Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial

Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement

Background

Breastfeeding impacts positively on multiple health outcomes, but < 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding.

Objectives

To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS.

Design

Evidence syntheses with stakeholder engagement.

Review methods

Systematic reviews examined effectiveness of breastfeeding support for (1) healthy women and (2) women with long-term conditions using Cochrane Pregnancy and Childbirth Group methods. Mixed-methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women and experiences of receiving/providing support for breastfeeding women with long-term conditions. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following National Institute for Health and Care Excellence guidance. All searches were conducted from May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were 23 stakeholders, 16 parents in the parents' panels, 15 women in the focus groups and 87 stakeholders who attended the workshops.

Results

We found considerably more interventions designed for healthy women (review 1) than aimed at women with long-term conditions (reviews 1 and 4); approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and the impact of support may be different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) and involving these sources in the provision of breastfeeding support for women with long-term conditions. In reviews 3 and 6, there was uncertainty about the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence.

Limitations

There was a lack of evidence for the effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information reported about intervention characteristics.

Conclusions

'Breastfeeding only' support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for 'breastfeeding plus' interventions is less consistent, but these may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and at 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good-quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women's and supporters' needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK.

Future work

Evaluation of breastfeeding support for all women, particularly those at risk of poor breastfeeding outcomes (e.g. long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies.

Study registration

This study is registered as PROSPERO CRD42022337239, CRD42021229769 and CRD42022374509. The reviews of economic evidence were not registered; however, the review protocol can be accessed via the repository held by Queen's University Belfast Research Portal (https://pure.qub.ac.uk/).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130995) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 20. See the NIHR Funding and Awards website for further award information.

The Influence of Participation in Pregnancy Courses and Breastfeeding Support Groups on Attitudes and Knowledge of Health Professionals about Breastfeeding

Numerous factors affect the behavior, attitudes, and knowledge of health professionals about breastfeeding. The aim of this paper is to determine the impact of participation in pregnancy courses and breastfeeding support groups on the attitudes and knowledge of health professionals about breastfeeding. The study compares two groups of health professionals according to the results they achieved on a validated questionnaire of behavior, attitudes, and knowledge about breastfeeding. The authors did not make personal contact with the respondents, as the questionnaires were filled out online. The two groups of respondents differed according to the frequency of participation in pregnancy courses, that is, groups for breastfeeding support. The results are presented tabularly and graphically (frequencies and percentages), while differences in the results between the infrequent and regular participants are shown with the Mann–Whitney U test (asymmetric distribution). Better results on the questionnaire were achieved by those who regularly attended breastfeeding support groups (Mdn = 149, IQR = 11) in comparison to infrequent visitors (Mdn = 137, IQR = 23). The same is found for regular visitors of pregnancy courses (Mdn = 149, IQR = 15.75) in comparison to infrequent visitors (Mdn = 137, IQR = 23). The differences are statistically significant (p < 0.00). Partial correlation confirms a more significant influence of breastfeeding support groups (<0.00) than pregnancy courses (p = 0.34). Working in breastfeeding support groups had a statistically significant positive effect on the attitudes and knowledge of health professionals about breastfeeding. The topic of breastfeeding should be given more space and importance during pregnancy courses as well. Personal experience working in breastfeeding support groups and pregnancy courses should be incorporated into the training of medical students.

Outcomes among participants vs nonparticipants of randomized trials during pregnancy: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the outcomes among individuals who were eligible and approached for participation in a randomized controlled trial during pregnancy, comparing those who enrolled with those who declined participation.

DATA SOURCES

MEDLINE, Scopus, CINAHL, the Cochrane Library, and Ovid were searched from study inception to May 2022.

STUDY ELIGIBILITY CRITERIA

This study included all obstetrical randomized controlled trials that reported clinical outcomes for both participants and nonparticipants.

METHODS

The primary outcome captured the presence of morbidity. It was a composite of the primary outcome of each study comparing the participant arm with the nonparticipant arm. If a primary outcome was not clearly defined, a surrogate was developed on the basis of the core outcomes for the clinical condition studied. The risk of bias was assessed with the Newcastle-Ottawa Scale. Subgroup analyses for relevant obstetrical and neonatal outcomes were performed. The summary comparisons were reported as odds ratios with 95% confidence intervals computed using random-effects meta-analysis with heterogeneity evaluated using the I2 statistic. A funnel plot was used to examine publication bias, and there was no asymmetry.

RESULTS

After reviewing more than 1100 abstracts, 17 obstetrical randomized controlled trials (103,610, with 26,293 participants and 77,317 nonparticipants) met our inclusion criteria and were analyzed. Of note, 9 studies were not rated as high quality, primarily for failing to control for confounding factors. Trial interventions were categorized as antepartum (n=11), intrapartum (n=5), or postpartum (n=1). Overall, participants in obstetrical randomized controlled trials had no difference in outcomes compared with nonparticipants (n=17: odds ratio, 0.88; 95% confidence interval, 0.52-1.49; I2=90%). Moreover, there was no difference seen when only randomized controlled trials that reported a primary outcome were included (n=12: odds ratio, 0.76; 95% confidence interval, 0.38-0.1.49; I2=93%). In addition, there was no difference noted in the subgroup where the randomized controlled trial intervention was not available to nonparticipants (n=7: odds ratio, 0.91; 95% confidence interval, 0.45-1.85; I2=68%).

CONCLUSION

Pregnant individuals who agreed to participate in randomized controlled trials had no difference in outcomes compared with those who decline participation. Pregnant individuals should be provided with this reassuring information when offered to participate in a randomized controlled trial. Moreover, this information may improve patient recruitment into randomized controlled trials.

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.

The cost-effectiveness of antenatal and postnatal education and support interventions for women aimed at promoting breastfeeding in the UK

Background

Breastfeeding is associated with health benefits to mothers and babies and cost-savings to the health service. Breastfeeding rates in the UK are low for various reasons including cultural barriers, inadequate support to initiate and sustain breastfeeding, lack of information, or choice not to breastfeed. Education and support interventions have been developed aiming at promoting breastfeeding rates. The objective of this study was to assess the cost-effectiveness of such interventions for women, initiated antenatally or in the first 8 weeks postnatally, aiming at improving breastfeeding rates, in the UK.

Methods

A decision-analytic model was constructed to compare costs and quality-adjusted life-years (QALYs) of a breastfeeding intervention from the perspective of health and personal social services in England. Data on intervention effectiveness and the benefits of breastfeeding were derived from systematic reviews. Other model input parameters were obtained from published sources, supplemented by expert opinion.

Results

The incremental cost-effectiveness ratio (ICER) of the modelled intervention added on standard care versus standard care was £51,946/QALY, suggesting that the intervention is not cost-effective under National Institute for Health and Care Excellence (NICE) criteria in England. Sensitivity analysis suggested that the cost-effectiveness of the intervention improved as its effectiveness increased and intervention cost decreased. At the base-case effect (increase in breastfeeding rates 16–26 weeks after birth by 19%), the intervention was cost-effective (<£20,000/QALY) if its cost per woman receiving the intervention became ≈£40–£45. At the base-case cost (£84), the intervention was cost-effective if it increased breastfeeding rates by at least 35–40%.

Conclusions

Available breastfeeding interventions do not appear to be cost-effective under NICE criteria in England. Future breastfeeding interventions need to have higher effectiveness or lower cost compared with currently available interventions in order to become cost-effective. Public health and other societal interventions that protect, promote and support breastfeeding may be key in improving breastfeeding rates in the UK.

Framework for the development and evaluation of complex interventions: gap analysis, workshop and consultation-informed update

BACKGROUND

The Medical Research Council published the second edition of its framework in 2006 on developing and evaluating complex interventions. Since then, there have been considerable developments in the field of complex intervention research. The objective of this project was to update the framework in the light of these developments. The framework aims to help research teams prioritise research questions and design, and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods.

METHODS

There were four stages to the update: (1) gap analysis to identify developments in the methods and practice since the previous framework was published; (2) an expert workshop of 36 participants to discuss the topics identified in the gap analysis; (3) an open consultation process to seek comments on a first draft of the new framework; and (4) findings from the previous stages were used to redraft the framework, and final expert review was obtained. The process was overseen by a Scientific Advisory Group representing the range of relevant National Institute for Health Research and Medical Research Council research investments.

