Baby-friendly hospital practices are associated with duration of full breastfeeding in primiparous but not multiparous Iranian women

Is the Frequency of Postpartum Breastfeeding Counseling Associated with Exclusive Breastfeeding at Six Months? An Analytical Cross-Sectional Study

Breastfeeding counseling is an essential public health tool in postpartum maternal and infant health. In this study, we aimed to explore the relationship between the frequency of postpartum breastfeeding counseling and the type of feeding outcome at six months. The study design was an analytical, cross-sectional study on mothers of 6-24-month-old children living in Riyadh, Saudi Arabia. We conducted an analysis with descriptive statistics as well as logistic regression models. The findings from our study can be summarized in the following points: First, only 31.9% of the women in our study received postnatal breastfeeding counseling in the first six months after delivery, with the majority receiving fewer than four sessions. Second, there seemed to be a drop in exclusive breastfeeding with time: from 35.3% in the first two months to 29.7% in the second two months and then 20.7% in the final two months. Third, previous exclusive breastfeeding increased the odds of exclusive breastfeeding in the proceeding delivery. Finally, exposure to one or more postnatal breastfeeding counseling sessions increased the odds of exclusive or predominant breastfeeding in the first six months. This study helps to guide decision makers in planning maternal child health services and relevant community-based efforts.

Improving breastfeeding support through the implementation of the Baby-Friendly Hospital and Community Initiatives: a scoping review

BACKGROUND

Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund, which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) grew out of step 10, with a focus on community-based implementation. The aim of this scoping review is to map and examine the evidence relating to the implementation of BFHI and BFCI globally.

METHODS

This scoping review was conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria followed the Population, Concepts, Contexts approach. All articles were screened by two reviewers, using Covidence software. Data were charted according to: country, study design, setting, study population, BFHI steps, study aim and objectives, description of intervention, summary of results, barriers and enablers to implementation, evidence gaps, and recommendations. Qualitative and quantitative descriptive analyses were undertaken.

RESULTS

A total of 278 articles were included in the review. Patterns identified were: i) national policy and health systems: effective and visible national leadership is needed, demonstrated with legislation, funding and policy; ii) hospital policy is crucial, especially in becoming breastfeeding friendly and neonatal care settings iii) implementation of specific steps; iv) the BFCI is implemented in only a few countries and government resources are needed to scale it; v) health worker breastfeeding knowledge and training needs strengthening to ensure long term changes in practice; vi) educational programmes for pregnant and postpartum women are essential for sustained exclusive breastfeeding. Evidence gaps include study design issues and need to improve the quality of breastfeeding data and to perform prevalence and longitudinal studies.

CONCLUSION

At a national level, political support for BFHI implementation supports expansion of Baby-Friendly Hospitals. Ongoing quality assurance is essential, as is systematic (re)assessment of BFHI designated hospitals. Baby Friendly Hospitals should provide breastfeeding support that favours long-term healthcare relationships across the perinatal period. These results can help to support and further enable the effective implementation of BFHI and BFCI globally.

Early initiation of breastfeeding is inversely associated with public and private c-sections in 73 lower- and middle-income countries

Although studies in low- and middle-income countries (LMICs) have examined the effects of c-sections on early initiation of breastfeeding (EIBF), the role of the place of birth has not yet been investigated. Therefore, we tested the association between EIBF and the type of delivery by place of birth. Data from 73 nationally representative surveys carried out in LMICs between 2010 and 2019 comprised 408,013 women aged 15 to 49 years. Type of delivery by place of birth was coded in four categories: home vaginal delivery, institutional vaginal delivery, c-section in public, and c-section in private health facilities. We calculated the weighted mean prevalence of place of birth and EIBF by World Bank country income groups. Adjusted Poisson regression (PR) was fitted taking institutional vaginal delivery as a reference. The overall prevalence of EIBF was significantly lower among c-section deliveries in public (PR = 38%; 95% CI 0.618-0.628) and private facilities (PR = 45%; 95% CI 0.54-0.566) compared to institutional vaginal deliveries. EIBF in c-sections in public facilities was slightly higher in lower-middle (PR = 0.650, 95% CI 0.635-0.665) compared to low (PR = 0.544, 95% CI 0.521-0.567) and upper-middle income countries (PR = 0.612, 95% CI 0.599-0.626). EIBF was inversely associated with c-section deliveries compared to institutional vaginal deliveries, especially in private facilities compared to public ones.

Breastfeeding Practices, Infant Formula Use, Complementary Feeding and Childhood Malnutrition: An Updated Overview of the Eastern Mediterranean Landscape

BACKGROUND

With increasing global rates of overweight, obesity and non-communicable diseases (NCDs) along with undernutrition and micronutrient deficiencies, the Eastern Mediterranean Region (EMR) is no exception. This review focuses on specific nutrition parameters among under five years children, namely ever breastfed, exclusive breastfeeding, mixed milk feeding, continued breastfeeding, bottle feeding, introduction of solid, semi-solid, or soft foods and malnutrition.

