Support for healthy breastfeeding mothers with healthy term babies

A multi-component intervention to support breastfeeding in Lebanon: A randomized clinical trial

Background

Effective evidence-based breastfeeding support interventions can bolster breastfeeding practices. This study investigated the effect of a multi-component breastfeeding support intervention delivered in hospital and home settings on six-month exclusive breastfeeding (EBF) relative to standard care.

Methods

This is a parallel group, randomized clinical trial, in which 362 healthy pregnant women with singleton pregnancy were randomly allocated to a multi-component intervention that included antenatal breastfeeding education, professional, and peer support, delivered in hospital and home settings for six months (experimental, n = 174), or to standard care (control, n = 188). The primary outcome was six-month EBF rate. Secondary outcomes were exclusive and any breastfeeding rates at one and three months, maternal breastfeeding knowledge, attitude, and behavior at six months, and satisfaction with the intervention.

Results

The crude six-month EBF rate was similar in both groups (35.2% vs. 28.1% in the experimental and control groups, respectively, p = 0·16). In adjusted analysis, six-month exclusivity was twice as likely in the experimental group relative to standard care (OR = 2.02; 95%CI: 1.20 to 3.39); whereas the odds for any breastfeeding were similar. Participants compliant with all three components were six times more likely to practice EBF for six months relative to standard care (OR = 6.63; 95% CI: 3.03 to 14.51). Breastfeeding knowledge of the experimental group, at six months, was significantly improved compared to the control. No changes were observed in breastfeeding attitude or behavior.

Conclusions

Combining education with peer and professional breastfeeding support improved six-month breastfeeding exclusivity and knowledge.

It's okay to breastfeed in public but…

Background

Decisions about infant feeding are embedded and are continuously made within a woman's social and cultural context. Despite the benefits of breastfeeding to both women and infants, and government policies and laws to protect and promote breastfeeding, breastfeeding in public remains a controversial issue. The purpose of this paper is to present findings from an Australian study that explored the perceptions and beliefs held by first time expectant mothers and their family and social networks towards breastfeeding in public.

Methods

This study collected data through fifteen family conversations to explore the views and beliefs of first time mothers and those in her social network towards breastfeeding. Breastfeeding in public was discussed in nine of the family conversations with 50 individual people contributing. We used a process of a descriptive contextual analysis drawing out specific elements of the family conversations to identify an underlying ideology around breastfeeding in public within these groups.

Results

The analysis focused on four key elements of the conversations. These included the descriptions of the event, the actions, the locations and feelings of the dominant players. Descriptions of the event outlined different beliefs and feelings related to breastfeeding in public and whether it should occur at all. Suggestions for not breastfeeding in public were timing your outings so feeding could take place at home, expressing breastmilk or using the dummy. When breastfeeding in public was considered acceptable, there were requisite social norms. Breastfeeding in public requires women to be discrete and covered-up, so as not to expose her breast. She is also required to feed in an appropriate place to avoid discomforting others, guard against judgement, and to protect herself from the unwanted male gaze.

Conclusions

Our findings suggest that controversy remains as to whether breastfeeding should occur in public at all. Even where breastfeeding in public is seen as a woman's choice, there are social rules that govern how it should be undertaken to make it an 'appropriate' activity. As a result, women need to take responsibility for others feelings, minimise the discomfort of others and 'keep themselves safe' if and when they breastfeed in public spaces.

Effectiveness of Peer Counselor Support on Breastfeeding Outcomes in WIC-Enrolled Women

OBJECTIVE

To evaluate the effectiveness of different quantities and types of breastfeeding (BF) peer counselor (BFPC) support on BF outcomes in women enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

DESIGN

Secondary data analysis using BFPC data from an upstate New York county WIC (April 1, 2009 to March 30, 2011) merged with New York State Department of Health WIC surveillance data.

PARTICIPANTS

A total of 2,149 WIC-enrolled mothers with live singleton births who accepted a BFPC referral and received different quantities and types of BFPC support (telephone, in person, and mailings).

MAIN OUTCOME MEASURES

Self-reported BF initiation and duration at 30 days.

ANALYSIS

Multivariable logistic regression was used to estimate the odds of BF outcomes at 30 days associated with different levels of BFPC support.

RESULTS

Mothers who accepted BFPC referrals and had at least 1 phone conversation or in-person contact had a significant 35% to 164% increased odds of positive BF outcomes. Mailings did not significantly improve outcomes.

CONCLUSIONS AND IMPLICATIONS

The Special Supplemental Nutrition Program for Women, Infants, and Children may need to identify barriers to BF duration and implement interventions in communities with low BF rates. Future studies may benefit from evaluating the impact of combined in-person support and phone contacts during the prenatal and postpartum periods on BF outcomes.

Proactive Peer (Mother-to-Mother) Breastfeeding Support by Telephone (Ringing up About Breastfeeding Early [RUBY]): A Multicentre, Unblinded, Randomised Controlled Trial

BACKGROUND

Breastfeeding rates are suboptimal internationally, and many infants are not receiving any breast milk at all by six months of age. Few interventions increase breastfeeding duration, particularly where there is relatively high initiation. The effect of proactive peer (mother-to-mother) support has been found to increase breastfeeding in some contexts but not others, but if it is shown to be effective would be a potentially sustainable model in many settings. We aimed to determine whether proactive telephone-based peer support during the postnatal period increases the proportion of infants being breastfed at six months of age.

METHODS

RUBY (Ringing Up about Breastfeeding earlY) was a multicentre, two-arm un-blinded randomised controlled trial conducted in three hospitals in Victoria, Australia. First-time mothers intending to breastfeed were recruited after birth and prior to hospital discharge, and randomly assigned (1:1) to usual care or usual care plus proactive telephone-based breastfeeding support from a trained peer volunteer for up to six months postpartum. A computerised random number program generated block sizes of four or six distributed randomly, with stratification by site. Research midwives were masked to block size, but masking of allocation was not possible. The primary outcome was the proportion of infants receiving any breast milk at six months of age. Analyses were by intention to treat; data were collected and analysed masked to group. The trial is registered with ACTRN, number 12612001024831.

FINDINGS

Women were recruited between Feb 14, 2013 and Dec 15, 2015 and randomly assigned to peer support (n = 574) or usual care (n = 578). Five were not in the primary analysis [5 post-randomisation exclusions]. Infants of women allocated to telephone-based peer support were more likely than those allocated to usual care to be receiving breast milk at six months of age (intervention 75%, usual care 69%; Adj. RR 1·10; 95% CI 1·02, 1·18). There were no adverse events.

INTERPRETATION

Providing first time mothers with telephone-based support from a peer with at least six months personal breastfeeding experience is an effective intervention for increasing breastfeeding maintenance in settings with high breastfeeding initiation.

FUNDING

The Felton Bequest, Australia, philanthropic donation and La Trobe University grant.

Community perceptions towards the new role of traditional birth attendants as birth companions and nutrition advocates in Kakamega County, Kenya

Delivery with skilled birth attendants is important for reducing maternal mortality in developing countries. However, traditional birth attendants (TBAs) are abundant in such settings, managing deliveries without the skills and resources necessary to prevent mortality in this situations. Interventions that have been proposed to mitigate the situation include redefining the role of TBAs to nutrition advocates and birth companions for pregnant women to health facilities. We thus explored community perceptions on these new roles of TBAs, as birth companions and nutrition advocates, and their influence on health facility deliveries in Kakamega County, Kenya. Qualitative data was collected through key informant interviews with health workers and focus group discussions with lactating mothers, pregnant women, husbands, community leaders, community health volunteers, and TBA. Content analysis was conducted; data was organized into subthemes and conclusions made from each subtheme using Atlas.ti software. TBAs adopted their birth companion role as the majority offered companionship to mothers delivering at health facilities. Mothers were happy with this role as TBAs continued providing companionship even after delivery. The community members were happy with the new role of TBAs and reported increased deliveries at the health facilities. In contrast, TBAs did not adopt the nutrition advocacy role sufficiently. We found that redefining the role of the TBAs into birth companions to support facility-based delivery is thus feasible and acceptable. Nutrition advocacy by the TBAs should be strengthened to maximize on the opportunity provided by the close association between TBAs and mothers and the community.

Mothers'Breastfeeding-Related Durations and Nursing Management During the Early Postpartum Period in a Mixed Hospital Ward with an Obstetrics Department: A Prospective Observational Study

PURPOSE

This study aimed to quantify duration of in-hospital breastfeeding (BF)-related activities in mothers after childbirth in a mixed ward-type hospital with an obstetrics department in Japan (hereafter, mixed ward).