RESULTS

Key changes to the previous framework include (1) an updated definition of complex interventions, highlighting the dynamic relationship between the intervention and its context; (2) an emphasis on the use of diverse research perspectives: efficacy, effectiveness, theory-based and systems perspectives; (3) a focus on the usefulness of evidence as the basis for determining research perspective and questions; (4) an increased focus on interventions developed outside research teams, for example changes in policy or health services delivery; and (5) the identification of six 'core elements' that should guide all phases of complex intervention research: consider context; develop, refine and test programme theory; engage stakeholders; identify key uncertainties; refine the intervention; and economic considerations. We divide the research process into four phases: development, feasibility, evaluation and implementation. For each phase we provide a concise summary of recent developments, key points to address and signposts to further reading. We also present case studies to illustrate the points being made throughout.

LIMITATIONS

The framework aims to help research teams prioritise research questions and design and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods. In many of the areas of innovation that we highlight, such as the use of systems approaches, there are still only a few practical examples. We refer to more specific and detailed guidance where available and note where promising approaches require further development.

CONCLUSIONS

This new framework incorporates developments in complex intervention research published since the previous edition was written in 2006. As well as taking account of established practice and recent refinements, we draw attention to new approaches and place greater emphasis on economic considerations in complex intervention research. We have introduced a new emphasis on the importance of context and the value of understanding interventions as 'events in systems' that produce effects through interactions with features of the contexts in which they are implemented. The framework adopts a pluralist approach, encouraging researchers and research funders to adopt diverse research perspectives and to select research questions and methods pragmatically, with the aim of providing evidence that is useful to decision-makers.

FUTURE WORK

We call for further work to develop relevant methods and provide examples in practice. The use of this framework should be monitored and the move should be made to a more fluid resource in the future, for example a web-based format that can be frequently updated to incorporate new material and links to emerging resources.

FUNDING

This project was jointly funded by the Medical Research Council (MRC) and the National Institute for Health Research (Department of Health and Social Care 73514).

Validation of the Arabic Maternal Breastfeeding Evaluation Scale (MBFES-A) among Lebanese women

Background

Maternal satisfaction with the breastfeeding experience is an important determinant of breastfeeding success. There is currently no valid tool to measure perceived maternal satisfaction with breastfeeding in the Arab context.

Methods

This cohort study tested the Maternal Breastfeeding Evaluation Scale (MBFES) on 450 healthy Lebanese mothers for internal consistency reliability and construct validity. Participants were recruited between April 2018 and February 2020.

Results

The Cronbach’s alpha reliability coefficient of the Arabic MBFES (MBFES-A) was 0.87. Exploratory factor analysis revealed that it has three components: Infant Satisfaction/Growth, Maternal Enjoyment/Role Attainment, and Lifestyle/Body Image with reliability coefficients of 0.88, 0.87, and 0.68, respectively. Four items were deleted because of low factor loadings and three items were relocated to the Infant Satisfaction/Growth subscale based on their factor loadings. Participants who were exclusively breastfeeding at one and/or 3 months had higher mean MBFES-A total and Infant Satisfaction/Growth and Maternal Enjoyment/Role Attainment subscale scores than participants who were partially breastfeeding, and significantly higher mean scores than mothers who were not breastfeeding (all p values < 0.001), findings that support the scale’s construct validity. Moreover, scores on the Infant Satisfaction/Growth subscale correlated with exclusive breastfeeding at one (r = 0.37, p < 0.001) and 3 months (r = 0.31, p < 0.001). The MBFES-A score had positive modest correlations with maternal attitude towards breastfeeding (r = 0.30, p < 0.001), exclusive breastfeeding at one (r = 0.27) and at 3 months (r = 0.26, p < 0.001 for both), as well as with the longest previous exclusive breastfeeding (r = 0.27, p < 0.001).

Conclusions

The 26-item MBFES-A is a reliable and valid instrument to use in future breastfeeding research in Middle East North Africa countries. There is a need for replication of our findings in other Arab contexts using new constructs to establish stronger construct validity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00409-w.

Adapting breastfeeding support in areas of socio-economic deprivation: a case study approach

BACKGROUND

There are inequalities in breastfeeding initiation and continuation rates, whereby socio-economically disadvantaged mothers are least likely to breastfeed. Breastfeeding peer support (BPS) interventions are recommended as a solution, and in the UK non-profit organisations are commissioned to deliver BPS services in areas of socio-economic deprivation. BPS interventions have a mixed evidence base, offering limited knowledge about the interaction between context and intervention and how this affects women's experiences.

METHODS

This interpretive study used a case study methodology to explore how and why two BPS services developed their services in socio-economically deprived contexts. Methods aimed to generate holistic understanding of BPS service development. Data collected across both cases comprised; observation (n = 1), and semi-structured interviews with: mothers who had (n = 10) and had not (n = 9) engaged with the BPS services, peer supporters (PSs) (n = 9), community health professionals (n = 5), infant feeding co-ordinators (n = 2), non-profit organisation managers (n = 3), and public health commissioners (n = 2). Inductive grounded theory analytic techniques of open coding and constant comparisons, followed by cross case comparisons, were used to analyse the data.

RESULTS

The over-arching theme - 'the transcending influence of society' - offers insights into the underlying context and drivers impacting service development. It reflects how funding and data sharing arrangements determined service operation and the peer's access to women. Four underpinning themes explain how: peer supporters were resourceful in adapting their services ('adapting and modifying the support'); BPS organisations worked to enable women's access to supportive breastfeeding environments, but did not necessarily focus service development on the needs of women living in areas of deprivation ('supporting women's journeys to access'); the BPS-professional connections for supporting access and how BPS could result in more supportive community environments ('embedding within healthcare practice'); and how management practices precluded meaningful use of data to provide context led service development ('ways of using knowledge').

CONCLUSIONS

Findings suggest that while PSs are commissioned to focus on those most in need, there is limited discussion, collection, or use of knowledge about women's lives to develop needs-led service delivery. The key recommendation is the development of a social ecological tool to facilitate the use and application of contextual knowledge.

Impact and Effectiveness of Group Strategies for Supporting Breastfeeding after Birth: A Systematic Review

Despite the multiple benefits of breastfeeding both for the mother and for the infant, during the first months there is a progressive decline in the number of mothers who continue breastfeeding, with most countries reporting lower than recommended figures. The objective of this review is to analyse the most effective group support practices for breastfeeding, as well as the characteristics associated to their success in maintaining breastfeeding. A systematic review has been conducted in the 2015–2020 period, in the following databases: MedLine, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library and LILACS. The findings were summarized in narrative and table formats. A total of thirteen articles were included, eight of them being experimental studies and five observational. The findings show high heterogeneity regarding the characteristics of the interventions and their periodicity. The most successful group strategies to support and maintain breastfeeding during postpartum are those that combine peer support with the leadership or counselling of a health professional or IBCLC. However, more studies are necessary, randomized and with interventions of similar characteristics, which allow for better data comparison.

Challenging procedures used in systematic reviews by promoting a case-based approach to the analysis of qualitative methods in nursing trials

This methodological discussion invites critical reflection about the procedures used to analyze the contribution of qualitative and mixed methods research to nursing trials by mounting an argument that these should rest on multiple publications produced about a project, rather than a single article. We illustrate the value-added of this approach with findings from a qualitative, cross-case analysis of three critical case exemplars from nursing researchers that each used a qualitative approach with a mixed method phase. The holistic lens afforded by a case-based approach informs nursing inquiry by documenting that the critical case exemplars presented evidence of (a) a sustained commitment of resources and expertise for the qualitative methods that extended across more than one phase of the trial, (b) the impact of the qualitative methods on the trial or its aftermath, (c) deploying a theoretical or conceptual framework for a variety of purposes, and (d) integrating qualitative and quantitative data for purposes of extending explanatory power. Findings challenge the practice of linking purposes served by qualitative and mixed methods to a single trial phase.

A systematic review of costing studies for implementing and scaling-up breastfeeding interventions: what do we know and what are the gaps?

