Women's perspectives on antenatal breast expression: a cross-sectional survey

Breastfeeding and Antepartum Breast Milk Expression (BABE): A Randomized Control Trial Utilizing an Electric Breast Pump and its Effect on Postpartum Breastfeeding

Objective: To evaluate the effect of antenatal breast milk expression (ABE) on exclusive breastfeeding. Materials and Methods: A randomized control study was performed with the primary outcome being formula use during the postpartum hospital stay. Secondary outcomes were the exclusive breastfeeding rate at 6 months postpartum and peripartum safety outcomes. Participants included multiparous and nulliparous patients who planned to breastfeed. Exclusion criteria included exclusively breastfeeding in prior pregnancies for greater than 6 months, medical contraindications for breastfeeding, multiple gestation, history of preterm delivery, or any contraindication to vaginal delivery. ABE group participants were instructed to pump for 20 minutes, three times daily, starting at 37 weeks of gestation. Results: Three-hundred four participants from two clinics were enrolled. There was no significant difference in formula use during hospital admission (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.34-1.22) or in exclusive breastfeeding at 6 months postpartum (OR 0.66, 95% CI 0.34-1.29). Colostrum use was more prevalent in the ABE group (OR 5.31, 95% CI 2.63-10.76). ABE participants were more likely to present in spontaneous labor (OR 2.09, 95% CI 1.05-4.14). Conclusion: ABE did not significantly improve exclusive breastfeeding rates, but safely provides women opportunities to become familiar with breastfeeding before delivery and can provide readily available colostrum. There was no negative secondary safety outcome related to ABE identified. Prenatal care providers can consider recommending ABE to patients with minimal to no experience with breastfeeding.

Teaching antenatal hand expression: a feasibility study in an inner urban U.S. hospital

BACKGROUND

Many women have low confidence in breastfeeding and have concerns regarding low milk volume or discomfort with breastfeeding. Antenatal hand expression may be an opportunity to help women feel more comfortable with breastfeeding and help promote exclusive breastfeeding. A study at a hospital in Philadelphia, Pennsylvania, U.S. assessed the feasibility of teaching antenatal hand expression at 39 weeks among socioeconomically disadvantaged populations, overall participant satisfaction and adoption of hand expression and breastfeeding.

METHODS

From March 2020 to June 2021, women recruited at 34-39 weeks were taught to hand express, collect, and store colostrum. Starting from 39 weeks, participants were asked to practice hand expression 1-3 times / day until delivery, log their experiences, and store colostrum expressed. Women were contacted to encourage continued hand expression and answer any questions. Postpartum, a survey assessed satisfaction with hand expression and issues encountered. The survey also inquired about breastfeeding plans and barriers, and whether women were exclusively breastfeeding (defined as infants who received only breastmilk from the time of birth). Chart review of postpartum or well-baby visit notes determined whether women continued breastfeeding.

RESULTS

Of the 29 participants, 72% (21/29) reported hand expressing at home, and no women reported contractions when hand expressing. Participants rated mean satisfaction of 8.1/10 (SD = 1.62) with antenatal hand expression, mean satisfaction of 9.4/10 (SD = 0.90) toward hand expression education, mean likelihood of 9.4/10 (SD = 1.24) recommending hand expression to others, and a mean score of 8.1/10 (SD = 1.69) on how helpful hand expression was in breastfeeding initiation. 90% (26/29) of women initiated breastfeeding after birth and 72% (21/29) exclusively breastfed on discharge, but only 11/29 (38%) continued exclusively breastfeeding when re-assessed 4-6 weeks postpartum. Barriers included maternal discomfort, low milk supply, and maternal or infant illness.

CONCLUSIONS

This study suggests that women in an urban setting would be willing to practice antenatal hand expression. A larger and adequately powered study could be feasible to determine associations between antenatal hand expression and breastfeeding rates and confidence.

