To explore the interaction between background breastfeeding rates and effectiveness of support.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 100 trials involving more than 83,246 mother-infant pairs of which 73 studies contribute data (58 individually-randomised trials and 15 cluster-randomised trials). We considered that the overall risk of bias of trials included in the review was mixed. Of the 31 new studies included in this update, 21 provided data for one or more of the primary outcomes. The total number of mother-infant pairs in the 73 studies that contributed data to this review is 74,656 (this total was 56,451 in the previous version of this review). The 73 studies were conducted in 29 countries. Results of the analyses continue to confirm that all forms of extra support analyzed together showed a decrease in cessation of 'any breastfeeding', which includes partial and exclusive breastfeeding (average risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.88 to 0.95; moderate-quality evidence, 51 studies) and for stopping breastfeeding before four to six weeks (average RR 0.87, 95% CI 0.80 to 0.95; moderate-quality evidence, 33 studies). All forms of extra support together also showed a decrease in cessation of exclusive breastfeeding at six months (average RR 0.88, 95% CI 0.85 to 0.92; moderate-quality evidence, 46 studies) and at four to six weeks (average RR 0.79, 95% CI 0.71 to 0.89; moderate quality, 32 studies). We downgraded evidence to moderate-quality due to very high heterogeneity.We investigated substantial heterogeneity for all four outcomes with subgroup analyses for the following covariates: who delivered care, type of support, timing of support, background breastfeeding rate and number of postnatal contacts. Covariates were not able to explain heterogeneity in general. Though the interaction tests were significant for some analyses, we advise caution in the interpretation of results for subgroups due to the heterogeneity. Extra support by both lay and professionals had a positive impact on breastfeeding outcomes. Several factors may have also improved results for women practising exclusive breastfeeding, such as interventions delivered with a face-to-face component, high background initiation rates of breastfeeding, lay support, and a specific schedule of four to eight contacts. However, because within-group heterogeneity remained high for all of these analyses, we advise caution when making specific conclusions based on subgroup results. We noted no evidence for subgroup differences for the any breastfeeding outcomes.

AUTHORS' CONCLUSIONS

When breastfeeding support is offered to women, the duration and exclusivity of breastfeeding is increased. Characteristics of effective support include: that it is offered as standard by trained personnel during antenatal or postnatal care, that it includes ongoing scheduled visits so that women can predict when support will be available, and that it is tailored to the setting and the needs of the population group. Support is likely to be more effective in settings with high initiation rates. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed with women practising exclusive breastfeeding.

Practice related factors that may impact on postpartum care for mothers and infants in Australian general practice: a cross-sectional survey

Background

While there is a significant focus on the health and well-being of women during pregnancy, labour and birth, much less emphasis is placed on the care of postpartum women and their infants in primary care following the birth. Some studies have investigated the role of GPs in postpartum care, and others examined facilitators and barriers to mothers accessing care. However there is little information available to investigate the effect of practice related factors on access to care of mothers and infants at this time.

Methods

A 20-item questionnaire for completion by the practice managers was mailed to 497 general practices in Southern Queensland, Australia between February and July 2013. Questionnaire items included practice demographics, practice procedures and personnel including appointment scheduling, billing, practice nurse function and qualifications and a free-text option for comments. Descriptive statistics are presented as numbers and percentages. Chi Squared test compared practice location with methods of identification of postpartum women, practice size with other Queensland data and ANOVA compared practice size with the number of postpartum appointments. Logistic regression was used to predict variables that were related to booked appointment times. Free text responses were grouped in common themes.

Results

The response rate was 27.4 %. At 67.2 % of the practices, mothers had to self-identify as needing a postpartum consultation and most consultations were allocated 15 minutes or less. Only 20 % of practices accepted the government insurance payment (bulk-billing) for all maternal and infant services, with more practices bulk-billing children only. Out-of-pocket expenses ranged from $10-$60. Nearly 80 % of practice nurses saw postpartum mothers or infants ‘nearly always’ or ‘sometimes’. Approximately 30 % had midwifery or child health training. There were higher odds of longer booked appointment times for solo practitioner practices (unadj OR 3.30 95%CI 1.03-10.57), but no other variables predicted booked appointment times

Conclusions

This study identified a number of practice related factors that, if addressed, could positively impact on postpartum care. These include ensuring ongoing practice relationships to assist with booking appropriate consultation times and guaranteeing that there are no financial impediments to women accessing care. Some factors can easily be adapted within practices. Others would require changes of policy at a local or national level.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1508-1) contains supplementary material, which is available to authorized users.

