The Impact of a Prenatal Education Video on Rates of Breastfeeding Initiation and Exclusivity during the Newborn Hospital Stay in a Low-income Population

Exclusive Breastfeeding in the Bronx-Successes and Shortcomings

OBJECTIVE

 Despite efforts to encourage breastfeeding, exclusive breastfeeding (EBF) rates in the Bronx remain suboptimal. Hospital restrictions and uncertainty surrounding the side effects of coronavirus disease 2019 (COVID-19) greatly impacted the mother-infant dyad during the postpartum hospitalization. Preliminary studies found an initial decrease in EBF, but lasting effects remain unknown. This study aimed to investigate the effect of the COVID-19 pandemic on birth hospitalization EBF rates among a high-risk urban patient population.

STUDY DESIGN

 A retrospective chart review was conducted on all newborns admitted to the newborn nursery at an urban medical center between 2019 and 2021. Patients were separated into prepandemic and pandemic cohorts. Patient demographics, maternal comorbidities, length of stay, feeding method, and newborn characteristics, including status as high risk for hypoglycemia, were collected. EBF was defined as receiving only mother's milk during the birth hospitalization. Descriptive statistics and bivariate analysis were used to examine the data.

RESULTS

 A total of 630 prepandemic and 643 pandemic newborns were included. The cohorts did not differ in baseline maternal characteristics. Prepandemic newborns were less likely to be high risk (23.3 vs. 29.4%, p = 0.01), more likely to see the hospital lactation consultant (53.2 vs. 24.0%, p < 0.001), and had a longer average length of stay (63.4 vs. 54.5 hours, p < 0.001). Most infants in both cohorts received some breastmilk during the hospitalization (97.6 vs. 94.6%, not significant). There was no difference in EBF between cohorts among all newborns (9.5 vs. 11.4%, p = 0.29) or among nonhigh-risk newborns (12.2 vs. 15.0%, p = 0.22).

CONCLUSION

 EBF rates in the Bronx, NY did not change during the pandemic period, despite an increase in high-risk newborns. Further investigation into the effect of lactation consultation, maternal race, ethnicity, and primary language should be further explored to understand the implications of health care disparities on the mother-infant dyad.

KEY POINTS

· The COVID-19 pandemic disrupted many aspects of the mother-infant dyad.. · EBF rates at an urban institution in the Bronx did not change during the COVID-19 pandemic.. · Further investigation is warranted to better understand the barriers to EBF in this population..

Prenatal Counseling and Preparation for Breastfeeding

Breastfeeding is the gold standard of infant nutrition and current guidelines suggest exclusive breastfeeding for 6 months, with continued breastfeeding through 24 months or beyond. Obstetric care professionals can encourage and educate their patients about breastfeeding through the prenatal period when many expectant parents make decisions about their infant feeding choices. Education and support should extend through the postpartum period and include parents who may have concerns surrounding medical comorbidities, breast augmentation, or substance use disorders.

Impact of parent-targeted eHealth educational interventions on infant procedural pain management: a systematic review

OBJECTIVE

The objective of this review was to determine whether electronic health (eHealth) educational interventions about infant procedural pain and pain management impact parental outcomes (eg, mental health, knowledge uptake), eHealth outcomes (eg, acceptance, use), and pain management outcomes (eg, parental involvement, infant pain response).

INTRODUCTION

Pain in infants is a common concern for parents. Routine postpartum care for infants in early life requires them to endure painful procedures, such as immunizations, yet infants often receive little to no pain management. Parents are an essential component of effective pain management, although they may not be aware of the roles they play. Despite the increased number of eHealth resources available to educate parents about infant pain management, their impact has yet to be synthesized.

INCLUSION CRITERIA

This review considered studies that evaluated eHealth educational interventions targeted at parents during pregnancy and up to 1 year postpartum. Interventions included, but were not limited to, mobile applications, web-based applications, websites, videos, interactive training, hands-on direct simulation, short message service (SMS), and desktop applications. Primary outcomes included parental outcomes (eg, stress or anxiety, self-efficacy, knowledge, attitudes), eHealth outcomes (eg, acceptance, use), and pain management outcomes (eg, parental involvement, infant pain response). Experimental, quasi-experimental, and observational study designs were included.

