Georgia's breastfeeding promotion program for low-income women

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

A scoping review of breastfeeding peer support models applied in hospital settings

BACKGROUND

The 2013 updated guidelines on management of severe acute malnutrition in infants and children recommends the support of exclusive breastfeeding. These guidelines are inconsistently applied in low and middle income countries (LMICs) due to barriers including unclear implementation guides, technical support and epidemiological factors. Peer support strategies have been used to offer psychological support to families with infants in NICU and improve mental health outcomes. Breastfeeding peer supporters (BFPS) have been shown to be effective in improving breastfeeding outcomes in community settings however, their success within hospital settings in LMICs is unknown. We conducted a scoping review to explore implementation of breastfeeding peer support strategies as have been applied to hospitalized infants globally and highlight their implementation strategies in order to guide future research and practice.

METHODS

A scoping review of the literature was conducted using the Arksey and O'Malley framework. A search was conducted in five online databases (PubMed, Cochrane library, Hinari, Google Scholar and Open Grey library). Data were extracted and charted in data extraction tables to capture general characteristics, modes of peer support delivery, implementation details and evaluation procedures.

RESULTS

From the online search 276 articles were identified, however only 18 met the inclusion criteria for the study. The majority of these articles were reports on in-patient breastfeeding peer support interventions applied in Europe and the United States of America and only two were from LMICs. The articles described peer supporters' identification, training (n = 13) and supervision (n = 14). The majority of the BFPS were employed (n = 10) compared to volunteers (n = 3) and support was mainly one-to-one (n = 11) rather than group support. Process and impact evaluation (n = 13) reported positive breastfeeding outcomes associated with breastfeeding peer support.

CONCLUSION

Breastfeeding peer support strategies are applied in different hospital settings and can be used to improve breastfeeding outcomes. However, to achieve integration, scalability and comparability of impact and outcomes, there is a need to standardize training, develop consistent implementation and supervision plans of in-patient peer supporters' strategies. Further research to assess sustainability and evaluate cost-effectiveness of in-patient breastfeeding peer support strategies will improve uptake and scalability of these potentially lifesaving interventions.

Community-based maternal and newborn educational care packages for improving neonatal health and survival in low- and middle-income countries

BACKGROUND

In low- and middle-income countries (LMICs), health services are under-utilised, and several studies have reported improvements in neonatal outcomes following health education imparted to mothers in homes, at health units, or in hospitals. However, evaluating health educational strategy to deliver newborn care, such as one-to-one counselling or group counselling via peer or support groups, or delivered by health professionals, requires rigorous assessment of methodological design and quality, as well as assessment of cost-effectiveness, affordability, sustainability, and reproducibility in diverse health systems.

OBJECTIVES

To compare a community health educational strategy versus no strategy or the existing approach to health education on maternal and newborn care in LMICs, as imparted to mothers or their family members specifically in community settings during the antenatal and/or postnatal period, in terms of effectiveness for improving neonatal health and survival (i.e. neonatal mortality, neonatal morbidity, access to health care, and cost).

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4), in the Cochrane Library, MEDLINE via PubMed (1966 to 2 May 2017), Embase (1980 to 2 May 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 2 May 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Community-based randomised controlled, cluster-randomised, or quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data. We assessed the quality of evidence using the GRADE method and prepared 'Summary of findings' tables.

MAIN RESULTS

We included in this review 33 original trials (reported in 62 separate articles), which were conducted across Africa and Central and South America, with most reported from Asia, specifically India, Pakistan, and Bangladesh. Of the 33 community educational interventions provided, 16 included family members in educational counselling, most frequently the mother-in-law or the expectant father. Most studies (n = 14) required one-to-one counselling between a healthcare worker and a mother, and 12 interventions involved group counselling for mothers and occasionally family members; the remaining seven incorporated components of both counselling methods. Our analyses show that community health educational interventions had a significant impact on reducing overall neonatal mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.78 to 0.96; random-effects model; 26 studies; n = 553,111; I² = 88%; very low-quality evidence), early neonatal mortality (RR 0.74, 95% CI 0.66 to 0.84; random-effects model; 15 studies that included 3 subsets from 3 studies; n = 321,588; I² = 86%; very low-quality evidence), late neonatal mortality (RR 0.54, 95% CI 0.40 to 0.74; random-effects model; 11 studies; n = 186,643; I² = 88%; very low-quality evidence), and perinatal mortality (RR 0.83, 95% CI 0.75 to 0.91; random-effects model; 15 studies; n = 262,613; I² = 81%; very low-quality evidence). Moreover, community health educational interventions increased utilisation of any antenatal care (RR 1.16, 95% CI 1.11 to 1.22; random-effects model; 18 studies; n = 307,528; I² = 96%) and initiation of breastfeeding (RR 1.56, 95% CI 1.37 to 1.77; random-effects model; 19 studies; n = 126,375; I² = 99%). In contrast, community health educational interventions were found to have a non-significant impact on use of modern contraceptives (RR 1.10, 95% CI 0.86 to 1.41; random-effects model; 3 studies; n = 22,237; I² = 80%); presence of skilled birth attendance at birth (RR 1.09, 95% CI 0.94 to 1.25; random-effects model; 10 studies; n = 117,870; I² = 97%); utilisation of clean delivery kits (RR 4.44, 95% CI 0.71 to 27.76; random-effects model; 2 studies; n = 17,087; I² = 98%); and care-seeking (RR 1.11, 95% CI 0.97 to 1.27; random-effects model; 7 studies; n = 46,154; I² = 93%). Cost-effectiveness analysis conducted in seven studies demonstrated that the cost-effectiveness for intervention packages ranged between USD 910 and USD 11,975 for newborn lives saved and newborn deaths averted. For averted disability-adjusted life-year, costs ranged from USD 79 to USD 146, depending on the intervention strategy; for cost per year of lost lives averted, the most effective strategy was peer counsellors, and the cost was USD 33.

AUTHORS' CONCLUSIONS

This review offers encouraging evidence on the value of integrating packages of interventions with educational components delivered by a range of community workers in group settings in LMICs, with groups consisting of mothers, and additional education for family members, for improved neonatal survival, especially early and late neonatal survival.

WIC Participation and Breastfeeding after the 2009 WIC Revision: A Propensity Score Approach

In this study, we examined the association between participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and breastfeeding outcomes before and after the 2009 revisions. Four-thousand-three-hundred-and-eight WIC-eligible children younger than 60 months were included from the 2005–2014 National Health and Nutrition Examination Survey (NHANES). We compared two birth cohorts with regard to their associations between WIC participation and being ever-breastfed and breastfed at 6 months. We estimated the average effect of the treatment for the treated to assess the causal effect of WIC participation on breastfeeding based on propensity score matching. The results showed that WIC-eligible participating children born between 2000 and 2008 were significantly less likely than WIC-eligible nonparticipating children to ever receive breastfeeding (p < 0.05) or to be breastfed at 6 months (p < 0.05). Among children born between 2009 and 2014, WIC-eligible participating children were no longer less likely to ever receive breastfeeding compared to WIC-eligible nonparticipating children; the gap remained in breastfeeding at 6-months (p < 0.05). The disparities in prevalence of ever breastfed between WIC-eligible participants and nonparticipants have been eliminated since the 2009 WIC revision. More efforts are needed to improve breastfeeding persistence among WIC-participating mother–infant dyads.

