Process-oriented training in breastfeeding for health professionals decreases women's experiences of breastfeeding challenges

Partners' experiences of breastfeeding: a qualitative evaluation of a breastfeeding support intervention in Sweden

BACKGROUND

The World Health Organization states that women and their families need breastfeeding support from the healthcare system. However, knowledge about the most effective way to involve the partner in breastfeeding is lacking. A qualitative evaluation can provide insight and knowledge about the partner's experiences towards a breastfeeding support intervention and thus contribute to how forthcoming breastfeeding support policies are designed. The aim of this study was to explore partners' experiences regarding breastfeeding while participating in The Breastfeeding Study.

METHODS

An exploratory, longitudinal and qualitative design was used. This study was part of The Breastfeeding Study, which took place in Sweden. The intervention was performed in line with the Ten Steps to Successful Breastfeeding. Partners in the in the intervention group (IG) were part of a structured breastfeeding support programme. An individual breastfeeding plan was established in cooperation with the parents-to-be during pregnancy, and the plan was followed up at the child healthcare centre. A purposive sample was recruited from March to December 2021. Interviews and diary entries from IG (n = 8) and control group (CG) (n = 8) during pregnancy and 2 months after birth were analysed by content analysis, in accordance with the COREQ guidelines.

RESULTS

Partners' experiences can be summarised under the main category of 'Striving to be part of the family and important that the family's everyday life was well-functioning'. IG partners experienced that both parents were involved and cooperated in the breastfeeding process and that guidance from healthcare professionals (HCPs) helped them to feel secure. CG partners experienced feeling excluded and not receiving support from HCPs.

CONCLUSION

Both parents need to be targeted in breastfeeding support policies to meet the support needs. Midwives at antenatal care and child healthcare nurses at the child healthcare centre have important roles to play in providing structured breastfeeding support and a breastfeeding plan. Both IG and CG partners strived to become a part of the infant's life and to make family life work. Midwives should involve both parents in a reflective dialogue on how the partner can be involved, apart from just feeding the infant.

TRIAL REGISTRATION

Retrospectively registered in ACTRN12623000648628.

Breastfeeding training improved healthcare professional's self-efficacy to provide evidence-based breastfeeding support: A pre-post intervention study

OBJECTIVE

To describe healthcare professional's (HCP's) perceived self-efficacy in their ability to provide breastfeeding support before and after a breastfeeding training program.

DESIGN

Pre-post intervention study.

SETTING

Antenatal care and child healthcare (CHC) centres in Sweden during 2020.

PARTICIPANTS

An intervention group consisting of 39 HCPs (midwives 51.3%, child healthcare nurses 46.2%) completing a questionnaire at baseline and after intervention, and a control group of 34 HCPs (midwives 61.8%, child healthcare nurses 38.2%) completing a questionnaire at baseline.

INTERVENTION

A breastfeeding training program in line with the Ten Steps to Successful Breastfeeding and WHO recommendations about breastfeeding.

MEASUREMENTS AND FINDINGS

The 11-item Breastfeeding Support Confidence Scale (BSCS) measures HCP's self-efficacy regarding providing breastfeeding support in line with Ten Steps to Successful Breastfeeding and WHO recommendations. The intervention group experienced a significantly increased self-efficacy from pre-intervention to post-intervention for 8 of the 11 BSCS items, with the overall BSCS index score increasing from 36.87 to 39.56 points (p = 0.001). The index score in the intervention group at follow-up was significantly higher than the corresponding score in the control group at baseline (p = 0.025). The intervention group had significantly higher scores at follow-up than the control group at baseline on the questions: "I'm sure that I can help mothers continue to breastfeed even if the infant doesn't follow the growth curve" (p = 0.026) and "I'm sure that I can help mothers continue to breastfeed when the breastfeeding is painful" (p = 0.048).

KEY CONCLUSIONS

The breastfeeding training program improved HCP' self-efficacy to provide evidence-based support to breastfeeding mothers.

IMPLICATIONS FOR PRACTICE

This training program is well suited to implement in clinical practice and follows the Ten Steps to Successful Breastfeeding.

TRIAL REGISTRATION

ACTRN12623000648628.