METHODS

Twenty-two postpartum mothers (primiparous and multiparous) who had vaginal delivery in a mixed ward were instructed to wear radio beacons. A smartphone was placed in the BF room and detected the presence of a nearby beacon, 24 hours daily, measuring the number of hours a mother spent in the nursing room (defined as BF time [hereafter, BF-related duration]). BF-related duration included time spent for BF, diaper changes before and after BF, bottle feeding, and support from nurses. BF-related total hours during postpartum hospitalization were calculated. The effects of parity and each postpartum day number (postpartum days 1-4) on Daily BF-related duration were determined.

RESULTS

Percentage of total postpartum hospitalization time spent for BF-related duration was 21.6% and 19.9% for primiparous and multiparous mothers, respectively, with no significant difference between groups. BF-related duration was significantly different between parity group and postpartum day, with peaks on postpartum day 4 (387.7 minutes) and day 2 (318.0 minutes) for primiparous and multiparous groups, respectively. (F = 2.813, p = 0.048).

CONCLUSION

Mothers spent 20% of their postpartum hospitalization period for BF-related activities. Individual support is necessary, especially for primiparous mothers, who spent more time than multiparous mothers for BF-related activities on postpartum day 4. In a mixed ward, postpartum mothers need a comfortable hospital environment in which midwives can dedicate themselves to mother-child dyad care.

Facebook support for breastfeeding mothers: A comparison to offline support and associations with breastfeeding outcomes

OBJECTIVES

For breastfeeding mothers, online support groups through Facebook may be a more convenient and preferred source for accessing breastfeeding information and support, but few studies exist that examine the use of Facebook groups specifically for breastfeeding support. This study explores the sources of support among users of Facebook breastfeeding support groups and a possible mechanism by which support received on Facebook may translate to behavioral outcomes among breastfeeding mothers.

METHODS

From July-September 2017 a survey was distributed online to African American mothers (N = 277) who participate in breastfeeding support groups on Facebook. The survey assessed network support from Facebook and other sources of breastfeeding support, perceived breastfeeding norms, breastfeeding self-efficacy and breastfeeding attitudes. Correlations and linear regression analysis were used to examine the relationship between covariates and outcome variables.

RESULTS

The average intended breastfeeding duration among participants in this study was 19 months. Participants reported the highest amount of breastfeeding support received from their Facebook support group, in comparison to other sources of support, and Facebook support was significantly correlated with intended breastfeeding duration (p < 0.05). Self-efficacy and breastfeeding attitudes remained significant predictors of intended breastfeeding duration within the final regression model.

CONCLUSIONS

Breastfeeding support received within Facebook groups may compensate for inadequate support received within mothers' networks. More research is needed to understand the mechanism through which Facebook support may contribute to prolonged breastfeeding durations.

Diet and Lifestyle Before and During Pregnancy - Practical Recommendations of the Germany-wide Healthy Start - Young Family Network

Diet and exercise before and during pregnancy affect the course of the pregnancy, the child's development and the short- and long-term health of mother and child. The Healthy Start - Young Family Network has updated the recommendations on nutrition in pregnancy that first appeared in 2012 and supplemented them with recommendations on a preconception lifestyle. The recommendations address body weight before conception, weight gain in pregnancy, energy and nutritional requirements and diet (including a vegetarian/vegan diet), the supplements folic acid/folate, iodine, iron and docosahexaenoic acid (DHA), protection against food-borne illnesses, physical activity before and during pregnancy, alcohol, smoking, caffeinated drinks, oral and dental hygiene and the use of medicinal products. Preparation for breast-feeding is recommended already during pregnancy. Vaccination recommendations for women planning a pregnancy are also included. These practical recommendations of the Germany-wide Healthy Start - Young Family Network are intended to assist all professional groups that counsel women and couples wishing to have children and during pregnancy with uniform, scientifically-based and practical information.

Can a Call Make a Difference? Measured Change in Women's Breastfeeding Self-efficacy Across Call Interactions on a Telephone Helpline

Background Telephone helplines providing 24-h specialist-nurse contact present a source of immediate support for women encountering challenges with breastfeeding and may serve to prolong breastfeeding duration by building self-efficacy. To date there is little evidence on interaction effectiveness and still less on the relative effectiveness for women from different socio-economic backgrounds. Research Aim To establish the effect on maternal breastfeeding self-efficacy of calls made to a nurse-led parenting helpline. Methods From a corpus of calls made to the Australian Child Health Line (N = 723), those made by women presenting a breastfeeding concern as a prime issue (n = 60) were scored for breastfeeding self-efficacy at commencement and completion of recorded interactions. Analyses examined the significance and direction of change from beginning to end of calls and compared difference in change across calls originating from high and low social advantage locations. Results A significant increase in self-efficacy was found, but with low effect size. There was considerable variation among calls; 53% showed improvement, 25% showed no change and 22% showed reduction in breastfeeding self-efficacy. While most calls were made by women from socially advantaged locations, change was more positive for the small number of callers from disadvantaged locations. Conclusion The potential of nurse-led reactive telephone support is evident, but dependent on qualities of the interaction. For women living in disadvantaged locations telephone support may be of particular significance given the greater social barriers to breastfeeding they are likely to encounter.

Sources of Information and Support for Breastfeeding: Alignment with Centers for Disease Control and Prevention Strategies

BACKGROUND AND OBJECTIVES

Research consistently supports health benefits of breastfeeding; however, rates in the United States remain below Healthy People 2020 goals. To increase breastfeeding, information and support are needed from multiple sources. Given differences in breastfeeding rates by demographic characteristics, sources of information and support may also differ. In addition, recent research suggests potential differences in health outcomes related to feeding method (direct breastfeeding only, feeding expressed human milk, combination-feeding with formula). This study examined (1) information and support received within Centers for Disease Control and Prevention (CDC)-defined strategies for supporting breastfeeding mothers, (2) differences in rates of information and support received by demographics, and (3) associations with feeding method at 6 weeks postpartum.

MATERIALS AND METHODS

A sample of 447 women participating in the Synergistic Theory Research Obesity and Nutrition Group (STRONG) Kids 2 study completed surveys with questions from the CDC Survey on Infant Feeding Practices II related to sources of information and support for breastfeeding and breast pump use, and about demographics and feeding method at 6 weeks postpartum.

RESULTS

Frequencies of supports received within each category indicate that professional supports were the most pervasive, followed by support from friends and relatives. However, women at greater risk for breastfeeding cessation (lower education, Women, Infants, and Children participants, single mothers) received information and support at lower rates. Education and information support was the only source significantly associated with feeding method.

CONCLUSION

New approaches are needed to increase efficacy of information delivery, especially for at-risk populations, to better meet CDC recommendations.

What Do Women Lose if They Are Prevented From Meeting Their Breastfeeding Goals?

This article explores the complex issue of breastfeeding and maternal mental health. Many women stop breastfeeding before they are ready, often leading to feelings of anxiety, guilt, and anger. Critics of breastfeeding promotion blame breastfeeding advocates for this impact, claiming that if the focus were merely on feeding the baby, with all methods equally valued and supported, maternal mental health would be protected. Established health impacts of infant feeding aside, this argument fails to account for the importance of maternal breastfeeding goals, or the physical and emotional rewards breastfeeding can bring. Although some women will take comfort in the message that what matters most is that the baby is fed, others view such suggestions as a lack of recognition of their wishes and the loss that they feel, exacerbating their grief and frustration. The purpose of this article is to highlight the importance of recognizing and valuing women’s individual breastfeeding goals, and not dismissing or invalidating their experience if they do not meet these by telling them that they do not matter. To move forward, we must recognize the impact of all infant feeding experiences, consider the impact of public messaging, and work to support more women to meet their goals.

Effectiveness of weekly cell phone counselling calls and daily text messages to improve breastfeeding indicators

Background

Every year, nearly one million deaths occur due to suboptimal breastfeeding. If universally practiced, exclusive breastfeeding alone prevents 11.6% of all under 5 deaths. Among strategies to improve exclusive breastfeeding rates, counselling by peers or health workers, has proven to be highly successful. With growing availability of cell phones in India, they are fast becoming a medium to spread information for promoting healthcare among pregnant women and their families. This study was conducted to assess effectiveness of cell phones for personalized lactation consultation to improve breastfeeding practices.

Methods

This was a two arm, pilot study in four urban maternity hospitals, retrained in Baby Friendly Hospital Initiative. The enrolled mother-infant pairs resided in slums and received healthcare services at the study sites. The control received routine healthcare services, whereas, the intervention received weekly cell phone counselling and daily text messages, in addition to counselling the routine healthcare services.

