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

Parent-identified gaps in preparation for the postpartum period in the United States: An integrative review

BACKGROUND

In the United States, 35% of all pregnancy-related deaths occur between 24 h and 6 weeks after delivery, yet the first outpatient visit is not typically scheduled until 6 weeks postpartum. Thus, the ability to independently navigate this period is critical to maternal well-being and safety. However, previous research suggests that many women feel unprepared to manage the challenges they encounter during this time, and there is a current need to synthesize the existing evidence. Therefore, the purpose of this integrative review is to describe parent-identified gaps in preparation for the postpartum period in the United States.

METHODS

Using the Integrative Review framework by Whittemore and Knafl, a systematic search of Medline, CINAHL, PsychInfo, Web of Science, and a hand-search was conducted for peer-reviewed articles published in English between 1995 and 2023. Results were reported according to PRISMA 2020 guidelines. Studies that met eligibility criteria were synthesized in a literature matrix.

RESULTS

Twenty-two studies met inclusion criteria. Four themes were identified: Mental Health Concerns, Physical Concerns, Infant Feeding and Care Concerns, and General Concerns and Recommendations. Many women, regardless of parity, reported feeling unprepared for numerous postpartum experiences, including depression, anxiety, physical recovery, breastfeeding, and infant care. Parents reported difficulty differentiating normal postpartum symptoms from complications. Hospital discharge teaching was viewed as simultaneously overwhelming and inadequate. Parent recommendations included the need for earlier and more comprehensive postpartum preparation during pregnancy, delivered in multiple formats and settings. Parents also reported the need for earlier postpartum visits and improved outpatient support.

CONCLUSIONS

Our findings indicate that many parents in the United States feel unprepared to navigate a wide variety of emotional, physical, breastfeeding, and infant-care experiences. Future research should explore innovative educational approaches to postpartum preparation during pregnancy as well as outpatient programs to bridge the current gaps in postpartum care.

Attitudes and barriers to breastfeeding among women at high-risk for not breastfeeding: a prospective observational study

BACKGROUND

Rates of breastfeeding are lower among minority and underserved populations in the United States. Our study objective was to assess pregnant persons attitudes and barriers to breastfeeding among a cohort at high risk for not breastfeeding.

METHODS

We disseminated the Iowa Infant Feeding Attitude Scale (IIFAS) to 100 pregnant persons at least 18 years of age attending a prenatal visit in a low-resource, academic practice in south-central Louisiana (Woman's Hospital). The IIFAS, as well as questions collecting information on breastfeeding experience and sociodemographic characteristics, were administered via interview. Medical records were reviewed to investigate associations between attitudes about breastfeeding in pregnancy and patient's feeding choices during the delivery hospital stay. Fisher exact tests and Wilcoxon rank-sum tests were used to assess associations between categorical and continuous variables respectively.

RESULTS

Of the 98 participants who completed the study, 8% were Hispanic, 63% were Black, 95% were Medicaid eligible, and 50% were unemployed. 59% (n = 58) went on to breastfeed/combination breast-formula feed (called "Any-Breastfeeding Group") during the delivery stay. Total IIFAS score during pregnancy was significantly higher among those who went on to breastfeed during delivery hospital stay (Any-Breastfeeding Group vs. Formula-Feeding-Only Group: 58.9 ± 5.5 vs. 53.7 ± 6.2 respectively, p < 0.001). In the group that went on to only formula feed (Formula-Feeding-Only Group), only 4% agreed breastfeeding was more convenient when surveyed during pregnancy, compared to 45% of the Any-Breastfeeding Group. 60% of Formula-Feeding-Only Group agreed formula is as healthy as breast milk.

CONCLUSION

The three major themes that coincided with favorability toward breastfeeding in the study, and can be addressed during prenatal counseling, are: mother-infant bonding, convenience, and health benefits. By identifying attitudes and barriers to breastfeeding for patients during pregnancy who went on to not breastfeed, directed educational opportunities can be developed to address these specific attitudes to ultimately increase breastfeeding initiation and continuation.

Practices and Policies That Support Breastfeeding Among Military Women: A Systematic Review

BACKGROUND

Previous and limited assessments of breastfeeding in women serving on active duty in the U.S. military demonstrate varied and conflicting data regarding breastfeeding outcomes. Disparities exist within the military where enlisted service members have consistently lower rates of breastfeeding duration compared to officers. Yet, little is known about successful care practices and military policies that promote breastfeeding in military women. The aim of this systematic review is to examine care practices and military policies associated with increased breastfeeding initiation and duration among women serving in the U.S. military.

MATERIALS AND METHODS

We searched Cochrane Database, Cumulative Index of Nursing and Allied Health Literature, PubMed, and PsycInfo for studies published from 2000 to 2022 that included U.S. military personnel and that focused on care practices and military policies that support breastfeeding. Our search terms included (breastfeeding OR breastfeed AND military) and (lactation OR lactating AND military). We included randomized controlled trials, quasi-experimental, cohort, cross-sectional, and other observational designs. We evaluated potential bias in studies using the Evidence Project Risk of Bias Tool and synthesized the overall evidence using the Johns Hopkins Nursing Evidence-Based Practice Synthesis and Recommendations Tool.

RESULTS

We included 14 studies that were independently reviewed by two authors. Breastfeeding initiation rates among military women were between 66% and 98%, and breastfeeding duration rates at 6 months ranged from 13% to 62%. In these studies, researchers examined various inpatient care practices (skin-to-skin care, timing of circumcision, and infant baths) (n = 3), care delivered by different types of providers (n = 3), group versus individual prenatal care (n = 2), breastfeeding education (n = 2), length of maternity leave (n = 2), and workplace support (n = 2). Skin-to-skin contact following delivery was positively associated with breastfeeding outcomes. There is insufficient evidence to determine if care by different types of medical providers, different types of prenatal care and education, timing of circumcision or baths, length of maternity leave, and workplace support influence breastfeeding outcomes.