Despite the well-established evidence that breastfeeding improves maternal and child health outcomes, global rates of exclusive breastfeeding remain low. Cost estimates can inform stakeholders about the financial resources needed to scale up interventions to ultimately improve breastfeeding outcomes in low-, middle- and high-income countries. To inform the development of comprehensive costing frameworks, this systematic review aimed to (1) identify costing studies for implementing or scaling-up breastfeeding interventions, (2) assess the quality of identified costing studies and (3) examine the availability of cost data to identify gaps that need to be addressed through future research. Peer-reviewed and grey literature were systematically searched using a combination of index terms and relevant text words related to cost and the following breastfeeding interventions: breastfeeding counselling, maternity leave, the World Health Organization International Code of Marketing of Breastmilk Substitutes, the Baby-Friendly Hospital Initiative, media promotion, workplace support and pro-breastfeeding social policies. Data were extracted after having established inter-rater reliability among the first two authors. The quality of studies was assessed using an eight-item checklist for key costing study attributes. Forty-five studies met the inclusion criteria, with the majority including costs for breastfeeding counselling and paid maternity leave. Most cost analyses included key costing study attributes; however, major weaknesses among the studies were the lack of clarity on costing perspectives and not accounting for the uncertainty of reported cost estimates. Costing methodologies varied substantially, standardized costing frameworks are needed for reliably estimating the costs of implementing and scaling-up breastfeeding interventions at local-, national- or global-levels.

Breastfeeding Support Offered at Delivery is Associated with Higher Prevalence of Exclusive Breastfeeding at 6 Weeks Postpartum Among HIV Exposed Infants: A Cross-Sectional Analysis

Objective HIV-exposed uninfected infants are almost twice as likely to die compared to infants born to HIV-uninfected women. HIV-exposed uninfected children whose mothers are on ART and who are breastfed have the lowest risk of dying by 24 months of age. Interventions to improve breastfeeding among HIV-infected mothers are needed. We aimed to assess the association between support/counseling provided by healthcare workers following delivery and the rate of exclusive breastfeeding (EBF) at 6-week postpartum. Methods This is a secondary analysis of data collected as part of a trial to evaluate the effect of conditional cash transfers on retention in and uptake of PMTCT services. Between April 2013 and August 2014, newly diagnosed HIV-infected women, ≤ 32 weeks pregnant, registering for antenatal care (ANC), in 89 clinics in Kinshasa, Democratic Republic of Congo, were recruited and followed through 6 weeks postpartum. At 6-week, participants were asked if they had given anything other than breastmilk to their infant in the 24 h preceding the interview (No = EBF) and whether a nurse or a doctor talked to them about breastfeeding after they gave birth (YES = received breastfeeding support/counseling). Logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (CI) measuring the strength of the association between EBF and receiving breastfeeding support/counseling by a healthcare provider following delivery. Results Of 433 women enrolled, 328 attended a 6-week postpartum visit including 320 (97%) with complete information on EBF. Of those 320, 202 (63%) reported giving nothing other than breastmilk to their infant in the previous 24 h; 252 (79%) reported that a healthcare provider came to talk to them about breastfeeding following delivery. Mothers who reported receiveing breastfeeding support/counseling from a healthcare provider were more likely to exclusively breastfeed compared to those who did not (69% vs. 38%, OR 3.74; 95% CI 2.14-6.54). Adjustment for baseline sociodemographic characteristics did not change the association substantially, (adjusted OR 3.72; 95% CI 2.06-6.71). Conclusion for Practice Receipt of breastfeeding support/counseling from a healthcare provider after delivery among HIV-infected mothers in care at 6-weeks postpartum in Kinshasa almost quadrupled the odds of EBF.

Cost-effectiveness of offering an area-level financial incentive on breast feeding: a within-cluster randomised controlled trial analysis

OBJECTIVE

To provide the first estimate of the cost-effectiveness of financial incentive for breastfeeding intervention compared with usual care.

DESIGN

Within-cluster ('ward'-level) randomised controlled trial cost-effectiveness analysis (trial registration number ISRCTN44898617).

SETTING

Five local authority districts in the North of England.

PARTICIPANTS

5398 mother-infant dyads (intervention arm), 4612 mother-infant dyads (control arm).

INTERVENTIONS

Offering a financial incentive (over a 6-month period) on breast feeding to women living in areas with low breastfeeding prevalence (<40% at 6-8 weeks).

MAIN OUTCOME MEASURES

Babies breast fed (receiving breastmilk) at 6-8 weeks, and cost per additional baby breast fed.

METHODS

Costs were compared with differences in area-level data on babies' breast fed in order to estimate a cost per additional baby breast fed and the quality-adjusted life year (QALY) gains required over the lifetime of babies to justify intervention cost.

RESULTS

In the trial, the total cost of providing the intervention in 46 wards was £462 600, with an average cost per ward of £9989 and per baby of £91. At follow-up, area-level breastfeeding prevalence at 6-8 weeks was 31.7% (95% CI 29.4 to 34.0) in control areas and 37.9% (95% CI 35.0 to 40.8) in intervention areas. The adjusted difference between intervention and control was 5.7 percentage points (95% CI 2.7 to 8.6; p<0.001), resulting in 10 (95% CI 6 to 14) more additional babies breast fed in the intervention wards (39 vs 29). The cost per additional baby breast fed at 6-8 weeks was £974. At a cost per QALY threshold of £20 000 (recommended in England), an additional breastfed baby would need to show a QALY gain of 0.05 over their lifetime to justify the intervention cost. If decision makers are willing to pay £974 (or more) per additional baby breast fed at a QALY gain of 0.05, then this intervention could be cost-effective. Results were robust to sensitivity analyses.

CONCLUSION

This study provides information to help inform public health guidance on breast feeding. To make the economic case unequivocal, evidence on the varied and long-term health benefits of breast feeding to both the baby and mother and the effectiveness of financial incentives for breastfeeding beyond 6-8 weeks is required.

Validation of a tool to evaluate women's satisfaction with breastfeeding for the Brazilian population

OBJECTIVE

To perform the construct validity and the internal consistency of the Maternal Breastfeeding Evaluation Scale tool, aiming at its application in the Brazilian population.

METHODS

Cross-sectional study that applied the tool to 287 Brazilian women 30 days after childbirth. Main component analysis with varimax rotation was used for the factor analysis, verifying the number of subscales and the maintenance or extraction of the components. Four hypotheses were tested using the unpaired Student's t-test for construct validation. The reliability analysis was performed using Cronbach's alpha coefficient.

RESULTS

The exploratory factor analysis identified the need to exclude an item and to reformulate the subscales. The results of the construct validity showed that all hypotheses proposed were confirmed: women who were breastfeeding, those who were exclusively breastfeeding, those who did not have problems related to breastfeeding, and those who intended to breastfeed for at least 12 months achieved significantly higher mean values in the scale. The tool showed adequate internal consistency (Cronbach's alpha=0.88, 95% CI: 0.86-0.90), as did the pleasure and fulfillment of the maternal role subscales (0.92, 95% CI: 0.91-0.93%); child growth, development, and satisfaction (0.70; 95% CI: 0.65-0.75); and maternal physical, social, and emotional aspects (0.75, 95% CI: 0.70-0.79).

CONCLUSIONS

The validation process of the Brazilian version of the Maternal Breastfeeding Evaluation Scale tool showed that it is valid and reliable tool to be applied to the Brazilian population.

Counselling interventions to enable women to initiate and continue breastfeeding: a systematic review and meta-analysis

Background

Many infants worldwide are not breastfeeding according to WHO recommendations and this impacts on the health of women and children. Increasing breastfeeding is identified as a priority area supported by current policy targets. However, interventions are complex and multi-component and it is unclear which elements of interventions are most effective to increase breastfeeding in which settings. Breastfeeding counselling is often part of complex interventions but evidence is lacking on the specific effect of counselling interventions on breastfeeding practices. The aim of this systematic review is to examine evidence on effectiveness of breastfeeding counselling to inform global guidelines.

Methods

A systematic search was conducted of six electronic databases in January 2018. Randomised controlled trials comparing breastfeeding counselling with no breastfeeding counselling or different formulations of counselling were included if they measured breastfeeding practices between birth and 24 months after birth.

Results

From the 5180 records identified in searches and a further 11 records found by hand searching, 63 studies were included. Of these, 48 were individually-randomised trials and 15 were cluster-randomised trials. A total of 69 relevant comparisons were reported involving 33,073 women. There was a significant effect of counselling interventions on any breastfeeding at 4 to 6 weeks (Relative risk [RR] 0.85, 95% CI 0.77, 0.94) and 6 months (RR 0.92, 95% CI 0.87, 0.94). Greater effects were found on exclusive breastfeeding at 4 to 6 weeks (RR 0.79, 95% CI 0.72, 0.87) and 6 months (RR 0.84, 95% CI 0.78, 0.91). Counselling delivered at least four times postnatally is more effective than counselling delivered antenatally only and/or fewer than four times. Evidence was mostly of low quality due to high or unclear risk of bias of the included trials and high heterogeneity.

