Determinants of breastfeeding initiation and cessation among employed mothers: a prospective cohort study

Returning to work after maternity leave: a systematic literature review

PURPOSE

Working women often experience difficulties associated with balancing family and career, particularly if they choose to have children. This systematic literature review aimed at investigating women's experience in returning to work after maternity leave.

METHODS

The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The literature search led to the identification of 52 articles, which underwent data extraction and qualitative analysis.

RESULTS

Results were organized in 5 categories: (1) Work-life balance; (2) Women's mental and physical health; (3) Job-related wellbeing and working experience; (4) Breastfeeding. Women's both mental and physical health seem connected to a longer maternity leave and a greater coworkers' and supervisors' support. Returning to work seems to constitute one of the most important barriers for exclusive breastfeeding or breastfeeding continuation. A shorter duration of maternity leave, a higher workload and the lack of occupational policies supporting breastfeeding seem to be hindering factors. Partner and family support, and the opportunity for fathers to work under a flextime system after childbirth seem to increase both breastfeeding initiation and duration. Women who continue breastfeeding after returning to work seem to experience more family-to-work conflict and overload.

CONCLUSIONS

This paper show that there are still many understudied aspects in exploring women's experience of returning to work after maternity leave. This represents an important gap in the literature, since returning to work represents a particularly critical time in women's personal and occupational life, in which challenges and barriers may arise, potentially affecting their experience in the immediate future and years to come.

Breastfeeding experiences of women with perinatal mental health problems: a systematic review and thematic synthesis

BACKGROUND

Despite its known benefits, breastfeeding rates among mothers with perinatal mental health conditions are staggeringly low. Systematic evidence on experiences of breastfeeding among women with perinatal mental health conditions is limited. This systematic review was designed to synthesise existing literature on breastfeeding experiences of women with a wide range of perinatal mental health conditions.

METHODS

A systematic search of five databases was carried out considering published qualitative research between 2003 and November 2021. Two reviewers conducted study selection, data extraction and critical appraisal of included studies independently and data were synthesised thematically.

RESULTS

Seventeen articles were included in this review. These included a variety of perinatal mental health conditions (e.g., postnatal depression, post-traumatic stress disorders, previous severe mental illnesses, eating disorders and obsessive-compulsive disorders). The emerging themes and subthemes included: (1) Vulnerabilities: Expectations versus reality; Self-perception as a mother; Isolation. (2) Positive outcomes: Bonding and closeness; Sense of achievement. (3) Challenges: Striving for control; Inconsistent advice and lack of support; Concerns over medication safety; and Perceived impact on milk quality and supply.

CONCLUSIONS

Positive breastfeeding experiences of mothers with perinatal mental health conditions can mediate positive outcomes such as enhanced mother/infant bonding, increased self-esteem, and a perceived potential for healing. Alternatively, a lack of consistent support and advice from healthcare professionals, particularly around health concerns and medication safety, can lead to feelings of confusion, negatively impact breastfeeding choices, and potentially aggravate perinatal mental health symptoms. Appropriate support, adequate breastfeeding education, and clear advice, particularly around medication safety, are required to improve breastfeeding experiences for women with varied perinatal mental health conditions.

Understanding lactation policies and resources across a university system: survey and document review

BACKGROUND

In the U.S., employees often return to work within 8-12 weeks of giving birth, therefore, it is critical that workplaces provide support for employees combining breastfeeding and work. The Affordable Care Act requires any organization with more than 50 employees to provide a space other than a restroom to express breastmilk and a reasonable amount of time during the workday to do so. States and worksites differ in the implementation of ACA requirements and may or may not provide additional support for employees combining breastfeeding and work. The purpose of this study was to conduct an analysis of the policies and resources available at 26 institutions within a state university system to support breastfeeding when employees return to work after giving birth.

METHODS

Survey data was collected from Well-being Liaisons in the human resources departments at each institution. In addition, we conducted a document review of policies and online materials at each institution. We used univariate statistics to summarize survey results and an inductive and deductive thematic analysis to analyze institutional resources available on websites and in policies provided by the liaisons.

RESULTS

A total of 18 (65.3%) liaisons participated in the study and revealed an overall lack of familiarity with the policies in place and inconsistencies in the resources offered to breastfeeding employees across the university system. Only half of the participating liaisons reported a formal breastfeeding policy was in place on their campus. From the document review, six major themes were identified: placing the burden on employees, describing pregnancy or postpartum as a "disability," having a university-specific policy, inclusion of break times for breastfeeding, supervisor responsibility, and information on lactation policies.

CONCLUSION

The review of each institution's online resources confirmed the survey findings and highlighted the burden placed on employees to discover the available resources and advocate for their needs. This paper provides insight into how institutions support breastfeeding employees and provides implications on strategies to develop policies at universities to improve breastfeeding access for working parents.

The Association Between Prenatal Food Insecurity and Breastfeeding Initiation and Exclusive Breastfeeding Duration: A Longitudinal Study Using Oregon PRAMS and PRAMS-2, 2008-2015

Background: In the United States, 11.1% of households experience food insecurity; however, pregnant women are disproportionately affected. Maternal food insecurity may affect infant feeding practices, for example, through being a source of chronic stress that may alter the decision to initiate and continue breastfeeding. Thus, we sought to determine whether prenatal food insecurity was associated with breastfeeding (versus not) and exclusive breastfeeding duration among Oregon women. Method: The Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) data of live births from 2008 to 2015 and the Oregon PRAMS-2 follow-up survey were used (n = 3,624) in this study. Associations with breastfeeding initiation and duration were modeled with multivariable logistic regression and accelerated failure time (AFT), respectively. Models were adjusted for maternal sociodemographic and pre-pregnancy health characteristics. Results: Nearly 10% of women experienced prenatal food insecurity. For breastfeeding initiation, unadjusted models suggested non-significant decreased odds (odds ratio (OR) 0.88 [confidence intervals (CI): 0.39, 1.99]), whereas adjusted models revealed a non-significant increased odds (OR 1.41 [CI: 0.58, 3.47]). Unadjusted AFT models suggested that food-insecure mothers had a non-significant decrease in exclusive breastfeeding duration (OR 0.76 [CI: 0.50, 1.17]), but adjustment for covariates attenuated results (OR 0.89 [CI: 0.57, 1.39]). Conclusions: Findings suggest minimal differences in breastfeeding practices when exploring food security status in the prenatal period, though the persistence of food insecurity may affect exclusive breastfeeding duration. Lower breastfeeding initiation may be due to other explanatory factors correlated with food insecurity and breastfeeding, such as education and marital status.

Association Between Length of Maternity Leave and Breastfeeding Duration in the United States: A Systematic Review

OBJECTIVE

To perform a systematic review to assess the association between the length of maternity leave and breastfeeding duration in the United States.

DATA SOURCES AND METHODS OF STUDY SELECTION

This review was conducted with a five-stage model for reviews. We included publications from 2000 to 2023, U.S.-based studies written in English, and primary research and peer-reviewed articles. In February 2023, a medical librarian conducted a search across seven databases, yielding 1,540 results. ClinicalTrials.gov was later searched, yielding no results. After duplicates were removed, 835 abstracts were screened. A full-text article review was then conducted of the remaining 34 articles.

TABULATION, INTEGRATION, AND RESULTS

Twenty-three articles met inclusion criteria, two of which were reviews. Of the nonreview articles, all found a positive relationship between increased maternity leave and duration of breastfeeding. Data showed that earlier return to work for the birth parent decreased the odds of breastfeeding dyads meeting breastfeeding recommendations. Many studies adjusted for confounders (eg, race, socioeconomic status); however, Black or Latinx mothers still experience shorter breastfeeding durations or lower breastfeeding exclusivity when given equal leave compared with White mothers.

CONCLUSION

Results show a positive relationship between length of maternity leave and breastfeeding duration. Advocacy for longer, paid parental leave and more robust research rooted in rigorous methods are needed.

Breastfeeding Duration and Cardiometabolic Health during Adolescence: A Longitudinal Analysis

OBJECTIVE

To investigate the longitudinal association between breastfeeding duration and cardiometabolic health, using repeated measures study design among children and adolescents.

STUDY DESIGN

This study included 634 offsprings aged 10 to 21 years (52% female) from the Early Life Exposure in Mexico to Environmental Toxicants birth cohort followed up to four time points during adolescence. Breastfeeding duration was prospectively quantified using questionnaires during early childhood. Cardiometabolic risk factors, body composition, and weight-related biomarkers were assessed as outcomes during adolescent follow-up visits. Sex-stratified linear mixed-effects models were used to model the association between quartiles of breastfeeding duration and outcomes, adjusting for age and additional covariates.