Results

1036 pregnant women were enrolled (518 - intervention and 518 - control). Rates of timely initiation of breastfeeding were significantly higher in intervention as compared to control (37% v/s 24%, p < 0.001). Pre-lacteal feeding rates were similar and low in both groups (intervention: 19%, control: 18%, p = 0.68). Rate of exclusive breastfeeding was similar between groups at 24 h after delivery, but significantly higher in the intervention at all subsequent visits (control vs. intervention: 24 h: 74% vs 74%, p = 1.0; 6 wk.: 81% vs 97%, 10 wk.: 78% vs 98%, 14 wk.: 71% vs 96%, 6 mo: 49% vs 97%, p < 0.001 for the last 4 visits). Adjusting for covariates, women in intervention were more likely to exclusively breastfeed than those in the control (AOR [95% CI]: 6.3 [4.9–8.0]).

Conclusion

Using cell phones to provide pre and postnatal breastfeeding counselling to women can substantially augment optimal practices. High rates of exclusive breastfeeding at 6 months were achieved by sustained contact and support using cell phones. This intervention shows immense potential for scale up by incorporation in both, public and private health systems.

Trial registration

This study was retrospectively registered with Clinical Trial Registry of India (http://www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=3060) Trial Number: CTRI/2011/06/001822 on date 20/06/2011.

Effect of breastfeeding education and support intervention (BFESI) versus routine care on timely initiation and exclusive breastfeeding in Southwest Ethiopia: study protocol for a cluster randomized controlled trial

BACKGROUND

Infant mortality rates are still high in Ethiopia. Breastfeeding is regarded as the simplest and least expensive strategy for reduction of infant mortality rates. Community-based educational and support interventions provided prenatally and postnatally are effective in increasing breastfeeding rates. However, such interventions are not widely implemented in Ethiopia. This study aims to assess the effect of breastfeeding education and support on timely initiation and duration of exclusive breastfeeding.

METHODS

A cluster-randomized controlled trial at the community level will be conducted to compare the effect of breastfeeding education and support versus routine care. The intervention will be provided by Women Development Army leaders who are already in the country's health system using a 40-h WHO breastfeeding counseling course, "Infant and Young Child Feeding Counseling: an integrated course" and the "Training of Trainers Manual for Counseling on Maternal, Infant and Young Child Nutrition" in the local language. Culturally appropriate operational packages of information will be developed for them. Using preset criteria at least 432 pregnant women in their third trimester will be recruited from 36 zones. Visits in the intervention arm include two prenatal visits and 8 postnatal visits. Supervisory visits will be conducted monthly to each intervention zone. Data will be entered into Epi-data version 3.1 and analyzed using STATA version 13.0. All analysis will be done by intention to treat analysis. We will fit mixed-effects linear regression models for the continuous outcomes and mixed-effects linear probability models for the binary outcomes with study zone as random intercept to estimate study arm difference (intervention vs. routine education) adjusted for baseline value of the outcome and additional relevant covariates. The protocol was developed in collaboration with the Jimma Zone and Mana district Health office. Ethical clearance was obtained from the Institutional Review Board of University of Oslo and Jimma University. This study is partly funded by NORAD's NORHED programme.

DISCUSSION

We expect that the trial will generate findings that can inform breastfeeding policies and practices in Ethiopia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT 03030651 January 25, 2017 version 3 dated 16 July 2018.

Investigating factors associated with success of breastfeeding in first-time mothers undergoing epidural analgesia: a prospective cohort study

Background

We investigated the possible risk factors that could influence the likelihood of breastfeeding at 5 to 9 weeks postpartum with our primary aim being to analyse the associations between psychological vulnerabilities, such as peripartum depression and anxiety, and continued breastfeeding. Our secondary aim was to investigate other non-psychological factors’ influence on continued breastfeeding.

Methods

A prospective cohort study was conducted in KK Women’s and Children’s Hospital in Singapore. Healthy nulliparous parturients at ≥36 weeks gestation with a singleton fetus who received epidural analgesia were recruited. Demographic and anaesthetic data were obtained. Self-reported psychological and pain determinants such as anxiety (State-Trait Anxiety Inventory), depression (Edinburgh Postnatal Depression Scale), stress (Perceived Stress Scale), pain susceptibility (Pain Catastrophizing Scale) and pain perception (McGill Pain Questionnaire) were also recorded at baseline. A phone interview was then performed at 5 to 9 weeks postpartum to obtain information on breastfeeding status.

Results

329 participants were included into this study, of which 263 (79.9%) of them were still breastfeeding at 5 weeks postpartum. Multivariate logistic regression analysis showed that a higher State-Trait Anxiety Inventory score (Adjusted Odds Ratio [AOR] 0.97; 95% Confidence Interval [CI] 0.94, 1.00) at baseline, higher intrapartum blood loss (AOR 0.76; 95% CI 0.61, 0.93), and occurrence of fetal anomalies (AOR 0.15; 95% CI 0.03, 0.72) were associated with reduced likelihood of breastfeeding at 5 to 9 weeks postpartum. Indians (AOR 0.56; 95% CI 0.20, 1.53), Malays (AOR 0.30; 95% CI 0.14, 0.62) and other ethnicities (AOR 0.36; 95% CI 0.16, 0.83) were less likely to continue breastfeeding compared to Chinese participants. On the other hand, receiving any support services on breastfeeding during the participants’ hospital stay was 3.3 times more likely (AOR 3.30; 95% CI 1.21, 9.02) to increase the likelihood of breastfeeding at 5 to 9 weeks postpartum.

Conclusion

We identified 5 independent association factors that could have significant influences on breastfeeding at 5 to 9 weeks postpartum. Healthcare providers could utilize this risk stratification to identify parturients likely to have poorer breastfeeding outcomes and undertake interventions that may help safeguard optimization of breastfeeding outcomes and parturient care.

Trial registration

Clinicaltrials.gov NCT02278601. Registered 26 October 2014.

Electronic supplementary material

The online version of this article (10.1186/s13006-018-0184-7) contains supplementary material, which is available to authorized users.

From initiation to cessation: Turning points and coping resources in the breastfeeding experience of first-time mothers

While most mothers initiate breastfeeding, many do not continue for recommended durations. This study aimed to understand the gap between breastfeeding initiation and duration through an in-depth exploration of first-time mothers' breastfeeding experiences. Contextual factors that may facilitate or deter breastfeeding maintenance were explored by identifying common turning points (significant events or periods promoting a change in thoughts/behaviors or facilitating maintenance) described by mothers with varied breastfeeding durations. In semistructured interviews conducted from March to June 2015, twenty-eight first-time mothers in Iowa were asked to describe their breastfeeding experiences from initiation through cessation. Using thematic analysis, seven turning points, consistent across varied durations and experiences were identified: breastfeeding problems, the unknowns, recurring stressors, living new life with baby, reentering social roles, special occasions, and letting go. Turning points were usually associated with stressful situations, and mothers described intrapersonal (e.g., determination) and interpersonal (e.g., social support) coping resources as facilitators of breastfeeding maintenance. These findings highlight contextual factors that may trigger turning points, representing critical intervention periods, and the importance of enhancing support networks. Interventions to facilitate longer breastfeeding durations should consider key turning points and availability of coping resources to determine strategies that best fit the mother at each point.

Social Support for Breastfeeding in the Era of mHealth: A Content Analysis

BACKGROUND

Several barriers to successful breastfeeding exist, including a lack of support from peers or professionals. With the emergence of mobile health (mHealth) tools to provide additional breastfeeding support, a more thorough review of social support resources was needed. Research Aim: The aim of this study was to determine mHealth breastfeeding support resources and characterize the type of social support they provide.

METHODS

A content analysis of mHealth programs ( n = 65), including text messaging ( n = 12) and mobile applications ( n = 53), was conducted on the basis of searches of the iTunes and Google Play stores ( n = 50) and PubMed, the Cumulative Index of Nursing and Allied Health, and American Business Information/INFORM Complete Plus ( n = 15). Results were then dual-coded for key characteristics and types of support provided.

