"It gave me so much confidence": First-time U.S. mothers' experiences with antenatal milk expression

Study Protocol for a Stepped-Wedge Cluster (Nested) Randomized Controlled Trial of Antenatal Colostrum Expression (ACE) Instruction in First-Time Mothers: The ACE Study

BACKGROUND

Although many mothers initiate breastfeeding, supplementation with human-milk substitutes (formula) during the birth hospitalization is common and has been associated with early breastfeeding cessation. Colostrum hand expressed in the last few weeks before birth, known as antenatal colostrum expression (ACE), can be used instead of human-milk substitutes. However, evidence is lacking on the efficacy of ACE on breastfeeding outcomes and in non-diabetic mothers.

METHODS AND PLANNED ANALYSIS

This multicenter stepped-wedge cluster (nested) randomized controlled trial aims to recruit 945 nulliparous pregnant individuals. The trial is conducted in two phases. During Phase 1, control group participants are under standard care. During Phase 2, participants are randomized to ACE instruction via a pre-recorded online video or a one-on-one session with a midwife. Adjusted logistic regression analysis will be used to examine the relationship between ACE instruction and breastfeeding outcomes.

RESEARCH AIMS AND QUESTIONS

Primary aim: (1) Does advising pregnant individuals to practice ACE and providing instruction improve exclusive breastfeeding rates at 4 months postpartum? Secondary research questions: (2) Do individuals who practice ACE have higher rates of exclusive breastfeeding during the initial hospital stay after birth? (3) Is teaching ACE via an online video non-inferior to one-on-one instruction from a midwife? (4) Does expressing colostrum in pregnancy influence time to secretory activation, or (5) result in any differences in the composition of postnatal colostrum?

DISCUSSION

Trial findings have important implications for maternity practice, with the online video providing an easily accessible opportunity for ACE education as part of standard antenatal care.

Breastfeeding outcomes at 3 months for women with diabetes in pregnancy: Findings from the Diabetes and Antenatal Milk Expressing randomized controlled trial

BACKGROUND

Women with diabetes in pregnancy have decreased exclusivity and duration of breastfeeding compared with women without diabetes, and their infants are at increased risk of hypoglycemia. Clinicians often suggest pregnant women with diabetes to express breastmilk, and studies have reported increased breastfeeding exclusivity in the early postnatal period for patients who have expressed. Little is known about longer term outcomes. We investigated whether advising low-risk women with diabetes in pregnancy to express beginning at 36 weeks of pregnancy increased exclusivity and maintenance of breastfeeding at 3 months.

METHODS

We conducted a multicenter, two-group, randomized controlled trial at six hospitals in Melbourne, Australia, between 2011 and 2015. Women were randomized to either standard maternity care or advised to hand express for 10 min twice daily, in addition to standard care. Women were telephoned at 12-13 weeks postpartum and asked a series of questions about feeding their baby, perceptions of their milk supply, and other health outcomes.

RESULTS

Of 631 women in the study, data for 570 (90%) were analyzed at 12-13 weeks. After adjustment, we found no evidence that women allocated to antenatal expressing were more likely to be giving only breastmilk (aRR 1.07 [95% CI 0.92-1.22]) or any breastmilk (aRR 0.99 [95% CI 0.92-1.06]) at 12-13 weeks postpartum compared with women in the standard care group.

CONCLUSION

While the practice of antenatal expression for low-risk women with diabetes during pregnancy is promising for increasing exclusivity of breastmilk feeding in hospital, at 12-13 weeks, there was no association with breastfeeding outcomes.

