The impact of a new universal postpartum program on breastfeeding outcomes

Prevalence and predictors of exclusive breastfeeding among immigrant and Canadian-born Chinese women

Breastfeeding is the optimal method for infant feeding, yet migrant women may be at risk for suboptimal exclusivity rates. In a cohort of immigrant and Canadian-born Chinese women, our objectives were to (a) describe patterns and prevalence of exclusive breastfeeding at 1, 3, and 6 months postpartum; (b) identify risk and protective factors associated with exclusivity; and (c) examine potentially differential importance of these factors across this 6-month period. This was a prospective study of 565 immigrants and Canadian-born Chinese women (Toronto, Canada). Exclusive breastfeeding was measured at 1, 3, and 6 months postpartum. Predictors comprised fixed (demographics, history of depression, immigrant status, prenatal breastfeeding classes, in-hospital formula supplementation, baseline social support, and baseline acculturative stress) and time-dependent (depression, anxiety, fatigue, and breastfeeding problems) variables. Descriptive statistics, logistic regression, and generalized linear mixed models, respectively, were undertaken to address the objectives. Patterns of breastfeeding practices included exclusive breastfeeding in all time points (26.8%) or none (32.9%) and moving from exclusive to nonexclusive (20.3%) or nonexclusive to exclusive breastfeeding (15.2%). Women less likely to breastfeed exclusively at 1, 3, or 6 months were those whose infants received in-hospital formula supplementation. Exclusivity attrition was higher between 3 and 6 months than 1-3 months. Immigrant status and in-hospital formula supplementation had a significant impact on exclusivity earlier in the postpartum period while breastfeeding problems were associated with decreased exclusivity across time. Proactive preventive efforts are need to maintain breastfeeding exclusivity especially between 3 and 6 months if women are to meet international breastfeeding recommendations.

A systematic approach towards the development of quality indicators for postnatal care after discharge in Flanders, Belgium

OBJECTIVE

to develop a set of quality indicators for postnatal care after discharge from the hospital, using a systematic approach.

DESIGN

key elements of qualitative postnatal care were defined by performing a systematic review and the literature was searched for potential indicators (step 1). The potential indicators were evaluated by five criteria (validity, reliability, sensitivity, feasibility and acceptability) and by making use of the 'Appraisal of Guidelines for Research and Evaluation', the AIRE-instrument (step 2). In a modified Delphi-survey, the quality indicators were presented to a panel of experts in the field of postnatal care using an online tool (step 3). The final results led to a Flemish model of postnatal care (step 4).

SETTING

Flanders, Belgium PARTICIPANTS: health care professionals, representatives of health care organisations and policy makers with expertise in the field of postnatal care.

FINDINGS

after analysis 57 research articles, 10 reviews, one book and eight other documents resulted in 150 potential quality indicators in seven critical care domains. Quality assessment of the indicators resulted in 58 concept quality indicators which were presented to an expert-panel of health care professionals. After two Delphi-rounds, 30 quality indicators (six structure, 17 process, and seven outcome indicators) were found appropriate to monitor and improve the quality of postnatal care after discharge from the hospital. KEY CONCLUSIONS AND IMPLICATIONS FOR CLINICAL PRACTICE: the quality indicators resulted in a Flemish model of qualitative postnatal care that was implemented by health authorities as a minimum standard in the context of shortened length of stay. Postnatal care should be adjusted to a flexible length of stay and start in pregnancy with an individualised care plan that follows mother and new-born throughout pregnancy, childbirth and postnatal period. Criteria for discharge and local protocols about the organisation and content of care are essential to facilitate continuity of care.

Infant Formula Feeding at Birth Is Common and Inversely Associated with Subsequent Breastfeeding Behavior in Vietnam

BACKGROUND

The association between infant formula feeding at birth and subsequent feeding patterns in a low- or middle-income context is not clear.

OBJECTIVE

We examined the association of infant formula feeding during the first 3 d after birth with subsequent infant formula feeding and early breastfeeding cessation in Vietnam.

METHODS

In a cross-sectional survey, we interviewed 10,681 mothers with children aged 0-23 mo (mean age: 8.2 mo; 52% boys) about their feeding practices during the first 3 d after birth and on the previous day. We used stratified analysis, multiple logistic regression, propensity score-matching analysis, and structural equation modeling to minimize the limitation of the cross-sectional design and to ensure the consistency of the findings.