RESULTS

Thirty-eight apps (76%) were free to users, 14 (28%) were offered in a variety of languages, and 47 (94%) provided informational support. The mobile applications were targeted largely to postpartum women, focused on breastfeeding duration, and included troubleshooting information. Mobile applications often included media components ( n = 12 [24%]); few were tailored or personalized ( n = 5 [10%]) and interactive ( n = 15 [30%]). Text-messaging programs were available in a variety of countries ( n = 7 [58%]) and provided mostly informational support ( n = 5 [42%]), were pro-breastfeeding ( n = 12 [100%]), were targeted to both pregnant and postpartum women ( n = 6 [50%]), focused on both breastfeeding initiation and duration ( n = 9 [75%]), and had two-way interactivity ( n = 6 [50%]) and personalization ( n = 5 [42%]).

CONCLUSIONS

Although freely available mobile applications and text-messaging programs exist, with potential for wide reach, the majority provide only informational support. These programs would benefit from additional study of their usefulness.

Effectiveness of breastfeeding interventions delivered to fathers in low- and middle-income countries: A systematic review

Adequate support for lactating mothers is crucial to improve the rates of early initiation, exclusive, and continued breastfeeding. Maternal breastfeeding intention and ongoing breastfeeding duration are strongly predicted by their partners' breastfeeding beliefs. Partner support has a significant effect on improving rates of any and exclusive breastfeeding, when compared with professional support, particularly in low-income populations. This systematic review investigates the effectiveness of breastfeeding interventions targeting fathers in low- and middle-income countries (LMIC). A systematic literature search was undertaken on Medline (EBSCOhost), PsycInfo, CINAHL, and Scopus databases and via manual searching. Inclusion criteria were experimental or quasiexperimental designs targeting fathers from LMIC, which measured either breastfeeding initiation, breastfeeding exclusivity, or duration of breastfeeding as the main outcomes. No time restriction was put in place, and all articles were published in English. The quality of selected papers was assessed using the Joanna Briggs Institute tool. A total of 8 articles were included from 6 interventions: 2 quasiexperimental and 4 randomized control trials. All interventions involved breastfeeding education targeting fathers; 2 were given only to fathers, and 4 delivered to both fathers and mothers. Among these interventions, 2 measured both early initiation and exclusive breastfeeding; one exclusive breastfeeding only; one exclusive breastfeeding, knowledge, and attitudes; one exclusive breastfeeding and knowledge; and one breastfeeding, continued breastfeeding, and awareness. Across all interventions, breastfeeding education showed significant improvement in breastfeeding outcomes in the intervention compared with the control groups. In summary, breastfeeding education interventions targeting fathers in LMIC are effective in improving early initiation of breastfeeding, exclusive breastfeeding, and continued breastfeeding. Thus, breastfeeding promotion should consider the education and involvement of fathers in the intervention.

Affect of Early Skin-to-Skin Mother-Infant Contact in the Maintenance of Exclusive Breastfeeding: Experience in a Health Department in Spain

BACKGROUND

Breastfeeding has been shown to result in extensive physical and psychological benefits for both the mother and the newborn. However, the rate and duration of exclusive breastfeeding (EBF) remains low worldwide. Mother-infant skin-to-skin contact (SSC) immediately after birth has demonstrated results that support the argument for breastfeeding continuation. Research aim: This study aimed to investigate the prevalence of EBF 3 months postpartum and the effect of early SSC in maintaining optimal EBF practices for mothers and their healthy newborns.

METHODS

We conducted an observational, retrospective study in Spain from 2013 to 2015. Pregnant women were interviewed immediately postpartum and again at 3 months postpartum regarding variables associated with breastfeeding initiation and continuation.

RESULTS

There were 1,071 women recruited. Early SSC was performed in 92% of vaginal births but only 57% of urgent cesarean births. Of women breastfeeding at discharge, 69.5% performed SSC with their newborn. We found that 68.6% of women were exclusively breastfeeding by discharge and 46.7% by 3 months postpartum. Type of feeding at discharge, country of origin, and parity were found to be associated with each other ( p = .003, p = .001, respectively). Early SSC was also significantly associated with type of feeding at discharge, 1 month, 2 months, and 3 months postpartum ( p < .001). Hypogalactia (19.8%) was the most frequently reported factor for breastfeeding discontinuation.

CONCLUSION

Breastfeeding promotion interventions are likely to improve breastfeeding rates at 3 months postpartum. Social and economic factors should be taken into account when such programs are planned to be implemented.

Proactive telephone support provided to breastfeeding mothers of preterm infants after discharge: a randomised controlled trial

Aim

The aim was to evaluate the effectiveness of proactive telephone support provided to breastfeeding mothers of preterm infants after discharge from neonatal intensive care units (NICU).

Methods

Between March 2013 and December 2015, a randomised controlled trial was conducted at six NICUs across Sweden. At each NICU, a breastfeeding support team recruited, randomised and delivered the support to participating mothers. The intervention group received a daily proactive telephone call up to 14 days after discharge from the support team. The control group could initiate telephone contact themselves. Primary outcome was exclusive breastfeeding eight weeks after discharge. Secondary outcomes were maternal satisfaction with breastfeeding, attachment, quality of life and parental stress.

Results

In total, 493 mothers were randomised, 231 to intervention group and 262 to control group. There were no differences between the groups for exclusive breastfeeding, odds ratio 0.96, 95% CI 0.66–1.38, nor for maternal satisfaction with breastfeeding, attachment or quality of life. The intervention group reported significantly less parental stress than the controls, t = 2.44, 95% CI 0.03–0.23, effect size d = 0.26.

Conclusion

In this trial, proactive telephone support was not associated with increased exclusive breastfeeding prevalence eight weeks following discharge. However, intervention group mothers showed significantly lower parental stress.

Effectiveness of interventions on breastfeeding self-efficacy and perceived insufficient milk supply: A systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to assess the efficacy on an intervention on breastfeeding self-efficacy and perceived insufficient milk supply outcomes. The literature search was conducted among 6 databases (CINAHL, Medline, PsyncInfo, Scopus, Cochrane, and ProQuest) in between January 2000 to June 2016. Two reviewers independently assessed the articles for the following inclusion criteria: experimental or quasi-experimental studies; healthy pregnant women participants intending to breastfeed or healthy breastfeeding women who gave birth to a term singleton and healthy baby; intervention administered could have been educational, support, psycho-social, or breastfeeding self-efficacy based, offered in prenatal or postnatal or both, in person, over the phone, or with the support of e-technologies; breastfeeding self-efficacy or perceived insufficient milk supply as outcomes. Seventeen studies were included in this review; 12 were randomized controlled trials. Most interventions were self-efficacy based provided on 1-to-1 format. Meta-analysis of RCTs revealed that interventions significantly improved breastfeeding self-efficacy during the first 4 to 6 weeks (SMD = 0.40, 95% CI 0.11-0.69, p = 0.006). This further impact exclusive breastfeeding duration. Only 1 study reported data on perceived insufficient milk supply. Women who have made the choice to breastfeed should be offered breastfeeding self-efficacy-based interventions during the perinatal period. Although significant effect of the interventions in improving maternal breastfeeding self-efficacy was revealed by this review, there is still a paucity of evidence on the mode, format, and intensity of interventions. Research on the modalities of breastfeeding self-efficacy should be pursued.

Development of a novel motivational interviewing (MI) informed peer-support intervention to support mothers to breastfeed for longer

Background

Many women in the UK stop breastfeeding before they would like to, and earlier than is recommended by the World Health Organization (WHO). Given the potential health benefits for mother and baby, new ways of supporting women to breastfeed for longer are required. The purpose of this study was to develop and characterise a novel Motivational Interviewing (MI) informed breastfeeding peer-support intervention.

Methods

Qualitative interviews with health professionals and service providers (n = 14), and focus groups with mothers (n = 14), fathers (n = 3), and breastfeeding peer-supporters (n = 15) were carried out to understand experiences of breastfeeding peer-support and identify intervention options. Data were audio-recorded, transcribed, and analysed thematically. Consultation took place with a combined professional and lay Stakeholder Group (n = 23). The Behaviour Change Wheel (BCW) guided intervention development process used the findings of the qualitative research and stakeholder consultation, alongside evidence from existing literature, to identify: the target behaviour to be changed; sources of this behaviour based on the Capability, Opportunity and Motivation (COM-B) model; intervention functions that could alter this behaviour; and; mode of delivery for the intervention. Behaviour change techniques included in the intervention were categorised using the Behaviour Change Technique Taxonomy Version 1 (BCTTv1).

Results

Building knowledge, skills, confidence, and providing social support were perceived to be key functions of breastfeeding peer-support interventions that aim to decrease early discontinuation of breastfeeding. These features of breastfeeding peer-support mapped onto the BCW education, training, modelling and environmental restructuring intervention functions. Behaviour change techniques (BCTTv1) included social support, problem solving, and goal setting. The intervention included important inter-personal relational features (e.g. trust, honesty, kindness), and the BCTTv1 needed adaptation to incorporate this.