Effect of antenatal milk expression education on lactation outcomes in birthing people with pre-pregnancy body mass index ≥25: protocol for a randomized, controlled trial

BACKGROUND

Birthing people with pre-pregnancy body mass indices (BMIs) ≥ 25 kg/m², particularly those without prior breastfeeding experience, are at increased risk for suboptimal lactation outcomes. Antenatal milk expression (AME) may be one way to counteract the negative effects of early infant formula supplementation common in this population.

METHODS

This ongoing, randomized controlled trial in the United States evaluates the efficacy of a telelactation-delivered AME education intervention versus an attention control condition on lactation outcomes to 1 year postpartum among 280 nulliparous-to-primiparous, non-diabetic birthing people with pre-pregnancy BMI ≥ 25 kg/m². The assigned study treatment is delivered via four weekly online video consultations between gestational weeks 37-40. Participants assigned to AME meet with study personnel and a lactation consultant to learn and practice AME. Instructions are provided for home practice of AME between study visits. Control group participants view videos on infant care/development at study visits. Participants complete emailed surveys at enrollment (34^0/7-36^6/7 gestational weeks) and 2 weeks, 6 weeks, 12 weeks, 6 months, and 12 months postpartum. Surveys assess lactation and infant feeding practices; breastfeeding self-efficacy, attitudes, and satisfaction; perception of insufficient milk; onset of lactogenesis-II; lactation support and problems; and reasons for breastfeeding cessation. Surveys also assess factors associated with lactation outcomes, including demographic characteristics, health problems, birth trauma, racial discrimination, and weight stigma. Health information and infant feeding data are abstracted from the pregnancy and birth center electronic health record. Milk samples are collected from the intervention group at each study visit and from both groups at each postpartum follow-up for future analyses. Qualitative interviews are conducted at 6 weeks postpartum to understand AME experiences. Primary outcomes of interest are breastfeeding exclusivity and breastfeeding self-efficacy scores at 2 weeks postpartum. Outcomes will be examined longitudinally with generalized linear mixed-effects modeling.

DISCUSSION

This is the first adequately powered trial evaluating the effectiveness of AME among U.S. birthing people and within a non-diabetic population with pre-pregnancy BMI ≥ 25 kg/m². This study will also provide the first evidence of acceptability and effectiveness of telelactation-delivered AME.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04258709.

Education and Experiences of Antenatal Breast Milk Expression: A Systematic Review

Background: Breastfeeding rates have stagnated recently despite recommendations to breastfeed until age 2 years. Antenatal breast milk expression (ABME) is a method used to prepare the breast for breastfeeding. However, there is limited evidence available on the benefits, risks, and impact of ABME on maternal-infant breastfeeding dyads. Methods: This review identified and summarized studies on women who engaged in ABME and their personal experiences. Databases searched included PubMed MEDLINE, Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and EMBASE. Initially, abstracts and titles were reviewed, and then, full-text studies were screened for inclusion by two blinded authors. Two authors assessed the quality of the studies using a standardized tool, two authors completed data extraction, and one author completed data harmonization into tables. Results: A total of 1,410 studies were identified (after duplicates removed) and 10 citations qualified for the inclusion criteria. Only two studies received an overall rating of strong quality and low-risk bias. The selected articles varied in primary outcomes; however, main focuses were experiences, knowledge, and perspective after practicing ABME. Data varied on timing of ABME, but most studies started between 34 and 36 weeks. The average amount of expressed milk was reported in four studies but was variable. Conclusions: This systematic review found that the literature is limited regarding ABME, and most studies were focused on women with diabetes. The current limited evidence suggests that ABME may be a helpful tool in improving maternal breastfeeding confidence and breastfeeding outcomes. Negative side effects reported related to ABME included difficulty learning the technique, discomfort, and feeling of awkwardness while expressing. Future research should focus on higher quality studies regarding use of ABME, proper teaching of ABME technique, and the use of ABME to improve breastfeeding outcomes in diverse populations of maternal-infant dyads.