METHODS

MEDLINE, CINAHL, PsycINFO, Embase, Scopus, Web of Science, and SciELO were searched for studies published in English up to June 14, 2021. Citation lists of relevant reviews and included studies were also searched for additional peer-reviewed articles. Two independent reviewers conducted critical appraisal using standardized tools from JBI, and data extraction, using a data extraction form designed by the authors. Statistical pooling of quantitative data was not possible due to heterogeneity; thus, the findings were reported narratively.

RESULTS

A total of 4163 unique studies were screened, with 11 studies ultimately included for synthesis. Five articles were randomized controlled trials, 5 articles were analytical cross-sectional studies, and 1 article was quasi-experimental. Studies reported on 4 unique eHealth educational interventions, all of which used video format and primarily targeted the postnatal period. The findings for all primary outcomes were mixed but suggested either improvements in outcomes or no impact. The certainty of evidence was determined as low or very low across primary outcomes for reasons related to imprecision, risk of bias, and indirectness.

CONCLUSIONS

Although heterogeneity of findings limited quantitative synthesis of data, this review suggests that short and engaging educational videos have the potential to positively impact parents' knowledge, confidence, and desire to be involved in procedural pain management for their children. Most of the interventions presented in this review describe evidence-based information about procedural pain management strategies that are known to be effective for infant populations. Thus, it is reasonable to assume that infant pain response should be lower when parents appropriately apply the strategies. However, the findings of this review were not able to confirm this assumption. More research is needed to evaluate the impact of parent-targeted pain management education on infant pain response.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020151569.

A systematic literature review of breastfeeding interventions among Black populations using the RE-AIM framework

BACKGROUND

Lactation support resources are less likely to be located in close proximity to where Black families live and there is a systemic racist health care belief that Black women prefer bottle feeding (with infant formula) over breastfeeding. Together, these lead to lower reported breastfeeding rates of Black babies compared to other racial / ethnic groups. It is imperative to have a deeper understanding of the cultural aspects as well as the underlying limitations that prevent Black women / persons from being supported to breastfeed. There is a need to know how effective breastfeeding interventions are in reaching the intended population; how well they work in promoting breastfeeding initiation and continuation; and how successful they are when implemented at the setting and staff level. The purpose of this investigation was to establish the level of internal and external validity that was reported by breastfeeding intervention studies among Black communities.

METHODS

Studies on breastfeeding interventions on Black people that were published between the years 1990 and 2019 were carefully examined through PubMed, EBSCOhost, Web of Science, and OneSearch. A total of 31 studies fulfilled the requirements to be included for this evaluation. In order to extract the information from the articles, the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework extraction tool was utilized.

RESULTS

On average, the proportion of studies that reported across reach, effectiveness, adoption, implementation, and maintenance indicators was 54, 35, 19, 48, and 9%, respectively. Across core RE-AIM indicators only sample size (100%) and breastfeeding outcomes (90%) were reported consistently. External validity indicators related to representativeness of participants (16%) and sites (3%) were rarely reported. Similarly, adherence to intervention protocol, and indicator of internal validity, was reported in a small proportion of articles (19%).

CONCLUSION

This body of literature under-reported on aspects associated to both internal and external validity across all RE-AIM domains. The reporting of the individual level of representativeness; the setting level of representativeness; the intervention's adherence to the protocol; the expenses; and the factors of sustainability would benefit from improvement in future research.