Short-term efficacy of two breast pumps and impact on breastfeeding outcomes at 6 months in exclusively breastfeeding mothers: A randomised trial

The provision of breast pumps is a potential strategy to increase breastfeeding duration. This trial compared the effectiveness and acceptability of two breast pumps in mothers exclusively breastfeeding (EBF) their healthy term infant. It also tested whether provision of pumps versus vouchers of equivalent value influenced breastfeeding or attainment of mothers' goals at 3 and 6 months. Mothers were randomised at 3- to 4-week post-partum (Beijing [n = 30], Moscow [n = 34], London [n = 45], New York [n = 3]) to groups A (Philips single-electric pump, Natural bottle), B (Medela Swing single-electric pump, Calma bottle), or C (Control; vouchers). At 6 weeks, group A and B mothers expressed for 10 min/breast; milk weight and opinions of pump/bottle were recorded. Feeding practices were assessed using questionnaires at 3 and 6 months. Milk weight/flow pattern did not differ between groups. Pump A scored significantly better for ease-of-use, cushion-feel, need-to-lean-forward, pleasant, comfort. At 3 and 6 months, %EBF or meeting their goal was not significantly different; (3 months: 86%, 85%, 84%; 6 months: 20%, 15%, 26%; meeting goal 24%, 17%, 27% for A, B, and C). Expressed breast milk (EBM) provision was higher in groups A and B (3 months: 76%, 76%, 24% (p < 0.001); 6 months: 83%, 87%, 32% (p < 0.001); and negatively predicted EBF at 6 months (OR no EBM 5.07, 95% CI [1.56, 16.5]). The pumps were equally effective for milk expression at 6 weeks. Pump provision did not significantly influence breastfeeding practices or attainment of goals but resulted in higher EBM provision, which was associated with lower EBF but not other breastfeeding categories at 6 months.

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

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

Randomized Controlled Trial to Prevent Infant Overweight in a High-Risk Population

OBJECTIVES

Infants are at risk of overweight. Infant overweight predisposes child, adolescent, and adult to obesity. We hypothesized that parent education, initiated prenatally and provided in the home, would reduce the incidence of infant overweight at age 12 months.

METHODS

Pregnant obese Latina women were recruited at Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and randomized to intervention versus control. Intervention subjects received home visits by trained Spanish-fluent community health workers who provided counseling on infant growth, breastfeeding, nutrition, child development, sleep, physical activity, and safety. Promotoras did not visit the control subjects. A research assistant collected outcome data on all subjects.

RESULTS

Compared to controls, parent education did not reduce infant overweight. Infant overweight developed rapidly and was present in 46% of infants by age 6 months. Infants overweight at 6 months were likely to be overweight at age 12 months (r = 0.60, P < .0001). Overweight was more common in formula-fed infants at ages 6 months (P < .06) and 12 months (P = .005). Breastfeeding was less common in families with employed mothers (P = .02) and unemployed fathers (P < .01), but the father living with the mother at the time of the prenatal visit predicted successful breastfeeding at infant age 2 months (P < .003). Compared to formula feeding, overweight at age 12 months was 2.7 times less likely for infants breastfed for ≥2 months (P = .01).

CONCLUSIONS

The lack of success of the intervention may be explained in part by a high cesarean section rate in the intervention group, food and employment insecurity, and confounding by WIC breastfeeding promotion, which was available to all mothers. Breastfeeding was the most important mediator of infant overweight. The study supports efforts by WIC to vigorously promote breastfeeding.

Intention and Initiation of Breastfeeding Among Women Who Are Incarcerated

The Baby-Friendly Hospital Initiative recommends that all mothers be shown how to breastfeed, even when mothers and newborns are separated. Most incarcerated women are separated from their infants after the postpartum hospital stay, creating barriers to breastfeeding. We examined breastfeeding among a sample of women participating in a prison-based pregnancy program. Quantitative data indicated that women who discussed breastfeeding with their doulas were more likely to initiate breastfeeding. Three qualitative themes were identified: Benefits of Breastfeeding, Barriers to Breastfeeding, and Role of the Doula. We identified incongruence between the expected standard of breastfeeding support and the care incarcerated women received. Findings suggest that prison-based doula care might be an effective intervention for supporting breastfeeding among incarcerated women and highlight the importance of education for perinatal nurses about breastfeeding support of incarcerated women.

Effectiveness of community-based peer support for mothers to improve their breastfeeding practices: A systematic review and meta-analysis

Breastfeeding is associated with reduced mortality in children aged less than 5 years. We conducted a systematic review and meta-analysis (registered as PROSPERO 2015: CRD42015019105) to examine the effectiveness of community-based peer support for mothers on their breastfeeding practices as compared to mothers who have not received such a support.

The Effect of Breast Pump Use on Exclusive Breastfeeding at 2 Months Postpartum in an Inner-City Population

BACKGROUND

Breastfeeding is the optimal form of infant nutrition, yet national rates are below recommendations with persistent disparities. Breast pumps may address the reasons that mothers discontinue breastfeeding.

OBJECTIVES

To determine whether breast pump use increases exclusive breastfeeding at 1.5-3.5 months postpartum.

MATERIALS AND METHODS

We reviewed charts for maternal-infant descriptors and feeding type for infants born between November 2013 and June 2014 who received any breast milk at a visit <14 days of age in our inner-city pediatric practice. We compared feeding at 1.5-3.5 months between those with breast pump and those without breast pump.

RESULTS

Of the 905 infants with feeding type recorded, 487 (54%) received any breast milk, of whom 355 (72.9%) had a visit at 1.5-3.5 months [95.4% African American (AA)]. Rates of any breastfeeding (93.8% vs. 38.9%) and exclusive breastfeeding (50.0% vs. 17.8%) were significantly higher in non-AAs than in AAs. Due to small numbers of non-AAs, further analyses were conducted for AAs only. The rate of exclusive breastfeeding at 1.5-3.5 months (19.4% vs. 16.3%) was similar between those with a breast pump and those without a breast pump, whereas rates of any breastfeeding were higher among those with no breast pump (46.9% vs. 31.4%, p = 0.004). Also, among AA mothers, rates of feeding at the breast were lower (21.5% vs. 44.4%, p < 0.0001) and rates of feeding expressed breast milk were higher (16.6% vs. 8.2%, p = 0.02) among those with a breast pump versus those without a breast pump.

CONCLUSIONS

Although breast pumps were free, breast pump use among predominantly AA WIC-eligible mothers was not associated with increased rates of exclusive breastfeeding at 1.5-3.5 months postpartum.

Community-Based Participatory Initiatives to Increase Breastfeeding Rates in Indiana

In 2012, the Centers for Disease Control and Prevention awarded the Indiana State Department of Health funding for breastfeeding activities. The grant, issued in part in response to the 2011 Surgeon General's Call to Action to Support Breastfeeding, focused on providing funding and technical support to small community-based organizations to address challenges encountered by breastfeeding mothers. Indiana used the funds to develop the Community Breastfeeding Support Initiative (CBSI). The goal was to provide funding and technical support to small community-based organizations to carry out self-selected projects in their communities. The 13 CBSI programs served 1345 individual clients (n = 3664 visits) during the 9-month period. This article provides valuable information about collaboration at the state level and the supporting infrastructure in place to carry out this project. Our findings about the number of clients served, number of visits, community-specific programs and activities, and lessons learned can be used by other organizations as they plan breastfeeding support programs for their community.

Evaluation of the impact of breast milk expression in early postpartum period on breastfeeding duration: a prospective cohort study

Background

Breast milk expression (breast pumping) has become prevalent as an important dimension of breastfeeding behavior. It is, however, not clear whether increasing breast milk expression contributes to extend the duration of breastfeeding. The objective of the present study was to evaluate the impact of breast milk expression in early postpartum period on breastfeeding duration amongst mothers of healthy term infants.