Antenatal Milk Expression as a Lactation Support Intervention for Parents of Infants With Severe Birth Defects: A Case Series

BACKGROUND

A diet high in parent's own milk (parental milk) is a lifesaving intervention for critically ill infants. Lactating parents whose infants are born with birth defects that require surgical repair (surgical infants) shortly after birth often struggle to initiate and maintain a milk supply that meets their infant's nutritional needs. Antenatal milk expression has been identified as a safe, feasible, and potentially effective strategy that promotes parents' direct chest/breastfeeding or milk expression (lactation) confidence and helps parents attain their lactation goals. Two cases are presented to illustrate the potential for using antenatal milk expression as a lactation support intervention for parents of surgical infants.

CASE PRESENTATION

Cases were drawn from a pilot study exploring the feasibility of implementing antenatal milk expression among pregnant parents of surgical infants. Participants were healthy women recruited after 30 weeks of gestation who received a fetal diagnosis of a complex congenital heart defect. Despite variability in clinical course and length of stay, parental milk was provided for the duration of each infant's hospitalization. Participant perceptions of antenatal milk expression varied.

CONCLUSION

More research is needed to evaluate the feasibility, efficacy, and parent or provider perceptions of antenatal milk expression as a lactation support intervention for parents of surgical infants.

Structured antenatal milk expression education for nulliparous pregnant people: results of a pilot, randomized controlled trial in the United States

BACKGROUND

Hand-expression, collection, and storage of breast milk during pregnancy (i.e., antenatal milk expression or AME) is a safe, potentially effective practice to reduce early, undesired infant formula supplementation among women with diabetes. The feasibility and potential impact of AME on lactation outcomes in the United States (U.S.) and among non-diabetic birthing people is unknown.

METHODS

The purpose of this study was to examine the feasibility of a structured AME intervention among nulliparous birthing people in the United States. We recruited 45 low-risk, nulliparous individuals at 34-36^6/7 weeks of gestation from a hospital-based midwife practice. Participants were randomized to AME or a control group receiving lactation education handouts. Interventions were delivered at weekly visits at 37-40 weeks of pregnancy. The AME intervention involved technique demonstration and feedback from a lactation consultant and daily independent practice. Lactation outcomes were assessed during the postpartum hospitalization, 1-2 weeks postpartum, and 3-4 months postpartum.

RESULTS

Between December 2016 and February 2018, 63 individuals were approached and screened for eligibility, and 45 enrolled into the study (71%). Of 22 participants assigned to AME, 18 completed at least one AME study visit. Participants reported practicing AME on at least 60% of days prior to their infant's birth. Most were able to express milk antenatally (15/18), more than half collected and froze antenatal milk (11/18), and 39% (7/18) supplemented their infants with antenatal milk after birth. No major problems were reported with AME. Perinatal and lactation outcomes, including infant gestational age at birth, neonatal intensive care unit admissions, delayed onset of lactogenesis II, and use of infant formula were similar between AME and control groups. Among participants in both groups who were feeding any breast milk at each assessment, breastfeeding self-efficacy increased and perceptions of insufficient milk decreased over the postpartum course.

CONCLUSIONS

In a small group of nulliparous birthing people in the U.S., AME education and independent practice beginning at 37 weeks of pregnancy was feasible. In some cases, AME provided a back-up supply of milk when supplementation was indicated or desired. The relationship between AME and lactation outcomes requires further study with adequately powered samples.

TRIAL REGISTRATION

This trial was retrospectively registered at ClinicalTrials.gov on May 11, 2021 under the following registration ID: NCT04929301. https://clinicaltrials.gov/ct2/show/NCT04929301 .