RESULTS

Median breastfeeding duration was 7 months (minimum = 0, maximum = 36). Boys in the second quartile (median breastfeeding = 5 months) had lower total fat mass % (β (SE) -3.2 (1.5) P = .037), and higher lean mass % (3.1 (1.6) P = .049) and skeletal muscle mass % (1.8 (0.8) P = .031) compared with the reference group (median breastfeeding = 2 months). A positive linear trend between breastfeeding duration and trunk lean mass % (0.1 (0.04) P = .035) was found among girls. No association was found with other cardiometabolic indicators.

CONCLUSION

Despite sex-specific associations of breastfeeding duration with body composition, there was a lack of substantial evidence for the protective effects of breastfeeding against impaired cardiometabolic health during adolescence among Mexican youth. Further longitudinal studies with a robust assessment of breastfeeding are recommended.

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.

Psychometric Properties of the Breastfeeding and Employment Scale

OBJECTIVE

To evaluate the psychometric properties of the Breastfeeding and Employment Scale (BES).

DESIGN

Secondary analysis of data from the Infant Feeding Practices Study II survey, a longitudinal study on infant feeding practices.

SETTING

United States.

PARTICIPANTS

Women who were employed, breastfeeding, and completed the Infant Feeding Practices Study II BES at the 3-month postpartum assessment (N = 508).

METHODS

Participants reported their perceived level of breastfeeding support in the workplace by responding to the nine binary items on the BES. We evaluated the instrument's internal consistency reliability (Kuder-Richardson 20), test-retest reliability (Cohen's kappa), construct validity (principal component analysis), and convergent validity (relationship with a similar item).

RESULTS

The internal consistency of the BES (Kuder-Richardson 20 = 0.72) supported the reliability of scale. The test-retest reliability was moderate (0.41-0.60). The Spearman's rho correlation coefficient was 0.66, indicating adequate test-rest reliability for the total BES score between the 3-month and 6-month assessments (p < .01). The factor analysis demonstrated that the items cluster into one factor (psychosocial and structural barriers to breastfeeding in the workplace). Participants who reported more barriers to breastfeeding in the workplace also reported a less supportive workplace environment, which supported the convergent validity of the scale.

CONCLUSION

The psychometric testing of the BES provided initial support for the reliability and validity of the instrument. It may be a useful tool for measuring workplace lactation support in a concise manner.

Breastfeeding in US working mothers: A systematic review

BACKGROUND

Previous studies demonstrate that exclusive breastfeeding has positive long-term health effects on the mother and infant, but research has shown that nearly 50% of mothers do not breastfeed for the recommended amount of time.

OBJECTIVE

This article systematizes previous quantitative research on the impact of work on breastfeeding practices to identify the factors that correlate to the cessation of breastfeeding in working mothers.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statements, we performed a systematic review that screened PubMed, CINAHL, PsycINFO, and Academic Search Complete databases for articles relating to maternal employment and breastfeeding.

RESULTS

Of the 13,106 articles assessed for eligibility, 21 studies met all requirements and were included in this systematic review. The 21 articles were divided into study type and methods, participant demographics, study outcomes, and additional factors that included stressors and stress levels, factors that increased or decreased rates of breastfeeding, and feeding methods. Articles outside of the United States were excluded due to differences in maternity leave policies of other countries impacting the data.

CONCLUSION

Cessation of breastfeeding and breastfeeding outcomes were seen to have a strong association with maternal employment, specifically with the policies and employer support in the workplace. Other factors such as race, level of education, and stress were also shown to relate to breastfeeding outcomes and are important to consider in future public health interventions and workplace policies.

Factors Affecting Breastfeeding in Births Given During the Day and at Night; A Cross-Sectional Comparative Study

Objective: How giving birth at night and during the day affects the breastfeeding process should be evaluated when health services are planned. In this study, we investigated the effect of giving birth at night and during the day on the breastfeeding process. Materials and Methods: In this cross-sectional comparative study, we included 228 women who gave birth at night and 192 women who gave birth during the day. We compared the effect of giving birth at night or during the day on breastfeeding with the univariate analysis in terms of intrapartum and postpartum factors. Results: While the mothers who gave birth during the daytime started the first breastfeeding earlier (p < 0.001), the duration of the first breastfeeding and skin-to-skin contact practice was longer in mothers who gave birth at night (p < 0.05). While the rate of formula supplementing in babies born at night was 44.8%, it was 55.2% in babies born during the day (p < 0.001). The rate of receiving support from health workers (p = 0.040) and intending to breastfeed babies exclusively after discharge (p < 0.05) was higher in mothers who gave birth during the day than it was in mothers who gave birth at night. Conclusion: Day and night labor have different advantages and disadvantages on breastfeeding. It is important to address these differences in terms of intrapartum and postpartum care process to prevent negative breastfeeding experiences in the early period.

Beyond mothers: the crucial role of family caregivers' knowledge on exclusive breastfeeding in rural western China

BACKGROUND

The exclusive breastfeeding rate in China remains significantly low. Numerous studies have identified the impact of maternal characteristics on exclusive breastfeeding; however, the correlation between primary family caregivers' characteristics, such as health and nutrition knowledge, and exclusive breastfeeding still lacks clarity. The aim of this study is to investigate the association between the health and nutrition knowledge of primary family caregivers and exclusive breastfeeding in rural China.

METHODS

In 2019, a cross-sectional study was conducted in two prefectures within the Qinba Mountains area, located in the southern region of Shaanxi province. Data on knowledge of health and nutrition, breastfeeding practices, breastfeeding family support, breastfeeding self-efficacy, and conflict frequency were collected via structured questionnaires from 372 caregiver-infant pairs. Infant feeding practices were assessed based on the caregivers' recall of the previous day (within the 24 h before the interview). The mother was interviewed first, followed by a brief questionnaire for the primary family caregiver, both conducted individually to minimize disruptions from other family members. Univariate and multivariate regression analyses were conducted to explore the correlation between knowledge of mothers and primary family caregivers and exclusive breastfeeding.

RESULTS

The exclusive breastfeeding rate for six-month-old infants in the sample was 15.7%. On average, mothers scored 4.6 (SD 1.4) for health and nutrition knowledge, while primary family caregivers scored 3.6 (SD 1.4). Both maternal (OR 1.48; 95% CI 1.16, 1.88) and primary family caregiver's (OR 1.34; 95% CI 1.05, 1.70) health and nutrition knowledge were significantly associated with exclusive breastfeeding. A positive correlation (OR 1.98; 95% CI 1.40, 2.80) existed between the average health and nutrition knowledge of the mother and primary family caregiver and exclusive breastfeeding. The primary family caregiver's health and nutrition knowledge was positively correlated with the practical family support perceived by the mother (OR 1.23; 95% CI 1.02, 1.49) and breastfeeding self-efficacy of the mother (β = 1.40; 95% CI 0.29, 2.50).

CONCLUSIONS

The characteristics of the primary family caregiver play a large role in exclusive breastfeeding. To promote exclusive breastfeeding, interventions should address the needs of the whole family instead of just mothers.

Barriers and facilitators to expressing milk on campus as a breastfeeding student

Objective: Despite the growing student parent population, many postsecondary institutions in the United States (U.S.) lack sufficient lactation policies for students. The objective of this study was to explore breastfeeding students' perceived awareness and use of on-campus lactation rooms and identify barriers and facilitators to expressing milk on campus.Participants:A convenience sample of breastfeeding students enrolled in colleges/universities in the U.S.Methods:Information about students' experiences expressing milk on campus was collected via an online survey. Thematic analysis was used to qualitatively analyze self-reported barriers/facilitators to expressing.Results:Ninety-three participants representing 68 unique institutions completed the survey. Barriers to expressing on campus included inadequate lactation spaces, lack of storage for breast pump equipment/expressed milk, and lack of time to express. Conversely, access to adequate lactation spaces, having appropriate breast pump equipment, and on-campus social support, were important facilitators.Conclusion:Comprehensive lactation policies may improve on-campus breastfeeding experiences among students.

Breastfeeding Practices and Associated Factors among Immigrant Muslim Arab Women Living in a Metropolitan Area of the Southwest of United States

Background

Muslim Arab immigrants are a fast-growing, under-studied, and underserved minority population in the United States. Little is known about breastfeeding practices in this population.

objectives

The objective of this study was to describe infant feeding practices and factors associated with these practices among immigrant Muslim Arab women.

design

A nonexperimental-one group, cross-sectional, descriptive, prospective design was used to identify infant feeding practices among immigrant Muslim Arab women.

methods

A convenience sample of one hundred sixteen immigrant Muslim Arab women with at least one child five years or younger was recruited from a large metropolitan area in the Southwestern region. Participants completed the social ecological model of health promotion self-reported questionnaire. Descriptive statistics were performed to identify infant feeding practices and logistic regression was used to identify factors associated with these practices.

results

Immigrant Muslim Arab mothers demonstrate high breastfeeding initiation rates (99.2%) and lengthy breastfeeding duration (M = 11.86, SD = 8.04), but low rates of exclusive breastfeeding at six months (21.6%). The most frequent reasons for early termination of breastfeeding were perceived insufficient milk (44.4%), child was still hungry after breastfeeding (37.5%), and the belief that the child was old enough to stop breastfeeding (32.9%).

conclusion

Development of educational interventions are needed to improve breastfeeding exclusivity and raise women's awareness of the importance of exclusive breastfeeding. Healthcare providers should help women gain confidence in their ability to produce enough milk to successfully continue breastfeeding.