CONCLUSION

Certain perinatal practices designed to encourage early skin-to-skin contact appear to improve breastfeeding initiation and duration among women serving in the U.S. military. However, there is an overall lack of quality evidence supporting effective practices and policies associated with increased breastfeeding initiation and duration in this population. Given the recent movement toward policy changes that support pregnant and postpartum service members across services, more research is needed to determine the impact of these and other practices and policies on breastfeeding rates, specifically among enlisted service members who have demonstrated lower breastfeeding rates than officers.

A dose-response relationship found between the Ten Steps to Successful Breastfeeding indicators and in-hospital exclusive breastfeeding in US hospitals

BACKGROUND

In-hospital exclusive breastfeeding (EBF) is associated with longer breastfeeding durations, yet only 64% of US newborns are EBF for 7 days. The Ten Steps to Successful Breastfeeding (Ten Steps) are a set of evidenced-based maternity practices shown to improve breastfeeding outcomes; these were updated in 2018.

METHODS

Using hospital-level data from the 2018 Maternity Practices in Infant Nutrition and Care Survey (n = 2045 hospitals), we examined the prevalence of implementation of Ten Steps indicators (each step and total number of steps implemented). Using linear regression, we also examined the association between the steps and EBF prevalence adjusted for hospital characteristics and all other steps. Discharge support was not included in the models since it primarily occurs after hospital discharge.

RESULTS

The most frequently implemented step was the provision of prenatal breastfeeding education (95.6%). Steps with low implementation included rooming-in (18.9%), facility policies supportive of breastfeeding (23.4%), and limited formula supplementation (28.2%). After adjusting for hospital characteristics and all other steps, limited formula supplementation (difference = 14.4: 95% confidence interval [CI]: 12.6, 16.1), prenatal breastfeeding education (difference = 7.0; 95% CI: 3.3, 10.8), responsive feeding (difference = 6.3; 95% CI: 3.7, 9.0), care right after birth (skin-to-skin; difference = 5.8; 95% CI: 4.2, 7.4), and rooming-in (difference = 2.4; 95% CI: 0.4, 4.6) were associated with higher in-hospital EBF prevalence. We found a dose-response relationship between the number of steps implemented and in-hospital EBF prevalence.

CONCLUSION

Increased implementation of the updated Ten Steps may improve EBF and infant and maternal health outcomes.

Breastfeeding Decision-Making Among Mothers with Opioid Use Disorder: A Qualitative Study

Background: Factors that contribute to low initiation and continuation of breastfeeding among mothers with opioid use disorder (OUD) are poorly understood. Objective: To understand barriers and facilitators to breastfeeding initiation and continuation beyond the birth hospitalization for mothers with OUD. Materials and Methods: We conducted 23 in-depth, semistructured interviews with mothers with OUD who cared for their infants at home 1-7 months after birth. Our interview guide was informed by the Theory of Planned Behavior (TPB) framework, which has been used to understand decision-making regarding breastfeeding. An iterative approach was used to develop codes and themes. Results: Among 23 participants, 16 initiated breastfeeding, 10 continued after hospital discharge, and 4 continued beyond 8 weeks. We identified factors influencing breastfeeding decisions in the four TPB domains. Regarding attitudes, feeding intentions were based on beliefs of the healthiness of breastfeeding particularly pertaining to infant withdrawal or exposure to mothers' medications. Regarding social norms, breastfeeding was widely recommended, but mothers had varying levels of trust in medical professional advice. Regarding perceived control, infant withdrawal and maternal pain caused breastfeeding to be difficult, with decisions to continue modulated by level of outside support. Regarding self-efficacy, mothers weighed their own recovery and well-being against the constant demands of breastfeeding, impacting decisions to continue. Conclusion: Mothers with OUD face unique barriers to breastfeeding related to their infants' withdrawal as well as their own health, recovery, and social context. Overcoming these barriers may serve as future intervention targets for breastfeeding promotion among this high-risk population.

Breastfeeding: crucially important, but increasingly challenged in a market-driven world

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

Breastfeeding reduces the risk of breast cancer: A call for action in high-income countries with low rates of breastfeeding

Women in the UK have a 15% lifetime risk of developing breast cancer. Like other high-income countries, women in the UK are having children later in life which increases their risk. The risk of breast cancer is reduced by 4.3% for every 12 months of breastfeeding, this is in addition to the 7.0% decrease in risk observed for each birth. Breastfeeding reduces the risk of Triple-Negative Breast Cancer (20%) and in carriers of BRCA1 mutations (22-55%). The mechanisms of reduced risk as a result of pregnancy are related to changes in RNA processing and cellular differentiation. The UK has a low rate of breastfeeding (81%) and this is contrasted to countries with higher (Sweden, Australia) and lower rates (Ireland). The low UK rate is in part due to a lack of experience in the population, todays grandmothers have less experience with breastfeeding (62%) than their daughters. An estimated 4.7% of breast cancer cases in the UK are caused by not breastfeeding. The UK only has 43% of maternity services with full Baby-Friendly accreditation which promotes compliance with the WHO 'Ten Steps to Successful Breast Feeding'. Legislation in the UK and Europe is far short of the WHO Guidance on restricting the advertising of formula milk. Expansion of the Baby-Friendly Hospital Initiative, stricter laws on the advertising of formula milk and legislation to support nursing mothers in the workplace have the potential to increase breastfeeding in the UK. Women with a family history of breast cancer should particularly be supported to breastfeed as a way of reducing their risk.

Outcomes of Childbirth Education in PRAMS, Phase 8

OBJECTIVE

To determine if childbirth education is associated with improved outcomes for national maternal child health goals in the United States.

METHODS

This was a secondary analysis of PRAMS data. The sample was limited to survey respondents who answered a question "During your most recent pregnancy, did you take a class or classes to prepare for childbirth and learn what to expect during labor and delivery?" The outcomes included nine national objectives from Title V and Healthy People. Logistic regression models were built with control for characteristics associated with attending childbirth education. Odds ratios were converted to adjusted risk ratios for interpretation. Stratification by maternal race/ethnicity and use of Medicaid identified opportunities for improvement in childbirth education.