METHODOLOGY

PubMed, Google Scholar, United Nations International Children's Emergency Fund (UNICEF) databases, World Health Organization (WHO) databases, the World Bank databases and the Global Nutrition Report databases were explored between 10 January and 6 June 2022, to review the nutrition situation among under five years children in the EMR.

RESULTS

The regional average prevalence of ever breastfed, exclusive breastfeeding, mixed milk feeding, continued breastfeeding, bottle feeding, introduction of solid, semi-solid, or soft foods was estimated at 84.3%, 30.9%, 42.9%, 41.5%, 32.1% and 69.3%, respectively. Iran, Iraq, Libya and Palestine have seen a decline over time in the prevalence of exclusive breastfeeding. Lebanon, Egypt, Kuwait and Saudi Arabia reported early introduction of infant formula. Moreover, Lebanon, Pakistan, Saudi Arabia and United Arab Emirates were seen to introduce food early to the child, at between 4-6 months of age. The estimated weighted regional averages for stunting, wasting and underweight were 20.3%, 8.9% and 13.1%, respectively. Of concern is the increasing prevalence of stunting in Libya. As for overweight and obesity, the average prevalence was reported to be 8.9% and 3%, respectively. Lebanon, Libya, Kuwait and Palestine showed an increased trend throughout this time.

CONCLUSIONS

In this review, the suboptimal infant and young child feeding patterns and the twofold incidence of malnutrition in the EMR are highlighted and we urge the prioritizing of measures to improve children's nutrition.

Factors That Influence Posthospital Infant Feeding Practices Among Women Who Deliver at a Baby Friendly Hospital in Southern United States

Introduction: The Baby Friendly Hospital Initiative has had a positive impact on breastfeeding initiation; however, little is known about posthospital infant feeding practices among women who deliver at baby friendly hospitals. Therefore we sought to evaluate posthospital breastfeeding outcomes among women who deliver at a baby friendly hospital (BFH) by (1) estimating exclusive breastfeeding rates at the postpartum visit (PPV), (2) quantifying the exclusive breastfeeding discontinuation rate, and (3) identifying which factors are associated with breastfeeding discontinuation. Methods: This was a prospective cohort study of women aged 14 and over, who delivered at the University of Alabama at Birmingham. The primary outcome was mode of infant feeding categorized as exclusive breastfeeding (EBF), combination breastfeeding and formula feeding (CF), and exclusive formula feeding (EFF) at the PPV. Secondary outcome was EBF discontinuation rate. Patients who initiated formula and/or who stopped breastfeeding were asked what influenced their decision. Results: At hospital discharge, 71.1% of the participants were EBF, 21.7% were CF, and 7.2% were EFF. At the PPV, the frequency of the primary outcome of EBF was 31.6% (95% confidence interval: 25.2-38.8); 34.6% (28.0-41.9) were CF, and 33.8% (27.3-41.1) were EFF. Therefore, the EBF absolute and relative discontinuation rates were 39.5% and 55.6%, respectively. No demographic factors, delivery characteristics, or maternal medical morbidities were associated with EBF in the multivariable logistic regression. However, women in the EBF group were more likely to report a workplace environment conducive to breastfeeding and partner and friend support. Conclusion: Significant breastfeeding discontinuation rates occur even among women who deliver at a BFH. Our findings suggest that multifactorial interventions, including a focus on the prevention of formula introduction, are needed in the early postpartum period to achieve higher EBF rates at the PPV.

What Women Really Think About Breastfeeding and Breast Pumping: A Qualitative Analysis of Women Who Deliver at a Baby-Friendly Hospital

Introduction: The Baby-Friendly Hospital Initiative has had a positive impact on breastfeeding initiation; however, posthospital exclusive breastfeeding (EBF) rates remain low. We aimed to analyze thoughts and attitudes toward breastfeeding at the postpartum visit among women who deliver at a Baby-Friendly hospital. Methods: Women ≥14 years who delivered a live-born infant at our center were eligible. Participants completed an infant feeding questionnaire at the postpartum visit recording patient and delivery characteristics, antepartum care and infant feeding details, reasons for breastfeeding discontinuation or formula initiation, workplace environment, and cultural beliefs about breastfeeding. Thematic coding via line-by-line analysis of the free responses was performed using NVivo12 by QSR international. Results: Of 263 participants, 110 responded to the open-ended question. Of these, 53 and 46 were negative-toned and positive-toned, respectively. Negative breastfeeding responses related to the mother addressed the need for more support, low milk supply, pressure to breastfeed and feelings of guilt if unsuccessful, maternal health issues, painful breastfeeding, and high time requirements. Negative breastfeeding responses about the baby included concerns about infant health, latching issues, and disinterest. Positive responses focused on the support system, maternal weight loss, health benefits for baby, and mom-baby bonding. Some women (27) commented specifically on pumping. Negative comments noted that pumping led to less milk production, was time consuming, and was too much work. Positive comments about pumping noted that it is a convenient alternative to breastfeeding. Conclusion: Efforts to improve posthospital EBF rates in accordance with national guidelines must acknowledge the complex experience of breastfeeding mothers.