'Is there any point in me doing this?' Views and experiences of women in the Diabetes and Antenatal Milk Expressing (DAME) trial

The Diabetes and Antenatal Milk Expressing (DAME) randomised controlled trial (RCT) was conducted in 2011–2015, at six sites in Melbourne, Australia to explore the effect of advising women with diabetes in pregnancy to express breast milk from 36 weeks gestation. Infants whose mothers were randomised to express in pregnancy were more likely to be exclusively breast milk fed during their hospital stay, and there was no evidence of harm. This paper explores women's views and experiences of antenatal expressing. In this two‐arm RCT, 635 women with diabetes in pregnancy who were otherwise of low medical risk were randomised at 36–37 weeks gestation to usual care (not expressing, n = 316), or the intervention, where women were advised to hand express for 10 min twice daily until birth (n = 319). Semistructured face‐to‐face interviews were conducted with 10 women who expressed antenatally. They were asked about their experiences of antenatal expressing, including how they felt about the overall experience, the amount of breast milk they expressed, making time to express, and their experience of breastfeeding. Thematic analysis of the in‐depth interviews identified six themes: (1) learning and adapting expressing, (2) feelings and sensations associated with expressing, (3) support, (4) dis/empowerment, (5) health, and (6) the value of breast milk. Women had both positive and negative experiences of antenatal expressing. If health professionals are advising antenatal expressing to women, it is important they understand the range of outcomes and experiences.

Women's experiences of antenatal expressing were both positive and negative; it is important to understand the range of experiences.

Women should be advised that some women express little or no breast milk antenatally and therefore be reassured if they are concerned.

For women with diabetes in pregnancy, their diabetes management is a significant time burden, and should be considered when discussing antenatal expressing with women.

Maternity care providers need to follow‐up with pregnant women advised to express, to provide education, reassurance, and reassess expressing techniques.

Maternity care providers need to manage and prioritise the use of expressed breast milk.

Integrative Review of Antenatal Milk Expression and Mother-Infant Outcomes During the First 2 Weeks After Birth

OBJECTIVE

To explore the practice of antenatal milk expression (AME) and related outcomes for mother-infant dyads during the first 2 weeks after birth.

DATA SOURCES

We searched the electronic databases MEDLINE, Embase, CINAHL, Emcare, Maternity & Infant Care Database, Scopus, and Web of Science for relevant literature. We also conducted backward reference searches on relevant publications and nondatabase searches after review of the full texts.

STUDY SELECTION

Articles were eligible for inclusion if they reported primary studies focused on AME, included samples of mother-infant dyads, and were published in English. We did not impose time or design limitations given the sparse availability of literature on AME. We identified 766 articles. After the removal of duplicates, we screened 588 articles, and of these, we included 15 articles in our review.

DATA EXTRACTION

We used the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines to guide data extraction and reporting. We evaluated the quality of evidence using the Melnyk and Fineout-Overholt rating system and the Joanna Briggs Institute critical appraisal tools.

DATA SYNTHESIS

We synthesized data from the included articles into four themes: Breastfeeding Self-Efficacy, Milk Supply, Infant Well-Being, and Infant Feeding Methods.

CONCLUSION

AME may support breastfeeding by improving breastfeeding self-efficacy and milk supply and by decreasing early formula use. Synthesized literature on AME shows the safety of the practice and that infants of women who practice AME have a greater likelihood of breastfeeding exclusivity during the short term.

Antenatal breastmilk expression for women with diabetes in pregnancy - a feasibility study

Background

Mothers with diabetes are less likely to achieve successful breastfeeding. Antenatal breastmilk expression (ABE) may facilitate earlier breastfeeding, but feasibility of introducing ABE and its acceptance among Scandinavian women have previously not been investigated.

Methods

This observational trial was conducted between the 1 January 2019 and the 12 March 2020 in Tromsø, Norway. We aimed to determine the feasibility of ABE in terms of practicality and acceptability among women with medically (metformin or insulin) treated diabetes. Women were invited to participate during antenatal visits from 32 weeks gestation. Participants received instruction and started ABE from gestation week 37 + 0. Participants, and their infants, were followed until 6–8 weeks after birth. We collected data on breastfeeding rates, infant hypoglycemia, transfer to the neonatal unit, and the women’s overall experience and satisfaction with antenatal breastmilk expression.