RESULTS

Of the 2,256 eligible respondents, 936 (41.5%) attended childbirth education. Attending childbirth education was associated with reduced likelihood of primary cesarean (ARR 0.79), increased attendance at postpartum visit (ARR 1.06), use of birth control (ARR 1.07), safe infant sleep (Back to Sleep ARR 1.04; Sleep on Own 1.12), and breastfeeding (Ever breastfeed ARR 1.08; still breastfeeding ARR 1.15). No association was found for LARC use or postpartum depression. Not all benefits of childbirth education were apparent for all racial/ethnic groups, nor for those with Medicaid insurance.

CONCLUSIONS FOR PRACTICE

Childbirth education is a community intervention that may help achieve population maternal and child health goals.

Evaluation of an Evidence-Based Prenatal Breastfeeding Education Curriculum Adapted for the COVID-19 Pandemic: Ready, Set, Baby Live COVID-19 Edition

In response to the cessation of in-person prenatal education services during the COVID-19 pandemic, we adapted an evidence-based curriculum to a live virtual format entitled Ready, Set, Baby Live COVID-19 Edition (RSB Live). In a sample of 146 pregnant people, participation in RSB Live was associated with high levels of knowledge about the benefits of breastfeeding, early infant hunger cues, and recommended maternity care practices, as well as high levels of satisfaction with adaptations to the session's content and virtual delivery. Participation was also associated with a significant increase in prenatal breastfeeding intention, a known predictor of breastfeeding outcomes. This study supports live, virtual education with a standardized curriculum as an effective and acceptable means of providing prenatal education.

Cross-cultural adaptation and content validation of the Infant Feeding Intentions Scale for Thai pregnant women

This study aimed to validate a translated and culturally adapted version of the Infant Feeding Intentions (IFI) Scale for use in Thailand. Prenatal breastfeeding intention is a strong indicator of breastfeeding initiation. The stronger the intention to breastfeed among pregnant women, the more likely breastfeeding will be initiated after childbirth and continue for an extended period. There are currently no IFI scales that have been validated for use in Thailand. The translation of the IFI scale from English to Thai was conducted through a six-stage approach that included initial translation, synthesis of translations, back-translation, expert committee review for content validity, reliability testing, and submission of the translated IFI to notify the scale developers. Both Item and Scale Content Validity Indices equaled 1, scored by five experts, who also validated the content for cross-cultural adaptation. The final Thai IFI (T-IFI) scale demonstrated high content validity. A total of 30 Thai pregnant women participated in the reliability testing. The Cronbach's alpha of the 5-item T-IFI scale was 0.857, which indicated satisfactory internal consistency. The T-IFI scale demonstrated high content validity and was culturally appropriate for use in a Thai-speaking population. It has potential to strengthen assessments of prenatal infant feeding intention among pregnant women in Thailand.

Saudi Hospitals Compliance With the (Baby-Friendly Hospitals Initiative) Evaluation Study

Introduction

National surveys from Saudi Arabia have shown that the breastfeeding rate in Saudi Arabia is lagging behind the global recommendations. The UNICEF and WHO have launched the 10-step Baby-Friendly Hospital Initiative (BFHI) for encouraging healthcare facilities across the world to support breastfeeding in a better way. In this study, we validated the Arabic version of the self-appraisal and monitoring tool based on the BFHI as well as assessed the determinants of breastfeeding practice in Saudi Arabia.

Methods

This was an analytical cross-sectional study. We used the free validated tool-Questionnaire for Breastfeeding Mother based on the BFHI Session 4.2 Guidelines. The tool was translated and validated in Arabic. A nonprobability sample included mothers of children based on the following inclusion criteria: 1) mothers living in Saudi Arabia; 2) mothers of children aged 0-12 months. The Arabic version was modified into six parts, and the questionnaire was left open for respondents for a period of six months. Descriptive statistics were performed using the Statistical Package for the Social Sciences, version 21 (IBM Corp., Armonk, NY).

Results

The sample size was 584, and during prenatal visits, 23.6% of mothers were provided with information about skin-to-skin contact immediately after childbirth. Of these, 40% started breastfeeding immediately and 43% were encouraged to breastfeed postnatally. On discharge, 34.6% of mothers received help for feeding-related issues.

Conclusion

Our hospitals are well set to adopt the BFHI in terms of policy making and coordinated postnatal care. However, prenatal care should be more focused on promoting breastfeeding. Massive and coordinated quality improvement steps are highly indicated to completely implement the initiative.

An Exploratory Study of the Associations Between the Hospital Work Environment and Implementation of Baby-Friendly Hospital Policy

A descriptive, cross-sectional study design was used to explore the relationships between the hospital work environment and implementation of the Baby-Friendly USA Ten Steps Policy in an urban hospital. Nurses reported the degree to which the Ten Steps policy was implemented, perceptions of the unit work environment using the Practice Environment Scale of the Nursing Work Index (PES-NWI), and self-efficacy related to the implementation of the policy. Results suggest that the work environment and the implementation of breastfeeding policy have separate and independent effects on nurse self-efficacy. Robust nursing leadership focused on education and skill development for clinicians, and focused on post-hospital care for patients and families are important contributory factors to successful breastfeeding policy implementation.

What works to protect, promote and support breastfeeding on a large scale: A review of reviews

Globally women continue to face substantial barriers to breastfeeding. The 2016 Lancet Breastfeeding Series identified key barriers and reviewed effective interventions that address them. The present study updates the evidence base since 2016 using a review of reviews approach. Searches were implemented using the Epistomenikos database. One hundred and fifteen reviews of interventions were identified and assessed for quality and risk of bias. Over half of reviews (53%) were high- or moderate quality, with the remaining low or critically low quality due to weaknesses in assessment of bias. A large portion of studies addressed high-income and upper-middle income settings, (41%), and a majority (63%) addressed health systems, followed by community and family settings (39%). Findings from reviews continue to strengthen the evidence base for effective interventions that improve breastfeeding outcomes across all levels of the social-ecological model, including supportive workplace policies; implementation of the Baby-Friendly Hospital Initiative, skin to skin care, kangaroo mother care, and cup feeding in health settings; and the importance of continuity of care and support in community and family settings, via home visits delivered by CHWs, supported by fathers', grandmothers' and community involvement. Studies disproportionately focus on health systems in high income and upper-middle income settings. There is insufficient attention to policy and structural interventions, the workplace and there is a need for rigorous assessment of multilevel interventions. Evidence from the past 5 years demonstrates the need to build on well-established knowledge to scale up breastfeeding protection, promotion and support programmes.