Methods

A prospective cohort study had been conducted from March to June 2010. Mothers who gave birth to healthy, full-term and singleton babies were enrolled at discharge. These women were interviewed at 6 weeks postpartum about their breastfeeding behaviors. According to expressing patterns at 6 week postpartum, women were divided into three groups: direct breastfeeding (group 1), combining direct breastfeeding with expressing (group 2), exclusive expressing (group 3). The investigators followed up the women by telephone thereafter at a bimonthly basis and documented breastfeeding duration. Survival analysis was conducted to explore the association between expressing patterns at 6 weeks postpartum and breastfeeding duration. Associated factors of exclusive expressing at 6 weeks postpartum were characterized by logistic regression analysis.

Results

Four hundred one eligible women were enrolled at discharge. Among the 389 women who attended the face-to-face interview at 6 weeks postpartum, 345 women continued breastfeeding. They were divided into 3 groups by their expressing patterns. According to survival analysis, women who exclusively expressed breast milk at 6 months postpartum (group 3) were 1.77 times as likely to stop breastfeeding as those who did not (group 1 and 2) (95 % confidence interval: 1.25–2.48; P <0.001). There is, however, no significant difference of breastfeeding duration between group 1 and group 2. Subgroup analysis showed that exclusive expressing women who were exclusively breastfeeding at 6 weeks postpartum had the shortest breastfeeding duration. Mother’s high education level, short maternity leave, breast milk expression in hospital and bottle-feeding in hospital were associated factors to exclusive expressing at 6 weeks postpartum.

Conclusions

Exclusive expressing in the early postpartum period may not help women to achieve long-term breastfeeding duration, especially in women who were exclusively breastfeeding.

Racial and ethnic disparities in breastfeeding

This article's aim is to review the literature on racial and ethnic disparities in breastfeeding rates and practices, address barriers to breastfeeding among minority women, conduct a systematic review of breastfeeding interventions, and provide obstetrician-gynecologists with recommendations on how they can help increase rates among minority women. In order to do so, the literature of racial and ethnic disparities in breastfeeding rates and barriers among minority women was reviewed, and a systematic review of breastfeeding interventions among minority women on PubMed and MEDLINE was conducted. Racial and ethnic minority women continue to have lower breastfeeding rates than white women and are not close to meeting the Healthy People 2020 goals. Minority women report many barriers to breastfeeding. Major efforts are still needed to improve breastfeeding initiation and duration rates among minority women in the United States. Obstetrician-gynecologists have a unique opportunity to promote and support breastfeeding through their clinical practices and public policy, and their efforts can have a meaningful impact on the future health of the mother and child.

WIC peer counselors' perceptions of breastfeeding in African American women with lower incomes

BACKGROUND

African American women have the lowest breastfeeding rates among all racial/ethnic groups in the United States. Peer counseling is an effective intervention in improving breastfeeding in this population. However, little is known on peer counselors' perceptions of breastfeeding in African American women.

OBJECTIVE

As part of a larger qualitative study, the goal of this study was to understand the contextual factors influencing breastfeeding decisions of low-income African American women from the perspective of breastfeeding peer counselors (PCs).

METHODS

Three focus groups were conducted with 23 PCs from the Women, Infants, and Children program in a southeastern state. All focus group discussions were audio-recorded, professionally transcribed, and analyzed using thematic analysis. Bronfenbrenner's socioecological model was used to group categories into themes.

RESULTS

Of the sample, 47.8% were African American, 78.2% were married, and 56.5% had some college education. Five main themes emerged to describe factors at multiple levels influencing breastfeeding in PCs' low-income African American clients: individual, microsystem, exosystem, macrosystem, and chronosystem. Novel findings included (1) having breast pumps may give African American women a "sense of security," (2) cultural pressures to be a "strong black woman" can impede breastfeeding support, and (3) breastfeeding "generational gaps" have resulted from American "slavery" and when formula was "a sign of wealth."

CONCLUSION

As PCs described, low-income African American women's breastfeeding decisions are affected by numerous contextual factors. Findings from this study suggest a need to broaden the public health approach to breastfeeding promotion in this population by moving beyond individual characteristics to examining historical and sociocultural factors underlying breastfeeding practices in African American women.

A clinic-based breastfeeding peer counselor intervention in an urban, low-income population: interaction with breastfeeding attitude

BACKGROUND

Whereas breastfeeding initiation rates have risen in all groups throughout the country, rates of breastfeeding duration have changed more slowly. Peer counseling has had some success in sustaining breastfeeding, but with intensive programs and variable effects.

OBJECTIVES

We aimed to improve rates of any and exclusive breastfeeding at 1 and 6 months using a low-intensity peer counseling intervention beginning prenatally. We also planned to study the interaction of breastfeeding attitude and self-efficacy with the intervention.

METHODS

One hundred twenty prenatal women underwent stratified randomization based on breastfeeding attitude, measured by the Iowa Infant Feeding Attitude Scale (IIFAS). The peer counselor contacted the intervention group by telephone or in clinic up to 4 months postdelivery. Study groups were compared on breastfeeding outcomes, adjusting for IIFAS strata, and on interactions with self-efficacy.

RESULTS

One hundred three women were followed to at least 1 month. Women with positive attitudes had significantly higher rates of initiation (93% vs 61%) and breastfeeding at 1 and 6 months (79% vs 25% and 12% vs 0%, respectively) than those with negative attitudes, regardless of intervention. After adjusting for self-efficacy, women who received peer counseling had significantly higher breastfeeding rates at 1 month (odds ratio = 3.2; 95% confidence interval, 1.02-9.8). The intervention group was marginally more likely to achieve their breastfeeding goal (43% vs 22%, P = .073).

CONCLUSION

Breastfeeding rates in all women improved during the study period. Breastfeeding attitude was more strongly associated with breastfeeding behavior than peer support. Peer counseling supported women with low self-efficacy and helped women achieve their breastfeeding goals.

Factors influencing breastfeeding duration: a survey in a Turkish population

Breastfeeding provides perfect nutrition for infants and is a source of many health benefits for both mother and baby. To obtain the maximum beneficial effects of breast milk, it is necessary to prolong the breastfeeding duration. In this study, we investigated the factors influencing the duration of breastfeeding. We conducted a 32-question survey of mothers with children aged 2-4 years, who presented to our medical school's pediatric outpatient clinics. The questionnaire solicited information on demographics and breastfeeding attitudes. We found correlations between total duration of breastfeeding and the time the mother and baby spent together (sharing a room to sleep at night) and the father's engagement in breastfeeding. Breastfeeding duration inversely correlated with maternal employment. Total duration of breastfeeding did not correlate with breastfeeding education by health personnel, the mother's education level, the gender of the child, regular prenatal care visits, the use of a pacifier, the interval between birth and the onset of breastfeeding, gestational age, method of delivery, or the birth weight of the infant.

CONCLUSION

Our findings suggest several strategies to increase the duration of breastfeeding, including educating fathers along with mothers, supporting a shared bedroom until the child is 2 years of age, and promoting measures that allow mothers to be with their children during working hours.

Prospective food diaries demonstrate breastfeeding characteristics in a UK birth cohort

Breastfeeding duration and exclusive breastfeeding rates are universally below those recommended by World Health Organization. Due to limitations and challenges associated with researching breastfeeding characteristics, the times when exclusivity is likely to be lost and when women are most likely to discontinue breastfeeding have not yet been identified. Prospective food diaries allow reliable description of the dynamics of breastfeeding to be made to help identify these key time periods. Food diaries detailing intake from birth until the cessation of breastfeeding were analysed for 718 infants recruited into a national arm of an international multicentre birth cohort study (EuroPrevall). Analyses included linear regression analysis and Kaplan-Meier time course analysis. Breastfeeding and exclusive breastfeeding cessation rates for younger mothers (<25 years) are high in the first few weeks after delivery but slow markedly in the period 10-12 weeks after delivery. Cessation rates are consistent from 0 to 26 weeks in older mothers. This difference in feeding patterns led to significant differences between the two different age groups at 26 weeks for breastfeeding (P = 0.006) and exclusive breastfeeding at 8 weeks (P = 0.009). Forty-nine per cent of younger mothers (<25 years) stopped breastfeeding before their infant was 3 weeks old. To increase breastfeeding duration, further work is required to investigate the attitudes and perceptions associated with such high breastfeeding cessation rates in younger mothers during these very early post-natal weeks.