Mixing Meds and Milk: Evaluation of a Performance Gap Intervention for Provider Education in Breastfeeding and Maternal Medication Use

The need for maternal medications is a known barrier to breastfeeding. Though most medications are compatible with lactation, healthcare providers use abundant caution, often viewing medications and breastfeeding as mutually exclusive. A dual intervention of an educational webinar and access to a mobile app for lactation pharmacology was used to enhance provider familiarity, confidence, and access to knowledge in medication use during breastfeeding. Surveys were administered before, one week after, and three months after the webinar to evaluate performance gap improvement. Usage data of the mobile app was collected over twelve months to monitor topic engagement. Results suggested the interventions temporarily increased provider confidence in maternal medication use during lactation; however, the increase was not sustained at three months. Even with one-time training and lactation-specific mobile app access, simply providing an informational resource is insufficient to support evidence-informed care for lactating patients. Longitudinal training on evidence-based medication safety is critical to care for the lactating dyad.

Effects of breastfeeding training programmes for midwives on breastfeeding outcomes: a systematic review and meta-analysis

BACKGROUND

Appropriate breastfeeding training for midwives is necessary to enhance their knowledge, attitude, and practice (KAP). However, evidence surrounding the effects of midwife breastfeeding training programmes is insufficient to draw a conclusion of its effectiveness on breastfeeding initiation, duration, and rates.

OBJECTIVE

The aim of this systematic review was to identify, summarise, and critically analyse the available literature to evaluate the effects of midwife breastfeeding training programmes on the midwives' KAP towards breastfeeding and breastfeeding initiation, duration and rates among postnatal mothers.

METHODS

Nine English and six Chinese databases were searched with relevant key words. The methodological quality of the included studies were assessed by two reviewers independently using the Joanna Briggs Institute critical appraisal checklists.

RESULTS

Nine English and one Chinese articles were included in this review. Five articles investigating midwives' KAP towards breastfeeding reported positive results (p < 0.05). The meta-analysis revealed that breastfeeding training programmes significantly improved midwives' breastfeeding-related knowledge and skills (standardised mean difference = 1.33; 95% confidence interval, 0.98 to 1.68; p < 0.01; I² = 36%), as well as their attitude towards breastfeeding (p < 0.05). An additional five articles measured the effects of breastfeeding training programmes on the initiation, duration, and rates of breastfeeding among postnatal mothers. Following the implementation of a breastfeeding training programme for midwives, mothers had significantly longer durations of exclusive breastfeeding (p < 0.05), fewer breastfeeding challenges (p < 0.05) (e.g. breast milk insufficiency), and higher satisfaction with breastfeeding counselling (p < 0.01), and fewer infants received breast milk substitutes in their first week of life without medical reasons (p < 0.05) in the intervention group compared with the control group. However, no significant effects were seen on the initiation and rates of breastfeeding after implementation of the programmes.

CONCLUSIONS

This systematic review has demonstrated that midwife breastfeeding training programmes could improve midwives' KAP towards breastfeeding. However, the breastfeeding training programmes had limited effects on breastfeeding initiation and rates. We suggest that future breastfeeding training programme should incorporate counselling skills alongside breastfeeding knowledge and skills training.

REVIEW REGISTRATION

This systematic review has been registered in the International prospective register of systematic reviews (PROSPERO) (ID: CRD42022260216).

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

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

Relationship of delayed lactogenesis II to maternal perception of insufficient milk: A longitudinal study

AIM

To analyze the relationship of delayed lactogenesis II with maternal perception of insufficient milk.

METHODS

A prospective, multicenter, longitudinal observational study was conducted. Data were obtained at discharge and between 1 and 5 months postpartum on the perception of insufficient milk and related variables, by means of a self-administered questionnaire, and subsequent postal and online follow-up. Logistic regression analysis was used to develop the explanatory model.

RESULTS

A total of 260 puerperal mothers participated. Of these, 31.9% had insufficient milk and 23.6% had delayed lactogenesis II. During postpartum admission, delayed lactogenesis II (OR = 2.26; 95%CI = 1.07-4.79), difficulty in breastfeeding (OR = 1.02; 95%CI = 1.00-1.03), and professional help in breastfeeding (OR = 0.70; 95%CI = 0.50-0.97) were associated with maternal perception of insufficient milk.