Conclusions

Breastfeeding counselling is an effective public health intervention to increase rates of any and exclusive breastfeeding. Breastfeeding counselling should be provided face-to-face, and in addition, may be provided by telephone, both antenatally and postnatally, to all pregnant women and mothers with young children. To inform scale-up globally there is a need to further understand the elements of breastfeeding interventions such as counselling and their effectiveness in different contexts and circumstances.

Study registration

This systematic review was registered in Prospero (CRD42018086494).

Interventions for supporting the initiation and continuation of breastfeeding among women who are overweight or obese

BACKGROUND

Exclusive breastfeeding is recommended for all infants until six months of age due to the many health benefits for both the mother and infant.Evidence suggests that mothers who are overweight (body mass index (BMI) 25.0 to 29.9 kg/m²) or obese (BMI ≥ 30.0 kg/m²) are less likely to initiate breastfeeding and to breastfeed for a shorter duration. Considering the rising prevalence of overweight and obesity globally and the known benefits of breastfeeding particularly in reducing the long-term risks of obesity and diabetes for infants, establishing effective ways to support and promote breastfeeding in women who are overweight or obese is paramount in achieving the goal of healthier communities.

OBJECTIVES

To assess the effectiveness of interventions to support the initiation or continuation of breastfeeding in women who are overweight or obese.

SEARCH METHODS

On 23 January 2019 we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) and reference lists of retrieved trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to support the initiation and continuation of breastfeeding in women who are overweight or obese. Interventions included social support, education, physical support, or any combination of these. Interventions were compared either with each other or against a control group.

DATA COLLECTION AND ANALYSIS

We assessed all potential trials identified from the search strategy. Two review authors extracted data from each included trial and assessed risk of bias. We resolved discrepancies through discussion with the third review author. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We found no trials comparing one type of support versus another. We included seven RCTs (including one cluster-RCT) involving 831 women. The number of women in each trial ranged from 36 to 226. The trials were conducted in high-income countries: USA (5 trials); Denmark (1 trial) and Australia (1 trial), between 2006 and 2015. Three trials only included women who were obese prior to pregnancy and four trials included both women who were overweight and women who were obese. We judged risk of bias in the included trials to be mixed; only one trial was judged to be low risk of bias for random sequence generation, allocation concealment and attrition bias.Physical breastfeeding support (manual or electric breast pump) versus usual care (no breast pump)Very low-certainty evidence from one small trial (39 women) looking at a physical support intervention (manual or electric breast pump) versus usual care (no pump) means it is unclear whether physical support improves exclusive breastfeeding at four to six weeks (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.20 to 1.51) or any breastfeeding at four to six weeks (RR 0.65, 95% CI 0.41 to 1.03). The trial did not report other important outcomes of interest in this review: non-initiation of breastfeeding, exclusive or any breastfeeding at six months postpartum.Multiple methods of breastfeeding support versus usual care Six trials (involving 792 women) used multiple methods of support including education and social support through telephone or face-to-face contact. One of these trials also provided physical support through providing a breast pump and a baby sling and one trial provided a small gift to the women at each trial visit. Support in the trials was provided by a professional (four trials) or a peer (two trials). One trial provided group support, with the other five trials supporting women individually. One trial (174 women) did not report on any of our main outcomes of interest.We are unclear about the effects of the intervention because we identified very low-certainty evidence for all of the important outcomes in this review: rate of non-initiation of breastfeeding (average RR 1.03, 95% CI 0.07 to 16.11; 3 trials, 380 women); exclusive breastfeeding at four to six weeks (average RR 1.21, 95% CI 0.83 to 1.77; 4 trials, 445 women); any breastfeeding at four to six weeks (average RR 1.04, 95% CI 0.57 to 1.89; 2 trials, 103 women); rate of exclusive breastfeeding at six months postpartum (RR 7.23, 95% CI 0.38 to 137.08; 1 trial, 120 women); and any breastfeeding at six months postpartum (average RR 1.42, 95% CI 1.08 to 1.87; 2 trials, 223 women).The included trials under the above comparisons also reported on some of this review's secondary outcomes but very low-certainty evidence means that we are unclear about the effects of the intervention on those outcomes.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the effectiveness of physical interventions, or multiple methods of support (social, educational or physical) for supporting the initiation or continuation of breastfeeding in women who are overweight or obese. We found no RCTs comparing one type of support to another type of support. All of our GRADE assessments resulted in very low-certainty evidence, with downgrading decisions based on limitations in trial design (e.g. risk of attrition bias), imprecision, inconsistency. The available trials were mostly of variable quality with small numbers of participants, confounded by poor adherence within both the intervention and control groups.Well designed, adequately powered research is needed to answer questions about the social, educational, physical support, or any combination of these interventions that could potentially help mothers who are overweight or obese to achieve optimal breastfeeding outcomes. We need trials that examine interventions designed specifically for women who are overweight or obese, delivered by people with training about how to overcome some of the challenges these women face when establishing and maintaining breastfeeding. Particular attention could be given to the assessment of antenatal interventions aimed at improving breastfeeding initiation in women with a raised BMI, and not just focusing on recruiting women who have an intention to breastfeed. Given that the majority of current trials were undertaken in the USA, further trials in a diverse range of countries and settings are required. Future trials need to give consideration to the theoretical basis of the intervention using established frameworks to enable replicability by others and to better determine the components of effective interventions.

Health education strategies targeting maternal and child health: A scoping review of educational methodologies

BACKGROUND

Health education during pregnancy is important to improve maternal and children outcomes. However, the strategies must be specifically designed for each context and demographic characteristics. Our objective was identify health education strategies targeting pregnant women with the intention of improving results of pregnancy at an urban level.

METHODS

We conducted a scoping review of the literature to answer the question: "what health education strategies targeting pregnant women were reported by primary healthcare teams or the community promoting health in pregnancy, childbirth, postpartum and childhood?" Potential eligible studies were selected using PubMed, Web of Science, LILACS and SciELO by 2 reviewers.

RESULTS

From a total of 3105 articles, 23 were deemed eligible. We identified 9 educational methodologies focusing on different outcomes of pregnancy, birth or maternal wellbeing.

CONCLUSIONS

It is important that health education strategies continue after childbirth, independent of the strategy. All the strategies presented in this review are suitable for transfer with a moderate chance of success of implementation or improvement of current education methodologies. Further research is required on health education, including a higher number of patients.

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.

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.

Explaining infant feeding: The role of previous personal and vicarious experience on attitudes, subjective norms, self-efficacy, and breastfeeding outcomes

OBJECTIVES

Breastfeeding confers important health benefits to both infants and their mothers, but rates are low in the United Kingdom and other developed countries despite widespread promotion. This study examined the relationships between personal and vicarious experience of infant feeding, self-efficacy, the theory of planned behaviour variables of attitudes and subjective norm, and the likelihood of breastfeeding at 6-8 weeks post-natally.

DESIGN

A prospective questionnaire study of both first-time mothers (n = 77) and experienced breastfeeders (n = 72) recruited at an antenatal clinic in South East England.

METHODS

Participants completed a questionnaire at 32 weeks pregnant assessing personal and vicarious experience of infant feeding (breastfeeding, formula-feeding, and maternal grandmother's experience of breastfeeding), perceived control, self-efficacy, intentions, attitudes (to breastfeeding and formula-feeding), and subjective norm. Infant feeding behaviour was recorded at 6-8 weeks post-natally. Multiple linear regression modelled the influence of vicarious experience on attitudes, subjective norm, and self-efficacy (but not perceived control) and modelled the influence of attitude, subjective norm, self-efficacy, and past experience on intentions to breastfeed. Logistic regression modelled the likelihood of breastfeeding at 6-8 weeks.

RESULTS

Previous experience (particularly personal experience of breastfeeding) explained a significant amount of variance in attitudes, subjective norm, and self-efficacy. Intentions to breastfeed were predicted by subjective norm and attitude to formula-feeding and, in experienced mothers, self-efficacy. Breastfeeding at 6 weeks was predicted by intentions and vicarious experience of formula-feeding.