Breastfeeding and Antepartum Breast Milk Expression (BABE): A Randomized Control Trial Utilizing an Electric Breast Pump and its Effect on Postpartum Breastfeeding

Objective: To evaluate the effect of antenatal breast milk expression (ABE) on exclusive breastfeeding. Materials and Methods: A randomized control study was performed with the primary outcome being formula use during the postpartum hospital stay. Secondary outcomes were the exclusive breastfeeding rate at 6 months postpartum and peripartum safety outcomes. Participants included multiparous and nulliparous patients who planned to breastfeed. Exclusion criteria included exclusively breastfeeding in prior pregnancies for greater than 6 months, medical contraindications for breastfeeding, multiple gestation, history of preterm delivery, or any contraindication to vaginal delivery. ABE group participants were instructed to pump for 20 minutes, three times daily, starting at 37 weeks of gestation. Results: Three-hundred four participants from two clinics were enrolled. There was no significant difference in formula use during hospital admission (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.34-1.22) or in exclusive breastfeeding at 6 months postpartum (OR 0.66, 95% CI 0.34-1.29). Colostrum use was more prevalent in the ABE group (OR 5.31, 95% CI 2.63-10.76). ABE participants were more likely to present in spontaneous labor (OR 2.09, 95% CI 1.05-4.14). Conclusion: ABE did not significantly improve exclusive breastfeeding rates, but safely provides women opportunities to become familiar with breastfeeding before delivery and can provide readily available colostrum. There was no negative secondary safety outcome related to ABE identified. Prenatal care providers can consider recommending ABE to patients with minimal to no experience with breastfeeding.

Teaching antenatal hand expression: a feasibility study in an inner urban U.S. hospital

BACKGROUND

Many women have low confidence in breastfeeding and have concerns regarding low milk volume or discomfort with breastfeeding. Antenatal hand expression may be an opportunity to help women feel more comfortable with breastfeeding and help promote exclusive breastfeeding. A study at a hospital in Philadelphia, Pennsylvania, U.S. assessed the feasibility of teaching antenatal hand expression at 39 weeks among socioeconomically disadvantaged populations, overall participant satisfaction and adoption of hand expression and breastfeeding.

METHODS

From March 2020 to June 2021, women recruited at 34-39 weeks were taught to hand express, collect, and store colostrum. Starting from 39 weeks, participants were asked to practice hand expression 1-3 times / day until delivery, log their experiences, and store colostrum expressed. Women were contacted to encourage continued hand expression and answer any questions. Postpartum, a survey assessed satisfaction with hand expression and issues encountered. The survey also inquired about breastfeeding plans and barriers, and whether women were exclusively breastfeeding (defined as infants who received only breastmilk from the time of birth). Chart review of postpartum or well-baby visit notes determined whether women continued breastfeeding.

RESULTS

Of the 29 participants, 72% (21/29) reported hand expressing at home, and no women reported contractions when hand expressing. Participants rated mean satisfaction of 8.1/10 (SD = 1.62) with antenatal hand expression, mean satisfaction of 9.4/10 (SD = 0.90) toward hand expression education, mean likelihood of 9.4/10 (SD = 1.24) recommending hand expression to others, and a mean score of 8.1/10 (SD = 1.69) on how helpful hand expression was in breastfeeding initiation. 90% (26/29) of women initiated breastfeeding after birth and 72% (21/29) exclusively breastfed on discharge, but only 11/29 (38%) continued exclusively breastfeeding when re-assessed 4-6 weeks postpartum. Barriers included maternal discomfort, low milk supply, and maternal or infant illness.

CONCLUSIONS

This study suggests that women in an urban setting would be willing to practice antenatal hand expression. A larger and adequately powered study could be feasible to determine associations between antenatal hand expression and breastfeeding rates and confidence.

Effect of antenatal milk expression education on lactation outcomes in birthing people with pre-pregnancy body mass index ≥25: protocol for a randomized, controlled trial

BACKGROUND

Birthing people with pre-pregnancy body mass indices (BMIs) ≥ 25 kg/m², particularly those without prior breastfeeding experience, are at increased risk for suboptimal lactation outcomes. Antenatal milk expression (AME) may be one way to counteract the negative effects of early infant formula supplementation common in this population.