Breastfeeding Motivation Predicts Infant Feeding Intention and Outcomes: Evaluation of a Novel Adaptation of the Treatment Self-Regulation Questionnaire

BACKGROUND

Identifying those at risk for suboptimal breastfeeding outcomes remains critical for improving maternal and child health. Prenatal breastfeeding motivation may be a key predictor useful for identifying those who would benefit from additional breastfeeding support.

RESEARCH AIMS

To (1) validate a breastfeeding-specific adaptation of the Treatment Self-Regulation Questionnaire (TSRQ-BF); and (2) determine if breastfeeding motivation predicts prenatal breastfeeding intentions and early breastfeeding outcomes.

METHODS

Participants in their third trimester of pregnancy (N = 150) completed several instruments, including the TSRQ-BF and infant feeding intention, and could opt to participate in an assessment of early breastfeeding outcomes (by medical record review). TSRQ-BF subscales were derived from factor analysis, and multivariable regression was used to evaluate the association between TSRQ-BF subscale scores and breastfeeding intention and outcomes during the birth hospitalization.

RESULTS

Autonomous (related to personal values/beliefs regarding self) and Autonomous-Baby (values/benefits for the infant) subscale scores were positively associated with intended exclusivity (aOR [95% CI]: 2.22 [1.57, 3.30], 4.94 [2.49, 11.07], respectively) while higher scores on these subscales predicted longer time to planned cessation (aHR [95% CI]: 0.72 [0.61, 0.84],0.52 [0.34, 0.81]). Higher Amotivation (lack of motivation) scores were negatively associated with intended exclusivity (0.45 [0.26, 0.74]). Higher scores on Autonomous, Autonomous-Baby, and Controlled (avoidance of negative feelings/punishment or gaining reward) subscales were associated with greater odds of hospital exclusivity (aOR [95% CI]: 3.39 [1.75, 8.00], 3.44 [1.66, 9.04] and 6.05 [1.88, 29.04]) and lower odds of 2-day formula supplementation (aOR [95% CI]: 0.31 [0.14, 0.59],0.28 [0.11, 0.59], 0.19 [0.04, 0.62]).

CONCLUSIONS

The TSRQ-BF predicted breastfeeding intent and outcomes, and may be helpful for identifying patients at risk for suboptimal breastfeeding outcomes before delivery.

The role of breastfeeding promotion in German hospitals for exclusive breastfeeding duration

Breastfeeding promotion and support in hospitals is expected to have a positive impact on maternal breastfeeding outcomes. The objective of this study is to examine the association between breastfeeding promotion in maternity hospitals in Germany and exclusive breastfeeding (EBF) rates during the first 4 months. Thus, a nationwide cross-sectional web-based survey of breastfeeding promotion was conducted in 103 hospitals. Mother-infant pairs (n = 962) were recruited at these hospitals for a prospective web-based survey of breastfeeding status at five-time points, that is, during a hospital stay, at discharge as well as after 0.5, 2, and 4 months. The hospital analysis was based on the "10 Steps to Successful Breastfeeding" of the World Health Organization and the United Nations Children's Fund, adapted for Germany. Their degree of implementation was stratified by a breastfeeding promotion index (BPI) as low (≤5 steps), medium (6-8 steps), and high (≥9 steps). The association between the BPI and the odds of EBF at each of the five-time points was estimated by multivariable regression models, adjusting for various maternal factors. At all time points, the proportion of EBF among mothers from high BPI hospitals exceeded the proportion of those from medium or low BPI hospitals. A high BPI was associated with higher odds of EBF during the hospital stay and at discharge, while maternal factors for EBF such as breastfeeding experience and no early use of a pacifier persisted beyond. The high commitment of hospitals and tailored support of mothers is essential for EBF.

Breastfeeding Practices in the United Arab Emirates: Prenatal Intentions and Postnatal Outcomes

Breastfeeding provides the ideal nutrition in infancy, and its benefits extend to the health of mothers. Psychosocial factors such as the intention to breastfeed, self-efficacy, or maternal confidence to breastfeed have been shown to impact breastfeeding outcomes in other communities. The aim of this study was to assess the potential associations between mothers’ prenatal intention to breastfeed and post-delivery breastfeeding practices. A cross-sectional study was conducted from March to September 2017. Emirati and non-Emirati mothers with children below the age of 2 were recruited from maternal and child health centers in various geographical areas in Abu Dhabi Capital district, United Arab Emirates. The variables (mothers’ intention to breastfeed, breastfeeding knowledge, support from family and health care professionals, and initiation and duration of breastfeeding) were collected by research assistants during an in-person interview, using a structured questionnaire. A total of 1799 mothers participated in this study. Mothers’ prenatal intention to breastfeed was significantly associated with breastfeeding initiation (p < 0.001) and length of exclusive breastfeeding (p = 0.006). Furthermore, intention to breastfeed during early pregnancy showed a strong association (p < 0.001) with mothers who had exclusively breast fed for more than three months. In addition, knowledge on the benefits of breastfeeding and getting support from relatives and non-relatives demonstrated significant relationship with a longer period of exclusive breastfeeding (p < 0.01) In total, mothers in the study reported receiving almost four thousand advice about breastfeeding, of which 3869 (97%) were encouraging to our others in the study. Our findings on prenatal intentions, knowledge and network support on exclusive breastfeeding indicates the importance of including breastfeeding knowledge and support as critical topics during prenatal education, not only to the mothers but also to close network members who seek a healthy pregnancy outcome.