CONCLUSION

Vicarious experience, particularly of formula-feeding, has been shown to influence the behaviour of first-time and experienced mothers both directly and indirectly via attitudes and subjective norm. Interventions that reduce exposure to formula-feeding (perhaps by limiting advertising) or cushion mothers from its effects may enable more mothers to meet their breastfeeding goals. Statement of contribution What is already known on this subject? Rates of breastfeeding in the United Kingdom are low and resistant to change. Self-efficacy may be an important and modifiable factor for breastfeeding initiation and maintenance. What does this study add? Self-efficacy may only be a relevant factor among mothers who already have personal experience of breastfeeding. Vicarious experience of formula-feeding has been shown to be related to a lower rate of breastfeeding at 6 weeks.

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.

Interventions for promoting the initiation of breastfeeding

BACKGROUND

Despite the widely documented risks of not breastfeeding, initiation rates remain relatively low in many high-income countries, particularly among women in lower-income groups. In low- and middle-income countries, many women do not follow World Health Organization (WHO) recommendations to initiate breastfeeding within the first hour after birth. This is an update of a Cochrane Review, first published in 2005.

OBJECTIVES

To identify and describe health promotion activities intended to increase the initiation rate of breastfeeding.To evaluate the effectiveness of different types of breastfeeding promotion activities, in terms of changing the number of women who initiate breastfeeding.To evaluate the effectiveness of different types of breastfeeding promotion activities, in terms of changing the number of women who initiate breastfeeding early (within one hour after birth).

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) and scanned reference lists of all articles obtained.

SELECTION CRITERIA

Randomised controlled trials (RCTs), with or without blinding, of any breastfeeding promotion intervention in any population group, except women and infants with a specific health problem.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial reports for inclusion, extracted data and assessed trial quality. Discrepancies were resolved through discussion and a third review author was involved when necessary. We contacted investigators to obtain missing information.

MAIN RESULTS

Twenty-eight trials involving 107,362 women in seven countries are included in this updated review. Five studies involving 3,124 women did not contribute outcome data and we excluded them from the analyses. The methodological quality of the included trials was mixed, with significant numbers of studies at high or unclear risk of bias due to: inadequate allocation concealment (N = 20); lack of blinding of outcome assessment (N = 20); incomplete outcome data (N = 19); selective reporting (N = 22) and bias from other potential sources (N = 17). Healthcare professional-led breastfeeding education and support versus standard care The studies pooled here compare professional health workers delivering breastfeeding education and support during the prenatal and postpartum periods with standard care. Interventions included promotion campaigns and counselling, and all took place in a formal setting. There was evidence from five trials involving 564 women for improved rates ofbreastfeeding initiation among women who received healthcare professional-led breastfeeding education and support (average risk ratio (RR) 1.43, 95% confidence interval (CI) 1.07 to 1.92; Tau² = 0.07, I² = 62%, low-quality evidence) compared to those women who received standard care. We downgraded evidence due to design limitations and heterogeneity. The outcome of early initiation of breastfeeding was not reported in the studies under this comparison. Non-healthcare professional-led breastfeeding education and support versus standard care There was evidence from eight trials of 5712 women for improved rates of breastfeeding initiation among women who received interventions from non-healthcare professional counsellors and support groups (average RR 1.22, 95% CI 1.06 to 1.40; Tau² = 0.02, I² = 86%, low-quality evidence) compared to women who received standard care. In three trials of 76,373 women, there was no clear difference between groups in terms of the number of women practicing early initiation of breastfeeding (average RR 1.70, 95% CI 0.98 to 2.95; Tau² = 0.18, I² = 78%, very low-quality evidence). We downgraded the evidence for a combination of design limitations, heterogeneity and imprecision (wide confidence intervals crossing the line of no effect). Other comparisonsOther comparisons in this review also looked at the rates of initiation of breastfeeding and there were no clear differences between groups for the following comparisons of combined healthcare professional-led education with peer support or community educator versus standard care (2 studies, 1371 women) or attention control (1 study, 237 women), breastfeeding education using multimedia (a self-help manual or a video) versus routine care (2 studies, 497 women); early mother-infant contact versus standard care (2 studies, 309 women); and community-based breastfeeding groups versus no breastfeeding groups (1 study, 18,603 women). None of these comparisons reported data on early initiation of breastfeeding.

AUTHORS' CONCLUSIONS

This review found low-quality evidence that healthcare professional-led breastfeeding education and non-healthcare professional-led counselling and peer support interventions can result in some improvements in the number of women beginning to breastfeed. The majority of the trials were conducted in the USA, among women on low incomes and who varied in ethnicity and feeding intention, thus limiting the generalisability of these results to other settings.Future studies would ideally be conducted in a range of low- and high-income settings, with data on breastfeeding rates over various timeframes, and explore the effectiveness of interventions that are initiated prior to conception or during pregnancy. These might include well-described interventions, including health education, early and continuing mother-infant contact, and initiatives to help mothers overcome societal barriers to breastfeeding, all with clearly defined outcome measures.

Normalising breastfeeding within a formula feeding culture: An Irish qualitative study

BACKGROUND

Breastfeeding rates in Ireland are among the lowest in Europe. Breastfeeding groups can provide support, information, and friendship for women. However, there is little research exploring community breastfeeding groups led by Public Health Nurses providing universal maternal and child care to all postnatal mothers in the community in Ireland.

AIM

The aim of this study was to explore breastfeeding women's experiences of a Public Health Nurse led support group.

METHODS

A qualitative descriptive design to explore women's experiences of a community breastfeeding support group was conducted. Data were collected using one to one interviews with breastfeeding women (n=7) in a primary healthcare setting. Transcripts were analysed using Burnard's thematic content analysis.

RESULTS

The overall theme identified was 'normalising breastfeeding' which emerged from the subthemes 'socialising and sharing', 'information and support seeking', 'building confidence', 'overcoming embarrassment', 'negative perceptions of others', and 'promoting breastfeeding to others'.

DISCUSSION

Women who attended the PHN led breastfeeding support group found it to be a cocoon of 'normality', whereas breastfeeding was considered almost something to be ashamed of in other circumstances. Many women attributed their success with breastfeeding to the support group.

CONCLUSION

Facilitating a sense of normalcy for breastfeeding women at individual, community and societal levels was essential in promoting breastfeeding. The community support group was influential in normalising breastfeeding for a sample of women, by minimising the potential for embarrassment, promoting social interaction and sharing, building confidence and knowledge. This buffered the effects of negative attitudes of others and personal feelings of shame.

BReastfeeding Attitude and Volume Optimization (BRAVO) trial: study protocol for a randomized controlled trial

BACKGROUND

A growing body of evidence shows the short-term benefits of breastfeeding, which include protection against infections, allergies, and lung diseases. However, evidence on the long-term benefits of breastfeeding is scarce and often conflicting. The BReastfeeding Attitude and Volume Optimization (BRAVO) trial is designed to study the effect of breastfeeding on early signs of later chronic diseases, particularly cardiovascular, respiratory, and metabolic risks later in life. In addition, the effectiveness of breastfeeding empowerment in promoting breastfeeding will also be evaluated.

METHODS/DESIGN

This study is an ongoing randomized trial in Jakarta, Indonesia, that began in July 2012. Pregnant women are being screened for their breastfeeding plan in the third trimester, and those with low intention to breastfeed are randomly allocated to either receiving an add-on breastfeeding-optimization program or usual care. Primary outcomes include breastfeeding rate, lung function, and blood pressure during the first year of life and vascular/cardiac characteristics, which will be measured at the age of 4 to 5 years. Child growth and infection/illness episodes are measured, whereas cognitive testing is planned for the children at 5 years of age.

DISCUSSION

To date, 784 women (80 %) have been randomized of the 1,000 planned, with satisfactory completeness of the 1-year follow up (90.1 %). Included mothers are of lower socioeconomic status and more often have blue-collar jobs, similar to what was observed in the pilot study.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01566812 . Registered on 27 March 2012.

Is baby-friendly breastfeeding support in maternity hospitals associated with breastfeeding satisfaction among Japanese mothers?