Results

Twenty-eight of 34 (82%) invited women consented to participate. All started ABE from week 37 + 0, and continued until hospital admission. No women reported any discomfort or side effects. Labor was induced at 38 weeks gestation. Twenty-four women brought harvested colostrum to the maternity ward, which was given to their infants during the first 24 h of life. Breastfeeding rates at discharge were 24/28 (86%) and 21/27 (78%) at 6–8 weeks after delivery. Seven (25%) infants were transferred to the neonatal unit; four because of hypoglycemia. Maternal satisfaction assessed 6–8 weeks after delivery revealed that all participants felt positive about the ABE, but one woman would not recommend it to other pregnant women.

Conclusions

Implementing a structured ABE guideline for women with medically treated diabetes was feasible. The intervention was associated with high level of satisfaction among study participants. No obvious side effects were observed, and breastfeeding rates at discharge and 6–8 weeks after delivery were higher than in comparable studies.

Trial registration

The study was registered at the research study registry at the University Hospital of North Norway (Nr 2018/7181).

Evaluating antenatal breastmilk expression outcomes: a scoping review

Background

Antenatal breastmilk expression (aBME) is recommended by some healthcare providers to improve lactation, breastfeeding, and newborn outcomes, particularly for women with diabetes as they face unique challenges with breastfeeding. However, there is limited evidence of the potential harms and benefits of this practice. Our objective was to conduct a scoping review to map the literature describing maternal and newborn outcomes of aBME.

Methods

We searched Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, British Library E-Theses Online Services (EThOS) database, OpenGrey, and Clinical trials.gov from inception to January 2020. Studies in English that reported on the effect of aBME on maternal and newborn outcomes, and the experiences of women who have engaged in the practice were included for screening. Titles, abstracts, and full-text articles were screened by two independent reviewers. A critical appraisal and clinical consultation were conducted. Key findings were extracted and summarized.

Results

We screened 659 studies and 20 met the inclusion criteria. The majority of included studies (n = 11, 55.0%) were published after 2015, and seven (35.0%) originated from Australia. Ten (50.0%) studies provided data on high-risk obstetrical populations, including those with diabetes (n = 8), overweight or obesity (n = 1), and preeclampsia (n = 1). Commonly reported outcomes included breastfeeding status at discharge or follow-up, mode of delivery, newborn blood glucose, and time to establishing full lactation. Maternal experiences were related to challenges with aBME, confidence and mastery, perceived impact, security and altruism, learning and resources, and physical symptoms as a result of aBME. The critical appraisal demonstrated limited high-quality evidence surrounding aBME.

Conclusions

Our findings demonstrate increasing interest in the safety, efficacy, and acceptability of aBME. Existing studies are heterogenous with variable research questions, outcomes, study designs, and methodology. The recommendations made in this review can be used to help inform  future studies evaluating aBME.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00371-7.

"It gave me so much confidence": First-time U.S. mothers' experiences with antenatal milk expression

Antenatal milk expression (AME) involves maternal hand-expression, collection, and storage of breast milk during pregnancy for the purposes of reducing the early formula use in breastfed infants. AME is not widely practiced in the United States, despite its growing popularity elsewhere. In this study, we examined the experiences of first-time mothers recruited from a U.S. midwife practice who engaged in AME within the context of a pilot randomized controlled trial. The AME intervention involved demonstration and practice of AME with a lactation consultant beginning at 37 weeks of gestation, reinforcement at weekly study visits until delivery, and daily home practice. Nineteen women participated in a semistructured interview at 1-2 weeks postpartum regarding their study experiences. Major themes included (1) perceived benefits and impact of AME, (b) AME implementation, and (c) use of AME milk. Women perceived multiple benefits of AME, most notably that it increased their confidence that they would be able to make milk and breastfeed successfully postpartum. Women expressed some concern that no/little milk expressed could be indicative of postpartum milk production problems. Regarding implementation, women found that the AME protocol fit well into their daily routine. There was mixed feedback regarding comfort with practicing AME in the presence of partners. Reasons for postpartum use of AME milk varied; barriers to provision included inadequate milk storage options at the birth hospital and unsupportive hospital providers/staff. With few caveats, AME appears to be an acceptable breastfeeding support intervention among a sociodemographically homogeneous group of first-time mothers in the United States.