Nutritional management of the low birth weight/preterm infant in community settings: a perspective from the developing world

Globally, about 20 million infants are born with low birth weight (LBW; <2500 g). Of all LBW infants, approximately 95% are born in developing countries. The greatest incidence of LBW occurs in South-Central Asia; the second greatest is in Africa. The two main reasons for LBW are preterm birth (<37 weeks) and intrauterine growth restriction (IUGR), which are risk factors for increased morbidity and mortality in newborn infants. Maternal nutrition status is one of the most important risk factors for LBW/IUGR. Providing balanced protein energy and multiple micronutrient supplements to pregnant women will reduce incidence of IUGR. Calcium supplementation during pregnancy will reduce the incidence of pre-eclampsia and preterm birth in developing countries. Exclusive breastfeeding is protective for a mother and her infant and has been shown to reduce morbidity and mortality in infancy. Kangaroo mother care for preterm infants will reduce severe morbidity and mortality as well. Community-based intervention packages are among the most effective methods of reducing morbidity and mortality in mothers and children. Future research should focus on improving triage of preterm and IUGR infants. Exclusive breastfeeding should be promoted, and appropriate alternative food supplements should be provided when breastfeeding is not possible.

Impact of policy changes on infant feeding decisions among low-income women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children

OBJECTIVES

We present infant feeding data before and after the 2009 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package change that supported and incentivized breastfeeding. We describe the key role of California WIC staff in supporting these policy changes.

METHODS

We analyzed WIC data on more than 180,000 infants in Southern California. We employed the analysis of variance and Tukey (honestly significant difference) tests to compare issuance rates of postpartum and infant food packages before and after the changes. We used analysis of covariance to adjust for poverty status changes as a potential confounder.

RESULTS

Issuance rates of the "fully breastfeeding" package at infant WIC enrollment increased by 86% with the package changes. Rates also increased significantly for 2- and 6-month-old infants. Issuance rates of packages that included formula decreased significantly. All outcomes remained highly significant in the adjusted model.

CONCLUSIONS

Policy changes, training of front-line WIC staff, and participant education influenced issuance rates of WIC food packages. In California, the issuance rates of packages that include formula have significantly decreased and the rate for those that include no formula has significantly increased.

A systematic review of peer support interventions for breastfeeding

AIMS AND OBJECTIVES

The objective of this systematic review was to describe peer support interventions supporting breastfeeding during pregnancy and the postnatal period.

BACKGROUND

Breastfeeding is an effective way to promote infants' health. Including a peer support element in breastfeeding programmes is a highly successful way to increase breastfeeding.

DESIGN

A systematic literature review.

METHODS

The review was conducted from the CINAHL, MEDLINE and the Cochrane Library databases from year 2000 until the end of February 2008. According to the inclusion criteria, the adopted studies focused on breastfeeding, breastfeeding support interventions and education of healthy mothers and infants from the perspective of mothers or family members. Additionally, the studies had to be conducted in Europe, North America, Australia or New Zealand to meet the criteria. Articles combining peer support and professional support were also included in the study.

RESULTS

The results indicated that during pregnancy, hospitalisation and the postnatal period, individual support and education were used most commonly. Peer support was strongly associated with the postnatal period. The combination of professional support and peer support by trained and experienced peer supporters was effective in ensuring the continuation of breastfeeding.

CONCLUSIONS

Only continuous breastfeeding support produces effective results. Diverse types of interventions are needed during different phases of motherhood. The role of peer support is most important during the postnatal period. If professional support is not available for mothers, peer support could provide an alternative worth considering.

RELEVANCE TO CLINICAL PRACTICE

Professionals require breastfeeding education to act as breastfeeding supporters as well as the support of their organisations in this work. Moreover, professionals need to gain knowledge of the role of peer support regarding the efficient combination of professional support and peer support to increase breastfeeding.

Sources of infant feeding information used by pregnant women

Selecting an infant feeding method is one of the most important decisions a mother-to-be makes. Little information is available to characterize women who plan to use both formula and breast milk. In this study, 89 pregnant women indicated their anticipated feeding method and the sources and initiator of infant feeding information. No differences were found in the type of resources used by women who planned to breastfeed, formula feed, or combination feed. Women in the study were four times more likely to initiate a conversation about infant feeding methods with a family member or friend than with a health care provider. Involving these key individuals in perinatal education classes and support programs is a simple, but powerful, strategy that childbirth educators can use to promote breastfeeding.

Increasing loyalty to breastfeeding: investigating a product development strategy

This article demonstrates how social marketing insights were used to influence women's loyalty to breastfeeding. The article reports on a social marketing campaign undertaken by the Australian Breastfeeding Association and a government health department, which used a product development strategy in order to increase breastfeeding loyalty. Seeking new approaches to support breastfeeding behaviors is critical and timely, because while initiation rates of breastfeeding are high in developed countries such as the United Kingdom, Australia, Canada, and the United States, duration rates are significantly lower. Results indicate that a product- focused strategy influences pregnant women's loyalty to exclusively breastfeeding.

Systematic review and meta-analysis of randomized controlled trials evaluating primary care-based interventions to promote breastfeeding in low-income women

BACKGROUND

Given the benefits of breastfeeding (BF), health care institutions recommend that a child should be breastfed for the first 6 months of its life. However, differences between social groups as regards BF behaviour are very prevalent.

OBJECTIVES

To identify effective programmes that can be implemented by GPs to promote BF in low-income women.

METHODS

A review of the literature was based on the Medline, Cochrane and Public Health databases (1985-2009), using index terms relating to BF, general medicine and social inequalities in health. Randomized controlled trials were included in our analysis. Two people independently selected which studies would be used by rating the quality of the articles. The results of these studies were presented in raw form and in terms of a pooled relative risk.

RESULTS

We analysed 10 studies (of the 343 articles originally selected) involving a population of 1445 'mother and child' pairs. The studies that assessed ways of encouraging the initiation of any form of BF showed that educational programmes are effective [relative risk (RR) for starting BF, 1.46, 95% confidence interval (CI): 1.03-2.08]. As regards the studies that involved ways to encourage mothers to continue BF, the programmes used showed significant success rates after 3-month postpartum (RR: 1.15, 95% CI: 1.01-1.30). The successful programmes usually involved multiple 'short' follow-up appointments (<20 to 30 minutes).

CONCLUSIONS

Educational programmes delivered in the context of ongoing personal contact with a health professional are effective in promoting BF in low-income women.

Provision of support strategies and services: results from an internet-based survey of community-based breastfeeding counselors

This study examined the determinants of support strategies and services provided by community-based breastfeeding counselors (CBBCs) and compared differences in extent of support provided by paid and volunteer counselors. Participants (N = 847) in this internet-based survey were mostly White/Caucasian (74.9%), college-educated (59.0%), and paid CBBCs (63.8%). The majority (75.9%) of volunteer CBBCs compared with their paid full-time (52.1%) and paid part-time (47.4%) counterparts had completed college. Being a full-time paid compared with volunteer/unpaid CBBC was associated with face-to-face counseling (OR = 3.69; 95% CI: 1.93, 7.06), use of client-centered counseling skills (OR = 6.23; 95% CI: 3.40, 11.45), making referrals to social service agencies (OR = 13.18; 95% CI: 6.86, 25.32), and helping position baby (OR = 3.77; 95% CI: 1.64, 8.69). Because of the disparities in CBBC usage of breastfeeding support strategies and continuing education between paid and volunteer CBBCs, there is a need to examine differences in training curricula and determine the facilitators and barriers of continuing education.