CONCLUSIONS

The occurrence of breastfeeding difficulties during postpartum admission and at discharge, especially when there is delayed lactogenesis II, should be considered risk indicators, suggesting the need for additional support to standardized care. The PIM is a suitable indicator to assess the quality of professional breastfeeding support in improvement interventions.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

1. To describe types of breastfeeding support for healthy breastfeeding mothers with healthy term babies. 2. To examine the effectiveness of different types of breastfeeding support interventions in terms of whether they offered only breastfeeding support or breastfeeding support in combination with a wider maternal and child health intervention ('breastfeeding plus' support).  3. To examine the effectiveness of the following intervention characteristics on breastfeeding support:      a. type of support (e.g. face-to-face, telephone, digital technologies, group or individual support, proactive or reactive);      b. intensity of support (i.e. number of postnatal contacts);      c. person delivering the intervention (e.g. healthcare professional, lay person);     d. to examine whether the impact of support varied between high- and low-and middle-income countries.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes results of searches of CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP)) (11 May 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. Support could be provided face-to-face, over the phone or via digital technologies. All studies had to meet the trustworthiness criteria.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed risk of bias and study trustworthiness.  The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 116 trials of which 103 contribute data to the analyses. In total more than 98,816 mother-infant pairs were included.  Moderate-certainty evidence indicated that 'breastfeeding only' support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at six months (Risk Ratio (RR) 0.93, 95% Confidence Interval (CI) 0.89 to 0.97); stopping exclusive breastfeeding at six months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4-6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4-6 (RR 0.83 95% CI 0.76 to 0.90). Similar findings were reported for the secondary breastfeeding outcomes except for any breastfeeding at two months and 12 months when the evidence was uncertain if 'breastfeeding only' support helped reduce the number of women stopping breastfeeding.  The evidence for 'breastfeeding plus' was less consistent. For primary outcomes there was some evidence that 'breastfeeding plus' support probably reduced the number of women stopping any breastfeeding (RR 0.94, 95% CI 0.91 to 0.97, moderate-certainty evidence) or exclusive breastfeeding at six months (RR 0.79, 95% CI 0.70 to 0.90).  'Breastfeeding plus' interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4-6 weeks, but the evidence is very uncertain (RR 0.73, 95% CI 0.57 to 0.95). The evidence suggests that 'breastfeeding plus' support probably results in little to no difference in the number of women stopping any breastfeeding at 4-6 weeks (RR 0.94, 95% CI 0.82 to 1.08, moderate-certainty evidence). For the secondary outcomes, it was uncertain if 'breastfeeding plus' support helped reduce the number of women stopping any or exclusive breastfeeding at any time points.  There were no consistent findings emerging from the narrative synthesis of the non-breastfeeding outcomes (maternal satisfaction with care, maternal satisfaction with feeding method, infant morbidity, and maternal mental health), except for a possible reduction of diarrhoea in intervention infants.  We considered the overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions and as studies utilised self-report breastfeeding data, there is also a risk of bias in outcome assessment.   We conducted meta-regression to explore substantial heterogeneity for the primary outcomes using the following categories: person providing care; mode of delivery; intensity of support; and income status of country.  It is possible that moderate levels (defined as 4-8 visits) of 'breastfeeding only' support may be associated with a more beneficial effect on exclusive breastfeeding at 4-6 weeks and six months. 'Breastfeeding only' support may also be more effective in reducing women in low- and middle-income countries (LMICs) stopping exclusive breastfeeding at six months compared to women in high-income countries (HICs). However, no other differential effects were found and thus heterogeneity remains largely unexplained. The meta-regression suggested that there were no differential effects regarding person providing support or mode of delivery, however, power was limited.  AUTHORS' CONCLUSIONS: When 'breastfeeding only' support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points.  For 'breastfeeding plus' interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face-to-face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.

Risk factors for self‐reported insufficient milk during the first 6 months of life: A systematic review

The objective of this systematic review was to identify multifactorial risk factors for self‐reported insufficient milk (SRIM) and delayed onset of lactation (DOL). The review protocol was registered a priori in PROSPERO (ID# CDR42021240413). Of the 120 studies included (98 on SRIM, 18 on DOL, and 4 both), 37 (31%) studies were conducted in North America, followed by 26 (21.6%) in Europe, 25 (21%) in East Asia, and Pacific, 15 (12.5%) in Latin America and the Caribbean, 7 (6%) in the Middle East and North Africa, 5 (4%) in South Asia, 3 (2.5%) in Sub‐Saharan Africa, and 2 (1.7%) included multiple countries. A total of 79 studies were from high‐income countries, 30 from upper‐middle‐income, 10 from low‐middle‐income countries, and one study was conducted in a high‐income and an upper‐middle‐income country. Findings indicated that DOL increased the risk of SRIM. Protective factors identified for DOL and SRIM were hospital practices, such as timely breastfeeding (BF) initiation, avoiding in‐hospital commercial milk formula supplementation, and BF counselling/support. By contrast, maternal overweight/obesity, caesarean section, and poor maternal physical and mental health were risk factors for DOL and SRIM. SRIM was associated with primiparity, the mother's interpretation of the baby's fussiness or crying, and low maternal BF self‐efficacy. Biomedical factors including epidural anaesthesia and prolonged stage II labour were associated with DOL. Thus, to protect against SRIM and DOL it is key to prevent unnecessary caesarean sections, implement the Baby‐Friendly Ten Steps at maternity facilities, and provide BF counselling that includes baby behaviours.