Timing of Introduction of Complementary Foods and Beverages to Infants of Low-Income Women

Background: Although rates of complementary food and beverage (CFB) consumption among infants under 4 to 6 months of age have been declining, they remain well above the American Academy of Pediatrics (AAPs) recommendations. It is unclear if women with low income in the United States are more likely than other women to introduce CFBs early. We examined timing of introduction of CFBs to infants of mothers with low income to further illuminate infant feeding practices in this potentially vulnerable population. Materials and Methods: We analyzed infant feeding data collected prospectively from 443 mother-infant dyads. Data were obtained by interview at 1, 3, and 6 months postpartum. We used Kaplan-Meier curves to show time to introduction of CFBs overall and by type of CFB, and log-rank tests to compare timing by demographic and clinical characteristics. Results: Participants were mostly non-Hispanic black or white, with a high school education or less. By month 3, 48% of infants were fed at least one CFB, increasing to over 83% by month 5. Women who did not work outside the home introduced CFBs significantly earlier than those who worked, as did women who smoked compared with those who did not. Timing did not differ by other participant characteristics. Conclusions: Introduction of CFBs before 4-6 months was common. Clinical guidance and intervention programs should support mothers toward the goal of improving infant diets in this at-risk population.

Women's Empowerment and Determinants of Early Initiation of Breastfeeding: A Scoping Review

INTRODUCTION

Early initiation of breastfeeding (EIBF), the immediate provision of mothers' breast milk to infants within the first hour of life, has been recommended by the WHO. However, EIBF is not widely practiced, thereby increasing infant mortality risk. This review explored the available and published studies that identified interventions that empower mothers to practice EIBF.

METHOD

We conducted a scoping review to answer the aforementioned aims. Empowerment, Women, Breastfeed, and Initiation were used as initial keywords, which were further developed using Medical Subject Headings by the National Center for Biotechnology Information. Five databases, namely: Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature via EBSCO, ProQuest, and MedLine via PubMed, were searched for potential articles. We also searched the references in addition to the main search.

FINDINGS

We included 28 articles in this review. Education was mostly used as women's empowerment indicator in EIBF intervention. Additionally, we identified barriers (C-section and postoperative pain, lactation problems and pregnancy complications, mothers' social and demographic factors, mothers' lack of professional support, babies' condition preventing EIBF) and facilitators (mothers' positive behavior in relation to educational level, completion of antenatal care, poor economic situations of mothers, babies' size at birth) of EIBF.

DISCUSSION

Education is the widely used intervention to promote mothers' participation in improving EIBF rate. Furthermore, mothers' and babies' deferring conditions and traditional practices are barriers for EIBF. This review recommends future research and empowerment efforts that sensitively address the identified barriers.

Fertility patients' use and perceptions of online fertility educational material

Background

Online educational information is highly sought out by patients with infertility. This study aims to assess patient-reported usage and helpfulness of fertility educational material on a clinic website and social media accounts.

Methods

Educational material was created on common fertility topics in text and video format and posted on the clinic website and social media accounts. At the first consultation for infertility, patients were provided with a postcard directing them to material online. At the first follow-up appointment, patients were invited to fill out a survey assessing whether patients viewed the online educational material and if they found the information helpful.

Results

98.4% (251/255) of patients completed the survey, of which 42.6% (106/249) looked at the online material. Of those who viewed the online information, 99.1% (115/116) found the information helpful or somewhat helpful and 67.6% (73/108) found reading the material online better prepared them for making fertility decisions at their doctor’s appointment

Conclusion

Patients found online fertility information on the clinic website and social media accounts useful for making fertility treatment decisions. Providing online educational material has the potential to improve patient care by empowering patients with the knowledge to make more informed treatment decisions, and improving the quality of the time spent with the physician.

Participation in the "nutrition at the Centre" project through women's group improved exclusive breastfeeding practices, as measured by the deuterium oxide dose-to-mother technique

Background

Evidence of interventions that are effective in improving exclusive breastfeeding (EBF) practices is needed to help countries revise their strategies. To assess whether mothers who had participated in the Nutrition at the Centre (N@C) project effectively demonstrated better EBF practices than did those who did not participate, we documented the processes of this nutritional intervention in Benin.

