Provider encouragement of breast-feeding: evidence from a national survey

Is there room for mothers' agency in the choice to breastfeed? A qualitative analysis of mothers' views on messages promoting breastfeeding in Quebec

INTRODUCTION

This exploratory cross-sectional study focuses on the experiences of mothers regarding health messages promoting breastfeeding. The objective is to describe the content and context in which messages are conveyed.

METHODS

A total of 944 new mothers responded to a questionnaire (15-31 January 2021) on their perception of health messages promoting breastfeeding and their feeling of agreement towards these messages, their intention to breastfeed, incentives received, and their relationship with the professionals. Frequencies were carried out for all non-textual data and textual data were analyzed using content thematic analysis. The recruitment was made through social media and snowball effect.

RESULTS

Most of the respondents reported wanting to breastfeed; 91% breastfed their child, 80.8% participants agreed with the messages they received, and 67.9% of respondents strongly agreeing that breastfeeding was the best choice for their child. Moreover, the content of the messages could sometimes be judgmental and coercive, leading to emotions such as guilt. Sixty-two women also reported a lack of support when they expressed their desire or their need to feed their baby in other ways (e.g. breastmilk with bottles or formulas).

CONCLUSIONS

The perceived issue of breastfeeding messages was not the content itself, but the way in which information was conveyed. Failure to take mothers' difficulties into account and failure to present alternatives to breastfeeding were seen as major issues by women. This study highlights the importance of rethinking the way in which information is provided by professionals, in order to reinforce the autonomy of new mothers regarding the feeding of their child.

Sequential interventions to maintain the safety and service provisions of human milk banking in India: keeping up with the call to action in response to the COVID-19 pandemic

BACKGROUND

WHO recommends donor milk as the next best choice if Mothers' own milk (MOM) is unavailable. At our milk bank, during the COVID 19 pandemic, we observed a steep decline in the collection of donor milk, while Pasteurised Donor human milk (PDHM) demand increased. This called for active intervention.

METHODS

We employed the quasi-experimental quality improvement initiative. During September 2020 (baseline period) the team members identified modifiable bottlenecks and suggested interventions (using WhatsApp to increase follow up, telehealth and digital tools) which were implemented in October 2020 and the impact was evaluated till March 2021. The SMART aim was "to meet the demand (estimated as 15,000 ml/month) of donor milk for adjoining 80-bedded NICU". Process measures were; daily amount of donor milk collected, pasteurized donor milk disbursed to NICU, number of donors and frequency of donations. The balancing measure was that the collection of donor milk should not undermine the provision of freshly expressed MOM for babies.

RESULTS

Collection of donor milk increased by 180% from baseline during the Intervention phase. This was sustained throughout the sustenance phase (November 2020 and March 2021) with an average monthly collection of 16,500 ml. Strikingly, the increased follow-up of mothers with emphasis on MOM decreased the NICU's donor milk requirement from 13,300 ml (baseline) to 12,500 ml (intervention) to 8,300 ml (sustenance). Monitoring of daily MOM used in the NICU revealed a 32% surge from 20,000 ml (baseline) to 27,000 ml (intervention) sustained at 25,000 ml per month.

CONCLUSION

By improving the provisions of human milk banks, near-exclusive human milk feeding can be ensured even during the pandemic time.

Effect of lullaby on volume, fat, total protein and albumin concentration of breast milk in premature infants' mothers admitted to NICU: a randomized controlled trial

Background

Listening to music can reduce or manage stress, fatigue, and accompanying symptoms in mothers. Music increases oxytocin secretion which affects breast milk. This study aimed to examine the effect of lullaby on volume, fat, total protein and albumin concentration of breast milk in mothers of premature infants admitted to the NICU.

Methods

This clinical trial was performed on 100 primiparous mothers whose premature infants were hospitalized in the NICU of Ayatollah Rouhani Hospital from January 2020 to December 2020. Using block randomization method, the participants were divided into three groups: control (A), playing lullaby for mother (B) and playing lullaby for a mother while holding a photo of her own baby (C). The mothers of the intervention groups listened to lullabies through headphones for 30 minutes every morning for 6 days. On the first and the sixth day of birth, the volume of breast milk (ml) and two milliliters of breast milk samples of all three groups were measured and compared in terms of fat, albumin concentration and total protein (mg/DL). ANOVA, Paired T-Test and ANCOVA model (the included variables were: basic value of dependent variable, group type, Maternal age, Birth weight, Gestational age and Maternal weight) was used for analytical statistics.

