Routinely collected infant feeding data: Time for global action

Breastfeeding rates of Aboriginal and Torres Strait Islander women in Australia: A systematic review and narrative analysis

BACKGROUND

Australian Aboriginal and Torres Strait Islander (referred to hereafter as Aboriginal) women breastfeed at lower rates than non-Aboriginal women, and rates vary across and within Aboriginal populations.

AIM

To determine rates of breastfeeding initiation and maintenance and compare individually collected survey data with existing routinely collected state and national breastfeeding data for Aboriginal women.

METHODS

CINAHL, Medline, EMBASE, SCOPUS, PsycINFO, and the Cochrane library were searched for peer-reviewed literature published between 1995 and 2021. Quantitative studies written in English and reporting breastfeeding for Aboriginal women or women having an Aboriginal infant were included. Screening and quality assessment included co-screening 10 % of papers. Two reviewers completed data extraction. A proportional meta-analysis was undertaken for breastfeeding initiation and narrative data synthesis used to summarise breastfeeding maintenance.

FINDINGS

The initial search identified 12,091 records, with 31 full text studies retrieved, and 27 reports from 22 studies met inclusion criteria. Breastfeeding initiation was 79 % (95 % CI 0.73, 0.85), however, rates were lower than non-Aboriginal women. Maintenance ranged between one week and five years. Rates and definitions varied significantly between studies, with inconsistencies in government collection and reporting of breastfeeding.

CONCLUSION

Significant variation in definitions and reporting make comparisons difficult. Breastfeeding rates were below recommended targets. Future pattern and trend analyses require standardised measures and definitions. Current collection and reporting of breastfeeding data, particularly routinely collected state-based data, is inadequate to present an accurate picture of current breastfeeding in Australia for Aboriginal women and infants, and to effectively inform interventions and policies.

Investigating midwives and nurses reporting of 'infant feeding at hospital discharge': an online survey across NSW Australia

BACKGROUND

The collection of data on 'infant feeding at hospital discharge' is used to monitor breastfeeding outcomes, health service benchmarking, and research. While some Australian states have clear definitions of this data collection point, there is no operational definition of 'infant feeding at hospital discharge' in the Australian state of New South Wales. Little is known about how midwives interpret the term 'infant feeding at hospital discharge', in particular, the timeframe used to calculate these important indicators. The purpose of this study was to explore midwives' and nurses' practices of reporting 'infant feeding at hospital discharge' in the Australian state of New South Wales.

METHODS

An online survey was distributed across public and private maternity hospitals in New South Wales, Australia. The survey asked midwives and nurses their practice of reporting 'infant feeding at discharge' from categories offered by the state Mothers and Babies report of either "full breastfeeding", "any breastfeeding", and "infant formula only". The Qualtrics survey was available from December 2021 to May 2022.

RESULTS

There were 319 completed surveys for analysis and all 15 NSW Health Districts were represented. Some participants reported using the timeframe 'since birth' as a reference (39%), however, the majority (54%, n = 173) referenced one of the feeding timeframes within the previous 24 h. Most midwives and nurses (83%, n = 265) recommended 24 h before discharge as the most relevant reference timeframe, and 65% (n = 207) were in favour of recording data on 'exclusive breastfeeding' since birth.

CONCLUSION

This study identified multiple practice inconsistencies within New South Wales reporting of 'infant feeding at hospital discharge'. This has ramifications for key health statistics, state reporting, and national benchmarking. While the Baby Friendly Hospital Initiative accreditation requires hospitals to demonstrate and continuously monitor at least a 75% exclusive breastfeeding rate on discharge, only 11 New South Wales facilities have achieved this accreditation. We recommend introducing an option to collect 'exclusive breastfeeding' on discharge' which is in line with participant recommendations and the Baby Friendly Hospital accreditation. Other important considerations are the updated World Health Organization indicators such as, "Ever breastfed"; "Early initiation of breastfeeding" (first hour); "Exclusively breastfed for the first two days after birth".

Breastfeeding rates of Aboriginal and Torres Strait Islander women in Australia: a systematic review and narrative analysis

BACKGROUND

Australian Aboriginal and Torres Strait Islander (referred to hereafter as Aboriginal) women breastfeed at lower rates than non-Aboriginal women, and rates vary across and within Aboriginal populations.

AIM

To determine rates of breastfeeding initiation and maintenance and compare individually collected survey data with existing routinely collected state and national breastfeeding data for Aboriginal women.

METHODS

CINAHL, Medline, EMBASE, SCOPUS, PsycINFO, and the Cochrane library were searched for peer-reviewed literature published between 1995 and 2021. Quantitative studies written in English and reporting breastfeeding for Aboriginal women or women having an Aboriginal infant were included. Screening and quality assessment included co-screening 10% of papers. Two reviewers completed data extraction. A proportional meta-analysis was undertaken for breastfeeding initiation and narrative data synthesis used to summarise breastfeeding maintenance.