Conclusions

The MI-informed breastfeeding peer-support intervention developed using this systematic and user-informed approach has a clear theoretical basis and well-described behaviour change techniques. The process described could be useful in developing other complex interventions that incorporate peer-support and/or MI.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1725-1) contains supplementary material, which is available to authorized users.

Orientações sobre amamentação na atenção básica de saúde e associação com o aleitamento materno exclusivo

Resumo O objetivo deste artigo é analisar a associação entre o recebimento de orientações sobre amamentação na atenção básica à saúde e o aleitamento materno exclusivo. Estudo transversal conduzido em 2013, mediante entrevista a 429 mães de crianças menores de seis meses, em unidades básicas da cidade do Rio de Janeiro. Razões de prevalência ajustadas do desfecho foram obtidas por regressão de Poisson, sendo mantidas no modelo final as variáveis associadas ao desfecho (p ≤ 0,05). A prevalência de aleitamento materno exclusivo foi de 50,1%. Na análise múltipla, a mãe receber orientação sobre aleitamento materno exclusivo na unidade básica se associou positivamente ao desfecho (RP =1,32). Associaram-se negativamente ao desfecho: renda materna < 1 salário mínimo (RP = 0,77), experiência prévia em amamentar por menos de 6 meses (RP = 0,73), não viver com companheiro (RP = 0,76), não amamentação exclusiva na alta hospitalar (RP = 0,78), consumo de bebida alcoólica (RP = 0,57), receber orientação sobre uso de bombas para ordenha das mamas (RP = 0,53), uso de chupeta (RP = 0,74) e idade crescente do bebê em meses (RP = 0,78). Ter recebido orientação sobre o aleitamento materno exclusivo contribuiu para o mesmo, enquanto orientações e práticas inadequadas se associaram a uma menor prevalência do desfecho.

Influence of Feeding Practices on Malnutrition in Haitian Infants and Young Children

Infant malnutrition remains an important cause of death and disability, and Haiti has the highest prevalence in the Americas. Therefore, preventive strategies are needed. Our aims were (1) To assess the prevalence of malnutrition among young children seen at a health center in Haiti; (2) Examine adherence to infant feeding practices recommended by the World Health Organization (WHO) and the association to nutritional status. This cross-sectional study recruited children from the Saint Espri Health Center in Port Au Prince in 2014. We recorded feeding practices, socio-demographic data, and anthropometric measurements (WHO-2006). We evaluated 278 infants and children younger than two years old, aged 8.08 ± 6.5 months, 53.2% female. 18.35% were underweight (weight/age <-2 SD); 13.31% stunted (length/age <-2 SD), and 13.67% had moderate or severe wasting (weight/length <-2 SD). Malnutrition was associated with male gender, older age, lower maternal education level, and greater numbers of siblings (Chi², p < 0.05). Adherence to recommended breastfeeding practices was 11.8-97.9%, and to complementary feeding practices was 9.7-90.3%. Adherence was associated with a lower prevalence of malnutrition.

CONCLUSION

Prevalence of infant and young child malnutrition in this population is high. Adherence to WHO-recommended feeding practices was associated with a better nutritional status.

Dojenje in tandemsko dojenje

Uvod: Tandemsko dojenje ali dojenje sorojencev je slabo poznan koncept. Matere, ki tandemsko dojijo, se srečujejo s socialno stigmo in slabo oporo s strani zdravstvenih strokovnjakov. Namen raziskave je bil proučiti znanje o  tandemskem dojenju med študenti zdravstvenih ved.Metode: Uporabljen je bil kvantitativni eksplorativni neeksperimentalni raziskovalni dizajn. V priložnostni vzorec so bili vključeni študenti zdravstvene nege (n = 66) in dietetike (n = 24). Podatki so bili zbrani s strukturiranim vprašalnikom (Cronbach α = 0,914). Uporabljena je bila opisna statistika, test hi-kvadrat in analiza variance.Rezultati: Da je popolnoma fiziološko, da ženska prekine dojenje starejšega otroka, če rodi naslednjega otroka, meni 50,7 % (n = 36) žensk in 84,2 % (n = 16) moških (χ2 = 6,898, p = 0,009). Kaj je izključno dojenje v prvih šestih mesecih, ve 79,2 % (n = 19) študentov dietetike in le 54,5 % (n = 36) študentov zdravstvene nege (χ2 = 4,489, p = 0,034). Nepravilnost trditve, da dojenčki v primeru tandemskega dojenja težje pridobivajo telesno težo, je prepoznalo 86,3 % (n = 44) žensk in 13,7 % (n = 7) moških.Diskusija in zaključek: V raziskavo vključeni študentje so izkazali pomanjkljivo znanje tako o dojenju na splošno kakor tudi o tandemskem dojenju. V študijski program bi bilo treba vnesti več vsebin o dojenju.

Pediatricians' experiences of working with breastfeeding: An interview study

OBJECTIVE

The aim of the study was to investigate pediatricians' experiences of working with breastfeeding.

METHOD

Semi-structured interviews were conducted with 12 pediatricians working at hospitals in Stockholm County. The interviews were recorded, transcribed and analyzed using content analysis and an inductive approach.

RESULTS

All pediatricians saw their role in working with breastfeeding as an important one, but their primary role as pediatricians was to ensure that infants received good nutrition. They delegated the practical aspects of breastfeeding to midwives, who were seen as experts, although the pediatricians believed they had a greater understanding of the necessity for supplemental feeding than did midwives. They also expressed the need for a common strategy regarding supplemental feeding and better teamwork with the midwives. Some respondents noted that it was difficult to advocate for breastfeeding without seeming critical of mothers who experienced problems with it or who did not want to do it. The results comprised a general theme, that breastfeeding is a genuine and difficult task, and five categories: factors decreasing breastfeeding, competence, roles of the professionals, supplemental feeding, the health-care system's responsibility.

CONCLUSIONS

Pediatricians have an interest in breastfeeding. However, they perceive inadequate communication with midwives and a need for better collaboration with them regarding breastfeeding. The study also identified a need for a national breastfeeding strategy and for improved conditions that create a breastfeeding-friendly environment.

Growing the IBCLC Workforce: A Florida Needs Assessment

BACKGROUND

Florida has fewer International Board Certified Lactation Consultants (IBCLCs) per 1,000 live births than the national average. An important strategy to support breastfeeding entails creating opportunities to prepare and train IBCLCs from underrepresented groups. However, it can be difficult for individuals to access lactation education and gain clinical experience necessary to become an IBCLC. Research aim: The Building a Better Breastfeeding Network project was a needs assessment designed to assess the interest in an IBCLC training program in Florida and perceived barriers and facilitators to completing such a program.

METHODS

An online survey was distributed via email to non-IBCLC students and maternal and child healthcare workers in Florida. Microsoft Excel was used to complete descriptive analyses.

RESULTS

Surveys were initiated by 1,939 eligible individuals from diverse racial and ethnic backgrounds across the state, 86% of whom responded that they would be possibly to very interested in an IBCLC training program. For those interested, cost was perceived as a potential barrier to enrolling in a program, but flexible course schedules and scholarship or financial aid availability would further attract participants. More than half were interested in working with underserved populations or in low-resource settings, but Black and Hispanic participants were significantly more likely to express interest in working in those settings.

CONCLUSION

Due to the high level of interest in an IBCLC training program in Florida, a formal lactation training program may be successful in attracting diverse students, particularly if funding and program flexibility needs are met.

Protocol for a feasibility trial for improving breast feeding initiation and continuation: assets-based infant feeding help before and after birth (ABA)

INTRODUCTION

Breast feeding improves the health of mothers and infants; the UK has low rates, with marked socioeconomic inequalities. While trials of peer support services have been effective in some settings, UK trials have not improved breast feeding rates. Qualitative research suggests that many women are alienated by the focus on breast feeding. We propose a change from breast feeding-focused interactions to respecting a woman's feeding choices, inclusion of behaviour change theory and an increased intensity of contacts in the 2 weeks after birth when many women cease to breast feed. This will take place alongside an assets-based approach that focuses on the positive capability of individuals, their social networks and communities.We propose a feasibility study for a multicentre randomised controlled trial of the Assets feeding help Before and After birth (ABA) infant feeding service versus usual care.