METHODS

This ongoing, randomized controlled trial in the United States evaluates the efficacy of a telelactation-delivered AME education intervention versus an attention control condition on lactation outcomes to 1 year postpartum among 280 nulliparous-to-primiparous, non-diabetic birthing people with pre-pregnancy BMI ≥ 25 kg/m². The assigned study treatment is delivered via four weekly online video consultations between gestational weeks 37-40. Participants assigned to AME meet with study personnel and a lactation consultant to learn and practice AME. Instructions are provided for home practice of AME between study visits. Control group participants view videos on infant care/development at study visits. Participants complete emailed surveys at enrollment (34^0/7-36^6/7 gestational weeks) and 2 weeks, 6 weeks, 12 weeks, 6 months, and 12 months postpartum. Surveys assess lactation and infant feeding practices; breastfeeding self-efficacy, attitudes, and satisfaction; perception of insufficient milk; onset of lactogenesis-II; lactation support and problems; and reasons for breastfeeding cessation. Surveys also assess factors associated with lactation outcomes, including demographic characteristics, health problems, birth trauma, racial discrimination, and weight stigma. Health information and infant feeding data are abstracted from the pregnancy and birth center electronic health record. Milk samples are collected from the intervention group at each study visit and from both groups at each postpartum follow-up for future analyses. Qualitative interviews are conducted at 6 weeks postpartum to understand AME experiences. Primary outcomes of interest are breastfeeding exclusivity and breastfeeding self-efficacy scores at 2 weeks postpartum. Outcomes will be examined longitudinally with generalized linear mixed-effects modeling.

DISCUSSION

This is the first adequately powered trial evaluating the effectiveness of AME among U.S. birthing people and within a non-diabetic population with pre-pregnancy BMI ≥ 25 kg/m². This study will also provide the first evidence of acceptability and effectiveness of telelactation-delivered AME.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04258709.

Education and Experiences of Antenatal Breast Milk Expression: A Systematic Review

Background: Breastfeeding rates have stagnated recently despite recommendations to breastfeed until age 2 years. Antenatal breast milk expression (ABME) is a method used to prepare the breast for breastfeeding. However, there is limited evidence available on the benefits, risks, and impact of ABME on maternal-infant breastfeeding dyads. Methods: This review identified and summarized studies on women who engaged in ABME and their personal experiences. Databases searched included PubMed MEDLINE, Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and EMBASE. Initially, abstracts and titles were reviewed, and then, full-text studies were screened for inclusion by two blinded authors. Two authors assessed the quality of the studies using a standardized tool, two authors completed data extraction, and one author completed data harmonization into tables. Results: A total of 1,410 studies were identified (after duplicates removed) and 10 citations qualified for the inclusion criteria. Only two studies received an overall rating of strong quality and low-risk bias. The selected articles varied in primary outcomes; however, main focuses were experiences, knowledge, and perspective after practicing ABME. Data varied on timing of ABME, but most studies started between 34 and 36 weeks. The average amount of expressed milk was reported in four studies but was variable. Conclusions: This systematic review found that the literature is limited regarding ABME, and most studies were focused on women with diabetes. The current limited evidence suggests that ABME may be a helpful tool in improving maternal breastfeeding confidence and breastfeeding outcomes. Negative side effects reported related to ABME included difficulty learning the technique, discomfort, and feeling of awkwardness while expressing. Future research should focus on higher quality studies regarding use of ABME, proper teaching of ABME technique, and the use of ABME to improve breastfeeding outcomes in diverse populations of maternal-infant dyads.

Antenatal Milk Expression as a Lactation Support Intervention for Parents of Infants With Severe Birth Defects: A Case Series

BACKGROUND

A diet high in parent's own milk (parental milk) is a lifesaving intervention for critically ill infants. Lactating parents whose infants are born with birth defects that require surgical repair (surgical infants) shortly after birth often struggle to initiate and maintain a milk supply that meets their infant's nutritional needs. Antenatal milk expression has been identified as a safe, feasible, and potentially effective strategy that promotes parents' direct chest/breastfeeding or milk expression (lactation) confidence and helps parents attain their lactation goals. Two cases are presented to illustrate the potential for using antenatal milk expression as a lactation support intervention for parents of surgical infants.