Incidence and Determinants of Caesarean Section in Shiraz, Iran

The rate of Caesarean section (CS) without medical indication has increased markedly worldwide in the past decades. This study reports the incidence of CS and identifies the determinants of elective and emergency CS as separate pregnancy outcomes in a cohort of Iranian women. Mothers (n = 700) of healthy, full-term infants were recruited from five maternity hospitals in Shiraz. The association between maternal socio-demographic and biomedical factors with mode of delivery was explored using multivariable, multinomial logistic regression. Most mothers underwent either an elective (35.4%) or emergency (34.7%) CS. After adjustment, women were more likely to deliver by elective CS than vaginally if they were older (≥30 year) compared to younger mothers (<25 year) (Relative Risk Ratio (RRR) 2.22; 95% Confidence Interval (CI) 1.28, 3.84), and had given birth at a private hospital (RRR 3.64; 95% CI 1.79, 7.38). Compared to those educated to primary or lower secondary level, university educated women were more likely to have undergone an elective (RRR 2.65; 95% CI 1.54, 4.58) or an emergency CS (RRR 3.92; 95% CI 2.27, 6.78) than a vaginal delivery. Similarly, overweight or obese women were more likely than healthy weight women to have undergone an elective (RRR 1.91; 95% CI 1.27, 2.87) or an emergency CS (RRR 2.02; 95% CI 1.35, 3.02) than a vaginal delivery. Specialist education of obstetricians and midwives along with financial incentives paid to private hospitals to encourage natural delivery may help in the reduction of unnecessary CS in Iran. In addition, to increase their childbirth knowledge and self-efficacy, pregnant women need to have the opportunity to attend purposefully designed antenatal childbirth preparation classes where they receive evidence-based information on natural childbirth and alternative methods of pain control, as well as the risks and indications for CS.

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.

The effectiveness on health education to prevent nipple trauma from breastfeeding: a systematic review

Abstract Objectives: to analyze the effectiveness on health education to prevent nipple trauma in breastfeeding compared to other interventions. Methods: systematic literature review was carried out in January 2019, according to PRISMA recommendations. The searches were conducted in Cinahl, PubMed, Web of Science, Scopus, and in the references cited in the selected articles. The studies were assessed for quality and level of evidence according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Results: twelve studies were selected, all conducted at the maternities. The interventions were classified in two categories: health education on breastfeeding and the use of nipple covers. Health education on breastfeeding presents a moderate level of evidence on the prevention of nipple trauma. There is a moderate to high level of evidence on the positive effects of guaiazulene, gel or peppermint water applied in the postpartum period to prevent nipple trauma. Conclusion: health education on breastfeeding with clinical demonstration is an important strategy to prevent nipple trauma and requires more than one educational approach. The use of nipple covers requires some consideration, since they must be removed prior to breastfeeding. All interventions were conducted in the postpartum period, which points out for the necessity of clinical research to prevent nipple trauma in prenatal care.

Determinants of in-hospital feeding practices in Shiraz, Iran: Results of a prospective cohort study

BACKGROUND

In-hospital feeding practices have been shown negatively to affect breastfeeding exclusivity and duration. The purpose of this study was to report the prevalence and determinants of delayed breastfeeding, provision of traditional prelacteal foods, and use of infant formula in hospital.

METHODS

Between June 2014 and March 2015, 700 women were recruited from three public and two private maternity hospitals in Shiraz, Iran. Data were collected at recruitment via face-to-face interviews and extracted from medical records. Multivariable logistic regression was used to explore the association of feeding practices with a variety of maternal characteristics and hospital practices.

RESULTS

Only 32.2% of infants were breastfed within 1 hour of birth, with 40.8% receiving a traditional prelacteal food, and 34.9% given formula during their hospital stay. Compared with infants delivered vaginally, those delivered by cesarean were more likely to have experienced delayed breastfeeding and received formula, but less likely to have received traditional prelacteal foods. Infants who did not experience skin-to-skin contact were more likely to have experienced delayed breastfeeding and received traditional prelacteal foods and formula in hospital.