Methods

This study was a cross-sectional design comparing the intervention group, namely, the Village Saving and Loan Association (VSLA-N@C), to the control group. The N@C project was an educational intervention based on behavioural and social changes related to nutrition. Through VSLA groups installed in communities, mothers were connected to the project; had weekly discussions around the process, benefits and challenges linked to EBF, and advocated during Breastfeeding Week celebrations. The study participants were mothers with children aged 4–5.5 months from the VSLA-N@C group (n = 53) and mothers (n = 50) from non-intervention areas who served as controls. With the deuterium oxide dose-to-mother technique, we quantified human milk intake (HMI) and non-milk oral intake (NMOI) and compared both groups using Student’s t-test. A child is considered to be exclusively breastfed if the NMOI is less than 86.6 g/day. Multivariate regression logistics adjusted for VSLA membership, mothers’ body mass index, and children’s age, weight-for-age and weight-for-length, thus enabling us to measure differences in EBF rates.

Results

Children of mothers from the VSLA-N@C group consumed significantly more human milk than those of mothers in the control group (900.2 ± 152.5 g/day vs 842.2 ± 188.6 g/day, P = 0.044). Children in the VSLA-N@C group had significantly less non-milk oral intake than did those in the control group (difference: 148.2 g/day, P = 0.000). Therefore, the EBF rate was significantly higher in the VSLA group (38% vs 8%, P < 0.0001), and mothers in VSLAs were 14 times more likely to practise EBF than were those in the control group (adjusted odds ratio [AOR] = 13.9, 95% CI 1.9–116.5, P = 0.015).

Conclusion

The EBF rate was significantly higher in the group of mothers who participated in the VSLA-N@C project than in those who did not receive the intervention. The N@C model could be promoted as a strategy for increasing EBF practices in poor and rural contexts, where it is possible to organize mothers into VSLA groups to discuss the process, benefits and challenges of EBF.

Using a Global Health Media Project Video to Increase Knowledge and Confidence in the Mothers of Admitted Neonates in Rwanda: A Prospective Interventional Study

INTRODUCTION

In resource-limited settings, the ratio of trained health care professionals to admitted neonates is low. Parents therefore, frequently need to provide primary neonatal care. In order to do so safely, they require effective education and confidence. The evolution and availability of technology mean that video education is becoming more readily available in this setting.

AIM

This study aimed to investigate whether showing a short video on a specific neonatal topic could change the knowledge and confidence of mothers of admitted neonates.

METHODS

A prospective interventional study was conducted in two hospitals in Kigali, Rwanda. Mothers of admitted neonates at a teaching hospital and a district hospital were invited to participate. Fifty-nine mothers met the inclusion criteria. Participants were shown 'Increasing Your Milk Supply, for mothers' a seven-minute Global Health Media Project video in the local language (Kinyarwanda). Before and after watching the video, mothers completed a Likert-based questionnaire which assessed confidence and knowledge on the subject.

RESULTS

Composite Likert scores showed a statistically significant increase in knowledge (pre = 27.2, post = 33.2, p < 0.001) and confidence (pre = 5.9, post = 14.2, p < 0.001). Satisfaction levels were high regarding the video content, language and quality. However, only 10% of mothers owned a smartphone.

DISCUSSION

We have shown that maternal confidence and knowledge on a specific neonatal topic can be increased through the use of a short video and these videos have the potential to improve the quality of care provided to admitted neonates by their parents in low-resource settings.

Intent to Breastfeed and Evaluation of Culturally Sensitive Education in a Migrant Pacific Islander Population

Background

The Marshallese, a Pacific Islander population, are a growing migrant population in the United States. Breastfeeding is the preferred method of infant feeding, but many cultural barriers deter exclusive breastfeeding. A culturally sensitive education intervention was implemented to meet the needs of the Marshallese population in a postpartum setting.

Objective

This study aimed to evaluate the impact of an education intervention, in native language, on breastfeeding rates among Marshallese mothers during hospitalization.