Do Stressful Events and Racial Discrimination Explain Racial Gaps in Exclusive Breastfeeding Duration? A Qualitative Interview Study with Black, Hispanic, and White Mothers Living in Ohio

OBJECTIVES

This study aimed to understand why breastfeeding and exclusive breastfeeding rates substantially decrease shortly after birth among mothers in the USA. Specifically, we aimed to illuminate the impact of stressful life events and racial discrimination on mothers' breastfeeding behaviors and duration.

METHODS

We conducted a qualitative analysis of semi-structured telephone interviews with women (N = 66; 47 White, 16 Black, and 3 Hispanic) who gave birth between 2019 and 2021 in Ohio. Interviews were conducted between March 2022 and May 2022. Interviews were digitally recorded, transcribed verbatim, analyzed, coded, and organized into themes.

RESULTS

After thematic analysis of the data, five key themes were identified: (1) stress, (2) breastfeeding barriers, (3) policy and system change to support breastfeeding mothers, (4) racial discrimination, and (5) breastfeeding motivators. Our study found that the breastfeeding experience was both a positive bonding experience and a challenging practice, characterized by physical, mental, and sociocultural struggles.

CONCLUSION FOR PRACTICE

Addressing stress during pregnancy, equitable access to culturally sensitive lactation support, improved parental leave, and enhanced workplace breastfeeding regulations are essential to increasing breastfeeding duration among racially marginalized women.

The Current Status of Prolonged Breastfeeding and Its Related Factors in Korean Infants and Their Mothers: A Nationwide Cross-Sectional Study

BACKGROUND

International authorities recommend prolonged breastfeeding (PBF) for 12-24 months or more with 6 months of exclusive breastfeeding (EBF). Based on the Korean National Health and Nutrition Examination Survey (KNHANES) data, this study attempted to help encourage and educate breastfeeding (BF) over 1 year by investigating long-term BF trends and related factors in Korean infants and their mothers.

METHODS

This cross-sectional study was based on data on children aged 12-23 months and their mothers from 2010 to 2020. BF rates were compared between KNHANES V (2010-2012), KNHANES VI (2013-2015), KNHANES VII (2016-2018), and part of KNHANES VIII (2019-2020). In addition, data related to mothers and infants, including demographics, socioeconomic, educational, and health status, were collected, and their association with BF status was analyzed.

RESULTS

Of the 933 infants included in the study, the proportions achieving full BF at 6 months of age and PBF at 12 and 18 months were 34.8%, 33.7%, and 7.1%, respectively. Over the past 10 years, the trends of all three BF practices have significantly decreased since 2016 (P < 0.001). Of the 849 infants whose maternal data were available, multiple logistic regression analysis showed that EBF for 6 months (defined as full BF at 1, 3, and 6 months of age) positively correlated with maternal and infants' factors such as unemployed status, past BF experience, no history of drinking, and infants' birth weight of ≥ 2.5 kg. The mother's education level, particularly the nutrition label impact, current employment status, and smoking and drinking status, were significantly associated with PBF for ≥ 12 months but were not related to PBF for ≥ 18 months, except for drinking status.

CONCLUSIONS

In Korea, the long-term BF rate of ≥ 12 months has declined in the past 10 years, and BF becomes rare after 18 months. Higher maternal interest in nutrition information appears to be driving access to PBF over 12 months than EBF for 6 months or PBF over 18 months. To promote PBF over 12 months in Korea, it may be helpful to strengthen nutrition education that specifically emphasizes the benefits of PBF along with EBF, especially during infant health examinations.

Associations between Perinatal Sleepiness and Breastfeeding Intentions and Attitudes and Infant Feeding Behaviors and Beliefs

Breastfeeding rates fall short of public health goals, but barriers are poorly understood. We examined whether excessive sleepiness during pregnancy and the postpartum period was associated with breastfeeding intentions, attitudes, initiation, and continuation in a tobacco-exposed sample participating in a randomized controlled trial to reduce smoke exposure (n = 399). We used the Epworth Sleepiness Scale (ESS) to examine associations between excessive sleepiness in early (12-16 weeks gestation) and late (32 weeks gestation) pregnancy and at 6 months postpartum, with breastfeeding attitudes using the Mitra index, intentions, initiation, and continuation, as well as other infant feeding practices using the Infant Feeding Questionnaire. Logistic regression models adjusted for age, racial/ethnic identity, parity, marital status, and maternal education showed that excessive sleepiness in late pregnancy was associated with less favorable attitudes toward breastfeeding. In addition, in unadjusted models, excessive sleepiness at 6 months postpartum was associated with less of a tendency to use feeding to calm a fussy infant. Excessive sleepiness was not associated with intent, initiation, or continuation of breastfeeding. Assessing excessive sleepiness in late pregnancy may assist in identifying individuals with negative attitudes to breastfeeding and lead to novel approaches to promoting breastfeeding in populations with lower breastfeeding rates.

Promotion, protection, and support of breastfeeding at work, and achieving sustainable development: a scoping review

This article aims to map promotion, protection, and support strategies aimed at working women who breastfeed and their potential impact on achieving the Sustainable Development Goals (SDGs), in particular SDGs 5 (gender equality and women's empowerment) and 8 (decent work and economic growth). This study is a scoping review based on the Joanna Briggs Institute (JBI) framework, whose searches were performed in PubMed, Web of Science, Scopus, Social Science Research Network, and Open Knowledge Repository databases. This study's search obtained 576 publications, of which 33 were included in the study. The narrative synthesis was organized into three axes: 1) promotion; 2) protection, and 3) support for breastfeeding in the work context. Actions aimed at women who breastfeed at work have the potential to directly achieve SDGs 5 and 8, and indirectly achieve SDGs 1 and 10. Increased breastfeeding rates also help to achieve another four SDGs (2, 3, 4, 12). Actions aimed at working women who breastfeed can contribute directly and indirectly to the achievement of eight of the 17 SDGs, and should therefore be encouraged and reinforced.

The Role of Work as a Social Determinant of Health in Mother's Own Milk Feeding Decisions for Preterm Infants: A State of the Science Review

In the United States, 10% of infants are born preterm (PT; <37 weeks gestational age) each year and are at higher risk of complications compared to full term infants. The burden of PT birth is borne disproportionately by Black versus non-Black families, with Black mothers significantly more likely to give birth to a PT infant. One proven strategy to improve short- and long-term health outcomes in PT infants is to feed mother's own milk (MOM; breast milk from the mother). However, mothers must make decisions about work and MOM provision following PT birth, and more time spent in paid work may reduce time spent in unpaid activities, including MOM provision. Non-Black PT infants are substantially more likely than Black PT infants to receive MOM during the birth hospitalization, and this disparity is likely to be influenced by the complex decisions mothers of PT infants make about allocating their time between paid and unpaid work. Work is a social determinant of health that provides a source of income and health insurance coverage, and at the same time, has been shown to create disparities through poorer job quality, lower earnings, and more precarious employment in racial and ethnic minority populations. However, little is known about the relationship between work and disparities in MOM provision by mothers of PT infants. This State of the Science review synthesizes the literature on paid and unpaid work and MOM provision, including: (1) the complex decisions that mothers of PT infants make about returning to work, (2) racial and ethnic disparities in paid and unpaid workloads of mothers, and (3) the relationship between components of job quality and duration of MOM provision. Important gaps in the literature and opportunities for future research are summarized, including the generalizability of findings to other countries.

Breastfeeding Practices of Women Returning to Full-Time Employment in China: Prevalence and Determinants

BACKGROUND

Returning to work after childbirth is a common reason for women to stop breastfeeding. This study aimed to assess breastfeeding practices and breastfeeding support available to employed women in China, and factors affecting breastfeeding duration.

METHODS

A cross-sectional survey of 1,243 breastfeeding women employed full-time was conducted. Participants completed a sociodemographic questionnaire and the Workplace Breastfeeding Support Scale (WBSS). Multiple linear regression analysis was used to explore the factors that are associated with breastfeeding.