FINDINGS

The initial search identified 12,091 records, with 31 full text studies retrieved, and 27 reports from 22 studies met inclusion criteria. Breastfeeding initiation was 78% (95% CI 0.71, 0.84), however, rates were lower than non-Aboriginal women. Maintenance ranged between one week and five years. Rates and definitions varied significantly between studies, with inconsistencies in government collection and reporting of breastfeeding.

CONCLUSION

Significant variation in definitions and reporting make comparisons difficult. Breastfeeding rates were below recommended targets. Future pattern and trend analyses require standardised measures and definitions. Current collection and reporting of breastfeeding data, particularly routinely collected state-based data, is inadequate to present an accurate picture of current breastfeeding in Australia for Aboriginal women and infants, and to effectively inform interventions and policies.

Midwife-Led Continuity of Antenatal Care and Breastfeeding Duration Beyond Postpartum Hospital Discharge: A Systematic Review

BACKGROUND

The World Health Organization recommends that infants should be exclusively breastfed for the first 6 months of life and that breastfeeding should continue for 2 years and beyond. Most women initiate breastfeeding, but many do not continue for the recommended duration. While midwife-led continuity of antenatal care is linked to improved mother and infant outcomes, the influence on breastfeeding duration has not been previously reviewed.

RESEARCH AIM

To critically analyze the literature that compared midwife-led continuity of antenatal care with other models of care where researchers have measured breastfeeding duration beyond postpartum hospital discharge.

METHODS

A systematic literature review with critical analysis was used to answer the research aim. We systematically searched and screened five databases for quantitative studies where researchers had reported breastfeeding duration beyond postpartum hospital discharge after midwife-led continuity of antenatal care, compared with another model of antenatal care. Methodological quality was assessed using tools from the Cochrane Collaboration (RoB2 and ROBINS-I). In total, nine studies met the inclusion criteria.

RESULTS

Clear conclusions about the association between midwife-led continuity of antenatal care and breastfeeding duration were not found. The risk of bias within non-randomized studies ranged from serious to critical, and a judgement of "some concerns" of risk of bias in the one randomized study.

CONCLUSION

To date, the question of whether midwife-led continuity of antenatal care improves breastfeeding duration has not been established. There has been a lack of consistency in definitions of breastfeeding and descriptions of models of care, which has weakened the evidence-based of literature reviewed.Our review protocol was registered with PROSPERO; although due to COVID-19, this registration was not checked for eligibility by the PROSPERO team (CRD42020151276). https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020151276.

The association of serum levels of zinc and vitamin D with wasting among Iranian pre-school children

PURPOSE

Wasting is a main indicator of Child's undernutrition that is associated with several non-communicable diseases and child mortality. This is the first population-based study which evaluated the association of serum zinc and vitamin D levels with wasting in a Middle East region. We also reported the prevalence of vitamin D and zinc deficiencies among Iranian pre-school children aged 6 years.

METHODS

This was a multicenter cross-sectional study that included 425 children aged between 5 and 7 years (on average 6 years) with BMI-for-age Z-scores of < - 1 SD resident in urban and rural areas of Iran in the spring of 2012 as part of the National Integrated Micronutrient Survey 2 (NIMS-2). Anthropometric measurements and blood sampling were obtained. The prevalence of vitamin D and zinc deficiencies together with the correlations of these variables with the increase of BMI-for-age Z-scores were evaluated.

RESULTS

The prevalence of vitamin D and zinc deficiencies was 18.8% and 12.7%, respectively. In addition, 31.1% of children were wasted. Children in the second tertile of 25(OH)D levels were less likely to have wasting compared with those in the first tertile in both crude and adjusted models (OR 0.47, 95% CI 0.27-0.83). A significant inverse association was found between serum levels of zinc and wasting (OR 0.57, 95% CI 0.34-0.96); such that after adjusting for confounders, children in the highest tertile of serum zinc had 47% less odds of wasting compared with those in the first tertile (OR 0.53, 95% CI 0.31-0.91).

CONCLUSION

The prevalence of vitamin D and zinc deficiencies among Iranian pre-school children aged 6 years was 18.8 and 12.7%, respectively. Serum levels of vitamin D and zinc were inversely associated with wasting either before or after controlling for confounders.

LEVEL OF EVIDENCE

Level III, case-control analytic studies.