METHODS AND ANALYSIS

A two-arm, non-blinded randomised feasibility study will be conducted in two UK localities. Women expecting their first baby will be eligible, regardless of feeding intention. The ABA infant feeding intervention will apply a proactive, assets-based, woman-centred, non-judgemental approach, delivered antenatally and postnatally tailored through face-to-face contacts, telephone and SMS texts. Outcomes will test the feasibility of delivering the intervention with recommended intensity and duration to disadvantaged women; acceptability to women, feeding helpers and professionals; and feasibility of a future randomised controlled trial (RCT), detailing recruitment rates, willingness to be randomised, follow-up rates at 3 days, 8 weeks and 6 months, and level of outcome completion. Outcomes of the proposed full trial will also be collected. Mixed methods will include qualitative interviews with women/partners, feeding helpers and health service staff; feeding helper logs; and review of audio-recorded helper-women interactions to assess intervention fidelity.

ETHICS AND DISSEMINATION

Study results will inform the design of a larger multicentre RCT. The National Research Ethics Service Committee approved the study protocol.

TRIAL REGISTRATION NUMBER

ISRCTN14760978; Pre-results.

Informing infant and young child feeding programming in humanitarian emergencies: An evidence map of reviews including low and middle income countries

Around 200 million people were affected by conflict and natural disasters in 2015. Whereas those populations are at a particular high risk of death, optimal breastfeeding and complementary feeding practices could prevent almost 20% of deaths amongst children less than 5 years old. Yet, coverage of interventions for improving infant and young child feeding (IYCF) practices in emergencies is low, partly due to lack of evidence. Considering the paucity of data generated in emergencies to inform programming, we conducted an evidence map from reviews that included low- and middle-income countries and looked at several interventions: (a) social and behavioural change interpersonal and mass communication for promoting breastfeeding and adequate complementary feeding; (b) provision of donated complementary food; (c) home-based fortification with multiple micronutrient powder; (d) capacity building; (e) cash transfers; (f) agricultural or fresh food supply interventions; and (g) psychological support to caretakers. We looked for availability of evidence of these interventions to improve IYCF practices and nutritional status of infants and young children. We identified 1,376 records and included 28 reviews meeting the inclusion criteria. The highest number of reviews identified was for behavioural change interpersonal communication for promoting breastfeeding, whereas no review was identified for psychological support to caretakers. We conclude that any further research should focus on the mechanisms and delivery models through which effectiveness of interventions can be achieved and on the influence of contextual factors. Efforts should be renewed to generate evidence of effectiveness of IYCF interventions during humanitarian emergencies despite the challenges.

A realist review of one-to-one breastfeeding peer support experiments conducted in developed country settings

The World Health Organisation guidance recommends breastfeeding peer support (BFPS) as part of a strategy to improve breastfeeding rates. In the UK, BFPS is supported by National Institute for Health and Care Excellence guidance and a variety of models are in use. The experimental evidence for BFPS in developed countries is mixed and traditional methods of systematic review are ill-equipped to explore heterogeneity, complexity, and context influences on effectiveness. This review aimed to enhance learning from the experimental evidence base for one-to-one BFPS intervention. Principles of realist review were applied to intervention case studies associated with published experimental studies. The review aimed (a) to explore heterogeneity in theoretical underpinnings and intervention design for one-to-one BFPS intervention; (b) inform design decisions by identifying transferable lessons developed from cross-case comparison of context-mechanism-outcome relationships; and (c) inform evaluation design by identifying context-mechanism-outcome relationships associated with experimental conditions. Findings highlighted poor attention to intervention theory and considerable heterogeneity in BFPS intervention design. Transferable mid-range theories to inform design emerged, which could be grouped into seven categories: (a) congruence with local infant feeding norms, (b) integration with the existing system of health care, (c) overcoming practical and emotional barriers to access, (d) ensuring friendly, competent, and proactive peers, (e) facilitating authentic peer-mother interactions, (f) motivating peers to ensure positive within-intervention amplification, and (g) ensuring positive legacy and maintenance of gains. There is a need to integrate realist principles into evaluation design to improve our understanding of what forms of BFPS work, for whom and under what circumstances.

Breastfeeding Challenges and the Preterm Mother-Infant Dyad: A Conceptual Model

Breastfeeding is an experience that only a mother and her infant(s) can share. Infants who can feed from the breast receive not only the best nutrition but also, due to the close physical contact between mother and child, it is the optimal nurturance they can receive from their mother. When breastfeeding is trouble free, maternal well-being is uniquely heightened. However, breastfeeding remains a challenge for many mother-infant dyads and more so for those whose infants are born prematurely. This article introduces a conceptual model of the breastfeeding challenges facing preterm mother-infant dyads. It distinguishes between a maternal caregiving and an infant growth/development components. Within the maternal component, two primary elements are considered, that is, maternal behavioral and nutritional care. The two primary elements within the infant component include infant non-nutritional and nutritional growth/development. It is proposed that an improved understanding of the factors associated with these four elements and how they interplay with each other within individual dyads will facilitate the identification of the breastfeeding challenges facing these mother-infant entities. Due to the intimate relationships existing between a mother and her infant(s), it is further advanced that breastfeeding studies would be optimized if mother-infant pairs are studied as one entity rather than mother and infant separately. It is proposed that this conceptual model will assist health professionals develop personalized breastfeeding management plans for individual preterm mother-infant dyads, while furthering the development of evidence-based interventions to optimize their breastfeeding experiences.

Focused breastfeeding counselling improves short- and long-term success in an early-discharge setting: A cluster-randomized study

Length of postnatal hospitalization has decreased and has been shown to be associated with infant nutritional problems and increase in readmissions. We aimed to evaluate if guidelines for breastfeeding counselling in an early discharge hospital setting had an effect on maternal breastfeeding self-efficacy, infant readmission and breastfeeding duration. A cluster randomized trial was conducted and assigned nine maternity settings in Denmark to intervention or usual care. Women were eligible if they expected a single infant, intended to breastfeed, were able to read Danish, and expected to be discharged within 50 hr postnatally. Between April 2013 and August 2014, 2,065 mothers were recruited at intervention and 1,476 at reference settings. Results show that the intervention did not affect maternal breastfeeding self-efficacy (primary outcome). However, less infants were readmitted 1 week postnatally in the intervention compared to the reference group (adjusted OR 0.55, 95% CI 0.37, -0.81), and 6 months following birth, more infants were exclusively breastfed in the intervention group (adjusted OR 1.36, 95% CI 1.02, -1.81). Moreover, mothers in the intervention compared to the reference group were breastfeeding more frequently (p < .001), and spend more hours skin to skin with their infants (p < .001). The infants were less often treated for jaundice (p = 0.003) and there was more paternal involvement (p = .037). In an early discharge hospital setting, a focused breastfeeding programme concentrating on increased skin to skin contact, frequent breastfeeding, good positioning of the mother infant dyad, and enhanced involvement of the father improved short-term and long-term breastfeeding success.

Is increasing urbanicity associated with changes in breastfeeding duration in rural India? An analysis of cross-sectional household data from the Andhra Pradesh children and parents study

OBJECTIVE

To investigate whether village-level urbanicity and lower level socioeconomic factors are associated with breastfeeding practices in transitioning rural communities in India.

SETTING

29 villages in Ranga Reddy district, southern India between 2011 and 2014.

PARTICIPANTS

7848 children under 6 years identified via a cross-sectional household survey conducted as part of the Andhra Pradesh Children and Parents Study.

OUTCOME MEASURES

Two key indicators of optimal breastfeeding: termination of exclusive breastfeeding before 6 months and discontinuation of breastfeeding by 24 months. Village urbanicity was classified as low, medium or high according to satellite assessed night-light intensity.

RESULTS

Breastfeeding initiation was almost universal, and approximately two in three children were exclusively breastfed to 6 months and a similar proportion breastfed to 24 months. Using multilevel logistic regression, increasing urbanicity was associated with breastfeeding discontinuation before 24 months (medium urbanicity OR 1.45, 95% CI 0.71 to 2.96; high urbanicity OR 2.96, 95% CI 1.45 to 6.05) but not with early (<6 months) termination of exclusive breastfeeding. Increased maternal education was independently associated with both measures of suboptimal breastfeeding, and higher household socioeconomic position was associated with early termination of exclusive breastfeeding.

CONCLUSION

In this transitional Indian rural community, early stage urbanicity was associated with a shorter duration of breastfeeding. Closer surveillance of changes in breastfeeding practices alongside appropriate intervention strategies are recommended for emerging economies.

Midwives' lived experience of caring for new mothers with initial breastfeeding difficulties: A phenomenological study

OBJECTIVE

The aim of this study is to obtain a deeper understanding of midwives' lived experiences of caring for new mothers with initial breastfeeding difficulties.