RESULTS

The mean exclusive breastfeeding duration and any breastfeeding duration of full-time employed women were 5.7 ± 0.5 months and 9.8 ± 1.5 months, respectively. The total WBSS score was 46.6 ± 5.3 (M ± SD). Generally, women perceived coworkers (M [SD] = 4.8 [1.0]) and supervisors (M [SD] = 5.7 [1.2]) to be supportive of breastfeeding. Lower scores on the WBSS were related to lack of technical and facility support, indicating no access to a refrigerator to store breast milk (M [SD] = 2.0 [1.5]) or to a breast pump (M [SD] = 1.7 [1.7]). Similarly, a private area for expressing breast milk (M [SD] = 1.4 [1.0]) was unavailable. Maternity leave, residential province, ethnicity, education level, average monthly household income, main reason for stopping exclusive breastfeeding, commute time greater than 1 hour, and the total WBSS score were also factors influencing breastfeeding duration of the full-time employed women.

CONCLUSIONS

There were gaps in breastfeeding practices and workplace breastfeeding support of Chinese full-time employed women when compared with the World Health Organization recommendations. Occupational health providers should consider these findings when developing programs to support breastfeeding in the workplace.

Work as an Understudied Driver of Racial Inequities in Breastfeeding

Breastfeeding inequities by race are a persistent public health problem in the United States. Inequities in occupation and working conditions likely contribute to relatively less breastfeeding among Black compared to White mothers, yet little research has addressed these interrelationships. Here, we offer a critical review of the literature and a conceptual framework to guide future research about work and racial inequities in breastfeeding. There is a strong public health case for promoting breastfeeding equity for mothers across race groups and occupation types. Existing theory suggests that employment opportunities and working conditions are a likely pathway that connects structural racism to Black-White breastfeeding inequities, in addition to other known factors. We propose a new conceptual model for studying the interrelationships among work, race, and breastfeeding outcomes.

Breastfeeding performance index and associated factors among children aged 0-6 months in Ethiopia: Analysis of the 2019 Ethiopia Mini Demographic and Health Survey

Background

Infants under the age of 6 months are commonly affected by malnutrition globally. The higher the breastfeeding performance index (BPI), the greater the advantage of breastfeeding will be. However, there is a lack of literature in the context of Ethiopia. Therefore, this study is aimed at investigating the magnitude and determinants of the breastfeeding performance index score among mothers of children under the age of 6 months in Ethiopia.

Methods

This study was conducted using the 2019 Ethiopia Mini Demographic and Health Survey (EMDHS) dataset. A stratified, two-stage cluster sampling technique was used in the study. The survey data were weighted using the “svy” function in STATA version 16. Descriptive statistics, bivariable and multivariable logistic regression were employed in the analysis. An adjusted odds ratio (AOR) with a 95% confidence interval (CI) was reported. The results were considered statistically significant if the p-value was < 0.05. The goodness of fit of the model was checked using the Hosmer–Lemeshow test.

Results

A total of 4,273 mothers with children under the age of 6 months were included in the analysis. Our analysis revealed that the prevalence of low breastfeeding performance index was 79.05% (95% CI: 78.01, 81.59). A unit increase in child age (AOR = 11.56; 95% CI: 6.97, 19.17), the richest wealth quintile (AOR = 2.76; 95% CI: 1.18, 6.5), a higher level of education (AOR = 5.41; 95% CI: 2.08, 14.05), being married or living with partner (AOR = 2.73; 95% CI: 1.18, 6.27), being women from Somali (AOR = 5.11; 95% CI: 2.08, 12.56), Afar (AOR = 3.03; 95% CI: 1.16, 7.91), Oromia (AOR = 1.88; 95% CI: 1.03, 3.41), Diredawa city administration (AOR = 2.89; 95% CI: 1.04, 8.07), and antenatal care (ANC) visit (AOR = 2.05; 95% CI: 1.31, 3.19) were positively associated with the low breastfeeding performance index.

Conclusion

The prevalence of the low breastfeeding performance index was found to be high. Hence, the findings of the study suggest the need to target interventions aimed at improving breastfeeding performance toward mothers with higher socioeconomic and demographic status and educational status. Antenatal care clients are among the targets of the intervention.

Feeding Practices of Infants and Toddlers by Their Mothers in Selected Northern Emirates of the United Arab Emirates

Research on the feeding practices of infants and young children in the United Arab Emirates (UAE) is limited, especially in the northern regions of the country. A retrospective web-based survey was conducted to assess child feeding practices among the mothers of young children aged 6 months to 2.5 years in the northern emirates of the UAE. Information from a total of 475 mothers was collected on maternal socio-demographic factors, child feeding practices, and the use of vitamin and mineral supplements. For the first 6 months, 46.7% of the infants were exclusively breastfed, 43.8% were fed on both breastmilk and formula, and 9.5% were given formula only. Significant differences in the types of feeding were found correlating with maternal age (p = 0.02) and employment status (p < 0.001) but not with educational level, with a higher proportion of younger and unemployed women exclusively breastfeeding. However, although a significantly higher proportion of mothers with lower educational levels breastfed their children for ≥6 months (p = 0.026), they introduced “other milk” (non-breastmilk or formula) before the child reached the age of 12 months (p = 0.022). In this study, 22.1% of the infants and 8.1% of the toddlers did not receive an animal source of iron, while 52.6% of the children received vitamin/mineral supplements. The median daily frequency intake of sweets and savory snacks was substantially higher than the respective intake of fruits and vegetables. Intervention programs that focus on healthy infant and toddler feeding, including food sources of iron and nutrient-dense food groups, are needed in the UAE.

Metabolic impact of infant formulas in young infants. An outlook from the urine metabolome

Introduction

Although breast milk is the ideal food source for newborns during the first six months of life, a high percentage of children receive infant formulas. There is evidence that specific diet habits may influence individual metabolic profile. Therefore, in newborns, such profile can be influenced by the use of infantile formulas given the composition differences that display compared to human milk. Up to now, there are no reports in the literature that address this issue.

Objectives

this work aims to compare the metabolic profile of full-term newborns that were feed with either breast milk (n = 32) or infantile formulas (n = 21). Methods: Metabolic profile was established based on urine analysis through gas chromatography-mass spectrometry (GC-MS) and nuclear magnetic resonance (H-NMR).

Results

our results evidenced a more gluconeogenic profile in breast-fed infants characterized by elevation of Kreb's cycle intermediaries like fumaric, succinic and ketoglutaric acids compared to infants receiving infant formula. In addition, infant formula fed infants presented urinary excretion of metabolites derived from specific compounds present in this type of diet that were not observed in breast-fed infants, for instance D-glucitol, and 4-deoxytetronic. Moreover, in infant formula fed infants there was excretion of basal levels of metabolites of clinical relevance like 3-hydroxy-3-methyl-glutaric, 2-methyl-3-keto-valeric and 3,4-dihydroxybutyric.

Conclusion

These results show the importance of understanding the metabolic impact of diet in newborn population in normal and pathological contexts.

Factors Associated With Exclusive Direct Breastfeeding in the First 3 Months

OBJECTIVE

To identify factors associated with exclusive direct breastfeeding in the first 3 months among mother and infant dyads living in the United States.

DESIGN

A secondary analysis of data collected using a cross-sectional online survey completed over a 4-month period in late 2019.

PARTICIPANTS

We recruited a convenience sample of 370 mothers with healthy full-term singleton infants between 1 and 12 weeks of age whose feeding methods consisted of direct breastfeeding at least once a day. Mothers had not returned to work/school at the time of the survey completion.

MEASUREMENTS

The questionnaire consisted of 34 questions about maternal and infant factors that influence decisions about infant feeding, professional support, and parental preferences.

RESULTS

Mothers who practiced feeding on demand (adjusted OR [aOR] = 35.76, 95% confidence interval [CI] [2.04, 500.00]) and mothers of infants 1 to 4 weeks of age (aOR = 2.74, 95% CI [1.54, 4.85]) were more likely to use exclusive direct breastfeeding. The odds of exclusive direct breastfeeding decreased with mothers who breastfed with a nipple shield while in the hospital/birth center/home (aOR = 0.13, 95% CI [0.05, 0.35]), used pacifiers (aOR = 0.31, 95% CI [0.21, 0.65]), or had perceptions of insufficient milk (aOR = 0.11, 95% CI [0.04, 0.26]).

CONCLUSION

Demand feeding and an infant's age of 1 to 4 weeks contributed to exclusive direct breastfeeding. Lower rates of exclusive direct breastfeeding were associated with the use of nipple shields immediately after birth, pacifier use, and perceptions of insufficient milk. Further investigation is warranted to fully differentiate exclusive direct breastfeeding from exclusive breastfeeding.

Low Job Control and Racial Disparities in Breastfeeding

BACKGROUND

Low job control may predict shorter breastfeeding (BF) among working mothers and may contribute to racial disparities in BF.

METHODS

We used demographic, employment, and health data for n = 631 observations from the Panel Study of Income Dynamics. Job control scores came from a job-exposure matrix.Using path analysis, we assessed whether job control predicted BF and mediated Black-White BF differences. We controlled for education, working hours, marital status, and low birthweight.