Understanding factors affecting breastfeeding practices in one city in the Kingdom of Saudi Arabia: an interpretative phenomenological study

Background

Breastfeeding duration has declined in the Kingdom of Saudi Arabia (KSA) in recent decades, although accurate national data about different breastfeeding indicators by infant age are lacking. This qualitative study, the first in KSA, aimed to understand the factors affecting mothers’ decisions and experiences regarding any breastfeeding practices.

Methods

A qualitative phenomenological approach was used to investigate mothers’ experiences of breastfeeding. Non-probability convenience sampling and snowballing strategies were designed to recruit participants. Semi-structured interviews were conducted with 16 mothers, from two hospitals and three primary health clinics in Al-Madinah city, from December 2017 to March 2018. Interpretative phenomenological analysis was the analysis framework.

Results

Three themes were identified: 1) ‘Up against the system’: policies, staff and systems were the main barriers to exclusive breastfeeding; 2) ‘Social support and negativity’: family support in the first 40 postpartum days protected breastfeeding continuation and was highly appreciated, but negative comments limited breastfeeding practices thereafter; and 3) ‘Managing tensions’: mothers’ religious beliefs about breastfeeding boosted their decisions; however, the challenge of managing tensions influenced mothers to stop breastfeeding earlier than they wished. The study revealed that mothers had no doubts about wanting to breastfeed their babies; but continuation was adversely affected by unhelpful hospital policies and staff actions, the lack of ongoing social support, and by others people’s negativity, rather than by the mothers’ own views. Stopping breastfeeding earlier than planned was a complex decision for most mothers. However, mothers said that they intended to breastfeed their next baby successfully.

Conclusions

Healthcare professionals (maternity staff, paediatricians and pharmacists) need education and training to support exclusive breastfeeding effectively. Increasing the number of hospitals with Baby Friendly Hospital Initiative accreditation, which includes staff practice changes, is needed to protect and support exclusive breastfeeding. Ongoing professional and peer support, and improving conditions at workplaces and universities, are needed to help mothers to continue breastfeeding successfully. Effective, coordinated national policies can support mothers’ decisions in relation to breastfeeding. Such changes will reduce the tensions experienced by women and help them to achieve their breastfeeding goals and to breastfeed for longer.

A detailed exploration of early infant milk feeding in a prospective birth cohort study in Ireland: combination feeding of breast milk and infant formula and early breast-feeding cessation

Breast-feeding initiation and continuation rates in the UK and Ireland are low relative to many European countries. As a core outcome of the prospective Cork Nutrition and Development Maternal-Infant Cohort (COMBINE) study (Cork, Ireland), we aimed to describe infant milk feeding practices in detail and examine the prevalence and impact of combination feeding of breast milk and infant formula on breast-feeding duration. COMBINE recruited 456 nulliparous mothers (2015-2017) for maternal-infant follow-up via interview at hospital discharge (median 3 (interquartile range (IQR) 2, 4) d (n 453)), 1 (n 418), 2 (n 392), 4 (n 366), 6 (n 362) and 9 (n 345) months of age. Median maternal age was 32 (IQR 29, 34) years, 97 % of mothers were of white ethnicity, 79 % were Irish-born and 75 % were college-educated. Overall, 75 % breastfed to any extent at discharge and 44 % breastfed solely. At 1, 2, 4, 6 and 9 months, respectively, 40, 36, 33, 24 and 19 % breastfed solely. Combination feeding of breast milk and infant formula was common at discharge (31 %) and 1 month (20 %). Reasons for combination feeding at 1 month included perceived/actual hunger (30 %), healthcare professional advice (31 %) and breast-feeding difficulties (13 %). Of mothers who breastfed to any extent at discharge, 45 % stopped within 4 months. Mothers who combination fed were more likely to cease breast-feeding than those who breastfed solely (relative risk 2·3 by 1 month and 12·0 by 2 months). These granular data provide valuable insight to early milk feeding practices and indicate that supporting early breast-feeding without formula use may be key to the successful continuation of breast-feeding.

Influence of providing information to participants about development of trial outcomes on response rates and attitudes to questionnaire completion: Protocol for a study within a trial

Background: Issues with questionnaire completion introduce bias and limit examinations in trials. Improving communication with participants about trial processes, such as outcome and questionnaire development, may improve questionnaire completion and response rates. Providing information about the involvement of stakeholders in the development of core outcome sets (COS) measured in trials may improve responding by tapping into subjective norms and behaviour change mechanisms. The aim of this Study Within a Trial (SWAT) is to examine if questionnaire response rates and participants’ attitudes towards questionnaire completion are impacted by providing information about COS use in a trial of a complex intervention.