CASE PRESENTATION

Cases were drawn from a pilot study exploring the feasibility of implementing antenatal milk expression among pregnant parents of surgical infants. Participants were healthy women recruited after 30 weeks of gestation who received a fetal diagnosis of a complex congenital heart defect. Despite variability in clinical course and length of stay, parental milk was provided for the duration of each infant's hospitalization. Participant perceptions of antenatal milk expression varied.

CONCLUSION

More research is needed to evaluate the feasibility, efficacy, and parent or provider perceptions of antenatal milk expression as a lactation support intervention for parents of surgical infants.

Structured antenatal milk expression education for nulliparous pregnant people: results of a pilot, randomized controlled trial in the United States

BACKGROUND

Hand-expression, collection, and storage of breast milk during pregnancy (i.e., antenatal milk expression or AME) is a safe, potentially effective practice to reduce early, undesired infant formula supplementation among women with diabetes. The feasibility and potential impact of AME on lactation outcomes in the United States (U.S.) and among non-diabetic birthing people is unknown.

METHODS

The purpose of this study was to examine the feasibility of a structured AME intervention among nulliparous birthing people in the United States. We recruited 45 low-risk, nulliparous individuals at 34-36^6/7 weeks of gestation from a hospital-based midwife practice. Participants were randomized to AME or a control group receiving lactation education handouts. Interventions were delivered at weekly visits at 37-40 weeks of pregnancy. The AME intervention involved technique demonstration and feedback from a lactation consultant and daily independent practice. Lactation outcomes were assessed during the postpartum hospitalization, 1-2 weeks postpartum, and 3-4 months postpartum.

RESULTS

Between December 2016 and February 2018, 63 individuals were approached and screened for eligibility, and 45 enrolled into the study (71%). Of 22 participants assigned to AME, 18 completed at least one AME study visit. Participants reported practicing AME on at least 60% of days prior to their infant's birth. Most were able to express milk antenatally (15/18), more than half collected and froze antenatal milk (11/18), and 39% (7/18) supplemented their infants with antenatal milk after birth. No major problems were reported with AME. Perinatal and lactation outcomes, including infant gestational age at birth, neonatal intensive care unit admissions, delayed onset of lactogenesis II, and use of infant formula were similar between AME and control groups. Among participants in both groups who were feeding any breast milk at each assessment, breastfeeding self-efficacy increased and perceptions of insufficient milk decreased over the postpartum course.

CONCLUSIONS

In a small group of nulliparous birthing people in the U.S., AME education and independent practice beginning at 37 weeks of pregnancy was feasible. In some cases, AME provided a back-up supply of milk when supplementation was indicated or desired. The relationship between AME and lactation outcomes requires further study with adequately powered samples.

TRIAL REGISTRATION

This trial was retrospectively registered at ClinicalTrials.gov on May 11, 2021 under the following registration ID: NCT04929301. https://clinicaltrials.gov/ct2/show/NCT04929301 .

'Is there any point in me doing this?' Views and experiences of women in the Diabetes and Antenatal Milk Expressing (DAME) trial

The Diabetes and Antenatal Milk Expressing (DAME) randomised controlled trial (RCT) was conducted in 2011–2015, at six sites in Melbourne, Australia to explore the effect of advising women with diabetes in pregnancy to express breast milk from 36 weeks gestation. Infants whose mothers were randomised to express in pregnancy were more likely to be exclusively breast milk fed during their hospital stay, and there was no evidence of harm. This paper explores women's views and experiences of antenatal expressing. In this two‐arm RCT, 635 women with diabetes in pregnancy who were otherwise of low medical risk were randomised at 36–37 weeks gestation to usual care (not expressing, n = 316), or the intervention, where women were advised to hand express for 10 min twice daily until birth (n = 319). Semistructured face‐to‐face interviews were conducted with 10 women who expressed antenatally. They were asked about their experiences of antenatal expressing, including how they felt about the overall experience, the amount of breast milk they expressed, making time to express, and their experience of breastfeeding. Thematic analysis of the in‐depth interviews identified six themes: (1) learning and adapting expressing, (2) feelings and sensations associated with expressing, (3) support, (4) dis/empowerment, (5) health, and (6) the value of breast milk. Women had both positive and negative experiences of antenatal expressing. If health professionals are advising antenatal expressing to women, it is important they understand the range of outcomes and experiences.