RESULTS

Lower job control predicted decreased odds of BF for at least 6 months (odds ratio, 0.61; 95% confidence interval, 0.31-0.90; reference, no BF). Low job control explained 31% of the Black-White difference for both shorter-term and longer-term BF.

CONCLUSIONS

Low job contributes to shorter BF and to BF disparities by race. Intervening to enhance job control could improve BF.

Influence of Health Literacy on Maintenance of Exclusive Breastfeeding at 6 Months Postpartum: A Multicentre Study

Background: International organizations recommend initiating breastfeeding within the first hour of life and maintaining exclusive breastfeeding for the first 6 months. However, worldwide rates of exclusive breastfeeding for 6-month-old infants is far from meeting the goal proposed by the World Health Organization, which is to reach a minimum of 50% of infants. Education is one of the factors affecting the initiation and continuation of breastfeeding, and incidentally, it is also related to lower health literacy. This study explored the influence of health literacy on maintenance of exclusive breastfeeding at 6 months postpartum. Methods: A longitudinal multicenter study with 343 women were recruited between January 2019 and January 2020. The first questionnaire was held during the puerperium (24−48 h) with mothers practicing exclusive breastfeeding, with whom 6-month postpartum breastfeeding follow-up was performed. Socio-demographic, clinical and obstetric variables were collected. Breastfeeding efficiency was assessed using the LATCH breastfeeding assessment tool. The health literacy level was evaluated by the Newest Vital Sign screening tool. A multivariate logistic regression model was used to detect protective factors for early exclusive breastfeeding cessation. Results: One third of the women continued exclusive breastfeeding at 6 months postpartum. Approximately half the participants had a low or inadequate health literacy level. An adequate health literacy level, a high LATCH breastfeeding assessment tool score (>9 points) and being married were the protective factors against exclusive breastfeeding cessation at 6 months postpartum. Conclusion: Health literacy levels are closely related to maintaining exclusive breastfeeding and act as a protective factor against early cessation. A specific instrument is needed to measure the lack of “literacy in breastfeeding”, in order to verify the relationship between health literacy and maintenance of exclusive breastfeeding.

Prenatal Provider Breastfeeding Toolkit: Results of a Pilot to Increase Women's Prenatal Breastfeeding Support, Intentions, and Outcomes

BACKGROUND

Breastfeeding rates for United States women with lower incomes fall below the government's Healthy People 2020 Goals. Breastfeeding recommendations combined with support from providers and peer counselors help women decide to begin and sustain breastfeeding, but peer counselor uptake is low.

RESEARCH AIM

To evaluate changes in referrals to Women, Infants, and Children's Supplemental Nutrition Program peer counselors, reported prenatal provider education and support, and breastfeeding outcomes (intention, initiation, 1-month duration of any and exclusive breastfeeding) after a prenatal breastfeeding promotion intervention.

METHOD

In this pre-post intervention study (2015-2016; upstate New York), providers implemented a Toolkit to discuss infant feeding recommendations and initiate peer counselor referral. We surveyed women pre- and post-implementation (after delivery; 1 month postpartum) about prenatal breastfeeding intentions, provider support, and breastfeeding outcomes. Analyses controlled for secular trends.

RESULTS

Pre-intervention (n = 71) and post-intervention (n = 70) participants were 49% Black, 61% publicly insured, and 16% uninsured. More post-intervention participants had > 1 Toolkit use (76%), peer counselor program referrals (60.0% post vs. 36.6% pre, p < .01), reported any breastfeeding intention (89% vs. 72%, p = .013), and intended to breastfeed for > 1 year (31% vs. 14%, p = .014). Post-intervention breastfeeding initiation and exclusivity were higher, but not significantly different. Post-intervention participants reported better prenatal breastfeeding support.

CONCLUSIONS

Implementing a prenatal Breastfeeding Toolkit, including facilitating peer counselor referral, was associated with increases in provider counseling, participants' breastfeeding intentions, and uptake of peer counselors. Replicating this approach may reinforce efforts to support breastfeeding in similar practices serving women with lower incomes.

The Determinants of Complementary Feeding Introduction Vary According to the Type of Food and Infants' Ages: A Cohort Study-ClaB, Brazil

INTRODUCTION

Food inadequacies in the first 6 months of life are considered a global problem, with an emphasis on early complementary feeding introduction (CFI). This study aimed to identify the determinants of CFI.

METHODS

A birth cohort study (N = 641). Data on infant feeding was collected before 30 days, and at 2, 4, and 6 months of age and, at baseline, data regarding socioeconomic status, demographics, maternal and infant health, obstetric history, and infant care. The hypothesis was that the risk determinants for early CFI vary according to the type of food and the age range of this introduction. Twelve Cox regression models were fit with four outcomes (formula; other types of milk; other beverages; and solid/semi-solid foods) considering three different age ranges of the infant at their introduction (< 2 months, 2-4 months, and 4-6 months).

RESULTS

The introduction of the four food groups analyzed was early (median ages of introduction: formulas = 45 days; other milks = 135 days; other beverages = 120 days; solids and semi-solids = 135 days). The determinants that increased the risk of introducing formulas before 2 months were: primiparity, employed without maternity leave, mothers with unsatisfactory prenatal counseling and those who had cesarean sections. Not living with a partner, infant pacifier use at 2 months of age had a higher risk of introducing formula between 2 and 4 months of age. Non-white skin color, more than 35 years old, low maternal education, and lower family income increased the risk of introducing other types of milk between 2 and 4 months of age. Between 4 and 6 months of age, adolescent and low education level mothers had a higher risk of introducing other types of milk, unemployed was a protective factor against the introduction of other foods and beverages in this age group.

CONCLUSIONS

The determinants of early CFI varied according to the type of food and the age of introduction.

Breastfeeding Support Rooms and Their Contribution to Sustainable Development Goals: A Qualitative Study

Objectives: Breastfeeding support rooms are low-cost interventions that may prolong breastfeeding and improve work performance. Thus, we sought to understand the experiences and perceptions of working women who use breastfeeding support rooms and the potential contribution to sustainable development goals. Methods: Descriptive and exploratory research was conducted through convenience sampling of women working in companies with breastfeeding support rooms in the state of Paraná, Brazil. A semi-structured questionnaire was applied through interviews and online self-completion. Results: Fifty-three women between 28 and 41 years old participated in the study. In addition, 88.7% had graduated from college, and 96% were married. From the women's experiences and perceptions, we identified that breastfeeding support rooms contribute to prolonged breastfeeding, improve physical and emotional well-being, allow women to exercise their professional activities comfortably, contribute to women's professional appreciation for the excellent relationship between employees and employers. Conclusion: In this novel study, we demonstrate how, from a female point of view, breastfeeding support rooms can contribute to 8 of the 17 sustainable development goals and should therefore be encouraged and promoted.

Trends and inequalities in breastfeeding continuation from 1 to 6 weeks: findings from six population-based British cohorts, 1985-2010

BACKGROUND

Understanding inequalities in breastfeeding practices may help to explain the UK's persistently low breastfeeding rates. A recent study using the quinquennial UK Infant Feeding Surveys (IFS) found that sociodemographic inequalities in breastfeeding initiation persisted between 1985 and 2010. The present study investigates the sociodemographic inequalities in breastfeeding continuation at 6 weeks after birth among mothers who initiated and maintained breastfeeding at 1 week in 1985-2010.

METHODS

Data were drawn from the 1985 to 2010 IFS and restricted to mothers who were breastfeeding at 1 week after birth. Time trends in the proportion of mothers in each sociodemographic group were examined. Logistic regression was used to estimate associations between breastfeeding at 6 weeks and sociodemographic factors, adjusting for confounders. Heterogeneity test was used to assess changes in these associations over time.

RESULTS

Sociodemographic inequalities in breastfeeding continuation at 6 weeks persisted over the 25-year period. In most survey years, mothers were most likely to breastfeed at 6 weeks if they were 30 or older versus under 25 (OR 1.49-1.99 across survey years, I²= 0%, heterogeneity P = 0.45); completed full-time education over age 18 compared to 18 or younger (OR 1.56-2.51, I²= 58.7%, P = 0.03); or of Black, Asian, Mixed, or other ethnicity compared to White (OR 1.45-2.48, I²= 44.8%, P = 0.16).

CONCLUSIONS

Among mothers breastfeeding at 1 week, those who were younger, White or had fewer years of full-time education were at greatest risk of discontinuing before 6 weeks. This risk persisted over time and was independent of their high risk of not initiating breastfeeding.

Smartphone-based counseling and support platform and the effect on postpartum lactation: a randomized controlled trial

BACKGROUND

Human milk lactation provides health benefits for both the mother and infant. Patients commonly report stopping breastfeeding sooner than they planned. Interventions with proper accessible counseling and support to the mother can potentially increase lactation rates and duration.