METHODS

A reflective lifeworld approach was used. Six midwives were recruited from a hospital in western Sweden. Data were collected via individual lifeworld interviews and analysed using phenomenological methods.

RESULTS

The essential meaning can be described as a midwife's wish to help new mothers reach their breastfeeding goals by trying to interact with them as individual women in unique breastfeeding situations. This wish constitutes a contradiction to the midwife's own desire to succeed in enabling mothers to breastfeed and the perceived risk of failure as a midwife if the mothers decide not to breastfeed. This is further described by five constituents: striving to provide individualised care, collegial and personal responsibility both enables and prevents care, a struggle to be sufficient, an uphill struggle and mutual joy becomes the motivation to care.

CONCLUSIONS

Caring for new mothers with initial breastfeeding difficulties is a balancing act between the midwife's personal desire to succeed in enabling mothers to breastfeed, the mothers' wishes, the infants' needs, the importance of collective collegial competence and the limitations in the health care organisation. This makes the midwife's efforts to provide individualised care frustrating and demanding as well as motivating.

Breastfeeding support and opiate dependence: A think aloud study

OBJECTIVE

international guidelines recommend the promotion and protection of breastfeeding for the substance exposed mother and baby. Yet few studies have explored the facilitators, moderators and barriers to successful breastfeeding for women enrolled on opiate maintenance treatment, or suggested targeted support strategies. The aim of this study was to explore the views of women with opiate dependence on proposed elements for inclusion in a breastfeeding support intervention.

DESIGN

a qualitative study using think aloud technique.

SETTING

tertiary maternity hospital in the North-East of Scotland. Interviews conducted between November 2013 and March 2014.

PARTICIPANTS

6 opiate dependent women within 6 months of giving birth. Participants were enrolled on opiate medication treatment during their pregnancy, had initiated breastfeeding and accessed in-hospital breastfeeding support.

FINDINGS

an intervention founded on practical, informational and environmental elements was endorsed as supportive of continued breastfeeding of an infant at risk of Neonatal Abstinence Syndrome. Opiate dependent women were more receptive to strategies promoting a person-centered approach that were specific to their individualized infant feeding needs and delivered within an emotionally supportive environment. Barriers to the acceptability of breastfeeding advice included discouraging, prescriptive and judgemental healthcare actions and attitudes.

KEY CONCLUSIONS

there are distinct facilitators, modifiers and barriers to breastfeeding within the context of opiate exposure. Using this awareness to underpin the key features of the design should enhance maternal receptiveness, acceptability and usability of the support intervention.

IMPLICATIONS FOR PRACTICE

additional and tailored support interventions are required to meet the specific needs of breastfeeding an infant experiencing opiate withdrawal. The elimination of disempowering institutional actions and attitudes is imperative if a conducive environment in which opiate dependent women feel supported is to be achieved.

"The right help at the right time": Positive constructions of peer and professional support for breastfeeding

Problem or issue

Support during the early establishment phase of breastfeeding is important but women report that health professionals can undermine their confidence with breastfeeding.

What is already known

Breastfeeding support provided in fragmented hospital based models of care predominantly reflect authoritative expert advice-giving which women describe as conflicting and unsupportive. Women show a preference for support from a known midwife, or a peer supporter, or a combination of the two.

What this paper adds

Peer support counsellors and privately practicing midwives approached breastfeeding support in a similar way. They interacted with women as a ‘knowledgeable friend’ and normalised breastfeeding challenges which enhanced women’s confidence with breastfeeding.

Early initiation and exclusive breastfeeding: Factors influencing the attitudes of mothers who gave birth in a baby-friendly hospital

OBJECTIVE

To investigate the initation time of breastfeeding, exclusive breastfeeding rates, and complementary feeding practices during the first six months of life among mothers who gave birth in a baby-friendly hospital.

MATERIALS AND METHODS

A cross-sectional study was conducted with 350 mothers. Demographic characteristics, obstetric history and information about breastfeeding initiation were collected at the hospital. Information about factors affecting breastfeeding duration and feeding practices of the infants were obtained at the end of six months.

RESULTS

Some 97.4% of the mothers initiated breastfeeding, 60.1% within the first hour. Exclusive breastfeeding was maintained for six months in 38.9%. Low education levels of mother/father, random breastfeeding, rare breastfeeding at night, nipple problems, bottle/pacifier use, and lack of social support were found associated with early cessation. Planned pregnancy [odds ratio (OR=2.02)] and vaginal delivery (OR=0.3) were found as the most important factors in early initiation, whereas antepartum breastfeeding education (OR=7.17) was the most important factor for exclusive breastfeeding duration in the logistic analysis. More than half (61.1%) of the infants were partially/bottle fed for six months; the most common reason was the belief that breast milk was insufficient.

CONCLUSION

Efforts to encourage mothers and society to breastfeed exclusively should be made as part of a primary public health strategy to prevent early cessation of breastfeeding.

Multicentre randomised study of the effect and experience of an early inhome programme (PreHomeCare) for preterm infants using video consultation and smartphone applications compared with inhospital consultations: protocol of the PreHomeCare study

INTRODUCTION

Although premature infants and their parents are discharged earlier to inhomecare programmes, how to optimally support parents during this transition remains unknown. The aim of this study is to compare the effects of early inhomecare (PreHomeCare) including video consultations and mobile applications with those of inhospital consultations regarding breast feeding, parental confidence and parent-infant interactions.

METHODS AND ANALYSIS

A randomised controlled intervention study will be conducted in four neonatal departments offering PreHomeCare (ie, premature infant inhomecare) in Denmark. Parents of hospitalised premature infants who fulfil the inclusion criteria for PreHomeCare will be randomised during hospitalisation to either the intervention (n=80) or control group (n=80) using 1:1 block randomisation. During PreHomeCare, the intervention group will receive a smartphone application with a video system and an infant scale, and the control group will receive usual care (ie, hospital consultations). Additionally, both groups will have planned nurse consultations two to three times a week: the intervention group through video consultations and the control group through inhospital consultations. Data collection will occur at inclusion/baseline, at the end of PreHomeCare and 1 month after discharge using questionnaires and hospital records. The primary outcome is the proportion of exclusively breastfed infants 1 month after discharge/end of PreHomeCare, the secondary outcomes are parent-infant interactions measured by the Mother and baby interaction scale and family confidence in caring for infants measured by the Karitane Parenting Confidence Scale. The process evaluation will consist of two qualitative studies: a field study and an interview study. Data collection will initially involve field observations of three scheduled video consultations with six families from the intervention group. These families will also be interviewed 1 month after PreHomeCare has ended.

ETHICS AND DISSEMINATION

The project has been approved by the Regional Ethics Committee and the Danish Data Protection Agency.

TRIAL REGISTRATION NUMBER

NCT02581800.

[Not Available]

Public health concerns associated with infant feeding have prompted the need to increase breastfeeding rates. To do so, initiatives have been implemented and proven successful in raising breastfeeding initiation rates. However, continued breastfeeding according to official recommendations remains scarce and many mothers feel emotionally burdened by their experience. This commentary thus raises the question about the effects of breastfeeding promotion on the well-being of families and takes a critical look at the strategies being put in place. A conceptual model as well as empirical evidences help better understand the balancing act underlying the decisions related to infant feeding and the risks of promoting breastfeeding without providing adequate support. The context of the transition towards a breastfeeding culture requires setting up services adapted to parents' current needs. An approach taking into account their satisfaction and reinforcing their self-efficacy must be adopted, namely through a more thorough implementation of the Baby-Friendly Initiative. Allocating resources allowing for proper enactment of this approach is essential to increase breastfeeding while ensuring families' well-being.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Understanding process and context in breastfeeding support interventions: The potential of qualitative research

Considerable effort has been made in recent years to gain a better understanding of the effectiveness of different interventions for supporting breastfeeding. However, research has tended to focus primarily on measuring outcomes and has paid comparatively little attention to the relational, organizational, and wider contextual processes that may impact delivery of an intervention. Supporting a woman with breastfeeding is an interpersonal encounter that may play out differently in different contexts, despite the apparently consistent aims and structure of an intervention. We consider the limitations of randomized controlled trials for building understanding of the ways in which different components of an intervention may impact breastfeeding women and how the messages conveyed through interactions with breastfeeding supporters might be received. We argue that qualitative methods are ideally suited to understanding psychosocial processes within breastfeeding interventions and have been underused. After briefly reviewing qualitative research to date into experiences of receiving and delivering breastfeeding support, we discuss the potential of theoretically informed qualitative methodologies to provide fuller understanding of intervention processes by focusing on three examples: phenomenology, ethnography, and discourse analysis. The paper concludes by noting some of the epistemological differences between the broadly positivist approach of trials and qualitative methodologies, and we suggest there is a need for further dialog as to how researchers might bridge these differences in order to develop a fuller and more holistic understanding of how best to support breastfeeding women.