WIC and breastfeeding support services: does the mix of services offered vary with race and ethnicity?

OBJECTIVE

The U.S. Department of Agriculture's Supplemental Nutrition Program for Women, Infants, and Children (WIC) nutrition services provides supplemental nutrition and counseling to more than 50% of families with young children in the United States. Given the program's significant reach, as well as large differences in rates of breastfeeding among whites, African Americans, and Hispanics, we explored the associations among breastfeeding initiation, the availability of WIC-based breastfeeding support, and the racial/ethnic composition of WIC clients in North Carolina.

METHODS

An electronic survey gathered data on ongoing breastfeeding support activities from local WIC directors in North Carolina. North Carolina Pregnancy and Nutrition Surveillance System data provided racial/ethnic composition and breastfeeding initiation rates. Linear and logistic regression models were used to examine county-level associations among (1) racial/ethnic composition of clients, (2) breastfeeding initiation, and (3) availability of the identified WIC breastfeeding support services.

RESULTS

Responses were received from 50 of the state's 100 counties and were generally representative of the state. Breastfeeding initiation by site was negatively associated with percentage of African American clients and positively associated with percentage of white or Hispanic clients (p<0.05). The availability and intensity of breastfeeding support services varied widely, with 50% offering clinic-based services, 46% offering home visits, 38% offering peer counseling, and 76% offering some other form of counseling. The WIC sites with larger Hispanic populations were more likely to be providing a broad base of services, including clinic-based services, peer counseling, and home visits (p<0.05); those with higher African American populations were significantly less likely to offer clinic-based breastfeeding support services (p<0.05) and trended toward fewer services in general.

CONCLUSIONS

Results confirmed previous findings of racial/ethnic disparities in breastfeeding rates. We also found that differences in the availability of breastfeeding support services were associated with the racial/ethnic composition of the catchment area. This apparent inequity in the availability of breastfeeding support services at different WIC sites may merit further exploration and may inform implementation of aspects of the U.S. Surgeon General's Call to Action to Support Breastfeeding.

Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries

Background

Given the recognized benefits of breastfeeding for the health of the mother and infants, the World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for the first six months of life. However, the prevalence of EBF is low globally in many of the developing and developed countries around the world. There is much interest in the effectiveness of breastfeeding promotion interventions on breastfeeding rates in early infancy.

Methods

A systematic literature was conducted to identify all studies that evaluated the impact of breastfeeding promotional strategies on any breastfeeding and EBF rates at 4-6 weeks and at 6 months. Data were abstracted into a standard excel sheet by two authors. Meta-analyses were performed with different sub-group analyses. The overall evidence were graded according to the Child Health Epidemiology Reference Group (CHERG) rules using the adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria and recommendations made from developing country studies for inclusion into the Live Saved Tool (LiST) model.

Results

After reviewing 968 abstracts, 268 studies were selected for potential inclusion, of which 53 randomized and quasi-randomized controlled trials were selected for full abstraction. Thirty two studies gave the outcome of EBF at 4-6 weeks postpartum. There was a statistically significant 43% increase in this outcome, with 89% and 20% significant increases in developing and developed countries respectively. Fifteen studies reported EBF outcomes at 6 months. There was an overall 137% increase, with a significant 6 times increase in EBF in developing countries, compared to 1.3 folds increase in developed country studies. Further sub-group analyses proved that prenatal counseling had a significant impact on breastfeeding outcomes at 4-6 weeks, while both prenatal and postnatal counseling were important for EBF at 6 months.

Conclusion

Breastfeeding promotion interventions increased exclusive and any breastfeeding rates at 4-6 weeks and at 6 months. A relatively greater impact of these interventions was seen in developing countries with 1.89 and 6 folds increase in EBF rates at 4-6 weeks and at 6 months respectively.

Effect of breastfeeding on weight retention from one pregnancy to the next: results from the North Carolina WIC program

OBJECTIVES

Pregnancy-related weight retention can contribute to obesity, and breastfeeding may facilitate postpartum weight loss. We investigated the effect of breastfeeding on long-term postpartum weight retention.

METHODS

Using data from the North Carolina Special Supplemental Nutrition Program for Women, Infants, and Children (WIC; 1996-2004), weight retention was assessed in women aged 18 years or older who had more than one pregnancy available for analysis (n=32,920). Using multivariable linear regression, the relationship between duration of breastfeeding after the first pregnancy and change in pre-pregnancy weight from the first pregnancy to the second pregnancy was estimated, controlling for demographic and weight-related covariates.

RESULTS

Mean time between pregnancies was 2.8 years (standard deviation (SD) 1.5), and mean weight retention from the first to the second pregnancy was 4.9kg (SD 8.7). In covariate-adjusted analyses, breastfeeding for 20 weeks or more resulted in 0.39kg (standard error (SE) 0.18) less weight retention at the beginning of the second pregnancy relative to no breastfeeding (p=0.025).

CONCLUSION

In this large, racially diverse sample of low-income women, long-term weight retention was lower among those who breastfed for at least 20 weeks.

Breastfeeding peer counseling: from efficacy through scale-up

An increasing number of publications have evaluated various breastfeeding peer counseling models. This article describes a systematic review of (a) the randomized trials assessing the effectiveness of breastfeeding peer counseling in improving rates of breastfeeding initiation, duration, exclusivity, and maternal and child health outcomes and (b) scientific literature describing the scale-up of breastfeeding peer counseling programs. Twenty-six peer-reviewed publications were included in this review. The overwhelming majority of evidence from randomized controlled trials evaluating breastfeeding peer counseling indicates that peer counselors effectively improve rates of breastfeeding initiation, duration, and exclusivity. Peer counseling interventions were also shown to significantly decrease the incidence of infant diarrhea and significantly increase the duration of lactational amenorrhea. Breastfeeding peer counseling initiatives are effective and can be scaled up in both developed and developing countries as part of well-coordinated national breastfeeding promotion or maternal-child health programs.

Breastfeeding women's experience of expressing: a descriptive study

There is an increasing trend in Australia and elsewhere for mothers to express breast milk. The purpose of this study was to explore breastfeeding women's experiences of expressing breast milk. An anonymous online questionnaire was sent to Victorian members of the Australian Breastfeeding Association via an e-mail link. Response fraction was 903 of 3024 (29.9%). The most common reason for expressing milk was to "store extra breast milk" (57%, 479/836). The most important reason was "not enough milk"/"to make more milk" (15%, 118/771). The majority of women (65%, 666/843) used an electric breast pump, and this method of expressing was preferred by 59% (454/769) of women. Adverse effects of pumps were pain (17%, 126/737) and damage to nipples (11%, 86/737). Breast pumps may have a role in enabling women to extend the duration of breast milk feeding, but further research is needed.

Breastfeeding support - the importance of self-efficacy for low-income women

Breastfeeding is a key determinant in promoting public health and reducing health inequality. Low-income women have a significantly lower level of breastfeeding. Midwives in the UK have been encouraged to implement the World Health Organization/United Nations Children's Fund's Ten Steps to Successful Breastfeeding, but to date, there has been no evaluation of the impact of the training initiative on the breastfeeding behaviours of low-income women. As part of a wider study, this qualitative component was designed to answer the question - what are the views and experiences of low-income women (defined by Jarman scores) in relation to their breastfeeding support received in the post-natal period? A sample of seven women was interviewed. The in-depth interviews were analysed using a qualitative, thematic approach based on the self-efficacy theory. The four themes that emerged from the data were the following: breastfeeding related to the woman's self-confidence, the social environment in which the woman lived, knowledge of breastfeeding and the influence of maternity services on breastfeeding outcomes. These themes were interpreted in relation to the self-efficacy theory. The findings suggest that the components that inform self-efficacy are consistent with the themes from the data, suggesting that midwives and other health professionals should take the psychosocial aspects of breastfeeding support into account. As this important feature of breastfeeding support is not explicitly part of the current Ten Steps to Successful Breastfeeding, we suggest that further research and debate could inform expansion of these minimum standards to include the psychosocial aspects.