The impact of Baby Friendly Initiative accreditation: An overview of systematic reviews

Despite its reported benefits, breastfeeding rates are low globally, and support systems such as the Baby Friendly Initiative (BFI) have been established to support healthy infant feeding practices and infant bonding. Increasingly reviews are being undertaken to assess the overall impact of BFI accreditation. A systematic synthesis of current reviews has therefore been carried out to examine the state of literature on the effects of BFI accreditation. A systematic search of CINAHL, MEDLINE, Maternal and Infant Health, Scopus, the Cochrane Library and PROSPERO was undertaken. Study selection, data extraction and critical appraisal of included reviews using the AMSTAR-2 tool were undertaken by two authors, with disagreements resolved through discussion with the third author. Due to heterogeneity, a narrative synthesis of findings was applied. Fourteen reviews met the inclusion criteria. Overall confidence in the results of the review was rated as high for three reviews, low for two reviews and critically low for nine reviews. Most evidence suggests some increase in breastfeeding initiation, exclusivity and duration of breastfeeding, and one main trial suggests decreased gastrointestinal infection and allergic dermatitis in infants. However, overall certainty in the evidence was rated as very low across all outcomes due to concerns over risk of bias within and heterogeneity between the original studies. More contemporary, good-quality randomised controlled trials or well-controlled prospective comparative cohorts are required to better evaluate the impact of full BFI accreditation, with particular attention paid to the context of the research and to long-term maternal and infant health outcomes.

Impact of Doula-Led Lactation Education on Breastfeeding Outcomes in Low-Income, Minoritized Mothers

Prenatal education may improve breastfeeding outcomes among low-income women. Our objective was to assess breastfeeding intentions and knowledge among women participating in doula-facilitated prenatal education classes from August 2016 to October 2017. Breastfeeding knowledge and infant feeding intentions were assessed before and after the classes. Breastfeeding rates were assessed at birth, 2-4 weeks postpartum, and 6-8 weeks postpartum. Paired t-tests tests were conducted. A total of 121 racially diverse, low-income women were enrolled. Intentions to breastfeed increased pre- to post-intervention (p = 0.007). Breastfeeding knowledge scores increased pre- to post-intervention (p <.001); specifically, among women who were exclusively breastfeeding or breastfeeding while supplementing with formula at birth (p < .001 and p = 0.046, respectively). Doula-facilitated breastfeeding education may help improve breastfeeding outcomes for low-income women.

Baby-Friendly Hospital Initiative for Neonatal Wards: impact on breastfeeding practices among preterm infants

OBJECTIVE

to assess breastfeeding support practices for preterm infants at two Baby-Friendly hospitals in southeastern Brazil, comparing the effect of implementing the guidelines for Baby-Friendly Hospital Initiative for Neonatal wards.

METHODS

a quasi-experimental study, pre- and post-intervention with control. Implementation of this initiative in the intervention hospital using Knowledge Translation. Data collection on compliance with the adapted Ten Steps, Three Guiding Principles and the Code before and after the intervention was carried out via interviews with mothers of preterm babies and professionals, unit observation and documentary analysis in the intervention and control hospitals. Intra-intergroup comparison was performed.

RESULTS

increases in global compliance with the Three Principles, Ten Steps, the Code, partial compliance with each Principle and in most Steps was greater in the intervention hospital. Conclusion: this initiative improved practices related to breastfeeding in the intervention hospital, demonstrating the potential to improve care and breastfeeding in neonatal wards.

The comparison of access to an eHealth resource to current practice on mother and co-parent teamwork and breastfeeding rates: A randomized controlled trial

BACKGROUND

Breastfeeding rates are suboptimal, putting mothers and their infants' health at risk. One modifiable risk factor amenable to intervention is partner support. Having women work as a team with their co-parents to meet their breastfeeding goals has been found to improve breastfeeding outcomes. eHealth resources have been found to be accessible and feasible ways to provide breastfeeding education yet, the best way to design breastfeeding interventions for mothers and their co-parents is not known.

OBJECTIVES

To compare two study conditions to determine: (1) which way is more effective to provide breastfeeding education to women and their co-parents on increasing breastfeeding rates and associated secondary outcomes, such as breastfeeding knowledge, attitude, self-efficacy and overcoming challenges; (2) the difference in co-parenting and partner support between the study groups; (3) how parents in both groups preferred to access breastfeeding information; and (4) the groups' satisfaction with the eHealth resource that was provided.

DESIGN

This study used a randomized controlled trial design (Clinicaltrials.org #NCT03492411). Participants were randomly allocated to study groups with concealed opaque envelopes by a blinded research assistant. Participants in Study Condition #1 (SC1) accessed a previously created, online e-Health resource, in addition to other generally available resources they could access in the community; participants in Study Condition #2 (SC2) accessed only the generally available resources.

SETTING

Participants were recruited in health care providers' offices and services for expectant parents in Ontario and via social media throughout Canada.

PARTICIPANTS

Expectant women (n = 113) and their co-parents (n = 104) were enrolled.

METHODS

After eligibility was determined, consents obtained and baseline surveys completed, group allocation was conducted. SC1 had a virtual meeting with a research assistant to review the eHealth resource. Weekly emails were sent to all participants for 6 weeks as reminders. Follow-up data were electronically collected from mothers and co-parents at 2 weeks post enrollment and 4, 12, 26 and 52-weeks postpartum.

RESULTS

Breastfeeding rates were high in both groups (SC1 63% and SC2 57% 'exclusive' 6 months) and (SC1 71% and SC2 78% 'any' 12 months) and not statistically significantly different. High scores were found in both groups in secondary outcome measures. Generally available breastfeeding resources were used in both groups with websites being used often and rated as most helpful. SC1 rated the eHealth resource provided to them highly.

CONCLUSION

The findings suggest both mothers and their co-parents should be targeted in breastfeeding education and web-based resources designed to meet their needs.

Facility readiness and counseling during antenatal care and the relationship with early breastfeeding in Haiti and Malawi

BACKGROUND

Early initiation of breastfeeding (within an hour of birth) has benefits for newborn health and survival. Optimal breastfeeding supports growth, health, and development. Health facilities provide essential pregnancy, maternal, and newborn care and offer support for early breastfeeding. We examined the relationship between the breastfeeding-related health service environment during antenatal care (ANC) and early initiation of breastfeeding.