RESULTS

Infant formula feeding during the first 3 d after birth (50%) was associated with a higher prevalence of subsequent infant formula feeding [stratified analysis: 7-28% higher (nonoverlapping 95% CIs for most comparisons); propensity score-matching analysis: 13% higher (P < 0.001); multiple logistic regression: OR: 1.47 (95% CI: 1.30, 1.67)]. This practice was also associated with a higher prevalence of early breastfeeding cessation (e.g., <24 mo) [propensity score-matching analysis: 2% (P = 0.08); OR: 1.33 (95% CI: 1.12, 1.59)]. Structural equation modeling showed that infant formula feeding during the first 3 d after birth was associated with a higher prevalence of subsequent infant formula feeding (β: 0.244; P < 0.001), which in turn was linked to early breastfeeding cessation (β: 0.285; P < 0.001).

CONCLUSIONS

Infant formula feeding during the first 3 d after birth was associated with increased subsequent infant formula feeding and the early cessation of breastfeeding, which underscores the need to make early, exclusive breastfeeding normative and to create environments that support it.

[Factors influencing the prevalence and duration of breastfeeding in Germany: results of the KiGGS study: first follow up (KiGGS Wave 1)]

Breastfeeding is the natural way of feeding infants in the first months of their lives and has been proven to have health benefits for both infants and mothers. Breastfeeding initiation and duration are affected by social, demographic and health factors. The aim of this study was to describe the current rates of breastfeeding initiation and duration in Germany, and to identify potential factors that underline these rates. Additionally, results are compared with the KiGGS basic (2003-2006; birth cohorts 1996-2002) study in order to reveal the development in the trends of breastfeeding initiation and duration in Germany. The KiGGS wave 1 (2009-2012) includes data on the breastfeeding behavior of mothers of 4410 children aged between 0 and 6 years (birth cohorts 2002-2012). Altogether, 82% (95% confidence interval 79.8-84.2 %) of children were ever breastfed, and the average breastfeeding duration was 7.5 months (7.2-7.8). There was a slight increase in the breastfeeding initiation in Germany over the last several years. Breastfeeding initiation among children aged 0-6 years increased by 4% points compared to 0- to 6-year-olds (birth cohorts 1996-2002) from the KiGGS basic study. The breastfeeding duration stayed unchanged. The breastfeeding behavior was mainly related to the age of the mother at birth, the mother's education level, smoking during pregnancy, and multiple or premature birth. Despite the overall increasing trend in breastfeeding initiation, there is still a growing need for breastfeeding promotion and support for young and less educated mothers, mothers who smoke during pregnancy, and also for mothers with premature babies or multiple births.

A prospective study of the introduction of complementary foods in contemporary Australian infants: What, when and why?

AIM

To accurately establish the extent to which breastfeeding exclusivity and duration and the introduction of foods other than breast milk are congruous with Australian infant feeding guidelines among a cohort of primiparous women and their infants in Australia.

METHOD

The Feeding Queensland Babies Study is primarily a questionnaire-based prospective birth cohort study of infant feeding attitudes and behaviours but also collected significant data on feeding patterns in infancy. These data were extracted from the demographic questionnaire and from questionnaires administered at 4 and 6 months of infant age. Participants were healthy primiparous Australian women aged between 18 and 40 years, recruited by convenience sampling in Queensland, Australia. Data were collected by self-administered questionnaire both online and on paper between October 2010 and September 2011.

RESULTS

Breastfeeding initiation in this cohort is high; however, by 4 months of age, 15.4% of mothers had completely ceased any breastfeeding, 28.7% of infants had been given formula and 18.5% had been introduced to baby cereal. By 6 months of age, 98.4% of infants had been introduced to non-milk foods, most commonly at a rate of one new food every 4 to 5 days.

CONCLUSION

Contemporary prospective data on infant feeding have value in describing trends that may influence the health outcomes of a generation of Australian children. Even in this group of relatively well-educated Australian women, premature cessation of breastfeeding and the early introduction of foods other than breast milk to infants demonstrate behaviours not congruous with evidence-based guidelines.