Socioeconomic and demographic factors indicative of lower economic status increased the risk of self‐reported insufficient milk (SRIM) and delayed onset of lactation (DOL).

Timely breastfeeding (BF) initiation and avoidance of in‐hospital commercial milk formula (CMF) supplementation are likely to reduce the prevalence of SRIM and DOL.

BF counselling designed to prevent SRIM and DOL needs to strengthen maternal BF self‐efficacy, maternal understanding of baby behaviours such as fussiness and maternal wellbeing.

Research is needed to better understand how the risk of DOL and SRIM increases with primiparity, caesarean sections, maternal overweight/obesity, and poor overall maternal health.

Intervention studies specifically designed to reduce the risk of SRIM and DOL are urgently needed in low‐ and middle‐income countries.

Women's advice to healthcare professionals regarding breastfeeding: "offer sensitive individualized breastfeeding support"- an interview study

Background

The World Health Organization recommends exclusive breastfeeding for 6 months followed by continued breastfeeding with complementary food up to 2 years of age or beyond. Few women achieve this recommendation in Sweden, and they often stop breastfeeding earlier than they would like. Investigating women’s advice to healthcare professionals is important for the provision of optimal breastfeeding support. The aim of this study was to explore women’s advice to healthcare professionals regarding support for continuing to breastfeed for at least 6 months.

Methods

This investigation used an exploratory study design, and a purposive sample of women was recruited between 2015 and 2016 through social media platforms. The work is a follow-up of an earlier study exploring women’s perceptions of the factors that assisted them in breastfeeding for at least 6 months. Telephone interviews were conducted with 139 Swedish women who reported that they had breastfed for at least 6 months. Women were asked the question, “Do you have any advice that you would like to give to healthcare professionals regarding breastfeeding support?”. The data were analysed using content analysis.

Results

The theme, “Professionals need to offer women sensitive, individualized breastfeeding support to promote a positive breastfeeding experience”, describes the women’s advice based on five categories: 1) providing evidence-based care, 2) preparing expectant parents during pregnancy, 3) creating a respectful and mutual dialogue, 4) offering individual solutions to breastfeeding problems, and 5) offering practical support.

Conclusions

This study highlights the importance of professionals providing evidence-based breastfeeding support in a sensitive and individualized manner. This consideration is an important prerequisite to strengthening women’s self-confidence and assisting them in reaching their breastfeeding goals, which may enhance the positive nature of their breastfeeding experience.

Information and Communication Systems to Tackle Barriers to Breastfeeding: Systematic Search and Review

Background

Breastfeeding has many benefits for newborns, mothers, and the wider society. The World Health Organization recommends mothers to feed newborns exclusively with breastmilk for the first 6 months after birth, but breastfeeding rates in many countries fail to align with the recommendations because of various barriers. Breastfeeding success is associated with a number of determinants, such as self-efficacy, intention to breastfeed, and attitudes toward breastfeeding. Information and communication technology (ICT) has been leveraged to support breastfeeding by means of improving knowledge or providing practical supports in different maternal stages. Previous reviews have examined and summarized the effectiveness and credibility of interventions; however, no review has been done from a human-computer interaction perspective that is concerned with novel interaction techniques and the perspective of end users.

Objective

The objective of this review was to provide a comprehensive overview of existing digital interventions that support breastfeeding by investigating systems’ objective, technology design, validation process, and quality attributes, both in terms of clinical parameters as well as usability and user experience.

Methods

A systematic search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the following libraries: PubMed, Science Direct, Association for Computing Machinery Digital Library (ACM Digital Library), and Institute of Electrical and Electronics Engineers Xplore (IEEE Xplore).