Infant food applications of complex carbohydrates: Structure, synthesis, and function

Professional health bodies such as the World Health Organization (WHO), the American Academy of Pediatrics (AAP), and the U.S. Department of Health and Human Services (HHS) recommend breast milk as the sole source of food during the first year of life. This position recognizes human milk as being uniquely suited for infant nutrition. Nonetheless, most neonates in the West are fed alternatives by 6 months of age. Although inferior to human milk in most aspects, infant formulas are able to promote effective growth and development. However, while breast-fed infants feature a microbiota dominated by bifidobacteria, the bacterial flora of formula-fed infants is usually heterogeneous with comparatively lower levels of bifidobacteria. Thus, the objective of any infant food manufacturer is to prepare a product that results in a formula-fed infant developing a breast-fed infant-like microbiota. The goal of this focused review is to discuss the structure, synthesis, and function of carbohydrate additives that play a role in governing the composition of the infant microbiome and have other health benefits.

Breastfeeding booklet and proactive phone calls for increasing exclusive breastfeeding rates: RCT protocol

Breastfeeding is associated with infant and maternal health benefits and considerable potential savings to health services. Despite this, only 37% of infants globally are exclusively breastfed for 6 months. Interventions are needed to improve breastfeeding rates. The aim of this study is to determine whether written breastfeeding information in pregnancy and proactive breastfeeding-focused support phone calls, provided by a health professional educated in breastfeeding management, increase exclusive breastfeeding rates at 3 months compared with general birth-related information with proactive support calls or standard care. This is a single-centre, randomised, controlled, three-arm, superiority study with blind outcome assessment. Eligible participants will include primigravidae with singleton pregnancies who speak Croatian, attending six primary care obstetric practices. We estimate a total sample size of 459, with computer generated stratified randomisation of 153 women per arm. Participants in the intervention and active control groups will receive booklets in pregnancy, phone calls 2 weeks later, and 2, 6 and 10 weeks after birth. The primary outcome will be the proportion of women exclusively breastfeeding at 3 months. Secondary outcomes will compare: infant feeding practices and attitudes, social support, breastfeeding difficulties, breastfeeding self efficacy and utilisation of breastfeeding support services. Follow-up at 6 months will compare exclusive and any breastfeeding and utilised support services. Analysis will be by intention to treat. This trial will contribute to future evidence syntheses identifying the most effective forms of breastfeeding support.

The impact of breastfeeding peer support for mothers aged under 25: a time series analysis

Breastfeeding has known positive health benefits for babies and mothers, yet the UK has one of the lowest breastfeeding initiation rates in Europe. Despite national guidance that recommends provision of breastfeeding peer support, there is conflicting evidence regarding its effectiveness, especially in high-income countries, and a lack of evidence among young mothers. This study evaluates the effectiveness of a breastfeeding peer support service (BPSS) in one UK city in increasing breastfeeding initiation and duration in young mothers. Routinely collected data were obtained on feeding method at birth, 2 and 6 weeks for all 5790 women aged <25 registered with a local general practitioner and who gave birth from April 2009 to September 2013. Segmented regression was used to quantify the impact of the introduction of the BPSS in September 2012 on the prevalence of breastfeeding at birth, 2 and 6 weeks, accounting for underlying trends. Results showed that breastfeeding prevalence at birth and 2 weeks began to increase month-on-month after the introduction of the BPSS, where previous figures had been static; prevalence at birth increased by 0.55 percentage points per month (95% CI 0.10-1.00, P = 0.018) and at 2 weeks by 0.50 percentage points (95% CI 0.15-0.86, P = 0.007). There was no change from an underlying marginally increasing trend in prevalence at 6 weeks. In conclusion, our findings suggest that a one-to-one BPSS provided by paid peer supporters and targeted at young mothers in the antenatal and post-natal periods may be beneficial in increasing breastfeeding initiation and prevalence at 2 weeks.

A Cluster Randomized Trial of Tailored Breastfeeding Support for Women with Gestational Diabetes

BACKGROUND

Women with gestational diabetes mellitus (GDM) and their infants are at increased risk of developing metabolic disease; however, longer breastfeeding is associated with a reduction in these risks. We tested an intervention to increase breastfeeding duration among women with GDM.

MATERIALS AND METHODS

We conducted a cluster randomized trial to determine the efficacy of a breastfeeding education and support program for women with GDM. Women were enrolled between 22 and 36 weeks of pregnancy and cluster randomized to an experimental lifestyle intervention or wait-list control group. Breastfeeding duration and intensity were prespecified secondary outcomes of the trial. Duration of exclusive and any breastfeeding was assessed at 6 weeks and at 4, 7, and 10 months postpartum. We quantified differences in breastfeeding rates using Kaplan-Meier estimates, log-rank tests, and Cox regression models.

RESULTS

We enrolled 100 women, of whom 52% were African American, 31% non-Hispanic white, 11% Hispanic, 9% American Indian or Alaskan Native, 2% Asian, 2% other, and 4% more than one race. In models accounting for within-cluster correlation and adjusted for study site, breastfeeding intention, and African American race, women allocated to the intervention group were less likely to stop breastfeeding (adjusted hazard ratio [HR] 0.40, 95% confidence interval [CI] 0.21-0.74) or to introduce formula (adjusted HR 0.50, 95% CI 0.34-0.72).

CONCLUSION

Our results suggest that targeted breastfeeding education for women with GDM is feasible and efficacious.

CLINICAL TRIALS REGISTRATION

http://clinicaltrials.gov/ct2/show/NCT01809431.

Breastfeeding Support in the Early Postpartum: Content of Home Visits in the SILC Trial

BACKGROUND

The Supporting breastfeeding In Local Communities (SILC) cluster randomized controlled trial evaluated whether a home visit focussed on infant feeding early in the postpartum period increased the percentage of infants breastfeeding at 4 months in low socioeconomic areas of Victoria, Australia. The visits were offered to women identified as at risk of early breastfeeding cessation after discharge home with a new baby. This paper describes the content of the home visits.

METHODS

SILC visited 1,043 women from September 2012 to March 2013, and completed a data sheet for each visit documenting topics discussed, as well as what support and resources were offered. Frequencies and percentages are presented.

RESULTS

Home visits most commonly included the provision of reassurance to women (91%). Topics discussed included general breastfeeding information (83%), supply and demand (83%), positioning (79%), and feeding frequency (78%). Newborn feeding/behavior (57%), expression of breastmilk (54%), nipple pain (41%), low breastmilk supply (41%), and the use of nipple shields (18%) were also prominent topics. The issues and support needs of women were similar across locations (rural, regional or metropolitan) and regardless of maternal parity or age. There was some variation in the resources suggested in different localities.

CONCLUSIONS

New mothers require help and reassurance independent of whether this is their first or subsequent child, reinforcing the need for support, breastfeeding information, and education about normal neonatal behavior. Key aspects of support are reassurance, normalization of infant behavior, and education.

Empowering women to breastfeed: Does the Baby Friendly Initiative make a difference?

The Baby-Friendly Hospital Initiative (BFI) is currently presented worldwide as the gold standard model of care for promoting and supporting breastfeeding. However, there is a lack of understanding about the ways in which health services, including the BFI, address the cultural change from a disembodied practice (formula feeding) to an embodied one (breastfeeding) in contexts where formula feeding is the norm. We used a qualitative case study methodology to compare the embodied experience of breastfeeding and the maternal experience of breastfeeding promotion and support services between mothers receiving care from institutions with low and high levels of BFI implementation in Québec, Canada. A total of 11 focus groups were conducted with mothers from six institutions-three with high and three with low levels of BFI implementation. We found the flexible approach to breastfeeding duration, characteristic of BFI services in our study, helped to avoid maternal guilt and shame; the shift to focusing on potential barriers and strategies for overcoming them empowered women to negotiate changes in infant feeding with others and self by addressing the embodied experience of a practice that may not feel natural at the beginning. Findings have implications for the concept of habitus and the construction of the breastfeeding body; we suggest that habitus can change if agents are provided with discursive tools to negotiate this embodied change. Implications for BFI services include the need to implement the 10 steps in a flexible, family-centred way that focuses on empowering women rather than simply reaching outcomes.