A call for better care: the impact of postnatal contact services on women's parenting confidence and experiences of postpartum care in Queensland, Australia

Background

Universal postnatal contact services are provided in several Australian states, but their impact on women’s postnatal care experience has not been evaluated. Furthermore, there is lack of evidence or consensus about the optimal type and amount of postpartum care after hospital discharge for maternal outcomes. This study aimed to assess the impact of providing Universal Postnatal Contact Service (UPNCS) funding to public birthing facilities in Queensland, Australia on women’s postnatal care experiences, and associations between amount and type (telephone or home visits) of contact on parenting confidence, and perceived sufficiency and quality of postnatal care.

Methods

Data collected via retrospective survey of postnatal women (N = 3,724) were used to compare women who birthed in UPNCS-funded and non-UPNCS-funded facilities on parenting confidence, sufficiency of postnatal care, and perceived quality of postnatal care. Associations between receiving telephone and home visits and the same outcomes, regardless of UPNCS funding, were also assessed.

Results

Women who birthed in an UPNCS-funded facility were more likely to receive postnatal contact, but UPNCS funding was not associated with parenting confidence, or perceived sufficiency or perceived quality of care. Telephone contact was not associated with parenting confidence but had a positive dose–response association with perceived sufficiency and quality. Home visits were negatively associated with parenting confidence when 3 or more were received, had a positive dose–response association with perceived sufficiency and were positively associated with perceived quality when at least 6 were received.

Conclusions

Funding for UPNCS is unlikely to improve population levels of maternal parenting confidence, perceived sufficiency or quality of postpartum care. Where only minimal contact can be provided, telephone may be more effective than home visits for improving women’s perceived sufficiency and quality of care. Additional service initiatives may be needed to improve women’s parenting confidence.

Unreadiness for postpartum discharge following healthy term pregnancy: impact on health care use and outcomes

OBJECTIVE

To document the association between a lack of readiness, termed "unreadiness," for postpartum discharge and the health of mothers and their term newborns.

METHODS

Prospective observational cohort study of 4300 mother-infant dyads in a national, pediatric, practice-based research network. The association between unreadiness for discharge and health care use, health-related behaviors, and health outcomes was analyzed by the use of bivariate, multivariate linear, and logistic models.

RESULTS

Sixteen percent of mother-infant dyads were unready for discharge. Unreadiness was significantly associated with maternal and infant health care use and health outcomes but not independently associated with health-related behaviors. In multivariable analyses, after we controlled for important covariates and confounders, unready dyads had more calls to health care providers than ready dyads (13.3% increase for mothers, P = .01; 18.7% increase for infants, P < .01) during the first 2 weeks after discharge. In this same time frame, unready dyads also had more symptom days (8.5% increase for mothers, P < .01; 8.7% increase for infants, P < .01). Unready mothers had lower mean physical (5.0% decrease, P < .01) and mental (4.4% decrease, P < .01) health status scores at 4 weeks after discharge.

CONCLUSIONS

Unreadiness at postpartum discharge was associated with increased health care use and poorer health outcomes in the first 2 to 4 weeks after discharge. Discharge plans should be individualized and jointly tailored to a family's needs rather than to a set timescale.

Predictors of breastfeeding exclusivity among migrant and Canadian-born women: results from a multi-centre study

The objective of this study was to examine and compare predictors of breastfeeding exclusivity among migrant and Canadian-born women. As part of a longitudinal study, a sample of 1184 mothers were recruited from 12 hospitals in Canada and completed questionnaires at 1 and 16 weeks post-partum that included diverse questions from the following domains: demographic, social, migration, obstetrical, breastfeeding and maternal mood. After bivariate analysis, multivariate logistic regression analysis was completed to examine and compare predictors of exclusive breastfeeding at 16 weeks post-partum. Among migrant women, factors predictive of breastfeeding exclusivity included non-refugee immigrant or asylum-seeking status, residence in Toronto or Vancouver, maternal age of ≥35 years, feels most comfortable in the country of origin or nowhere and higher Gender-related Development Index of the country of origin. Factors predictive of not exclusively breastfeeding included maternal age of <20 years, not planning to exclusively breastfeed, not making the decision to breastfeed before pregnancy and not exclusively breastfeeding at 1 week post-partum. Among Canadian-born women, factors predictive of a lower likelihood of breastfeeding exclusivity included not living with father of infant, infant neonatal intensive care unit admission, planned duration of exclusive breastfeeding for <6 months, not exclusively breastfeeding at 1 week post-partum and Edinburgh Postnatal Depression Scale score of ≥10. The only similar risk factor predicting a lower likelihood of breastfeeding exclusivity between migrant and Canadian-born women was not exclusively breastfeeding at 1 week post-partum; all other risk factors were dissimilar, suggesting that these groups might benefit from different strategies to optimise breastfeeding outcomes.