Results

A total of 35 papers discussing 30 interventions were included. The main goals of these interventions were organized into 4 categories: breastfeeding education (n=12), breastfeeding promotion (n=8), communication support (n=6), and daily practical support (n=4). Of the interventions, 13 target mothers in the postnatal period. Most interventions come in forms of client communication systems (n=18), which frequently leverage Web technologies, text message, and mobile apps to provide breastfeeding support. Systems predominantly focus on mothers; validation strategies were rather heterogeneous, with 12 user studies concerning usability and user experience and 18 clinical validation studies focusing on the effects of the interventions on breastfeeding determinants; 5 papers did not report results. Generally, straightforward systems (eg, communication tools or Web-based solutions) seem to be more effective than complex interventions (eg, games).

Conclusions

Existing information and communication systems offer effective means of improving breastfeeding outcomes, but they do not address all relevant periods in parenthood (eg, the antenatal period) and often do not involve important stakeholders, such as partners. There is an opportunity to leverage more complex technical systems to open up avenues for the broader design of ICT to support breastfeeding; however, considering evaluation outcomes of existing support systems of higher complexity, such systems need to be designed with care.

"I Just Want to Do Everything Right:" Primiparous Women's Accounts of Early Breastfeeding via an App-Based Diary

INTRODUCTION

Our objective was to describe the early breastfeeding experience of primiparous women.

METHODS

Healthy, primiparous women intending to exclusively breastfeed downloaded a commercial infant feeding mobile application (app) during their postpartum hospitalization. Women free-texted breastfeeding thoughts and experiences through 8 weeks postpartum in the app's diary. Diary content was qualitatively coded.

RESULTS

Thirty-five participants completed diaries and were included in analyses. The overarching theme was Seeking sustainability and validation. Mothers felt overwhelmed, anxious, and frustrated with the intensity and unpredictability of breastfeeding and inconsistent professional breastfeeding support. The ability to exclusively breastfeed was seen as a bellwether of maternal competence. Breastfeeding progress was primarily measured through external feedback (e.g., weight checks) and managed through strict adherence to provider feeding plans. As breastfeeding problems and intensity abated, women exhibited optimism and assumed greater independence in feeding decisions.

DISCUSSION

The primiparous breastfeeding experience is fraught with internally imposed and externally reinforced pressure to produce and persevere despite inadequate breastfeeding support infrastructure.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

To describe forms of breastfeeding support which have been evaluated in controlled studies, the timing of the interventions and the settings in which they have been used.To examine the effectiveness of different modes of offering similar supportive interventions (for example, whether the support offered was proactive or reactive, face-to-face or over the telephone), and whether interventions containing both antenatal and postnatal elements were more effective than those taking place in the postnatal period alone.To examine the effectiveness of different care providers and (where information was available) training.To explore the interaction between background breastfeeding rates and effectiveness of support.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 100 trials involving more than 83,246 mother-infant pairs of which 73 studies contribute data (58 individually-randomised trials and 15 cluster-randomised trials). We considered that the overall risk of bias of trials included in the review was mixed. Of the 31 new studies included in this update, 21 provided data for one or more of the primary outcomes. The total number of mother-infant pairs in the 73 studies that contributed data to this review is 74,656 (this total was 56,451 in the previous version of this review). The 73 studies were conducted in 29 countries. Results of the analyses continue to confirm that all forms of extra support analyzed together showed a decrease in cessation of 'any breastfeeding', which includes partial and exclusive breastfeeding (average risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.88 to 0.95; moderate-quality evidence, 51 studies) and for stopping breastfeeding before four to six weeks (average RR 0.87, 95% CI 0.80 to 0.95; moderate-quality evidence, 33 studies). All forms of extra support together also showed a decrease in cessation of exclusive breastfeeding at six months (average RR 0.88, 95% CI 0.85 to 0.92; moderate-quality evidence, 46 studies) and at four to six weeks (average RR 0.79, 95% CI 0.71 to 0.89; moderate quality, 32 studies). We downgraded evidence to moderate-quality due to very high heterogeneity.We investigated substantial heterogeneity for all four outcomes with subgroup analyses for the following covariates: who delivered care, type of support, timing of support, background breastfeeding rate and number of postnatal contacts. Covariates were not able to explain heterogeneity in general. Though the interaction tests were significant for some analyses, we advise caution in the interpretation of results for subgroups due to the heterogeneity. Extra support by both lay and professionals had a positive impact on breastfeeding outcomes. Several factors may have also improved results for women practising exclusive breastfeeding, such as interventions delivered with a face-to-face component, high background initiation rates of breastfeeding, lay support, and a specific schedule of four to eight contacts. However, because within-group heterogeneity remained high for all of these analyses, we advise caution when making specific conclusions based on subgroup results. We noted no evidence for subgroup differences for the any breastfeeding outcomes.