Women's experiences of antenatal expressing were both positive and negative; it is important to understand the range of experiences.

Women should be advised that some women express little or no breast milk antenatally and therefore be reassured if they are concerned.

For women with diabetes in pregnancy, their diabetes management is a significant time burden, and should be considered when discussing antenatal expressing with women.

Maternity care providers need to follow‐up with pregnant women advised to express, to provide education, reassurance, and reassess expressing techniques.

Maternity care providers need to manage and prioritise the use of expressed breast milk.

Evaluation of a breastmilk hand expression toolkit: the M.I.L.K survey study

Background

Breastmilk hand expression (BMHE) is recommended to promote lactation, relieve breast engorgement, and collect milk for future infant feedings. Resources to teach this skill are limited and infrequently developed in partnership with the obstetrical population. In collaboration with maternity care experts and individuals with recent breastfeeding experience, we designed a one-page toolkit that describes the process of BMHE and includes step-by-step instructions and images to illustrate the technique. This study aimed to evaluate the readability, clarity of content, layout, and informational value of this BMHE toolkit.

Methods

Individuals who intended to breastfeed, were currently breastfeeding, or had recently breastfed were electronically surveyed and completed a two-part survey that consisted of radio, multi-select, Likert scale, and open-ended questions. Part one captured sociodemographic factors, obstetrical history, and breastfeeding practices. Part two collected feedback on the BMHE toolkit. Participants were recruited electronically through social media and posters were circulated in antenatal and postnatal care settings in Ottawa, Canada between November 2020 and February 2021.

Results

Of the 123 participants, 117 (95.1%) had heard of hand expression prior to reviewing the toolkit and 99 (80.5%) had hand expressed before. Among the 48 participants who were no longer exclusively breastfeeding at the time of the survey, 22 (45.8%) had exclusively breastfed their infant for at least six months and 7 (14.6%) had discontinued exclusive breastfeeding within the first month. When asked about the BMHE toolkit, 118 (95.9%) participants said it was informative, 115 (93.5%) said it was easy to understand, and 114 (92.7%) said it was well laid-out. When asked about information seeking behaviours, participants indicated a preference for online resources (58.5%) and video resources (22.0%).

Conclusions

The BMHE toolkit was well received by participants and the feedback was favourable overall. The survey feedback will be used to create a revised version of the toolkit that has been validated by the obstetrical patient population. Future research should focus on identifying implementation strategies to optimize the use of the toolkit and increase its effectiveness as an educational resource to teach participants correctly BMHE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00448-3.

Integrative Review of Antenatal Milk Expression and Mother-Infant Outcomes During the First 2 Weeks After Birth

OBJECTIVE

To explore the practice of antenatal milk expression (AME) and related outcomes for mother-infant dyads during the first 2 weeks after birth.

DATA SOURCES

We searched the electronic databases MEDLINE, Embase, CINAHL, Emcare, Maternity & Infant Care Database, Scopus, and Web of Science for relevant literature. We also conducted backward reference searches on relevant publications and nondatabase searches after review of the full texts.

STUDY SELECTION

Articles were eligible for inclusion if they reported primary studies focused on AME, included samples of mother-infant dyads, and were published in English. We did not impose time or design limitations given the sparse availability of literature on AME. We identified 766 articles. After the removal of duplicates, we screened 588 articles, and of these, we included 15 articles in our review.

DATA EXTRACTION

We used the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines to guide data extraction and reporting. We evaluated the quality of evidence using the Melnyk and Fineout-Overholt rating system and the Joanna Briggs Institute critical appraisal tools.