Methods: This is a randomised, single-blinded, parallel group intervention SWAT, embedded within a feasibility trial of an infant feeding intervention to prevent childhood obesity. The SWAT intervention consists of a brief written description and explanation about the development and use of a COS of infant feeding outcomes to prevent childhood obesity, used in the trial. Participants are parents or caregivers of infants aged two months at questionnaire completion. Participants will be randomly assigned to receive the SWAT intervention prior to questionnaire completion (SWAT Intervention), or not (SWAT Comparator). The primary outcome of interest is response rates, which will be measured as proportion of questionnaire completion and individual item response rates. Participants’ attitudes will also be assessed using closed-ended and an open-ended question to evaluate participants’ attitudes about questionnaire completion. 

Discussion: We hypothesise that providing information about development and use of a COS will increase questionnaire response rates and attitudes toward questionnaire completion relative to the control condition. Findings will indicate the potential usefulness of this strategy for improving participant attitudes and response rates in trials. 

Trial Registration: This SWAT is registered on the Northern Ireland Hub for Trials Methodology: Research SWAT Repository ( SWAT57).

A core outcome set for trials of infant-feeding interventions to prevent childhood obesity

BACKGROUND

Standardisation of outcomes measured and reported in trials of infant-feeding interventions to prevent childhood obesity is essential to evaluate and synthesise intervention effects. The aim of this study is to develop an infant-feeding core outcome set for use in randomised trials of infant-feeding interventions, with children ≤1 year old, to prevent childhood obesity.

METHODS

Core outcome set development followed four stages: (1) systematic review of outcomes reported in the extant literature; (2) meeting with national and international stakeholders to discuss and clarify identified outcomes; (3) e-Delphi study with national and international stakeholders to prioritise outcomes; (4) meeting with national and international stakeholders to reach consensus on outcomes. Stakeholders in stages 2-4 were paediatricians, general practitioners, nurses, midwives, non-clinician researchers, parents, dieticians, nutritionists, and childcare providers.

RESULTS

Twenty-six outcomes were identified for inclusion in the core outcome set. These were grouped in nine outcome domains: 'breastfeeding and formula feeding', 'introduction of solids', 'parent feeding practices and styles', 'parent knowledge and beliefs', 'practical feeding', 'food environment', 'dietary intake', 'perceptions of infant behaviour and preferences', and 'child weight'.

CONCLUSIONS

The core outcome set identified in this study is the minimum that should be measured and reported in trials of infant-feeding interventions to prevent childhood obesity. This standardisation of outcomes will enable more comprehensive examination and synthesis of the effects of infant-feeding interventions to prevent childhood obesity.

Influence of providing information to participants about development of trial outcomes on response rates and attitudes to questionnaire completion: Protocol for a study within a trial

Background: Issues with questionnaire completion introduce bias and limit examinations in trials. Improving communication with participants about trial processes, such as outcome and questionnaire development, may improve questionnaire completion and response rates. Providing information about the involvement of stakeholders in the development of core outcome sets (COS) measured in trials may improve responding by tapping into subjective norms and behaviour change mechanisms. The aim of this Study Within a Trial (SWAT) is to examine if questionnaire response rates and participants’ attitudes towards questionnaire completion are impacted by providing information about COS use in a trial of a complex intervention. Methods: This is a randomised, single-blinded, parallel group intervention SWAT, embedded within a feasibility trial of an infant feeding intervention to prevent childhood obesity. The SWAT intervention consisting of a brief written description and explanation about the development and use of a COS of infant feeding outcomes to prevent childhood obesity, used in the trial. Participants are parents or caregivers of infants aged two months at questionnaire completion. Participants will be randomly assigned to receive the SWAT intervention prior to questionnaire completion (I1 condition), or to receive the information following completion of all questionnaires (I2 condition). The SWAT will be assessed using closed-ended and an open-ended question to evaluate participants’ attitudes about questionnaire completion. Response rates will be measured as proportion of full questionnaire completion and individual item response rates. Discussion: We hypothesise that providing information about development and use of a COS will increase questionnaire response rates and attitudes toward questionnaire completion relative to the control condition. Findings will indicate the potential usefulness of this strategy for improving participant attitudes and response rates in trials.  Trial Registration: This SWAT is registered on the Northern Ireland Hub for Trials Methodology: Research SWAT Repository (SWAT57).

Routinely collected infant feeding data: Time for global action

The importance of breastfeeding is clear. However, global action to support breastfeeding is hindered by the lack of reliable standard data, which continues to impede progress. Routinely collected data can monitor the effectiveness of health policy, evaluate interventions, and enhance international research collaboration and comparisons. Use of routine data to support effective public health initiatives such as smoking cessation has been demonstrated. However, the data collected about infant feeding practices worldwide is inconsistent in timing, methods, definitions, detail, storage, and consistency. Improvements to the reach and quality of routinely collected data about infant feeding are needed to strengthen the global evidence and policy base. An international collaborative effort is called for to progress this.