OBJECTIVE

This study aimed to investigate the impact of introducing a smartphone-based daily feedback and counseling platform between women after delivery and a multidisciplinary lactation support team on lactation rates and various maternal and neonatal outcomes. Counseling was provided via a specifically developed application from a multidisciplinary team (obstetricians, nurses, lactation counselors, and psychologist) in an attempt to assist and counsel to maintain lactation.

STUDY DESIGN

This was a prospective, single-center, randomized controlled trial. Women planning to lactate were recruited at postpartum day 1 and were randomized to (1) routine lactation counseling and support (control group) or (2) additional daily detailed counseling and feedback on lactation from the team via the application (App group). The primary outcome was partial or full lactation at 3 months after delivery. The secondary outcomes included lactation at additional time points up to 6 months after delivery. The study was adequately powered to detect a 15% difference in the primary outcome.

RESULTS

A total of 197 patients were recruited, 97 in the App group and 100 in the control group. The 2 groups did not differ in any background or delivery characteristics. The App group showed higher rates of lactation 6 weeks after delivery (96.9% vs 82.0%; P<.001) and 3 months after delivery (81.4% vs 69.0%; P=.049) than the control group. Patients in the App group reported excellent satisfaction from the use of the application and their overall postnatal care.

CONCLUSION

Our study has provided further information on the growing efficacy of technology platforms in obstetrical care. The introduction of a smartphone-based daily feedback and counseling platform between postpartum patients and a multidisciplinary lactation support team increased the lactation rates after delivery with excellent patient satisfaction.

Returning to Work and Breastfeeding Duration at 12 Months, WIC Infant and Toddler Feeding Practices Study-2

Background: Returning to work can impact breastfeeding duration; limited data exist on how this may impact a lower income population. Methods: Data from U.S. Department of Agriculture's longitudinal study WIC Infant and Toddler Feeding Practices Study-2 were used to assess breastfeeding duration (<12 versus ≥12 months) by age of the baby when women first returned to work and work status (full time and part time). Multivariable logistic regression was used to determine the association of the timing of return to work, work status, and the combination (timing and work status) with breastfeeding duration. Results: Among women who had worked prenatally and initiated breastfeeding, 20.2% breastfed for ≥12 months. Compared to women who did not return to work, fewer women breastfed for ≥12 months if they returned full time or part time (34.1%, 12.0%, and 20.0%, respectively, p < 0.0001). Work status negatively impacted breastfeeding for ≥12 months (full-time adjusted odds ratio [aOR]: 0.24; 95% confidence interval [CI]: 0.13, 0.44 and part-time aOR: 0.51; 95% CI: 0.31, 0.83). Compared to women who did not return, those who returned full time within 3 months or returned part time >1 to 3 months after birth had lower odds of breastfeeding ≥12 months. Conclusions: Returning to work within 3 months after birth had a negative impact on breastfeeding for ≥12 months, particularly for those who returned full time. Efforts to support maternity leave and flexible work schedules could prolong breastfeeding durations among a low-income population. This study was a registered study at clinicaltrials.gov (NCT02031978).

Lessons Learned During Large-Scale Implementation Project Focused on Workplace Lactation Practices and Policies

PURPOSE

This practice-based research funded by the Centers for Disease Control and Prevention (CDC) focuses on the translation of evidence-based practices and policies into real-world applications. To the best of our knowledge, this is the largest study to research the implementation process for lactation accommodations and policies for work sites.

DESIGN OR APPROACH

Pre-/post-test evaluation of work-site lactation accommodations, and 6-month follow-up with business that worked on the project.

SETTING/PARTICIPANTS

34 businesses across New Hampshire.

METHOD

The team developed work-site selection criteria to award mini-grants; developed trainings and a toolkit; and worked with 34 businesses over a 3-year period. Pre-/post-implementation data were collected using the CDC work-site scorecard. A 6-month follow-up phone interview was conducted with each site.

RESULTS

We assessed the CDC scorecard and evaluated the challenges of implementing lactation spaces by industry. In our 6-month follow-up, we found that spaces were still being utilized and we identified specific research to inform practical evidence-based applications and lessons learned when implementing a work-site lactation space.

CONCLUSION

We successfully provided financial/technical support to develop or improve 45 lactation spaces, with policies and practices to support mothers and families for 34 businesses. We identified key takeaway lessons that can be used to guide the development of lactation spaces and policies in work sites. Sites self-report that these work-site changes were sustainable at 6-month follow-up.

Availability of Lactation Accommodation Information for Urology Residency Programs

OBJECTIVE

To assess whether urology residency programs publish information about lactation accommodations online. Although residencies are required to provide lactation accommodations, there is limited data on whether programs disclose this information.

MATERIALS AND METHODS

Webpages of U.S. urology residency programs were assessed for presence of information about lactation. Program characteristics were noted, as were mentions of resident wellness and diversity. Associations between program characteristics and published lactation accommodations were determined by univariate analysis and development of a multivariate logistic regression model.

RESULTS

Of 145 urology residency programs, 72.4% included information about lactation accommodations anywhere on the institution's website There was great variability in ease of accessing information and of quality of information available. Information was most commonly on graduate medical education websites (28.3%) followed by human resources (24.1%), press releases (7.6%), or other sections (11.0%), and least likely to be found on urology residency websites (1.4%). Programs with lactation accommodations anywhere on the institution website were more likely to be larger (p < 0.001), university-based (p < 0.001), and to publish information about resident wellness (p < 0.001), diversity and inclusion (p < 0.001). On multivariate analysis, only university-based setting presence of wellness information were predictors of availability of lactation accommodation information.

CONCLUSION

Lactation accommodation information is usually not available on urology residency websites and most online information is found elsewhere. Predictors of publishing lactation accommodation information were university-based setting and information about resident wellness. Efforts to recruit and retain female urologists should include making this information more easily accessible.

Attitudes and Barriers to Breastfeeding among Mothers in Princess Nourah Bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia

Background

Breastfeeding provides unsurpassed natural nutrition to the newborn and infant. It has a nearly perfect mix of food elements and vitamins that infants need to grow up. Nonetheless, the tendency for breastfeeding remains below the expected levels.

Objectives

To explore the attitudes and barriers to breastfeeding among mothers in Princess Nourah Abdulrahman University (PNU), Riyadh, Saudi Arabia.

Methods

A cross-sectional study was conducted, from January to April 2019; 399 PNU students, employees, and faculty mothers aged 18 years and above with experience of childbirth and breastfeeding were included in the study using a predesigned validated questionnaire. The questionnaire consisted of four scales: sociodemographic, attitude toward breastfeeding, barriers to breastfeeding, and induced lactation knowledge.

Results

The participants' mean age was 34.1 ± 10.4 years; most (87.8%) were Saudi; 92.8% were married; 62% had a bachelor's degree; and 43% had "enough income." While 40% of the mothers reported >6 months "exclusive breastfeeding" for the first baby, only 34.8% did so for the last baby, and 54.5% did so for most of all babies altogether. The mothers' parity ranged between 1 birth and 4 births in 23.5% and 17.5% of the participants, respectively. An overall score of breastfeeding attitude averaged 59.6 ± 7.3. The tendency for scoring a negative attitude to breastfeeding was significantly reported (p < 0.5) among 127 (31.8%) 31- to 40-year-old mothers; 153 (38.3%) bachelor's degree holders; and 157 (39.3%) employees (χ ² (4) 14.6, p = 0.006; χ ² (4) 10.4, p = 0.034; and χ ² (4) 20.4, p < 0.001, respectively). "Mother's illness" was the most commonly (63%) reported barrier to "not to breastfeed," followed by "work" (45.5%) and "father not supporting breastfeeding" (14.8%).

Conclusions

An overall negative attitude toward breastfeeding among PNU mothers was noted. Barriers included mother's sickness and work. Efforts to minimize such negative attitudes and barriers among susceptible mothers are warranted.

The experiences of trained breastfeeding support providers that influence how breastfeeding support is practised: A protocol for a qualitative evidence synthesis

BACKGROUND

Many women stop breastfeeding before they intend to as they cannot overcome breastfeeding difficulties. Breastfeeding support, as an evidence-based intervention by trained lay or professional breastfeeding support providers, can prevent early unintended cessation. Yet some women report dissatisfaction with support and reluctantly stop breastfeeding despite receiving this intervention. Understanding the experiences which shape how support is provided can inform effective implementation of breastfeeding support interventions. This review aims to synthesise experiences of trained breastfeeding support providers in high income settings and how these may influence their breastfeeding support practices.