DATA SYNTHESIS

We synthesized data from the included articles into four themes: Breastfeeding Self-Efficacy, Milk Supply, Infant Well-Being, and Infant Feeding Methods.

CONCLUSION

AME may support breastfeeding by improving breastfeeding self-efficacy and milk supply and by decreasing early formula use. Synthesized literature on AME shows the safety of the practice and that infants of women who practice AME have a greater likelihood of breastfeeding exclusivity during the short term.

Evaluating antenatal breastmilk expression outcomes: a scoping review

Background

Antenatal breastmilk expression (aBME) is recommended by some healthcare providers to improve lactation, breastfeeding, and newborn outcomes, particularly for women with diabetes as they face unique challenges with breastfeeding. However, there is limited evidence of the potential harms and benefits of this practice. Our objective was to conduct a scoping review to map the literature describing maternal and newborn outcomes of aBME.

Methods

We searched Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, British Library E-Theses Online Services (EThOS) database, OpenGrey, and Clinical trials.gov from inception to January 2020. Studies in English that reported on the effect of aBME on maternal and newborn outcomes, and the experiences of women who have engaged in the practice were included for screening. Titles, abstracts, and full-text articles were screened by two independent reviewers. A critical appraisal and clinical consultation were conducted. Key findings were extracted and summarized.

Results

We screened 659 studies and 20 met the inclusion criteria. The majority of included studies (n = 11, 55.0%) were published after 2015, and seven (35.0%) originated from Australia. Ten (50.0%) studies provided data on high-risk obstetrical populations, including those with diabetes (n = 8), overweight or obesity (n = 1), and preeclampsia (n = 1). Commonly reported outcomes included breastfeeding status at discharge or follow-up, mode of delivery, newborn blood glucose, and time to establishing full lactation. Maternal experiences were related to challenges with aBME, confidence and mastery, perceived impact, security and altruism, learning and resources, and physical symptoms as a result of aBME. The critical appraisal demonstrated limited high-quality evidence surrounding aBME.

Conclusions

Our findings demonstrate increasing interest in the safety, efficacy, and acceptability of aBME. Existing studies are heterogenous with variable research questions, outcomes, study designs, and methodology. The recommendations made in this review can be used to help inform  future studies evaluating aBME.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00371-7.

The sleeper effect of perceived insufficient milk supply in US mothers

OBJECTIVE

To test whether perception of insufficient milk (PIM) supply in the breast-feeding relationship of one child predicts how long mothers breast-feed subsequent children, and whether this association differs for first-time mothers v. mothers with previous children.

DESIGN

Secondary analysis of Infant Feeding Practices Study II (ordinary least squares regression) and Year 6 follow-up.

SETTING

Mailed, self-report survey of US mother-infant dyads, 2005-2012.

PARTICIPANTS

Women pregnant with a singleton were recruited from a consumer opinion panel. Exclusion criteria included: mother age <18; infant born <5 lbs, born before 35 weeks or with extended NICU stay, and mother or infant diagnosed with condition that impacts feeding. A subsample with PIM data (n 1460) was analysed.

RESULTS

We found that women who weaned because of PIM with the index child stopped breast-feeding 5·7 weeks earlier than those who weaned due to other reasons (4·9 weeks earlier for multiparas, P < 0·001; 7·1 weeks earlier for primiparas, P < 0·001). Using Year 6 follow-up data (n 350), we found subsequent child 1 weaned 9·2 weeks earlier if the mother experiences PIM as a multipara (P = 0·020) and 10·6 weeks earlier if the mother experiences PIM as a primipara (P = 0·019). For subsequent child 2 (n 78), the magnitude of association was even larger, although insignificant due to low power.

CONCLUSIONS

These findings indicate that PIM may carry forward in the reproductive life course, especially for first-time mothers. Perceptions of breast milk insufficiency and contributors to actual inadequate milk supply with the first child should be targeted, rather than intervening later in the reproductive life course.