The effect of delivery method on breastfeeding initiation from the The Ontario Mother and Infant Study (TOMIS) III

OBJECTIVE

To report on the relationship between delivery method (cesarean vs. vaginal) and type (planned vs. unplanned) and breastfeeding initiation in hospital and continuation to 6 weeks postpartum as self-reported by study participants.

DESIGN

Quantitative sequential mixed methods design.

SETTING

Women were recruited from 11 hospital sites in Ontario, Canada.

PARTICIPANTS

Participants included 2,560 women age 16 years or older who delivered live, full-term, singleton infants.

METHODS

Data were collected from an in-hospital questionnaire, hospital records, and a 6-week postpartum interview.

RESULTS

Ninety-two percent of women reported initiating breastfeeding, and 74% continued to 6 weeks. The method of delivery, when defined as cesarean versus vaginal, was not a determining factor in breastfeeding initiation in hospital or in the early postdischarge period. An unexpected delivery method (i.e., unplanned cesarean or instrument-assisted vaginal deliveries) was associated, at a statistically significant level, with an increased likelihood of initiating breastfeeding and continuation to 6 weeks postdischarge.

CONCLUSION

Breastfeeding can be considered a coping strategy that serves to normalize an abnormal experience and allows the individual to once again assume control. These unexpected results warrant further investigation to understand why women make the decision to initiate breastfeeding, why they choose to continue breastfeeding, and how they can be supported to achieve exclusive breastfeeding as recommended for infants in the first 6 months.

The effect of early postpartum home visits by health visitors: a natural experiment

OBJECTIVE

The purpose of this study was to assess if the absence of early home visits influenced the mothers' breastfeeding duration and use of medical services.

DESIGN

Data from mothers who had given birth during a strike period were compared with data from a reference period with usual work practice.

SAMPLE

The study included 3,834 newborn and 375 health visitors, 75 of whom worked during the strike period.

INTERVENTION

All families were offered nonstandardized home visits after discharge in the reference period. During the strike, the service was based on individual risk assessment.

RESULTS

Overall, no difference in breastfeeding duration between the two periods was seen, but unvisited mothers in the strike period had shorter durations of full breastfeeding than a comparable group of mothers in the reference period (p < .005). Moreover, mothers in the strike period reported a significantly higher use of medical services. The mothers' needs for postnatal visits differed depending on parity: primiparae underlined uncertainty, multiparae underlined previous breastfeeding experience. Mothers had missed out on guidance on all areas of the health visitors' service.

CONCLUSION

Nonstandardized home visits by health visitors were associated with a longer breastfeeding duration. The postnatal visits depended on parity and unmet needs increased the use of medical services.

In-hospital formula supplementation of breastfed babies: a population-based survey

BACKGROUND

  In-hospital formula supplementation of breastfed newborns is commonplace despite its negative association with breastfeeding duration. Although several studies have described the use of formula supplementation, few have explored the factors that may be associated with its use. The aim of this study was to explore factors associated with in-hospital formula supplementation using data from a large Australian population-based survey.

METHODS

  All women who gave birth in September and October 2007 in two Australian states were mailed questionnaires 6 months after the birth. Women were asked how they fed their baby while in hospital after the birth. Multivariable logistic regression was used to explore specified a priori factors associated with in-hospital formula supplementation.

RESULTS

  Of 4,085 women who initiated breastfeeding, 23 percent reported their babies receiving formula supplementation. Breastfed babies had greater odds of receiving formula supplementation if their mother was primiparous (adj. OR=2.16; 95% CI: 1.76-2.66); born overseas and of non-English-speaking background (adj. OR=2.03; 95% CI: 1.56-2.64); had a body mass index more than 30 (adj. OR=2.27; 95% CI: 1.76-2.95); had an emergency cesarean section (adj. OR=1.72; 95% CI: 1.3-2.28); or the baby was admitted to a special care nursery (adj. OR=2.72; 95% CI: 2.19-3.4); had a birthweight less than 2,500 g (adj. OR=2.02; 95% CI: 1.3-3.15) or was born in a hospital not accredited with Baby-Friendly Hospital Initiative (BFHI) (adj. OR=1.53; 95% CI: 1.2-1.94).