METHODS

Using data from recent Service Provision Assessment (SPA) surveys in Haiti and Malawi, we defined three indicators of the health service environment: availability of facilities with ANC services reporting routine breastfeeding counseling; provider training on breastfeeding; and breastfeeding counseling during ANC. We linked SPA data geographically to Demographic and Health Surveys (DHS) data from Haiti and Malawi. Multilevel, multivariable logistic regressions examined associations between the health service environment and early initiation of breastfeeding, controlling for women's background characteristics, with separate analyses for urban and rural residence.

RESULTS

Over 95% of facilities in Haiti and Malawi reported routinely providing breastfeeding counseling during ANC. Only 40% of both urban and rural providers in Malawi and 29 and 26% of providers at urban and rural facilities in Haiti (respectively) received recent training in counseling on breastfeeding. Further, only 4-10% of clients received counseling. Breastfeeding counseling was generally more common among clients who attended ANC with a provider who had received recent training. After linking SPA and DHS data, our analysis showed that having more providers recently trained on breastfeeding was significantly associated with increased odds of early breastfeeding among women in urban areas of Haiti and Malawi. Additionally, women in urban areas of Malawi lived near facilities with more counseling during ANC were more likely to begin breastfeeding within an hour of birth compared with women in areas with less counseling.

CONCLUSIONS

Our study identified gaps in the health system's capacity to implement the recommended global guidelines in support of optimal breastfeeding practices. While breastfeeding counseling during ANC can promote early breastfeeding, counseling was not common. The study provides evidence that provider training could help improve counseling and support for early initiation of breastfeeding.

Application and evaluation of the best practice guideline: Breastfeeding

OBJECTIVE

To analyse the progress of care in the promotion of breastfeeding and describe breastfeeding results following the implementation of the RNAO guideline in various types of national health centres.

METHOD

Quantitative descriptive longitudinal study of the results of implementing the recommendations of the RNAO-Breastfeeding guideline in 9 national health centres following the implementation methodology of the programme of the Best Practice Spotlight Organization®. Process and result variables are collected at hospital level and in primary care by registering on the CAREVID platform. The weighted mean was calculated as a summary statistic.

RESULTS

The implementation of the recommendations of the Breastfeeding guideline was associated with a relative increase in: skin-to-skin contact 57,7% (p < 0,000), exclusive breastfeeding in the 1st intake 47,8% (p < 0,000), exclusive breastfeeding on hospital discharge 18,4% (p < 0,000) and prenatal education 63,95% (p < 0,00).

CONCLUSION

The implementation of the RNAO-Breastfeeding guideline in different national health centres has increased the application of the recommendations based on scientific evidence, generalising appropriate breastfeeding care (such as prenatal education, application of skin-to-skin contact and exclusive breastfeeding in the first intake) and is consequently significantly approaching the international recommendations on breastfeeding.

Perspectives about the baby friendly hospital/health initiative in Australia: an online survey

BACKGROUND

Evidence supports the health and economic benefits of breastfeeding, and the positive impact of the Baby Friendly Health Initiative (BFHI) on increasing breastfeeding rates and improving breastfeeding outcomes. The BFHI is a World Health Organization and United Nations International Children's Emergency Fund initiative to promote, support and maintain breastfeeding. The BFHI was updated in 2018 and includes the Ten Steps to Successful Breastfeeding (the Ten Steps 2018) and the International Code of Marketing of Breast-milk Substitutes (the WHO Code). Despite policy and guideline support for breastfeeding and the BFHI, there are currently only 70 accredited hospitals, healthcare centres and regional clusters in Australia, accounting for 23% of maternity facilities. This research aimed to explore health professionals and other stakeholders' perspectives on the uptake and implementation of the BFHI in Australia from an organisational change perspective.

METHODS

An online survey administered via relevant Australian-based professional associations was fully or partially completed by 332 participants who support mothers and newborns in their roles. Descriptive statistics and content analysis were used to analyse quantitative and qualitative data.

RESULTS

The majority of participants supported legislating the WHO Code, closely monitoring BFHI compliance, ensuring sufficient knowledge about breastfeeding and the BFHI among staff, improving care within maternity facilities, continuous support of mothers' post-discharge, and improving social media support of breastfeeding. It was also perceived that an interdisciplinary team approach and multidisciplinary involvement were important requirements for successfully implementing the BFHI. There was no consensus among participants that Australian health policies support breastfeeding and the implementation of the BFHI.

CONCLUSIONS

This study emphasised the significance of legislation around the Code, executive and leadership support and culture, and providing adequate resources concerning uptake and implementation of the BFHI. Considering that uptake of the BFHI has been limited and no formal government support has been provided to further develop the BFHI and support the Code in Australia, findings of this research may help with potential future actions to facilitate the BFHI uptake and Code implementation.

Development, psychometric assessment, and predictive validity of the comprehensive breastfeeding knowledge scale

AIM

To develop a breastfeeding knowledge scale that aligns with the Baby Friendly Hospital Initiative and psychometrically test it among expectant parents.

BACKGROUND

Although breastfeeding is recommended by all leading health authorities, rates remain suboptimal with women often not achieving their breastfeeding goals. One factor found to positively influence infant feeding behaviours is increased maternal breastfeeding knowledge. However, little research has been conducted validating the dimensions of breastfeeding knowledge to guide interventions to promote positive breastfeeding outcomes.

DESIGN

Following an extensive literature review, the 28-item Comprehensive Breastfeeding Knowledge Scale (CBKS) was developed and psychometrically tested.

METHOD

A sample of 217 Canadian expectant parents (113 women and 104 coparents) was recruited and administered the CBKS with follow-up questionnaires at 4 and 12 weeks postpartum. Psychometric analyses included exploratory factor analysis, internal consistency, concurrent validity, and predictive validity.

RESULTS

Exploratory factor analysis resulted in three dimensions: (1) managing milk supply; (2) persisting through challenges; and (3) correcting misconceptions. Coefficient alpha for the total scale was 0.83 and support for concurrent validity was demonstrated through significant positive correlations with the Iowa Infant Feeding Attitude scale. Further, higher total and subscale scores in pregnancy were associated with exclusive breastfeeding at 4 and 12 weeks postpartum, providing good evidence for predictive validity.