METHODS

A qualitative systematic review of trained breastfeeding supporters' experiences of supporting women to breastfeed, as part of a generic healthcare role or focused breastfeeding support role, will be conducted. A systematic search will be performed of the databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL +), MEDLINE ALL, Maternity and Infant Care, EMBASE, APA PsycINFO, Web of Science and Scopus. Title and abstract screening using eligibility criteria will be conducted using Covidence software. Eligible papers will be agreed by the review team following full text screening and reported using PRISMA guidelines. CASP and COREQ tools will assess study methodological quality and quality of reporting. Data will be extracted using a bespoke form and coded, using Excel software for data management. Analysis will involve the three stages of thematic synthesis: initial free coding, development of descriptive and subsequent analytical themes. Confidence in findings will be assessed using the CERQual framework.

DISCUSSION

This review is the first to date to synthesise qualitative evidence on experiences which influence how trained lay and professional providers support women with breastfeeding. Findings will enable deeper understanding of the underpinning mechanisms of breastfeeding support provision and inform the development of tailored interventions to improve breastfeeding rates.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42020207380.

Exclusive breastfeeding continuation and associated factors among employed women in North Ethiopia: A cross-sectional study

BACKGROUND

Exclusive Breastfeeding (EBF) can prevent up to 13% of under-five mortality in developing countries. In Sub-Saharan Africa the rate of EBF at six months remains very low at 36%. Different types of factors such as maternal, family and work-related factors are responsible for the low rate of EBF among employed women. This study aimed to assess the prevalence of EBF continuation and associated factors among employed women in North Ethiopia.

MATERIALS AND METHODS

A community-based, cross-sectional study was conducted in two towns of Tigray region, North Ethiopia. Employed women who had children between six months and two years were surveyed using multistage, convenience sampling. Women filled in a paper based validated questionnaire adopted from the Breastfeeding and Employment Study toolkit (BESt). The questions were grouped into four parts of sociodemographic characteristics, maternal characteristics, family support and work-related factors. Factors associated with EBF continuation as a binary outcome (yes/no) were determined using multivariable logistic regression.

RESULTS

Four-hundred and forty-nine women participated in this study with a mean (SD) age 30.4 (4.2) years. Two hundred and fifty-four (56.4%) participants exclusively breastfed their children for six months or more. The main reason for discontinuation of EBF was the requirement of women to return to paid employment (31.5%). Four-hundred and forty (98.2%) participants believed that breastfeeding has benefits either to the infant or to the mother. Three hundred and seventy-one (82.8%) of the participants received support from their family at home to assist with EBF, most commonly from their husbands and mothers. Having family support (adjusted odds ratio [AOR] = 2.1, 95%, CI 1.2-3.6; P = 0.005), having frequent breaks at work (AOR = 2.6, 95% CI, 1.4-4.8; P = 0.002) and the possibility of buying or borrowing required equipment for expressing breast milk (AOR = 1.7, 95% CI, 1.0-3.0; P = 0.033) were statistically associated with an increased chance of EBF.

CONCLUSION

Although returning to work was reported by the study participants as the main reason for discontinuation of EBF, families and managers' support play significant roles in EBF continuation, which in the absence of six-month's maternity leave for employed women in Ethiopia would be of benefit to both mothers and children.

Trends in breastfeeding practices and mothers' experience in the French NutriNet-Santé cohort

Background

France has one of the lowest rates in the world regarding breastfeeding initiation and duration. Few studies have explored breastfeeding practices in France since the middle of the twentieth century, or following from initiation to cessation. The purpose of our study was to determine trends in breastfeeding over the past decades regarding public health recommendations, and to examine mothers’ perceptions about factors known to have an impact on breastfeeding support and cessation.

Methods

From the NutriNet-Santé cohort, 29,953 parous women (launched in 2009 to study relation between nutrition and health), were included in the present study. Using web-questionnaires, they were asked retrospectively if they had breastfed their youngest child or not, and if so, the duration of exclusive and total breastfeeding. For those who had breastfed, we investigated their perceptions about support at initiation and during the entire breastfeeding period and reasons for breastfeeding cessation. We also asked those who did not breastfeed about their perceptions and reasons for infant formula feeding their youngest child. Analyses were weighted according to the French census data.

Results

In the NutriNet-Santé cohort, 67.3% of mothers breastfed their youngest child. The proportion of breastfed children increased over the past few decades, from 55.0% (95% CI 54.3, 55.6) in the 1970s to 82.9% (82.4, 83.4) in the 2010s. Total and exclusive breastfeeding duration went from 3.3 months and 2.4 months respectively in the 1970s to 5.9 months and 3.2 months respectively in the 2010s. Most mothers felt supported at initiation and during the breastfeeding period. A reported desire to have breastfed longer than two months was 59.5%. Mothers who did not breastfeed did it by choice (64.3%). They did not feel guilty (78.2%) and did not perceive a problem not to breastfeed (58.8%), but almost half of them would have liked to have breastfed (45.9%).

Conclusion

Breastfeeding duration has increased in the past decades but did not reach the public health recommendations threshold. Targets other than mothers have to be considered for breastfeeding education, like the partner and her environment, to increase breastfeeding practices.

Trial registration

The study was registered at ClinicalTrials.gov (NCT03335644).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00397-x.

'It's quite a taboo subject': an investigation of mother's experiences of breastfeeding beyond infancy and the challenges they face

Current recommendations state that women should breastfeed their child up to 2 years and beyond. However, the UK has one of the lowest breastfeeding rates in the world. This could in part be explained by the stigma mothers face when breastfeeding an older child. This research aims to provide a detailed understanding of what motivates women to continue breastfeeding beyond infancy and the barriers they face to (i) add to existing research literature which has examined this area and (ii) support and normalize this practice. Semi-structured interviews were conducted between April and June 2018 with 24 women who had breastfed at least one child past 12 months. A theory-driven thematic analysis identified themes that ran through the interviews centering on the benefits of continued breastfeeding, the stigma mothers faced when breastfeeding past infancy and the challenges of returning to work. The women felt that continued breastfeeding enabled them to play a central role in their child's health and develop an attachment led parental style but faced social and cultural stigma due to a lack of public awareness of current breastfeeding recommendations. Interventions which raise awareness of breastfeeding beyond infancy are needed to normalize this practice in the UK.

Factors Associated with Delayed Initiation and Cessation of Breastfeeding Among Working Mothers in Abu Dhabi, the United Arab Emirates

INTRODUCTION

Despite the enormous benefits of breastfeeding, working mothers face more challenges to meet the World Health Organization (WHO) recommendations regarding successful breastfeeding practices. Little research has been done to understand the breastfeeding practices among working mothers in the United Arab Emirates (UAE). Thus, the aim of this study was to investigate the prevalence and factors associated with delayed initiation and cessation of breastfeeding among working mothers with children under the age of two years in Abu Dhabi, the UAE.

METHODS

A cross-sectional multicenter study was conducted from March to September 2017. The study included both Emirati and non-Emirati mothers of children below the age of two years. The data were collected from seven government health care centers in Abu Dhabi as well as from the community. Mothers with young children attending the centers during the study days were approached by trained research assistants, who provided oral and written information about the study.

RESULTS

Among the 1610 mother-child pairs with complete data who were included in this study, 606 were working mothers giving an employment rate of 37.6%. The mean (standard deviation) of maternal age and children's age were 30.9 (5.1) years and 8.6 (6.1) months, respectively. Of the 606 mothers, 217 (35.8%) delayed initiation of breastfeeding, and 359 (59.2%) ceased breastfeeding. In multivariable logistic regression analysis, factors associated with delayed breastfeeding initiation among working mothers were older mother age (adjusted odds ratio [AOR] 1.04, 95% confidence interval [CI]1.01, 1.08), being of non-Arab nationality (AOR 2.24, 95% CI 1.53, 3.27), caesarean section (AOR 2.70, 95% CI 1.84, 3.96), non-rooming-in (AOR 3.85, 95% CI 1.56, 9.51) and mothers with low birth weight children (AOR 2.47, 95% CI 1.23, 4.94). The main factors associated with cessation of breastfeeding were being of non-Arab nationality (AOR 1.59, 95% CI 1.09, 2.31) and mother with high-income rating (AOR 2.79, 95% CI 1.36, 5.75).

CONCLUSION

The study highlighted the need for urgent actions to improve the working mothers' conditions in order to promote optimal breastfeeding practices, including both early initiation and continuation of breastfeeding among all mothers in the UAE regardless of employment status. Policies to improve EBF rates among professional working mothers should include maternity leave extension to enable mothers to continue breastfeeding.

Work, race and breastfeeding outcomes for mothers in the United States

Background

In the United States, mothers’ employment status and occupation are related to breastfeeding. However, it is unclear whether not working leads to longer breastfeeding duration even when compared to professional/managerial jobs, which tend to accommodate breastfeeding better than service/manual labor jobs. Furthermore, occupation and breastfeeding are racially patterned, and it is possible that race could moderate the relationships between mother’s work and breastfeeding.