While the World Health Organization's Baby-Friendly Hospital Initiative has increased breastfeeding duration and exclusivity, a survey found that only 8.5 % of maternity hospitals in 31 developed countries could be designated baby-friendly. Baby-friendly breastfeeding support is sometimes criticized as mother unfriendly. This study examined whether baby-friendly breastfeeding support was associated with breastfeeding satisfaction, duration, and exclusivity among Japanese mothers. In this cross-sectional study, 601 breastfeeding Japanese mothers completed questionnaires at their infants' 4-month health checkups at two wards in Yokohama, Japan; 363 were included in the analysis. Baby-friendly breastfeeding support was measured based on the WHO's "Ten Steps to Successful Breastfeeding." We measured satisfaction using two subscales of the Japanese version of the Maternal Breastfeeding Evaluation Scale. The association of baby-friendly support with maternal satisfaction was assessed using multiple linear regression, while the prevalence ratios (PRs) for breastfeeding were estimated using Poisson regression. Mothers were stratified by prepartum exclusive breastfeeding intention (yes, n = 256; no, n = 107). Mothers who experienced early skin-to-skin contact with their infants were more likely to report breastfeeding satisfaction than those who did not. Among mothers without exclusive breastfeeding intention, those who were encouraged to feed on demand were more likely to be breastfeeding without formula at 1 month (PR 2.66 [95 % CI 1.32, 5.36]) and to perceive breastfeeding as beneficial for their baby (regression coefficient = 3.14 [95 % CI 0.11, 6.17]) than those who were not so encouraged. Breastfeeding satisfaction was a useful measure of breastfeeding outcome. Early skin-to-skin contact and encouragement to feed on demand in the hospital facilitate breastfeeding satisfaction.

Supporting breastfeeding In Local Communities (SILC) in Victoria, Australia: a cluster randomised controlled trial

OBJECTIVES

Breastfeeding has significant health benefits for mothers and infants. Despite recommendations from the WHO, by 6 months of age 40% of Australian infants are receiving no breast milk. Increased early postpartum breastfeeding support may improve breastfeeding maintenance. 2 community-based interventions to increase breastfeeding duration in local government areas (LGAs) in Victoria, Australia, were implemented and evaluated.

DESIGN

3-arm cluster randomised trial.

SETTING

LGAs in Victoria, Australia.

PARTICIPANTS

LGAs across Victoria with breastfeeding initiation rates below the state average and > 450 births/year were eligible for inclusion. The LGA was the unit of randomisation, and maternal and child health centres in the LGAs comprised the clusters.

INTERVENTIONS

Early home-based breastfeeding support by a maternal and child health nurse (home visit, HV) with or without access to a community-based breastfeeding drop-in centre (HV+drop-in).

MAIN OUTCOME MEASURES

The proportion of infants receiving 'any' breast milk at 3, 4 and 6 months (women's self-report).

FINDINGS

4 LGAs were randomised to the comparison arm and provided usual care (n=41 clusters; n=2414 women); 3 to HV (n=32 clusters; n=2281 women); and 3 to HV+drop-in (n=26 clusters; 2344 women). There was no difference in breastfeeding at 4 months in either HV (adjusted OR 1.04; 95% CI 0.84 to 1.29) or HV+drop-in (adjusted OR 0.92; 95% CI 0.78 to 1.08) compared with the comparison arm, no difference at 3 or 6 months, nor in any LGA in breastfeeding before and after the intervention. Some issues were experienced with intervention protocol fidelity.

CONCLUSIONS

Early home-based and community-based support proved difficult to implement. Interventions to increase breastfeeding in complex community settings require sufficient time and partnership building for successful implementation. We cannot conclude that additional community-based support is ineffective in improving breastfeeding maintenance given the level of adherence to the planned protocol.

TRIAL REGISTRATION NUMBER

ACTRN12611000898954; Results.

Association between breastfeeding support and breastfeeding rates in the UK: a comparison of late preterm and term infants

OBJECTIVE

To explore the association between breastfeeding support and breastfeeding among late preterm (gestation 34-36 weeks) and term (gestation ≥37 weeks) infants.

METHODS

Secondary analysis of the UK 2010 Infant Feeding Survey. Logistic regression was used to determine the association of breastfeeding support with breastfeeding at 10 days and 6 weeks in late preterm and term infants.

RESULTS

The study included 14,525 term and 579 late preterm infants. A total of 11,729 infants initiated breastfeeding (11,292 (81.1%) term, 437 (79.4%) late preterm infants, p=0.425). Of these, 9230 (84.3%) term and 365 (85.6%) late preterm infants were breastfeeding at 10 days (p=0.586); of these 7547 (82.0%) term and 281 (75.4%) late preterm infants were still breastfeeding at 6 weeks (p=0.012). Mothers who reported receiving contact details for breastfeeding support groups had a higher likelihood of breastfeeding late preterm (adjusted ORs, aOR 3.14, 95% CI 1.40 to 7.04) and term infants (aOR 2.24, 95% CI 1.86 to 2.68) at 10 days and term infants at 6 weeks (aOR 1.83, 95% CI 1.51 to 2.22). Those who reported that they did not receive enough help with breastfeeding in hospital had a lower likelihood of breastfeeding late preterm at 10 days and term infants at 10 days and 6 weeks, compared to those who reported having enough help.

CONCLUSIONS

Receiving sufficient help with breastfeeding in hospital and the contact details for breastfeeding support groups is associated with breastfeeding term infants up to 6 weeks and late preterm infants at 10 days.

UK women's experiences of breastfeeding and additional breastfeeding support: a qualitative study of Baby Café services

BACKGROUND

Whilst 81 % of UK women initiate breastfeeding, there is a steep decline in breastfeeding rates during the early postnatal period, with just 55 % of women breastfeeding at six weeks. 80 % of these women stopped breastfeeding sooner than they intended, with women citing feeding difficulties and lack of adequate support. As part of efforts to increase breastfeeding continuation rates, many public and voluntary organisations offer additional breastfeeding support services, which provide practical support in the early postnatal period and beyond. This paper focuses on the qualitative experiences of UK users of Baby Café services to examine their experiences of breastfeeding and breastfeeding support.

METHODS

The study was based upon in-depth interviews and focus groups with users of eight Baby Café breastfeeding support groups across the UK. Thirty-six interviews and five focus groups were conducted with a total of fifty-one mothers using the service. Interviews and group discussions were analysed using N Vivo software to draw out key themes and discussions.

RESULTS

Whilst each mother's infant feeding journey is unique, reflecting her own personal circumstances and experiences, several themes emerged strongly from the data. Many women felt that they had been given unrealistic expectations of breastfeeding by professionals keen to promote the benefits. This left them feeling unprepared when they encountered pain, problems and relentlessness of early infant feeding, leading to feelings of guilt and inadequacy over their feeding decisions. Mothers valued the combination of expert professional and peer support provided by Baby Café services and emphasised the importance of social support from other mothers in enabling them to continue feeding for as long as they wished.

CONCLUSIONS

The research emphasises the need for realistic rather than idealistic antenatal preparation and the importance of timely and parent-centred breastfeeding support, particularly in the immediate postnatal weeks. The findings suggest that effective social support, combined with reassurance and guidance from skilled practitioners, can help women to overcome difficulties and find confidence in their own abilities to achieve their feeding goals. However, further work is needed to make sure such services are readily accessible to women from all sectors of the community.

Goals, dilemmas and assumptions in infant feeding education and support. Applying theory of constraints thinking tools to develop new priorities for action

Three important infant feeding support problems are addressed: (1) mothers who use formula milk can feel undersupported and judged; (2) mothers can feel underprepared for problems with breastfeeding; and (3) many mothers who might benefit from breastfeeding support do not access help. Theory of constraints (TOC) is used to examine these problems in relation to ante-natal education and post-natal support. TOC suggests that long-standing unresolved problems or 'undesirable effects' in any system (in this case a system to provide education and support) are caused by conflicts, or dilemmas, within the system, which might not be explicitly acknowledged. Potential solutions are missed by failure to question assumptions which, when interrogated, often turn out to be invalid. Three core dilemmas relating to the three problems are identified, articulated and explored using TOC methodology. These are whether to: (1) promote feeding choice or to promote breastfeeding; (2) present breastfeeding positively, as straightforward and rewarding, or focus on preparing mothers for problems; and (3) offer support proactively or ensure that mothers themselves initiate requests for support. Assumptions are identified and interrogated, leading to clarified priorities for action relating to each problem. These are (1) shift the focus from initial decision-making towards support for mothers throughout their feeding journeys, enabling and protecting decisions to breastfeed as one aspect of ongoing support; (2) to promote the concept of an early-weeks investment and adjustment period during which breastfeeding is established; and (3) to develop more proactive mother-centred models of support for all forms of infant feeding.