Results

The difference between the mean compositions of breast milk before and after the intervention in three groups of A, B and C: in terms of the breast milk volume were 66.33 ± 4.80, 71.30 ± 4.18 and 75.91 ± 6.80 ml; in terms of triglyceride level was 177.84 ± 50.57, 210.72 ± 34.55 and 224.17 ± 12.97 mg/DL, cholesterol level was 14.57 ± 3.70, 21.96 ± 3.82 and 26.26 ± 5.16 mg/DL, albumin concentration was 0.90 ± 0.30, 1.22 ± 0.19 and 1.46 ± 0.28 mg/DL and total protein level was 1.61 ± 0.61, 2.20 ± 0.57 and 2.72 ± 0.30 mg/DL. Finally, the results of ANCOVA analysis for the effects of the intervention, taking into account the baseline values, showed that the intervention was effective and had the greatest effect on cholesterol levels.

Conclusion

In this small trial, there was a statistically significant association between trial arm and biochemical composition of breastmilk though further studies are needed to see if these changes result in meaningful clinical outcomes to the infant.

Trial registration

IRCT, IRCT20191114045439N1. Registered 14 January 2020- prospective, https://en.irct.ir/trial/43671

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00511-7.

Interventions supporting medical practitioners in the provision of lactation care: A systematic review and narrative analysis

Most children globally are not breastfed to recommendations. Medical practitioners are frequently visited in the first 6 months post‐partum, and the interaction at such visits significantly influences subsequent infant feeding decisions. Medical practitioners report that clinical practice in lactation is often disproportionately reliant on personal experience. This systematic review synthesises the literature on lactation health interventions used to support clinical decision making by medical practitioners. MEDLINE, Embase, PsycINFO, Scopus and Cochrane Library databases were searched for peer‐reviewed empirical studies published after 2000. Two reviewers independently screened and then assessed full‐text articles against inclusion criteria. Quality of reporting and risk of bias were independently assessed using three validated tools. No conclusions can be made regarding the success or failure of implementation strategies used or the outcomes of putting them into effect due to problems with study methodology, intervention reporting and risk of bias. Good‐quality research, which follows proven implementation frameworks, is needed to guide and sustain the incorporation of evidence‐based decision support into medical practitioners' care of breastfeeding mothers and infants.

A Qualitative Exploration of the Determinants of Exclusive Breastfeeding (EBF) Practices in Wajir County, Kenya

Background

The World Health Organization recommends exclusive breastfeeding for the first six months of life. A qualitative study was conducted to assess the factors that influence the practice of exclusive breastfeeding amongst mothers attending Wajir County Hospital, Kenya.

Method

This study was part of a cross-sectional study to compare the exclusive breastfeeding rates amongst primiparous and multiparous mothers with infants under 6 months old attending Wajir County Hospital. Focus group discussions and key informant interviews were conducted to collect information on exclusive breastfeeding and related factors. Four focus group discussions were conducted with mothers who exclusively breastfed and the same number with mothers who did not exclusively breastfeed their babies. Key informant interviews were conducted with nine healthcare providers. The data were transcribed, and a content analysis identified common themes and inferences.

Results

The exclusive breastfeeding rate among the mothers in the larger study was 45.5%. There was no disparity between the practice of exclusive breastfeeding between primiparous and multiparous mothers. Despite the high knowledge and positive attitudes towards exclusive breastfeeding of most mothers, the practice of exclusive breastfeeding was unsatisfactory. The major hindrances identified were cultural barriers propagated by mothers-in-law and traditional birth attendants; the belief that babies cannot live without water; and a few unsupportive health workers. The uptake of exclusive breastfeeding was enhanced by Islamic teaching on breastfeeding, education from a few supportive healthcare providers; support from husbands; and positive deviance among some lactating mothers who practiced exclusive breastfeeding.

Conclusions

Deeply rooted cultural factors were the major hindrance to the practice of exclusive breastfeeding. Most of the mothers did not practice exclusive breastfeeding, despite the majority being knowledgeable and having positive attitudes towards the practice. The influence of mother-in-law’s and traditional birth assistants were major barriers. Strengthening the Community Health Strategy through training traditional birth attendants on Infant Young Child Nutrition practices, designing mechanisms linking traditional birth assistants to existing health facilities for support, and capacity building and monitoring is critical in promoting exclusive breastfeeding. Behavior change and communication through multiple channels within the community should be utilized to maximize promotion of exclusive breastfeeding among all stakeholders.