CONCLUSIONS

Although four out of the five hospitals were designated as Baby-Friendly, several of the 10 Steps to Successful Breastfeeding were not adhered to. The high rate of cesarean delivery was a barrier to the early initiation of breastfeeding and the majority of infants did not experience early skin-to-skin contact. Maternity care practices should be reviewed and include a clear breastfeeding care plan for women who undergo a cesarean delivery.

Infant Feeding Guidelines for the Asia Pacific Region

Good nutrition for infants, during the first 1000 days from conception, is one of the most important determinants of a healthy long life. Breastfeeding is the most important component of infant nutrition and reduces morbidity and mortality. With the changes to the climate currently occurring, issues of nutrition and food supply are only going to increase in importance. The Sustainable Development Goals of the United Nations, place nutrition at the forefront of world development and a sustainable planet. The vision of Asia-Pacific Academic Consortium for Public Health (APACPH) is to "achieve the highest possible level of health of all the people of the nations of the Asia-Pacific region." Much of the burden of disease, early deaths, and disability in the Asia Pacific region could be reduced with public health efforts to address the major risk factors, including nutrition-related causes and smoking. The United Nations Decade of Action on Nutrition 2016-2025 has recently been launched with the aim of reducing the global burden of inappropriate nutrition. The goals include increasing rates of exclusive breastfeeding to 6 months, reducing wasting and stunting, and reducing the rates of low birthweight. This is the position endorsed in these guidelines along with the principles of the Baby Friendly Hospital Initiative. These guidelines expand the information on infants that was included in the 2016 APACPH Dietary Guidelines. APACPH covers many different environments, geographical areas, cultures, and socioeconomic groups. These guidelines are generally applicable to all infants in our region, specific local advice may sometimes be needed.

Baby-friendly hospital practices are associated with duration of full breastfeeding in primiparous but not multiparous Iranian women

There is evidence that the Baby-Friendly Hospital Initiative (BFHI) results in improved breastfeeding outcomes in Western countries, but little is known of its impact in Middle-Eastern countries. This study investigated the impact of BFHI practices on duration of full breastfeeding in a cohort of 700 Iranian mothers recruited between June 2014 and March 2015 from maternity hospitals in Shiraz and followed-up prospectively for 6 months. At baseline, mothers self-reported exposure to 7 of the BFHI Ten Steps to Successful Breastfeeding (Steps 3 to 9). Data on breastfeeding outcomes were collected at baseline, 1, 3, 4, and 6 months postpartum. Cox regression analysis was conducted to determine the impact of individual and cumulative BFHI Steps on the duration of full breastfeeding, defined as the number of weeks since discharge that an infant received only breast milk and no complementary formula or food. Mothers reported experiencing on average 3.9 (SD 1.13, range 1 to 7) Steps, and only 28% of infants were fully breastfed at 6 months. There was a protective inverse relationship for primiparous (p for trend = .022) but not multiparous mothers (p for trend = .069), between the number of Steps a woman was exposed to and the likelihood of her discontinuing full breastfeeding within 6 months postpartum. Greater exposure to BFHI practices potentially could increase primiparous mothers' chances of fully breastfeeding to 6 months. Continual monitoring of the BFHI Steps and repeated education of healthcare staff are required to ensure that Iranian mothers receive adequate breastfeeding support.

Duration of Breastfeeding, but Not Timing of Solid Food, Reduces the Risk of Overweight and Obesity in Children Aged 24 to 36 Months: Findings from an Australian Cohort Study

This study aimed to determine whether breastfeeding duration and the timing of solid food were independently associated with being overweight or obese in early childhood. Subjects were 953 children participating in the Study of Mothers and Infants Life Events Affecting Oral Health (SMILE) birth cohort study, based in Adelaide, Australia. Socio-demographic information and data on breastfeeding duration and age of introduction of solid food were collected at birth, 3, 4, 6, 12, and 24 months via mailed or online questionnaires completed by mothers. The weight and height of children were measured at a dental examination when children were aged between 24 and 36 months. Body mass index was calculated, and children were categorised into weight groups according to the World Health Organization growth standards. Multivariable logistic regression analysis was conducted, adjusting for maternal age at birth, education, socio-economic status, pre-pregnancy weight, smoking in pregnancy, method of delivery, and child’s birthweight. Risk of overweight/obesity was independently associated with maternal pre-pregnancy BMI, smoking in pregnancy, and birthweight. Children that were breastfed for 12 months or more had a significantly lower risk of being overweight/obese than those breastfed for less than 17 weeks (AOR 0.49; 95%CI 0.27, 0.90; p for trend =0.009). Age of introduction of solid food, however, was not associated with the risk of being overweight/obese at 24 to 36 months. This study provides further evidence of an inverse relationship between breastfeeding and risk of overweight/obesity, however, no association with the timing of solid food was detected.