Methods

Using data from the Panel Study of Income Dynamics, we modeled breastfeeding duration based on mother’s employment/occupation (not working, professional/managerial work, or service/labor work) during the first 6 months postpartum, as well as mother’s race (White, Black or other) and other potential confounders. We used zero-inflated negative binomial regression models and tested an interaction between employment/occupation type and race. Predictive margins were used to compare breastfeeding duration among subgroups.

Results

Mothers working in service/labor occupations had the shortest breastfeeding duration of the three employment/occupation groups, and there was no significant difference in duration between not working and professional/managerial occupation. White mothers had longer breastfeeding duration than Black mothers on average. When we included an interaction between employment/occupation and race, we found that among White mothers, non-working mothers breastfed the longest, while mothers in service/labor work breastfed for the shortest duration, but among Black mothers, mothers in professional/managerial work breastfed for longer than mothers in the other two work categories.

Discussion

Race moderated the relationship between employment status/occupation type and breastfeeding such that, for White mothers, not working was the most advantageous circumstance for breastfeeding, in line with traditional work-family conflict theory. In contrast, for Black mothers, professional/managerial work was the most advantageous circumstance. These findings support the idea of the Market-Family Matrix, which allows that different work scenarios may be more or less advantageous for parenting behaviors like breastfeeding, depending on mothers’ circumstances.

Breastfeeding at the workplace: a systematic review of interventions to improve workplace environments to facilitate breastfeeding among working women

BACKGROUND

Breastfeeding can be affected by maternal employment. This is important considering that in 2019, 47.1% of women globally participated in the labor force. The aim of this study was to review workplace interventions to promote, protect and support breastfeeding practices among working mothers globally.

METHODS

A systematic review was conducted following the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Observational, experimental and qualitative peer-reviewed studies in English and Spanish, published between 2008 and 2019 were included. The review focused on working women who were pregnant, breastfeeding or who recently had a child, and women's working environments. The outcomes of interest included breastfeeding intentions, initiation, exclusivity and duration, confidence in breastfeeding or breastmilk extraction, and perceived support at workplace. Quality was assessed according to National Institute for Health and Care Excellence (NICE) checklist for systematic reviews. It was registered on PROSPERO (#140624).

RESULTS

Data was extracted from 28 quantitative and 9 qualitative studies. The most common interventions were designated spaces for breastfeeding or breastmilk extraction (n = 24), and the support from co-workers (n = 20). The least common interventions were providing breast pumps (n = 4) and giving mothers the flexibility to work from home (n = 3). Studies explored how interventions affected different breastfeeding outcomes including breastfeeding duration, breastfeeding exclusivity, confidence in breastmilk expression, and breastfeeding support. The evidence suggests that workplace interventions help increase the duration of breastfeeding and prevent early introduction of breastmilk substitutes. Having a lactation space, breastmilk extraction breaks, and organizational policies are key strategies. However, to achieve equitable working conditions for breastfeeding mothers, organizational and interpersonal changes need to occur as well.

CONCLUSIONS

The systematic review revealed that interventions at the workplace are important in protecting, promoting and supporting breastfeeding among working mothers. To achieve equitable work environments and fair nutritional opportunities for infants of working mothers, interventions should focus at the three ecological layers - individual, interpersonal, and organizational. The quality of studies can be improved. There is a need for studies assessing impacts of workplace interventions on infant feeding practices, mothers' self-esteem and outcomes such productivity and abstentionism.

Using citizen science to engage the public in monitoring workplace breastfeeding support in Australia

ISSUE ADDRESSED

Returning to work is a major barrier to continued breastfeeding. While many large organisations in Australia have policies to support breastfeeding and expressing at work, it is not known how these are implemented in practice, what support is available in smaller workplaces or to what extent workplace support meets the needs of breastfeeding mothers.

METHODS

This pilot study trialled a citizen science approach where members of the public provided photographs and descriptions of breastfeeding facilities and support within their workplaces. The study was promoted through community networks and social media, and data were submitted via an online survey. Data were analysed inductively to identify key themes.

RESULTS

Thirty-seven participants provided data on breastfeeding support in their workplace. Three key themes were identified: physical features and facilities; workplace culture; and organisational and occupational characteristics. There was considerable variation in workplace support and around half of the participants indicated that they had to use communal, poorly equipped and/or unhygienic spaces to breastfeed or express at work.

CONCLUSION

While some employers have taken important steps towards supporting mothers to combine breastfeeding and work, there is room for improvement. Through this pilot study, we have demonstrated the feasibility and value of using a citizen science approach to obtain data from a range of workplaces along with perceptions of workplace characteristics that support or hinder breastfeeding and expressing at work. SO WHAT?: Citizen science is a useful approach to capturing data on workplace support for breastfeeding and could be scaled up to enable ongoing monitoring. The findings raise important issues around the interpretation and implementation of current legislation to support mothers in the workplace.

Understanding factors affecting breastfeeding practices in one city in the Kingdom of Saudi Arabia: an interpretative phenomenological study

Background

Breastfeeding duration has declined in the Kingdom of Saudi Arabia (KSA) in recent decades, although accurate national data about different breastfeeding indicators by infant age are lacking. This qualitative study, the first in KSA, aimed to understand the factors affecting mothers’ decisions and experiences regarding any breastfeeding practices.

Methods

A qualitative phenomenological approach was used to investigate mothers’ experiences of breastfeeding. Non-probability convenience sampling and snowballing strategies were designed to recruit participants. Semi-structured interviews were conducted with 16 mothers, from two hospitals and three primary health clinics in Al-Madinah city, from December 2017 to March 2018. Interpretative phenomenological analysis was the analysis framework.

Results

Three themes were identified: 1) ‘Up against the system’: policies, staff and systems were the main barriers to exclusive breastfeeding; 2) ‘Social support and negativity’: family support in the first 40 postpartum days protected breastfeeding continuation and was highly appreciated, but negative comments limited breastfeeding practices thereafter; and 3) ‘Managing tensions’: mothers’ religious beliefs about breastfeeding boosted their decisions; however, the challenge of managing tensions influenced mothers to stop breastfeeding earlier than they wished. The study revealed that mothers had no doubts about wanting to breastfeed their babies; but continuation was adversely affected by unhelpful hospital policies and staff actions, the lack of ongoing social support, and by others people’s negativity, rather than by the mothers’ own views. Stopping breastfeeding earlier than planned was a complex decision for most mothers. However, mothers said that they intended to breastfeed their next baby successfully.

Conclusions

Healthcare professionals (maternity staff, paediatricians and pharmacists) need education and training to support exclusive breastfeeding effectively. Increasing the number of hospitals with Baby Friendly Hospital Initiative accreditation, which includes staff practice changes, is needed to protect and support exclusive breastfeeding. Ongoing professional and peer support, and improving conditions at workplaces and universities, are needed to help mothers to continue breastfeeding successfully. Effective, coordinated national policies can support mothers’ decisions in relation to breastfeeding. Such changes will reduce the tensions experienced by women and help them to achieve their breastfeeding goals and to breastfeed for longer.

Effectiveness of a breastfeeding program for mothers returning to work in Japan: a quasi-experimental study

BACKGROUND

Maternal employment has been described as a barrier to breastfeeding in many countries. In Japan, many mothers quit breastfeeding after returning to work because they do not know how to continue breastfeeding. The primary objective of this study was to investigate the effectiveness of a breastfeeding support program for mothers. The secondary objective was to explore the effectiveness of a pamphlet for mothers returning to work.

METHODS

This was a quasi-experimental design study with a program group (n = 48), pamphlet group (n = 46) and comparison group (n = 47) that took place from February 2017 to August 2018. Participants in the program and pamphlet groups were women who planned to return to work within 4-12 months after giving birth, while the comparison group included women who had been back at work for at least 3 months. The program involved a 90-min breastfeeding class, a pamphlet, a newsletter, and email consultation. The pamphlet group was sent only the pamphlet, while the comparison group received no intervention. The outcome was breastfeeding continuation rate at 3 months after returning to work.

RESULTS

The breastfeeding continuation rate 3 months after returning to work was significantly higher in the program group than in the comparison group (79.2% vs. 51.1%, p = 0.004). After adjusting for background factors, the program intervention had an effect on breastfeeding rates (adjusted odds ratio = 4.68, 95% confidence interval: 1.57, 13.96; p = 0.006). However, comparing the pamphlet and comparison groups revealed no significant differences in breastfeeding continuation rates at 3 months after returning to work (69.6% vs. 51.1%, p = 0.07).

CONCLUSIONS

Program intervention was associated with a significant increase in breastfeeding continuation rates 3 months after returning to work. Randomized controlled trials are needed to make this program applicable in practice. Pamphlet intervention resulted in no significant difference. Further study is necessary after examining the contents of the pamphlet.