Effect of breast-feeding on weight retention at 3 and 6 months postpartum: data from the North Carolina WIC Programme

OBJECTIVE

Pregnancy-related weight retention can contribute to obesity, and breast-feeding may facilitate postpartum weight loss. We investigated the effect of breast-feeding on postpartum weight retention.

DESIGN

A retrospective follow-up study of weight retention, compared in women who were fully breast-feeding, combining breast-feeding with formula-feeding (mixed feeding), or formula-feeding at 3 months (n 14 330) or 6 months (n 4922) postpartum, controlling for demographic and weight-related covariates using multiple linear regression.

SETTING

The North Carolina Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

SUBJECTS

Participants in the North Carolina WIC Programme who delivered a baby between 1996 and 2004.

RESULTS

In covariate-adjusted analyses, there was no association between breast-feeding and weight retention at 3 months postpartum. At 6 months postpartum, as compared to formula-feeders, mean weight retention was 0·84 kg lower in mixed feeders (95 % CI 0·39, 1·29; P = 0·0002) and 1·38 kg lower in full breast-feeders (95 % CI 0·89, 1·87; P ≤ 0·0001).

CONCLUSIONS

Breast-feeding was inversely associated with weight retention at 6 months postpartum in this large, racially diverse sample of low-income women. Further, full breast-feeding had a larger protective effect than did breast-feeding combined with formula-feeding.

Impact of peer nutrition education on dietary behaviors and health outcomes among Latinos: a systematic literature review

OBJECTIVE

This systematic review assesses the impact of peer education/counseling on nutrition and health outcomes among Latinos and identifies future research needs.

DESIGN

A systematic literature search was conducted by: (1) searching Internet databases; (2) conducting backward searches from reference lists of articles of interest; (3) manually reviewing the archives of the Center for Eliminating Health Disparities among Latinos; (4) searching the Journal of Nutrition Education and Behavior; and (5) directly contacting researchers in the field. The authors reviewed 22 articles derived from experimental or quasi-experimental studies.

OUTCOME MEASURES

Type 2 diabetes behavioral and metabolic outcomes, breastfeeding, nutrition knowledge, attitudes and behaviors.

RESULTS

Peer nutrition education has a positive influence on diabetes self-management and breastfeeding outcomes, as well as on general nutrition knowledge and dietary intake behaviors among Latinos.

CONCLUSIONS AND IMPLICATIONS

There is a need for longitudinal randomized trials testing the impact of peer nutrition education interventions grounded on goal setting and culturally appropriate behavioral change theories. Inclusion of reliable scales and the construct of acculturation are needed to further advance knowledge in this promising field. Operational research is also needed to identify the optimal peer educator characteristics, the type of training that they should receive, the client loads and dosage (ie, frequency and amount of contact needed between peer educator and client), and the best educational approaches and delivery settings.

Understanding breastfeeding initiation and continuation in rural communities: a combined qualitative/quantitative approach

OBJECTIVE

To determine factors associated with breastfeeding in rural communities.

METHODS

We combined qualitative and quantitative data from the Family Life Project, consisting of: (1) a longitudinal cohort study (N=1292) of infants born September 2003-2004 and (2) a parallel ethnographic study (N=30 families). Demographic characteristics, maternal and infant health factors, and health services were used to predict breastfeeding initiation and discontinuation using logistic and Cox regression models, respectively. Ethnographic interviews identified additional reasons for not initiating or continuing breastfeeding.

RESULTS

Fifty-five percent of women initiated breastfeeding and 18% continued for at least 6 months. Maternal employment at 2 months and receiving WIC were associated with decreased breastfeeding initiation and continuation. Ethnographic data suggested that many women had never even considered breastfeeding and often discontinued breastfeeding due to discomfort, embarrassment, and lack of assistance.

CONCLUSIONS

Breastfeeding rates in these rural communities lag behind national averages. Opportunities for increasing breastfeeding in rural communities include enhancing workplace support, maximizing the role of WIC, increasing hospital breastfeeding assistance, and creating a social environment in which breastfeeding is normative.

A qualitative evaluation of a breastfeeding peer counselor program

The Breastfeeding Initiative program is a collaboration between the Michigan Department of Community Health (Women, Infants, and Children Division) and Michigan State University Extension. It aims to increase breastfeeding rates among low-income women through the use of peer counselors. The study's purpose was to identify the program's strengths, operation procedures, and improvement areas from participants' and peer counselors' perspectives. Six focus groups were conducted: 3 of peer counselors and 3 of program participants. Findings revealed that peer counselors and participants were satisfied with the quality of services due to emotional and practical assistance and breast pumps provided by peer counselors. Peer counselors' job satisfaction was explained positively by the intrinsic rewards of helping others and negatively by perceived inadequate resources and recognition. Operating procedures varied greatly. Possible improvements include expanding services, providing peer counselors with additional support, and standardizing peer counselor operating procedures. The peer counselor model can effectively support low-income breastfeeding women.

Effects of socioeconomic status on breastfeeding duration in mothers of preterm and term infants

BACKGROUND

The propensity to breastfeed is not only of importance with regard to the beneficial effects on the individual, but is also of concern as an indicator of health behaviour related to social conditions. Thus, our aim was to investigate the impact of socioeconomic status (SES) on breastfeeding duration in mothers of preterm and term infants.

METHODS

Prospective population based cohort study. Data for infants registered in breastfeeding databases of two Swedish counties 1993-2001 were matched with data from two national registries-the Medical Birth Registry and Statistics Sweden. A total of 37,343 mothers of 2093 preterm and 35,250 term infants participated.

RESULTS

All socioeconomic factors; maternal educational level, maternal unemployment benefit, social welfare and equivalent disposable income, were strongly associated with breastfeeding when examined individually in mothers of preterm and term infants. Some of the associations attenuated when investigated simultaneously. Independently of SES and confounders, mothers of preterm infants were at higher risk of weaning before the infant was 2 months (adjusted odds ratio (OR) 1.70; 95% confidence interval ((CI) 1.46-1.99)), 4 months (OR 1.79; CI 1.60-2.01), 6 months (OR 1.48; CI 1.33-1.64), and 9 months old (OR 1.19; CI 1.06-1.34), compared with mothers of term infants.

CONCLUSIONS

In Sweden, despite its social welfare support system and a positive breastfeeding tradition, SES clearly has an impact on the breastfeeding duration. Mothers of preterm infants breastfeed for a shorter time compared with mothers of term infants, even when adjustments are made for SES and confounders.

Factors associated with intention to breastfeed among low-income, inner-city pregnant women

OBJECTIVES

To examine the relationship between sociodemographic factors, maternal characteristics, and intention to breastfeed among low-income, inner-city pregnant women.

METHODS

English and Spanish speaking low-income women recruited from local Philadelphia health centers were surveyed at the time of their first prenatal care visit. At the time of the visit, respondents were asked whether or not they planned to breastfeed their infant. The responses of 2,690 women were included in these analyses. Multivariate logistic regression was used to assess the independent associations of race/ethnicity, nativity status, education, and other factors on the odds of intending to breastfeed.