The Effectiveness of Multilevel Promotion of Exclusive Breastfeeding in Rural Indonesia

Purpose.

To examine the effectiveness of multilevel promotion on exclusive breastfeeding (EBF) duration and prevalence.

Design.

A pretest-posttest control group design, quasi-experiment.

Setting.

Two public health centers in the Demak District, Central Java, Indonesia.

Subjects.

A total of 163 families were enrolled, including pregnant mothers, fathers, and grandmothers.

Intervention.

The multilevel promotion of EBF was conducted at the subdistrict, village, family, and individual levels. This was a complex intervention that modified breastfeeding determinants, integrated multidisciplinary partnerships, and involved community leaders (i.e., voluntary health workers, traditional birth attendants, Muslim scholars, and heads of villages). The strategies applied were advocacy, training, media, and home visit counseling.

Measures.

EBF duration and prevalence.

Analysis.

Survival analyses, Cox proportional-hazard model.

Results.

The duration of EBF increased after the multilevel promotion. The median postintervention duration in the intervention group was 18 weeks compared with .1 week in the control group (p < .001). The prevalence of EBF at 1, 8, 16, and 24 weeks for the intervention versus control groups was 75.3% vs. 28.0%, 64.2% vs. 14.6%, 50.6% vs. 8.5%, and 37.0% vs. 3.7%, respectively (p < .001). Mothers in the control group were three times more likely to stop exclusive breastfeeding per unit of time than were mothers in the intervention group (adjusted hazard ratio 3.01; 95% confidence interval: 1.96, 4.63).

Conclusion.

Multilevel promotion can prolong the duration and increase the prevalence of EBF.

Development and psychometric testing of the Japanese version of the maternal breastfeeding evaluation scale

BACKGROUND

Exclusive breastfeeding for 6 months after delivery is globally recommended as optimal infant feeding. However, if mothers evaluate their own breastfeeding by this standard, many might be disappointed because they fail to meet it. In contrast, the Maternal Breastfeeding Evaluation Scale (MBFES) measures mothers' satisfaction with breastfeeding regardless of the duration or exclusivity of breastfeeding. The MBFES has been used in Western countries, but not in Japan.

OBJECTIVES

This study aimed to develop a Japanese version of the MBFES (the JMBFES) and to conduct psychometric testing among Japanese-speaking mothers in Japan.

METHODS

The JMBFES was developed using forward translation, blind back-translation, panel discussion, and pilot testing. Breastfeeding Japanese mothers (n = 414) completed the JMBFES when their infants were 4 months old. For validation testing we used principal components analysis (promax rotation). We deleted items as necessary to improve reliability. We also used multiple linear regression to examine associations of JMBFES scores with breastfeeding intention and with breastfeeding outcomes.

RESULTS

The analysis revealed subscales that were generally similar to the original 30-item MBFES. Reliability was satisfactory (Cronbach's alpha ≥ .77). Scores on the JMBFES and on most of its subscales were positively associated with both breastfeeding intention and breastfeeding outcomes. The subscale measuring potentially negative experiences was not statistically significantly associated with breastfeeding at 1 month, after adjustment for likely confounders.

CONCLUSION

The results of reliability testing (Cronbach's alpha) and of validation testing indicate that the JMBFES can be used in Japan to explore mothers' satisfaction with breastfeeding.

What can qualitative research do for randomised controlled trials? A systematic mapping review

OBJECTIVE

To develop an empirically based framework of the aspects of randomised controlled trials addressed by qualitative research.

DESIGN

Systematic mapping review of qualitative research undertaken with randomised controlled trials and published in peer-reviewed journals.

DATA SOURCES

MEDLINE, PreMEDLINE, EMBASE, the Cochrane Library, Health Technology Assessment, PsycINFO, CINAHL, British Nursing Index, Social Sciences Citation Index and ASSIA.

ELIGIBILITY CRITERIA

Articles reporting qualitative research undertaken with trials published between 2008 and September 2010; health research, reported in English.

RESULTS

296 articles met the inclusion criteria. Articles focused on 22 aspects of the trial within five broad categories. Some articles focused on more than one aspect of the trial, totalling 356 examples. The qualitative research focused on the intervention being trialled (71%, 254/356); the design, process and conduct of the trial (15%, 54/356); the outcomes of the trial (1%, 5/356); the measures used in the trial (3%, 10/356); and the target condition for the trial (9%, 33/356). A minority of the qualitative research was undertaken at the pretrial stage (28%, 82/296). The value of the qualitative research to the trial itself was not always made explicit within the articles. The potential value included optimising the intervention and trial conduct, facilitating interpretation of the trial findings, helping trialists to be sensitive to the human beings involved in trials, and saving money by steering researchers towards interventions more likely to be effective in future trials.

CONCLUSIONS

A large amount of qualitative research undertaken with specific trials has been published, addressing a wide range of aspects of trials, with the potential to improve the endeavour of generating evidence of effectiveness of health interventions. Researchers can increase the impact of this work on trials by undertaking more of it at the pretrial stage and being explicit within their articles about the learning for trials and evidence-based practice.

Antenatal education and breastfeeding in a cohort of primiparas

AIMS

To assess the association between attendance at antenatal education sessions and breastfeeding during the first year of life.

BACKGROUND

Although there is evidence that antenatal education encourages breastfeeding, the size and duration of its effect remain unclear.

DESIGN

A prospective cohort study.

METHODS

The study was conducted in Bizkaia (North of Spain) between May 2005-June 2007 with a consecutive sample of 614 primiparas. Women were classified into three groups according to whether they had received antenatal education and, if so, how many classes (0, 1-4, or 5 or more). Telephone interviews at 1·5, 3, 6 and 12 months were used to estimate the risk of cessation of any breastfeeding and to compare the groups with Cox proportional hazards regression models adjusted for potential confounders.

FINDINGS

Initially, 90% of women breastfed their infants, with no differences between the groups. During the first month, the risk of cessation of any breastfeeding was three times as high among non-attendees and twice as high among women who attended 1-4 classes compared with those who attended 5 or more classes. The risk was, however, similar in the three groups from the end of first month onwards.

CONCLUSION

The results suggest that though antenatal education may be associated with higher rates of breastfeeding in our setting this is only the case for the first month after the birth. Further research is necessary to optimize this beneficial effect to achieve long-term continuation of 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 infants be exclusively breastfed until six months of age, with breastfeeding continuing as an important part of the infant's diet till at least two years of age. However, breastfeeding rates in many countries currently do not reflect this recommendation.

OBJECTIVES

To assess the effectiveness of support for breastfeeding mothers.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (3 October 2011).

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 trial quality and extracted data.

MAIN RESULTS

Of the 67 studies that we assessed as eligible for inclusion, 52 contributed outcome data to the review (56,451 mother-infant pairs) from 21 countries. All forms of extra support analysed together showed an increase in duration of 'any breastfeeding' (includes partial and exclusive breastfeeding) (risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.88 to 0.96). All forms of extra support together also had a positive effect on duration of exclusive breastfeeding (RR at six months 0.86, 95% CI 0.82 to 0.91; RR at four to six weeks 0.74, 95% CI 0.61 to 0.89). Extra support by both lay and professionals had a positive impact on breastfeeding outcomes. Maternal satisfaction was poorly reported.

AUTHORS' CONCLUSIONS

All women should be offered support to breastfeed their babies to increase the duration and exclusivity of breastfeeding. Support is likely to be more effective in settings with high initiation rates, so efforts to increase the uptake of breastfeeding should be in place. 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. Support that is only offered reactively, in which women are expected to initiate the contact, is unlikely to be effective; women should be offered ongoing visits on a scheduled basis so they can predict that support will be available. Support should be tailored to the needs of the setting and the population group.