CONCLUSION

Preliminary data suggest the CBKS is a valid and reliable measure of breastfeeding knowledge. Upon further testing, this self-report measure may be used to (1) identify women with low breastfeeding knowledge requiring targeted support, (2) individualize health professional care with breastfeeding women, and (3) evaluate the effectiveness of breastfeeding interventions and programs.

Breastfeeding and the Risk of Infant Illness in Asia: A Review

Infancy remains the most vulnerable period of human life for death, illness, and establishing a lifetime trajectory of growth and health. It is estimated that there are 5.3 million deaths under five years of age worldwide and approximately 800,000 lives could be saved by improving breastfeeding rates and duration. In Asia, an estimated 300,000-350,000 child deaths could be prevented with optimal breastfeeding and the majority would be under 12 months of age. We present a systematic review of studies of infection and breastfeeding in infants in Asia and further review interactions of selected infectious diseases and breastfeeding. Initially, 2459 records of possible interest were identified, 153 full text papers were reviewed in detail, and 13 papers describing diarrhoeal disease and/or acute respiratory tract infection were selected for inclusion in the review. Additional papers were selected to discuss specific diseases and their relationship to breastfeeding. The review found that a variety of methods were used with differing definitions of breastfeeding and diseases. Overall, breastfeeding when compared to the use of infant formula, is associated with significantly lower rates of diarrhoeal disease and lower respiratory tract infection, with a reduction of 50% or more to be expected, especially in infants under six months of age. The relationship between breastfeeding and specific diseases including measles and HTLV1 were reviewed. Breastfeeding reduces some disease rates, but there remain a few conditions where breastfeeding may be contra-indicated.

The Economic Influence of Breastfeeding on the Health Cost of Newborns

BACKGROUND

Breastfeeding provides health benefits for women and newborns. However, few studies have explored how these health benefits translate into economic savings.

RESEARCH AIM

This study aimed to estimate the healthcare costs savings generated by exclusive breastfeeding for healthy newborns.

METHODS

We designed a longitudinal two-group observational study that included healthy women and newborns ( N = 236) in Toledo, Spain. Over the first 6-months of the infants' lives, we reviewed their clinical histories to determine their consumption of healthcare resources and the type of nutrition provided. The sample was categorized into two groups: exclusive breastfeeding ( n = 46) and non-exclusive breastfeeding for 6 months ( n = 190). Two-part regression models were applied to determine whether there were differences in healthcare costs between the groups.

RESULTS

The average age of the women was 32 ( SD: 5.3). The average birth weight of the newborns was 3.3 kg. ( SD: 0.38). At 6 months, 19.5% ( n = 46) of the women breastfed exclusively, 28.4% ( n = 67) combined breastfeeding with formula, and 45.8% ( n = 108) used formula only. Healthcare costs during follow-up reached €785.58 (44% for specialized care, 42% for primary care, 9.8% for medical emergencies, 3% for medications and approximately 1% for medical tests). The statistical analysis estimated a lower healthcare cost of between €454.40 and €503.50 for exclusively breastfed newborns.

CONCLUSION

Breastfeeding generated savings in healthcare costs; therefore, it could be a cost-efficient option compared with alternatives. Researchers who evaluate the efficiency of strategies that promote breastfeeding can contribute to the sustainability of health services.

Evaluation of Ready, Set, BABY: A prenatal breastfeeding education and counseling approach

BACKGROUND

Comprehensive prenatal education on infant feeding is recommended by many United States health organizations because of the need to maximize maternal preparedness for managing lactation physiology. Ready, Set, BABY (RSB) is a curriculum developed for counseling women about breastfeeding benefits and management including education on optimal maternity care practices. We hypothesized that RSB would be acceptable to mothers and that mothers' strength of breastfeeding intentions would increase, and their comfort with the idea of formula feeding would decrease after educational counseling using the materials. We also hypothesized that mothers' knowledge of optimal maternity care practices would increase after participation.

METHODS

Materials were sent to a total of seven sites in the United States and Puerto Rico. Local health care practitioners completed training before counseling mothers with the curriculum. A pre- and postintervention questionnaire was administered to participants. Statistical analysis of results included paired t tests, Wilcoxon signed-rank tests, and McNemar's tests.

RESULTS

Four hundred and sixteen expectant women participated. In the pre- and postintervention comparison, maternal participation in RSB significantly improved Infant Feeding Intentions Scale scores (P < 0.001) and knowledge of Baby-Friendly recommended maternity care practices (P < 0.001), while significantly decreasing comfort with the idea of formula feeding (P < 0.001). The education materials were positively rated by participants.

CONCLUSIONS

The findings indicate that the approach of using RSB in prenatal counseling group classes or individual sessions improves breastfeeding intentions. Future testing is needed to determine the effectiveness of the materials for impacting breastfeeding outcomes.

Infant Feeding Guidelines for the Asia Pacific Region

Good nutrition for infants, during the first 1000 days from conception, is one of the most important determinants of a healthy long life. Breastfeeding is the most important component of infant nutrition and reduces morbidity and mortality. With the changes to the climate currently occurring, issues of nutrition and food supply are only going to increase in importance. The Sustainable Development Goals of the United Nations, place nutrition at the forefront of world development and a sustainable planet. The vision of Asia-Pacific Academic Consortium for Public Health (APACPH) is to "achieve the highest possible level of health of all the people of the nations of the Asia-Pacific region." Much of the burden of disease, early deaths, and disability in the Asia Pacific region could be reduced with public health efforts to address the major risk factors, including nutrition-related causes and smoking. The United Nations Decade of Action on Nutrition 2016-2025 has recently been launched with the aim of reducing the global burden of inappropriate nutrition. The goals include increasing rates of exclusive breastfeeding to 6 months, reducing wasting and stunting, and reducing the rates of low birthweight. This is the position endorsed in these guidelines along with the principles of the Baby Friendly Hospital Initiative. These guidelines expand the information on infants that was included in the 2016 APACPH Dietary Guidelines. APACPH covers many different environments, geographical areas, cultures, and socioeconomic groups. These guidelines are generally applicable to all infants in our region, specific local advice may sometimes be needed.