AUTHORS' CONCLUSIONS

When breastfeeding support is offered to women, the duration and exclusivity of breastfeeding is increased. Characteristics of effective support include: that it is offered as standard by trained personnel during antenatal or postnatal care, that it includes ongoing scheduled visits so that women can predict when support will be available, and that it is tailored to the setting and the needs of the population group. Support is likely to be more effective in settings with high initiation rates. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed with women practising exclusive breastfeeding.

Nurses and midwives professional support increases with improved attitudes - design and effects of a longitudinal randomized controlled process-oriented intervention

Background

Becoming parents for the first time is challenging. Mothers need both social and professional support to handle these challenges. Professionals’ attitudes affect quality of care and support. So to improve professional support, an intervention consisting of a process-oriented training was performed. Due to the positive results of the intervention there is a need to illuminate the methodological approach further. The overall aim was therefore to describe a methodological approach to improve and evaluate health care professionals’ attitudes toward breastfeeding and parental support in order to improve quality of care in childbearing.

Methods

This study was a longitudinal randomized control intervention study, in which groups of mothers received care in childbearing from midwives and child health nurses. These health professionals had gone through a process-oriented training, or not. In order to improve attitudes of health professionals the training was based on evidence, practical skills and reflective processes (both private and professional experiences) in relation to breastfeeding and parental support. Included in the longitudinal study were health professionals from five intervention municipalities n = 36 and health professionals from five control municipalities n = 45. All mothers who fulfilled the inclusion criteria were consecutively identified from the hospital register and asked to participate in the study. Mothers who accepted to participate were included in the interventions group (n = 206) or control groups (n = 162, n = 172 respectively) based on which municipality they belonged to.

Results

The results of the process-oriented training improved the professionals’ attitudes toward breastfeeding and parental support. These improved attitudes in health professionals increased intervention-group mother’s satisfaction with professional and social support. Intervention-group mother’s relation to and feelings for their baby as well as breastfeeding was also improved.

Conclusion

These results stress the importance of professionals’ attitude in quality of care during childbearing, as well as pointing to the possibility to improve professionals’ attitudes with a process-oriented training.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR), trial registration: ACTRN12611000354987.

Existential security is a necessary condition for continued breastfeeding despite severe initial difficulties: a lifeworld hermeneutical study

Background

The majority of new mothers in Sweden initiate breastfeeding and many experience initial difficulties. This experience is an important cause of early breastfeeding cessation. To increase understanding, there is a need to explore the lived experiences of the decision to continue or cease breastfeeding. The aim of this study is therefore to explain and understand how this decision is influenced by the meaning of severe initial difficulties.

Methods

A lifeworld hermeneutical approach was used for the study. The study was conducted in Sweden with eight mothers who experienced severe difficulties with initial breastfeeding. All except one were interviewed on two different occasions resulting in fifteen interviews. The interviews were conducted between 2010 and 2013.

Results

Mothers who experience severe difficulties with initial breastfeeding feel both overtaken and violated not only by their own infants and their own bodies but also by their anger, expectations, loneliness and care from health professionals. These feelings of being overtaken and invaded provoke an existential crisis and place mothers at a turning point in which these feelings are compared and put in relation to one another in the negotiation of the decision to continue or cease breastfeeding. This decision thus depends on the possibility of feeling secure with the breastfeeding relationship. If insecurity dominates, this can, in severe cases, create a feeling of fear of breastfeeding that is so great that there is no alternative but to stop breastfeeding.

Conclusions

Existential security in the breastfeeding relationship seems to be an underlying factor for confidence and therefore a necessary condition for continued breastfeeding when having severe initial breastfeeding difficulties. Unresolved feelings of insecurity may be a serious barrier to further breastfeeding that can result in a fear of breastfeeding. Such fear can force the mother to cease breastfeeding. This study highlights how women are situated in a complex cultural and biological context of breastfeeding that has existential consequences for them. An existential crisis forces mothers into a turning point for the breastfeeding decision. In the existential crisis, mothers’ responsibility for the mother-infant relationship guides continuing or ceasing breastfeeding.