CONCLUSIONS

  The number of factors associated with in-hospital formula supplementation suggests that this practice is complex. Some results, however, point to an opportunity for intervention, with the BFHI appearing to be an effective strategy for supporting exclusive breastfeeding.

Which mothers wean their babies prematurely from full breastfeeding? An Australian cohort study

AIM

To identify the maternal and infant characteristics associated with an early transition from full breastfeeding to complementary or no breastfeeding during the first 2 months of life in a large, representative cohort of Australian infants.

METHOD

Multinomial logistic modelling was performed on data for infants with complete breastfeeding and sociodemographic data (N = 4679) including maternal age, education, smoking, employment, pregnancy and birth outcomes.

RESULTS

Ninety-one percent of women initiated breastfeeding. Sixty-nine percent of infants were being fully breastfed at 1 month, and 59% were fully breastfed at 2 months. Maternal characteristics - age less than 25 years, smoking in pregnancy, early full-time postnatal employment and less educational attainment - were associated with early breastfeeding cessation. Infant factors - multiple birth, caesarean birth, infant or first birth - were associated with a transition to complementary breastfeeding in the first postnatal month.

CONCLUSION

Breastfeeding duration is substantially affected by breastfeeding outcomes in the first postpartum month. The first month is an important window for evidence-based interventions to improve rates of full breastfeeding in groups of women identified as at risk of early breastfeeding cessation.

Neonatal exposure to daidzein, genistein, or the combination modulates bone development in female CD-1 mice

Neonatal exposure to genistein (GEN), an isoflavone abundant in soy, favorably modulates bone mineral density (BMD) and bone strength in mice at adulthood. The study objective was to determine whether early exposure to a combination of the soy isoflavones daidzein (DAI) and GEN that naturally exists in soy protein-based infant formula results in greater benefits to bone at adulthood than either treatment alone. Male and female CD-1 mice (n = 8-16 pups per group per gender) were randomized to subcutaneous injections of DAI (2 mg x kg body weight(-1) x d(-1)), GEN (5 mg x kg body weight(-1) x d(-1)), DAI+GEN (7 mg x kg body weight(-1) x d(-1)), diethylstilbesterol (DES; positive control) (2 mg x kg body weight(-1) x d(-1)), or control (CON) from postnatal d 1-5 and were studied to 4 mo of age. BMD, biomechanical bone strength, and bone microarchitecture were assessed at the femur and lumbar vertebrae (LV). Females treated with DAI, GEN, DAI+GEN, or DES had greater (P < 0.05) BMD at the LV compared with CON and vertebra in the DAI and DES group were more resistant to compression fractures. Microstructural analyses demonstrated that treatment with DAI and GEN resulted in greater (P < 0.05) trabecular connectivity and trabecular thickness, respectively, than the CON. In conclusion, neonatal exposure to DAI and/or GEN had a positive effect on the skeleton of female mice at adulthood, but, compared with individual treatments, DAI+GEN did not have a greater benefit to bone in females or males.

Reasons for in-hospital formula supplementation of breastfed infants from low-income families

In-hospital formula supplementation of breastfed infants negatively impacts breastfeeding duration. Infants from low-income families have some of the lowest exclusive breastfeeding rates in the United States. The objectives of this study were to identify (1) reasons low-income breastfeeding mothers begin in-hospital formula supplementation and (2) risk factors for in-hospital formula supplementation. We surveyed 150 low-income mothers in a Washington, DC, clinic. Sixty percent had initiated breastfeeding, and 78% of these breastfed infants received formula supplementation in the hospital. There was no clear medical need for supplementation for 87% of the breastfed infants receiving supplementation. Infants of mothers who did not attend a prenatal breastfeeding class were almost 5 times more likely to receive in-hospital formula supplementation than those infants whose mothers had attended a class (OR, 4.7; 95% CI, 1.05-21.14). Improved knowledge about breastfeeding among nursing and medical providers is important to minimize unnecessary formula supplementation for breastfed infants.