Prevalence and predictors of exclusive breastfeeding among women in Kigoma region, Western Tanzania: a community based cross-sectional study

Background

Exclusive breastfeeding (EBF) for the first six months of infants' lives is a cost effective intervention in saving children's lives and can avert 13 - 15% of the 9 million deaths of children under 5 years old in resource poor settings. However, EBF rates have been shown to be low in resource poor settings, ranging between 20 and 40%. In Tanzania, the prevalence of EBF among infants under 6 months is 41%, with limited information on predictors of EBF. The aim of the study was to determine prevalence of EBF and its predictors in Kigoma Municipality, Western Tanzania.

Methods

A cross-sectional study was conducted in March to May 2010 among 402 consenting women, with infants aged 6 to 12 months, from randomly selected households. A questionnaire was used to collect information on demographic characteristics, knowledge of EBF, infant feeding practices, and on HIV status.

Results

The prevalence of EBF among women in Kigoma Municipality was 58%. Knowledge of EBF was relatively higher (86%) compared to the practice. In the multivariable analysis, women with adequate knowledge of EBF (AOR 5.4), women who delivered at health facilities (AOR 3.0) and women who had no problems related to breasts, like engorgement/cracked nipples (AOR 6.6) were more likely to exclusively breastfeed compared to others.

Conclusions

Prevalence of EBF in Kigoma municipality was slightly higher than the national figure of 41%, however it was way below the EBF prevalence of 90% recommended by the WHO. Strategies that target improving knowledge and skills for lactation management among women, as well as strategies to improve health facility delivery, may help to improve EBF in this setting.

Group interventions to improve health outcomes: a framework for their design and delivery

BACKGROUND

Delivering an intervention to a group of patients to improve health outcomes is increasingly popular in public health and primary care, yet "group" is an umbrella term which encompasses a complex range of aims, theories, implementation processes and evaluation methods. We propose a framework for the design and process evaluation of health improvement interventions occurring in a group setting, which will assist practitioners, researchers and policy makers.

METHODS

We reviewed the wider literature on health improvement interventions delivered to patient groups and identified a gap in the literature for designing, evaluating and reporting these interventions. We drew on our experiences conducting systematic reviews, intervention, mixed method and ethnographic studies of groups for breastfeeding and weight management. A framework for health improvement group design and delivery evolved through an iterative process of primary research, reference to the literature and research team discussion.

RESULTS

Although there is an extensive literature on group processes in education, work, politics and psychological therapies, far less is known about groups where the aim is health improvement. Theories of behaviour change which are validated for individual use are often assumed to be generalisable to group settings, without being rigorously tested. Health improvement or behaviour change interventions delivered in a group setting are complex adaptive social processes with interactions between the group leader, participants, and the wider community and environment. Ecological models of health improvement, which embrace the complex relationship between behaviour, systems and the environment may be more relevant than an individual approach to behaviour change.

CONCLUSION

The evidence for effectiveness and cost-effectiveness of group compared with one-to-one interventions for many areas of health improvement in public health and primary care is weak or unknown. Our proposed framework is the first step towards advocating a more systematic approach to designing, evaluating and reporting interventions in group settings, which is necessary to improve this currently weak evidence base. This framework will enable policy makers and practitioners to be better informed about what works, how it works and in which contexts when aiming to improve health in a group setting.

How usual is usual care in pragmatic intervention studies in primary care? An overview of recent trials

BACKGROUND

Because pragmatic trials are performed to determine if an intervention can improve current practice, they often have a control group receiving 'usual care'. The behaviour of caregivers and patients in this control group should be influenced by the actions of researchers as little as possible. Guidelines for describing the composition and management of a usual care control group are lacking.

AIM

To explore the variety of approaches to the usual care concept in pragmatic trials, and evaluate the influence of the study design on the behaviour of caregivers and patients in a usual care control group.

DESIGN OF STUDY

Review of 73 pragmatic trials in primary care with a usual care control group published between January 2005 and December 2009 in the British Medical Journal, the British Journal of General Practice, and Family Practice. Outcome measures were: description of the factors influencing caregiver and patients in a usual care control group related to an individual randomised design versus cluster randomisation.

RESULTS

In total, 38 individually randomised trials and 35 cluster randomised trials were included. In most trials, caregivers had the freedom to treat control patients according to their own insight; in two studies, treatment options were restricted. Although possible influences on the behaviour of control caregivers and control patients were more often identified in individually randomised trials, these influences were also present in cluster randomised trials. The description of instructions and information provided to the control group was often insufficient, which made evaluation of the trials difficult.

CONCLUSION

Researchers in primary care medicine should carefully consider the design of a usual care control group, especially with regard to minimising the risk of study-induced behavioural change. It is recommended that an adequate description of the information is provided to control caregivers and control patients. A proposal is made for an extension to the CONSORT statement that requires authors to specify details of the usual care control group.

Supervision of community peer counsellors for infant feeding in South Africa: an exploratory qualitative study

BACKGROUND

Recent years have seen a re-emergence of community health worker (CHW) interventions, especially in relation to HIV care, and in increasing coverage of child health interventions. Such programmes can be particularly appealing in the face of human resource shortages and fragmented health systems. However, do we know enough about how these interventions function in order to support the investment? While research based on strong quantitative study designs such as randomised controlled trials increasingly document their impact, there has been less empirical analysis of the internal mechanisms through which CHW interventions succeed or fail. Qualitative process evaluations can help fill this gap.

METHODS

This qualitative paper reports on the experience of three CHW supervisors who were responsible for supporting infant feeding peer counsellors. The intervention took place in three diverse settings in South Africa. Each setting employed one CHW supervisor, each of whom was individually interviewed for this study. The study forms part of the process evaluation of a large-scale randomized controlled trial of infant feeding peer counselling support.

RESULTS

Our findings highlight the complexities of supervising and supporting CHWs. In order to facilitate effective infant feeding peer counselling, supervisors in this study had to move beyond mere technical management of the intervention to broader people management. While their capacity to achieve this was based on their own prior experience, it was enhanced through being supported themselves. In turn, resource limitations and concerns over safety and being in a rural setting were raised as some of the challenges to supervision. Adding to the complexity was the issue of HIV. Supervisors not only had to support CHWs in their attempts to offer peer counselling to mothers who were potentially HIV positive, but they also had to deal with supporting HIV-positive peer counsellors.

CONCLUSIONS

This study highlights the need to pay attention to the experiences of supervisors so as to better understand the components of supervision in the field. Such understanding can enhance future policy making, planning and implementation of peer community health worker programmes.

Support for breastfeeding mothers

BACKGROUND

There is extensive evidence of the benefits of breastfeeding for infants and mothers. In 2003, the World Health Organization (WHO) recommended infants be fed exclusively on breast milk until six months of age. However, breastfeeding rates in many developed countries continue to be resistant to change.

OBJECTIVES

To assess the effectiveness of support for breastfeeding mothers.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2006), MEDLINE (1966 to November 2005), EMBASE (1974 to November 2005) and MIDIRS (1991 to September 2005).

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

We have included 34 trials (29,385 mother-infant pairs) from 14 countries. All forms of extra support analysed together showed an increase in duration of 'any breastfeeding' (includes partial and exclusive breastfeeding) (relative risk (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.86 to 0.96). All forms of extra support together had a larger effect on duration of exclusive breastfeeding than on any breastfeeding (RR 0.81, 95% CI 0.74 to 0.89). Lay and professional support together extended duration of any breastfeeding significantly (RR before 4-6 weeks 0.65, 95% 0.51 to 0.82; RR before 2 months 0.74, 95% CI 0.66 to 0.83). Exclusive breastfeeding was significantly prolonged with use of WHO/UNICEF training (RR 0.69, 95% CI 0.52 to 0.91). Maternal satisfaction was poorly reported.

AUTHORS' CONCLUSIONS

Additional professional support was effective in prolonging any breastfeeding, but its effects on exclusive breastfeeding were less clear. WHO/UNICEF training courses appeared to be effective for professional training. Additional lay support was effective in prolonging exclusive breastfeeding, while its effects on duration of any breastfeeding were uncertain. Effective support offered by professionals and lay people together was specific to breastfeeding and was offered to women who had decided to breastfeed. Further trials are required to assess the effectiveness (including cost-effectiveness) of both lay and professional support in different settings, particularly those with low rates of breastfeeding initiation, and for women who wish to breastfeed for longer than three months. Trials should consider timing and delivery of support interventions and relative effectiveness of intervention components, and should report women's views. Research into appropriate training for supporters (whether lay or professional) of breastfeeding mothers is also needed.