Methods

This quasi-experimental study was a retrospective data analysis of a quality improvement project in a hospital seeking Baby-Friendly status. Randomized record reviews of Marshallese mothers receiving the culturally targeted education (N = 40) between the ages of 18 and 45, delivering between 37 and 42 weeks gestation, were compared with mothers prior to implementation of the education (N = 40).

Results

Birthweight, discharge weight, and delivery method were not statistically different. No statistical difference existed between feeding intent and discharge feeding behavior.

Conclusion

Exclusive breastfeeding rates among Marshallese mothers are lower than desired. Culturally appropriate breastfeeding education in a hospital setting may not affect feeding patterns, but clarification is needed on cultural definitions of exclusive breastfeeding. Further studies are needed.

Reasons for Early Cessation of Breastfeeding Among Women with Low Income

Background: Most women in the United States do not meet their breastfeeding goals, and low-income women breastfeed at lower rates than the general population. While risk factors for early cessation have been documented, specific reasons for discontinuing among this population are less understood. We examined reasons for cessation among low-income mothers to inform the development of targeted strategies to address breastfeeding disparities. Materials and Methods: We performed a secondary data analysis using prospective data collected during a randomized intervention trial of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-eligible women interviewed in the third trimester and at 1, 3, and 6 months postpartum. We included the 221 women who initiated breastfeeding and stopped by 6 months. Women's reasons for discontinuing breastfeeding were grouped by thematic category and compared by time of breastfeeding cessation. Results: The most common reasons reported overall for breastfeeding cessation were concerns about breast milk supply and latch difficulty. Some reasons differed significantly by time of cessation. Latch difficulty was reported most often by women who breastfed for 1 month or less; supply concerns increased with increasing breastfeeding duration. Returning to work/school was uncommonly reported for those who stopped by 1 month, but more frequently reported in those with later cessation. Conclusions: We found that low-income women reported similar reasons for early breastfeeding cessation as have been reported for other populations of women. These results underscore the need for appropriately timed, culturally sensitive interventions to reduce disparities in duration of breastfeeding, specifically to address latch difficulty in the first few weeks and supply concerns as infants grow.

A Randomized Trial of Prenatal Video Education to Improve Breastfeeding Among Low-Income Women

Background: Many women initiate breastfeeding but do not meet their duration goals, and low-income women initiate and continue breastfeeding at lower rates than their counterparts. One-on-one counseling is associated with increased breastfeeding but requires significant resources. In contrast, video education, which requires fewer resources and is effective in other health care settings, such as vaccine uptake, has gone untested for prolonging breastfeeding duration among low-income women. Objective: To determine whether use of an educational breastfeeding video shown individually to low-income pregnant women in the prenatal clinic would prolong duration of any and exclusive breastfeeding. Methods: A multicenter, randomized, controlled trial was conducted in four prenatal clinics. Low-income pregnant women were randomized to view the intervention (breastfeeding education) or control (prenatal nutrition) video in the third trimester and interviewed by telephone at 1, 3, and 6 months postpartum about infant feeding practices. Kaplan-Meier survival curves with log-rank tests and Cox proportional hazards regression were utilized to compare groups. Results: Of the 816 eligible women approached, 64% participated: 263 assigned to the intervention, and 259 assigned to the control. Six-month data were obtained for 211 (80%) and 220 (85%) women, respectively. Rate of breastfeeding cessation did not differ by group (hazard ratios; HR = 1.00, 95% confidence interval [CI]: 0.81-1.24 and HR = 0.93, 95% CI: 0.76-1.14, for any and exclusive breastfeeding, respectively). Conclusion: A single viewing of a breastfeeding education video shown in the prenatal clinic did not impact breastfeeding duration or exclusivity among low-income women in this study. Although not sufficient alone, educational videos may be useful as one component of a comprehensive program to promote breastfeeding.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Using a Music Video Parody to Promote Breastfeeding and Increase Comfort Levels Among Young Adults

BACKGROUND

North Americans are not meeting the World Health Organization's breastfeeding recommendations. Young adults understand that breastfeeding is healthy but are uncomfortable seeing breastfeeding. Research aim: The aim of the current project was to determine if a music video parody promoting breastfeeding is perceived by young adults to be an effective means of promotion and if exposure to such a video could increase comfort levels.