Breastfeeding: What are the Barriers? Why Women Struggle to Achieve Their Goals

Despite recognized health benefits for both mothers and infants, significant disparities still exist in the rates of breastfeeding in the United States. Major organizations representing the health of women and children (including the Centers for Disease Control and Prevention [CDC], American Academy of Pediatrics [AAP], American Congress of Obstetrics and Gynecology [ACOG], American Academy of Family Physicians [AAFP], United Nations International Children's Emergency Fund (UNICEF), the World Health Organization [WHO], and the United States Public Health Service [PHS]) recommend exclusive breastfeeding, but statistics show that although many women initiate breastfeeding, few meet the recommended goals for duration and exclusivity. This article reviews the evidence related to barriers (prenatal, medical, societal, hospital, and sociocultural) that many mothers face, and explore the known barriers and the impact they have on a woman's ability to breastfeed her infant. Strategies will be discussed to address (and potentially overcome) some of the most common barriers women face along with a list of resources that can be useful in this effort. Gaps in care and areas that need further research will be noted. This article is targeted toward physicians and other healthcare providers who work with women and who can assist with and advocate for the removal of barriers and thereby improve the health of women and children by increasing the rates of breastfeeding initiation, duration, and exclusivity in the United States.

Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis

AIM

To provide comprehensive evidence of the effect of interventions on early initiation, exclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health systems and services (ii) Home and family environment (iii) Community environment (iv) Work environment (v) Policy environment or a combination of any of above.

METHODS

Of 23977 titles identified through a systematic literature search in PUBMED, Cochrane and CABI, 195 articles relevant to our objective, were included. We reported the pooled relative risk and corresponding 95% confidence intervals as our outcome estimate. In cases of high heterogeneity, we explored its causes by subgroup analysis and meta-regression and applied random effects model.

RESULTS

Intervention delivery in combination of settings seemed to have higher improvements in breastfeeding rates. Greatest improvements in early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding rates, were seen when counselling or education were provided concurrently in home and community, health systems and community, health systems and home settings, respectively. Baby friendly hospital support at health system was the most effective intervention to improve rates of any breastfeeding.

CONCLUSION

To promote breastfeeding, interventions should be delivered in a combination of settings by involving health systems, home and family and the community environment concurrently.

Evaluating the prevention of premature cessation of exclusive breastfeeding in the general practice setting during the scheduled child immunisation consultation: a pilot study

The purpose of this study was to test and evaluate the feasibility and clinical acceptability of the use of an infant feeding data collection tool during the scheduled childhood immunisation consultation, and to explore the appropriateness of this consultation as a site for a future intervention aiming to increase exclusive breastfeeding through the provision of advice and support to mothers. This descriptive exploratory (quantitative and qualitative) study used purposeful sampling to enrol five general practices in Hobart, Tasmania. General practitioners (GPs) and practice nurses (PNs) trialled and evaluated a paper-based data collection tool over a 6-week period from May through to June 2011. Twenty-two (13 GPs; 2 GP registrars and 7 PNs) participants trialled and evaluated the data collection tool (n = 54). From the evaluation questionnaire, field notes and informal interviews (n = 7), six conceptual headings emerged: setting; time pressures; resources and collaboration; mothers need to talk; professional exclusion; and lack of collaboration. The scheduled childhood immunisation consultation provides an opportunity for mothers and primary health practitioners to talk briefly about infant feeding and for the collection of infant feeding data. However, the immunisation consultation is not well suited to a breastfeeding support intervention as it is already very busy focusing on immunisation issues. Consideration should be given to the evaluation of a dedicated general practice/primary health ‘infant feeding’ consultation.