RESULTS

About half (53%) of the respondents reported that they intended to breastfeed their infant. In adjusted logistic regression models, immigrant black (adjusted OR [aOR] 5.82; 95% confidence interval [CI] 3.86, 8.77), other Hispanic (who were predominantly foreign-born) (aOR 6.05; 95% CI 3.92, 9.33), and island-born Puerto Rican (aOR 3.48; 95% CI 2.04, 5.95) women were significantly more likely to report that they intended to breastfeed than non-Hispanic whites. Somewhat surprisingly, non-Hispanic, US-born African Americans in this low-income sample were more likely to report that they intended to breastfeed than non-Hispanic white respondents (aOR 1.59; 95% CI 1.20, 2.11). Lower education, not living with the baby's father, multiparous pregnancy, and smoking were negatively and independently associated with intention to breastfeed. Maternal age, household income, public housing, and depressive symptoms were not significant predictors of breastfeeding intention in adjusted multivariate models.

CONCLUSIONS

Significant differences were documented in breastfeeding intention in our sample of low-income, inner-city women. Most notable was the higher likelihood of anticipated breastfeeding among our immigrant sub-groups when compared with non-Hispanic white women. An unexpected finding was the higher likelihood of anticipated breastfeeding among native-born, non-Hispanic African American women than among non-Hispanic white respondents. Because intentions are important predictors of future behavior, more focus needs to be directed towards breastfeeding promotion during the prenatal period and towards a better understanding of why some mothers intend to breastfeed while others do not.

Lower breastfeeding rates persist among the Special Supplemental Nutrition Program for Women, Infants, and Children participants, 1978-2003

OBJECTIVE

We set out to compare rates of breastfeeding between women who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) with those of non-WIC mothers from 1978 to 2003.

METHODS

The Ross Laboratories Mothers Survey is a national survey designed to determine patterns of milk feeding during infancy. Mothers were asked to recall the type of milk fed to their infant in the hospital and during each month of age. Rates of breastfeeding in the hospital and at 6 months of age were evaluated. Logistic regression analyses identified significant predictors of breastfeeding in 2003.

RESULTS

From 1978 through 2003, rates for the initiation of breastfeeding among WIC participants lagged behind those of non-WIC mothers by an average of 23.6 +/- 4.4 percentage points. At 6 months of age, the gap between WIC participants and non-WIC mothers (mean: 16.3 +/- 3.1 percentage points) steadily increased from 1978 through 2003 and exceeded 20% by 1999. Demographic factors that were significant and positive predictors of breastfeeding initiation in 2003 included some college education, living in the western region of the United States, not participating in the WIC program, having an infant of normal birth weight, primipary, and not working outside the home. For mothers of infants 6 months of age, WIC status was the strongest determinant of breastfeeding: mothers who were not enrolled in the WIC program were more than twice as likely to breastfeed at 6 months of age than mothers who participated in the WIC program.

CONCLUSIONS

Breastfeeding rates among WIC participants have lagged behind those of non-WIC mothers for the last 25 years. The Healthy People 2010 goals for breastfeeding will not be reached without intervention. Food package and programmatic changes are needed to make the incentives for breastfeeding greater for WIC participants.

How to integrate a lactation consultant in an outpatient clinic environment

Successful efforts in improving breastfeeding initiation rates at an urban teaching hospital prompted the hospital to create a lactation consultant (LC) position in the outpatient setting to focus on breastfeeding duration. This article reviews the complexity of the clinic setting, with the challenges and benefits of the consultant's first year in one of the hospital's outpatient clinics. Preliminary data collected by the consultant suggest that patients counseled by the LC in the outpatient clinic setting have longer breastfeeding duration rates.

Why do women stop breastfeeding? Findings from the Pregnancy Risk Assessment and Monitoring System

OBJECTIVE

We examined breastfeeding behaviors, periods of vulnerability for breastfeeding cessation, reasons for breastfeeding cessation, and the association between predelivery intentions and breastfeeding behaviors.

STUDY DESIGN

Using 2 years (2000 and 2001) of data from the Pregnancy Risk Assessment and Monitoring System we assessed the percentage of women who began breastfeeding, continued for < 1 week, continued for 1 to 4 weeks, and continued for > 4 weeks and their reasons for not initiating or stopping. Predelivery breastfeeding intentions of women and their relationship with subsequent breastfeeding behaviors were examined also.

RESULTS

We found that 32% of women did not initiate breastfeeding, 4% started but stopped within the first week, 13% stopped within the first month, and 51% continued for > 4 weeks. Younger women and those with limited socioeconomic resources were more likely to stop breastfeeding within the first month. Reasons for cessation included sore nipples, inadequate milk supply, infant having difficulties, and the perception that the infant was not satiated. Women who intended to breastfeed, thought they might breastfeed, or had ambivalent feelings about breastfeeding were more likely to initiate breastfeeding and to continue through the vulnerable periods of early infancy than were those who did not plan to breastfeed.

CONCLUSIONS

Our findings indicate a need to provide extensive breastfeeding support after delivery, particularly to women who may experience difficulties in breastfeeding.

Increasing breastfeeding rates in New York City, 1980-2000

Our objective was to determine temporal patterns of breastfeeding among women delivering infants in New York City (NYC) and compare national breastfeeding trends. All hospitals in NYC with obstetric units were contacted in May and June 2000 to provide information on the method of infant feeding during the mother's admission for delivery. Feeding was categorized as "exclusive breastfeeding," "breast and formula," or "exclusive formula." The first two categories were further grouped into "any breastfeeding" in the analysis. Hospitals were classified as "public" and "private," and patients were classified by insurance type as "service" and "private." Data between public and private hospitals and service and private patients were compared. Breast-feeding trends over time were compared by using previous iterations of the same survey. Of 16,932 newborns, representing approximately 80.0% of all reported live births in the city during the study period, 5,305 (31.3%) were exclusively breastfed, 6,189 (36.6%) were fed a combination of breast milk and formula, and the remaining 5,438 (32.1%) were exclusively formula-fed. Infants born in private hospitals were 1.6 times more likely to be exclusively breastfed compared with infants discharged from public hospitals (33% vs. 21%, respectively). Similarly, private patients were more likely than service patients to exclusively breastfeed their infants (39.6% vs. 22.9%, respectively) and to use a combination of breast and formula (i.e., any breastfeeding) (73.6% vs. 62.0%, respectively). From 1980 to 2000, the proportion of exclusive breastfeeding increased from 25.0% to 31.0%, the percentage of combined feeding increased from 8.0% to 37.0%, and the percentage of any breastfeeding increased from 33.0% to 68.0%. NYC has more than doubled the rate of breastfeeding since 1980. However, there is much progress to be made, and continued efforts are vital to maintain current gains in breastfeeding, improve the rates further, and prolong the duration of breastfeeding.

Differential response to breastfeeding peer counseling within a low-income, predominantly Latina population

This study aims to identify those most responsive to breastfeeding peer counseling (PC) using data from a US-based randomized trial. The authors ran a series of logistic regression models to identify differential responses to PC, using breastfeeding status at 0, 1, 3, and 6 months postpartum as the dependent variables. Three subgroups were found to be most responsive to breastfeeding PC. Multiparae receiving PC were 6 times more likely to initiate breastfeeding than were multiparous controls (odds ratio [OR] = 6.4; 95% confidence interval [CI] = 1.9-20.8). Similarly, those with uncertain prenatal breastfeeding intentions in the PC group were 7 times (OR = 7.4; 95% CI = 1.5-37.0) more likely to initiate breastfeeding than their control group counterparts. Among subjects partially breastfeeding on day 1 postpartum, those receiving PC were 12 times (OR = 11.9; 95% CI = 1.2-111.1) more likely to breastfeed through 3 months postpartum than were controls. These findings have important implications to the Supplemental Food Program for Women, Infants and Children.