METHODS

Young adults rated how comfortable they felt looking at breastfeeding and bottle-feeding images (pretest). Two months later, a subset of participants watched the music video parody "Breastfeeding My Baby." In Phase 1, participants completed the picture-rating task again (posttest) after a 2-month delay, plus a survey to assess memory and perception of the video. In Phase 2, participants were reminded of the video before completing the comfort ratings, and in the final phase, posttest measures were administered only 1 week after exposure to the video.

RESULTS

Across all phases, the video was perceived to be effective and was memorable. Breastfeeding comfort ratings were comparable at pretest across participant groups; comfort ratings improved at posttest for participants who saw the video but only if they were reminded of seeing it before providing their ratings. At shorter intervals between seeing the video and completing the posttests, comfort ratings for breastfeeding images increased for all participants, highlighting the general importance of exposure to breastfeeding.

CONCLUSION

Young adults are receptive to using a music video parody to promote breastfeeding, which can help to increase comfort levels with breastfeeding.

Systematic Review of Evidence for Baby-Friendly Hospital Initiative Step 3

BACKGROUND

The Ten Steps to Successful Breastfeeding outline maternity practices that protect, promote, and support breastfeeding and serve as the foundation for the Baby-Friendly Hospital Initiative. Research aim: This systematic review describes interventions related to Step 3 of the Ten Steps, which involves informing pregnant women about the benefits and management of breastfeeding. Our main objective was to determine whether prenatal clinic- or hospital-based breastfeeding education increases breastfeeding initiation, duration, or exclusivity.

METHODS

The electronic databases MEDLINE and CINAHL were searched for peer-reviewed manuscripts published in English between January 1, 2000, and May 5, 2016. Bibliographies of relevant systematic reviews were also screened to identify potential studies.

RESULTS

Thirty-eight studies were included. The research studies were either randomized controlled trials or quasi-experimental studies conducted in developed or developing countries. Findings suggest that prenatal interventions, delivered alone or in combination with intrapartum and/or postpartum components, are effective at increasing breastfeeding initiation, duration, or exclusivity where they combine both education and interpersonal support and where women's partners or family are involved. However, varying study quality and lack of standardized assessment of participants' breastfeeding intentions limited the ability to recommend any single intervention as most effective.

CONCLUSION

Future studies should test the strength of maternal breastfeeding intentions, assess the role of family members in influencing breastfeeding outcomes, compare the effectiveness of different health care providers, and include more explicit detail about the time and full cost of different interventions.

Antenatal breastfeeding education for increasing breastfeeding duration

BACKGROUND

Breast milk is well recognised as the best food source for infants. The impact of antenatal breastfeeding (BF) education on the duration of BF has not been evaluated.

OBJECTIVES

To assess the effectiveness of antenatal breastfeeding (BF) education for increasing BF initiation and duration.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register on 1 March 2016, CENTRAL (The Cochrane Library, 2016, Issue 3), MEDLINE (1966 to 1 March 2016) and Scopus (January 1985 to 1 March 2016). We contacted experts and searched reference lists of retrieved articles.