ABM Clinical Protocol #7: Model Maternity Policy Supportive of Breastfeeding

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Influences of Cesarean Delivery on Breastfeeding Practices and Duration: A Prospective Cohort Study

BACKGROUND

Mothers are encouraged to exclusively breastfeed for the first 6 months. However, cesarean delivery rates have increased worldwide, which may affect breastfeeding. Research aim: This study aimed to determine the potential effects of cesarean delivery on breastfeeding practices and breastfeeding duration.

METHODS

This was a 6-month cohort study extracted from a 24-month prospective cohort study of mother-infant pairs in three communities in Hunan, China. Data about participants' characteristics, delivery methods, breastfeeding initiation, use of formula in the hospital, exclusive breastfeeding, and any breastfeeding were collected at 1, 3, and 6 months following each infant's birth. The chi-square test, logistic regression model, and Cox proportional hazard regression model were used to examine the relationship between breastfeeding practices and cesarean delivery.

RESULTS

The number of women who had a cesarean delivery was 387 (40.6%), and 567 (59.4%) women had a vaginal delivery. The exclusive breastfeeding rates at 1, 3, and 6 months were 80.2%, 67.4%, and 21.5%, respectively. Women who had a cesarean delivery showed a lower rate of exclusive breastfeeding and any breastfeeding than those who had a vaginal delivery ( p < .05). In addition, cesarean delivery was related with using formula in the hospital and delayed breastfeeding initiation. Cesarean delivery also shortened the breastfeeding duration (hazard ratio = 1.40, 95% confidence interval [1.06, 1.84]).

CONCLUSION

Healthcare professionals should provide more breastfeeding skills to women who have a cesarean delivery and warn mothers about the dangers of elective cesarean section for breastfeeding practices.

The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature

There is no doubt regarding the multiple benefits of breastfeeding for infants and society in general. Therefore, the World Health Organization (WHO) in a conjoint effort with United Nations International Children's Emergency Fund (UNICEF) developed the "Ten Steps to Successful Breastfeeding" in 1992, which became the backbone of the Baby Friendly Hospital Initiative (BFHI). Following this development, many hospitals and countries intensified their position towards creating a "breastfeeding oriented" practice. Over the past two decades, the interest increased in the BFHI and the Ten Steps. However, alongside the implementation of the initiative, extensive research continues to evaluate the benefits and dangers of the suggested practices. Hence, it is our intention to make a critical evaluation of the current BFHI and the Ten Steps recommendations in consideration of the importance of providing an evidence-based breastfeeding supported environment for our mothers and infants.

Effect of maternal country of birth on breastfeeding practices: results from Portuguese GXXI birth cohort

Background

Maternal country of birth has been associated with perinatal health outcomes but less is known regarding breastfeeding practices in contemporary European settings. This study investigated effect of maternal country of birth on breastfeeding initiation and duration by comparing native Portuguese and migrant mothers.

Methods

We analyzed data of 7065 children of the Generation XXI (GXXI) birth cohort recruited at birth (2005–06) and followed-up 4 years later. Logistic regression was used to assess the effect of maternal country of birth on breastfeeding initiation. Kaplan-Meier estimate was used to compare breastfeeding duration by maternal country of birth and length of residence by migrant mothers in Portugal.

Results

Breastfeeding initiation and the type of breastfeeding practice were similar for native Portuguese and migrant mothers. The migrants had significantly higher median duration in months of any breastfeeding (Odds Ratio [OR] 6.0, 95% Confidence Interval [CI] 5.4,6.6) and exclusive breastfeeding (OR 4.0, 95% CI 3.8,4.2) than native Portuguese mothers (OR 4.0, 95% CI 3.8,4.2 and OR 3.0, 95% CI 2.9,3.0). Migrant mothers who resided in Portugal for either ≤5 years (OR 5.0, 95% CI 3.9,6.1 and OR 4.0, 95% CI 3.8,4.2) or >  5 years (OR 6.0, 95% CI 5.5,6.5 and OR 4.0, 95% CI 3.7,4.3) years had similar duration of any breastfeeding or exclusive breastfeeding, in both cases higher than the native Portuguese mothers. No significant differences were found when world regions were compared.

Conclusions

Maternal country of birth does not influence breastfeeding initiation and type of feeding practice. However, migrant mothers have longer breastfeeding duration of either exclusive or any breastfeeding, which was not changed by length of residence in Portugal.

Electronic supplementary material

The online version of this article (10.1186/s13006-018-0157-x) contains supplementary material, which is available to authorized users.

Maternal intention to exclusively breast feed among mainland Chinese mothers: A cross-sectional study

OBJECTIVE

to examine postpartum maternal recall of their intentions to exclusively breast feed among breastfeeding women and identify its predictors.

DESIGN AND SETTING

a cross-sectional descriptive study was conducted in a regional teaching hospital at Guangzhou, China between April 1 and July 14, 2014.

PARTICIPANTS

571 mothers who were within four days after delivery were recruited to the study.

MEASUREMENTS

data were collected by four research assistants with maternal intention to breast feed data sheet, the Network Support for Breastfeeding Scale (NSBS), and a socio-demographic data sheet.

FINDINGS

greater than half of the mothers (69.5%) intended to exclusively breast feed. The logistic regression analysis revealed six variables which predicted postpartum maternal recall of their intentions to exclusively breast feed. They were support from husband, being breast-fed as an infant, previous breast feeding experience, attending antenatal breast feeding class, time of decision to breast feed, and the rating of the importance of my baby's health.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

health care professionals could develop strategies to enhance mothers' intention to exclusively breast feed, such as providing antenatal breast feeding class on internet, a strong focus on the benefits of exclusive breast feeding on the baby's health in the education programme, and more efforts directed toward educating school-aged children and adolescents to modify societal perceptions of what are considered normal infant feeding. Mothers' husband could be encouraged in supporting exclusive breast feeding.