Dads as breastfeeding advocates: results from a randomized controlled trial of an educational intervention

OBJECTIVE

Recognizing that an expectant father may influence a mother's decision to breast- or formula-feed, we tested the effectiveness of a simple, educational intervention that was designed to encourage fathers to advocate for breastfeeding and to assist his partner if she chooses to breastfeed.

STUDY DESIGN

We conducted a randomized controlled trial in which expectant fathers (n = 59) were assigned randomly to attend either a 2-hour intervention class on infant care and breastfeeding promotion (intervention) or a class on infant care only (control group). The classes, which were led by a peer-educator, were interactive and informal and utilized different media to create an accessible environment for participants. Couples were recruited during the second trimester from a university obstetrics practice.

RESULTS

Overall, breastfeeding was initiated by 74% of women whose partners attended the intervention class, as compared with 41% of women whose partners attended the control class (P = .02).

CONCLUSION

Expectant fathers can be influential advocates for breastfeeding, playing a critical role in encouraging a woman to breastfeed her newborn infant.

Correlates of breastfeeding initiation in southeast Arkansas

OBJECTIVES

Southeast Arkansas is a primarily rural, low-income area with low breastfeeding rates. Given the demonstrated positive impacts of breastfeeding on a variety of health indicators, it is important to understand and counteract this situation.

METHODS

We reviewed the medical records of 1,260 women who delivered infants at the only major hospital in southeastern Arkansas between February 1997 and January 1998 to determine the rate of breastfeeding initiation and to assess associated factors.

RESULTS

Only 18% of mothers initiated breastfeeding. Black mothers, unmarried mothers, and those with less than high school education were least likely to breastfeed. Participation in childbirth education classes was positively associated with breastfeeding, but participation in the Supplemental Food Program for Women, Infants, and Children, health care provider, and hospital variables were not predictive in multivariate models.

CONCLUSIONS

Breastfeeding promotion programs are clearly needed in this region, and health care providers and the Supplemental Food Program for Women, Infants, and Children can play significant roles.

The Baby-Friendly way: the best breastfeeding start

In 1991, the World Health Organization and the United Nations Children's Fund launched the Baby-Friendly Hospital Initiative. "Baby-Friendly" is a designation that a hospital or birthing site can receive by demonstrating compliance with the "Ten Steps to Successful Breastfeeding." Baby-Friendly is more than a catchy name or a snappy slogan. With Baby-Friendly policies in place, breastfeeding initiation and duration rates increase and infant illness decreases. This article reviews the development of the Baby-Friendly Hospital Initiative, describes the components of the initiative, and evaluates current data that favor the universal implementation of the Baby-Friendly Hospital Initiative.

Nutrient intakes and food choices of infants and toddlers participating in WIC

OBJECTIVES

To examine the nutrient intakes, foods consumed, and feeding patterns of infants and toddlers participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

DESIGN

Cross-sectional telephone survey, including 24-hour dietary recalls of infants' and toddlers' food and nutrient intakes, as reported by parents or other primary caregivers.

SUBJECTS

National random sample of 3,022 children ages 4 to 24 months who participated in the 2002 Feeding Infants and Toddlers study. Sample sizes by age were infants 4 to 6 months: 265 WIC participants, 597 nonparticipants; infants 7 to 11 months: 351 WIC participants, 808 nonparticipants; and toddlers 12 to 24 months: 205 WIC participants, 791 nonparticipants.

STATISTICAL ANALYSES PERFORMED

We used Statistical Analysis Software (version 8.2) to examine the breastfeeding status, infant feeding patterns, and foods consumed; the personal computer version of the Software for Intake Distribution Estimation to estimate mean usual intake of food energy and of key nutrients targeted by the WIC program; and methods recommended by the Institute of Medicine to assess nutrient adequacy.

RESULTS

Infants participating in WIC were less likely than nonparticipants to have ever been breastfed or to be currently breastfeeding, and they were more likely to be consuming formula. Mean usual nutrient intakes exceeded the adequate intake for WIC participants, and the percentage with inadequate nutrient intake was less than 1%. Reported mean energy intakes exceeded mean energy requirements, with the largest discrepancy observed for WIC participants. Sizeable proportions of WIC and non-WIC infants and toddlers did not consume fruits and vegetables on the recall day.

APPLICATIONS

WIC providers should focus nutrition education on appropriate infant and toddler feeding patterns, should continue to reinforce their message of the importance delaying the use of cow's milk until 1 year of age, and should stress the importance of fruit and vegetable consumption.

Who is breast-feeding? Recent trends from the pregnancy risk assessment and monitoring system

OBJECTIVE

To examine breast-feeding initiation and continuation among women with recent live births in 10 states.

STUDY DESIGN

By using Pregnancy Risk Assessment and Monitoring System surveillance data (n = 96,204), we assessed breast-feeding initiation and continuation for > or =10 weeks among women with recent deliveries from 1993 to 1998. We used 1993 as the base for comparing results by using univariate and multivariate analyses.

RESULTS

Ten states showed a significant increase of 18% in initiation of breast-feeding from 1993 to 1998, from 57.0% (95% confidence interval [CI], 55.6-58.4) to 67.5% (95% CI, 66.1-68.9). Initiation increased among vulnerable groups such as low-income and black women, participants in the Special Supplemental Nutrition Program for Women, Infants, and Children program, and mothers of infants admitted to the neonatal intensive care unit. The percentage of women predominantly breast-feeding at > or =10 weeks among women who initiated remained stable: 58.5% (95% CI, 56.5-60.5) in 1993 and 57.9% (95% CI, 56.0-59.8) in 1998. More women in vulnerable groups initiated breast-feeding, but those from higher socioeconomic groups continued breast-feeding.

CONCLUSIONS

Breast-feeding initiation significantly increased, and several states exceeded the year 2010 objective. Breast-feeding continuation among women who initiated remained stable; however, gaps remained, indicating a continued need to implement breast-feeding promotion programs.

Characteristics of teenage mothers and predictors of breastfeeding initiation in the Michigan WIC Program in 1995. Women, Infants, and Children

Although breast milk is recommended as the optimal source of infant nutrition, breastfeeding initiation is below recommended levels, especially among teenage mothers. Breastfeeding initiation rates among Michigan (US) teenage mothers (12-19 y) were compared by demographics and health behaviors. Multivariate analyses determined which factors were significant independent predictors of breastfeeding initiation among teenage mothers enrolled prenatally in the Michigan Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program in 1995. Significant predictors independently associated with breastfeeding initiation were race/ethnicity, education, marital status, postpartum anemia status, parity, prenatal trimester of WIC enrollment, and smoking. The strongest predictor of breastfeeding initiation differed for white mothers (positive predictor: education beyond high school [OR = 3.13]) and black mothers (negative predictor: multiparous [OR = 0.25]). Initiation rates for this population of teenage mothers fall below the national average for mothers of all ages and the US Healthy People 2010 goals. Research is needed concerning how breastfeeding support and education can be improved to reach the US national health goals.

Peer counselors for breastfeeding mothers in the hospital setting: trials, training, tributes, and tribulations

Boston Medical Center (BMC), an inner-city, Baby-Friendly teaching hospital with approximately 2000 births per year, has employed breastfeeding peer counselors since 1998. The Breastfeeding Center frequently receives requests for information on our peer counselor program. This article reviews program models, training methods, practicalities, benefits, and challenges associated with employing breastfeeding peer counselors in the hospital setting. Specifically, it focuses on 3 different models of peer counseling programs used at BMC: the telephone model, the postpartum model, and the neonatal intensive care model, and it considers the benefits and issues associated with each model.