Importance of the lactation period in developmental programming in rodents

Lactation is a critical period during which maternal nutritional and environmental challenges affect milk composition and, therefore, organ differentiation, structure, and function in offspring during the early postnatal period. Evidence to date shows that lactation is a vulnerable time during which transient insults can have lasting effects, resulting in altered health outcomes in offspring in adult life. Despite the importance of the developmental programming that occurs during this plastic period of neonatal life, there are few comprehensive reviews of the multiple challenges—especially to the dam—during lactation. This review presents milk data from rodent studies involving maternal nutritional challenges and offspring outcome data from studies involving maternal manipulations during lactation. Among the topics addressed are maternal nutritional challenges and the effects of litter size and artificial rearing on offspring metabolism and neural and endocrine outcomes. The lactation period is an opportunity to correct certain functional deficits resulting from prenatal challenges to the fetus, but, if not personalized, can also lead to undesirable outcomes related to catch up-growth and overnutrition.

Maternal and newborn outcomes of antenatal breastmilk expression: a scoping review protocol

INTRODUCTION

Mothers with diabetes face unique challenges associated with breastfeeding initiation and maintenance. Antenatal breastmilk expression (BME) may be suggested to mothers, including mothers with diabetes, to improve breastfeeding, maternal, and infant outcomes postpartum. However, there have been few evaluations of the potential harms and benefits of this practice. The objective of our scoping review will be to broadly examine the literature describing maternal and infant outcomes of antenatal BME.

METHODS AND ANALYSIS

This scoping review will address the research question: 'Among women who engaged in antenatal BME, what maternal and infant outcomes have been evaluated?' A search of published and unpublished studies available in English will be conducted in February 2020 using the following databases: Medline (OVID), Embase (OVID), CINAHL (EBSCOHost), and Cochrane Database of Systematic Reviews (OVID). A search of the British Library E-Theses Online Services (EThOS) database and OpenGrey will be conducted to identify relevant grey literature. This scoping review will use a five-step framework to guide the selection, extraction, and analysis of eligible studies. Clinical consultation will be included as a sixth step to our methodology. Literature reporting on the effect of antenatal BME on maternal and infant outcomes, breastfeeding initiation and duration, and the experiences of women who have engaged in the practice will be considered. The data will be summarised with attention paid to high-risk obstetrical populations such as women with diabetes. Our results will be reported as outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

ETHICS AND DISSEMINATION

Research ethics board approval will not be required due to the nature of the study's methodology. The results of this review will be disseminated through peer-reviewed publication and presentation at relevant conferences.

TRAIL REGISTRATION NUMBER

Open Science Framework (osf.io/gfp2q).

"It gave me so much confidence": First-time U.S. mothers' experiences with antenatal milk expression

Antenatal milk expression (AME) involves maternal hand-expression, collection, and storage of breast milk during pregnancy for the purposes of reducing the early formula use in breastfed infants. AME is not widely practiced in the United States, despite its growing popularity elsewhere. In this study, we examined the experiences of first-time mothers recruited from a U.S. midwife practice who engaged in AME within the context of a pilot randomized controlled trial. The AME intervention involved demonstration and practice of AME with a lactation consultant beginning at 37 weeks of gestation, reinforcement at weekly study visits until delivery, and daily home practice. Nineteen women participated in a semistructured interview at 1-2 weeks postpartum regarding their study experiences. Major themes included (1) perceived benefits and impact of AME, (b) AME implementation, and (c) use of AME milk. Women perceived multiple benefits of AME, most notably that it increased their confidence that they would be able to make milk and breastfeed successfully postpartum. Women expressed some concern that no/little milk expressed could be indicative of postpartum milk production problems. Regarding implementation, women found that the AME protocol fit well into their daily routine. There was mixed feedback regarding comfort with practicing AME in the presence of partners. Reasons for postpartum use of AME milk varied; barriers to provision included inadequate milk storage options at the birth hospital and unsupportive hospital providers/staff. With few caveats, AME appears to be an acceptable breastfeeding support intervention among a sociodemographically homogeneous group of first-time mothers in the United States.