SELECTION CRITERIA

All identified published, unpublished and ongoing randomised controlled trials (RCTs) assessing the effect of formal antenatal BF education or comparing two different methods of formal antenatal BF education, on the duration of BF. We included RCTs that only included antenatal interventions and excluded those that combined antenatal and intrapartum or postpartum BF education components. Cluster-randomised trials were included in this review. Quasi-randomised trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We assessed all potential studies identified as a result of the search strategy. Two review authors extracted data from each included study using the agreed form and assessed risk of bias. We resolved discrepancies through discussion. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review update includes 24 studies (10,056 women). Twenty studies (9789 women) contribute data to analyses. Most studies took place in high-income countries such as the USA, UK, Canada and Australia. In the first five comparisons, we display the included trials according to type of intervention without pooling data. For the 'Summary of findings' we pooled data for a summary effect.Five included studies were cluster-randomised trials: all of these adjusted data and reported adjustments as odds ratios (OR). We have analysed the data using the generic inverse variance method and presented results as odds ratios, because we were unable to derive a cluster-adjusted risk ratio from the published cluster-trial. We acknowledge that the use of odds ratio prevents the pooling of these cluster trials in our main analyses. One method of BF education with standard (routine) careThere were no group differences for duration of any BF in days or weeks. There was no evidence that interventions improved the proportion of women with any BF or exclusive BF at three or six months. Single trials of different interventions were unable to show that education improved initiation of BF, apart from one small trial at high risk of attrition bias. Many trial results marginally favoured the intervention but had wide confidence intervals crossing the line of no effect. BF complications such as mastitis and other BF problems were similar in treatment arms in single trials reporting these outcomes. Multiple methods of BF education versus standard careFor all trials included in this comparison we have presented the cluster-adjusted odds ratios as reported in trial publications. One three-arm study found the intervention of BF booklet plus video plus Lactation Consultant versus standard care improved the proportion of women exclusively BF at three months (OR 2.60, 95% CI 1.25 to 5.40; women = 159) and marginally at six months (OR 2.40, 95% CI 1.00 to 5.76; women = 175). For the same trial, an intervention arm without a lactation consultant but with the BF booklet and video did not have the same effect on proportion of women exclusively BF at three months (OR 1.80, 95% CI 0.80 to 4.05; women = 159) or six months (OR 0.90, 95% CI 0.30 to 2.70; women = 184). One study compared monthly BF sessions and weekly cell phone message versus standard care and reported improvements in the proportion of women exclusively BF at both three and six months (three months OR 1.80, 95% CI 1.10 to 2.95; women = 390; six months OR 2.40, 95% CI 1.40 to 4.11; women = 390). One study found monthly BF sessions and weekly cell phone messages improved initiation of BF over standard care (OR 2.61, 95% CI 1.61 to 4.24; women = 380). BF education session versus standard care, pooled analyses for 'Summary of findings' (SoF)This comparison does not include cluster-randomised trials reporting adjusted odds ratios. We did not downgrade any evidence for trials' lack of blinding; no trial had adequate blinding of staff and participants. The SoF table presents risk ratios for all outcomes analysed. For proportion of women exclusively BF there is no evidence that antenatal BF education improved BF at three months (RR 1.06, 95% CI 0.90 to 1.25; women = 822; studies = 3; moderate quality evidence) or at six months (RR 1.07, 95% CI 0.87 to 1.30; women = 2161; studies = 4; moderate quality evidence). For proportion of women with any BF there were no group differences in BF at three (average RR 0.98, 95% CI 0.82 to 1.18; women = 654; studies = 2; I² = 60%; low-quality evidence) or six months (average RR 1.05, 95% CI 0.90 to 1.23; women = 1636; studies = 4; I² = 61%; high-quality evidence). There was no evidence that antenatal BF education could improve initiation of BF (average RR 1.01, 95% CI 0.94 to 1.09; women = 3505; studies = 8; I² = 69%; high-quality evidence). Where we downgraded evidence this was due to small sample size or wide confidence intervals crossing the line of no effect, or both.There was insufficient data for subgroup analysis of mother's occupation or education.

AUTHORS' CONCLUSIONS

There was no conclusive evidence supporting any antenatal BF education for improving initiation of BF, proportion of women giving any BF or exclusively BF at three or six months or the duration of BF. There is an urgent need to conduct a high-quality, randomised controlled study to evaluate the effectiveness and adverse effects of antenatal BF education, especially in low- and middle-income countries. Evidence in this review is primarily relevant to high-income settings.

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.