Racial and Ethnic Disparities in Human Milk Intake at Neonatal Intensive Care Unit Discharge among Very Low Birth Weight Infants in California

OBJECTIVES

To examine how infant and maternal factors, hospital factors, and neighborhood-level factors impact or modify racial/ethnic disparities in human milk intake at hospital discharge among very low birth weight infants.

STUDY DESIGN

We studied 14 422 infants from 119 California Perinatal Quality Care Collaborative neonatal intensive care units born from 2008 to 2011. Maternal addresses were linked to 2010 census tract data, representing neighborhoods. We tested for associations with receiving no human milk at discharge, using multilevel cross-classified models.

RESULTS

Compared with non-Hispanic whites, the adjusted odds of no human milk at discharge was higher among non-Hispanic blacks (aOR 1.33 [1.16-1.53]) and lower among Hispanics (aOR 0.83 [0.74-0.93]). Compared with infants of more educated white mothers, infants of less educated white, black, and Asian mothers had higher odds of no human milk at discharge, and infants of Hispanic mothers of all educational levels had similar odds as infants of more educated white mothers. Country of birth and neighborhood socioeconomic was also associated with disparities in human milk intake at discharge.

CONCLUSIONS

Non-Hispanic blacks had the highest and Hispanic infants the lowest odds of no human milk at discharge. Maternal education and country of birth were the biggest drivers of disparities in human milk intake, suggesting the need for targeted approaches of breastfeeding support.

Lactation Education for Resident Obstetricians: Promoting Breastfeeding Advocates for the Future

Obstetrics and gynecology residency training programs are historically lacking in breastfeeding education and advocacy. Healthy People 2020 supports interventions that promote breastfeeding as a primary care strategy with significant health benefits to the newborn and woman. Midwives are well poised to engage obstetrics and gynecology residents in lactation education. A few educational interventions have been described in the literature to increase knowledge, confidence, and behavior related to lactation among residents. This article describes a breastfeeding education curriculum developed by midwifery faculty at Boston University School of Medicine. The project included 3 lectures and a simulation center workshop covering topics including lactogenesis, prenatal, intrapartum, and postpartum interventions that promote or limit lactation, hands-on latch assistance, hand expression, use of breast pumps and storage of human milk, and common disorders of lactation. Postintervention evaluations demonstrated improvements in knowledge and confidence. Providing breastfeeding education to resident physicians may be an intervention to promote patient breastfeeding education and support and close the gap of disparities in breastfeeding rates.

A Pilot Study to Assess Breastfeeding Knowledge, Attitudes, and Perceptions of Individuals Who Work in Perinatal Opioid Use Disorder Treatment Settings

Background: Although current evidence suggests that there are unique benefits of breastfeeding for mothers receiving comprehensive treatment, including counseling and pharmacotherapy, for opioid use disorder (OUD) and their infants, breastfeeding rates in this population are low. Support and counseling about breastfeeding are key predictors of infant feeding behaviors. Thus, identifying knowledge and attitudes regarding breastfeeding of individuals who work in OUD treatment facilities could offer insight into targets for breastfeeding-promotion interventions in such settings. Materials and Methods: Individuals who work at two urban perinatal OUD treatment centers were e-mailed a link to complete a questionnaire electronically. Breastfeeding knowledge, attitudes, and perceptions of those who completed the questionnaire were described using descriptive statistics. Results: Among the 24 survey respondents, most correctly identified the health benefits of breastfeeding for infants with neonatal abstinence syndrome, whereas less than half correctly identified the health benefits of breastfeeding for all infants. Only 16% reported receiving work-related breastfeeding education. The leading perceived breastfeeding challenges for women in treatment for OUD were (1) concern with transfer of medication (e.g., methadone) through breast milk, (2) daily commutes for treatment, and (3) beliefs that formula is better than breastfeeding. Conclusions: Professionals who work in perinatal OUD treatment centers could benefit from education regarding breastfeeding in mothers in treatment for OUD.

Educational Objectives and Skills for the Physician with Respect to Breastfeeding, Revised 2018

The Academy of Breastfeeding Medicine is a worldwide organization of physicians dedicated to the promotion, protection and support of breastfeeding and human lactation. Our mission is to unite into one association members of the various medical specialties with this common purpose.

"I Felt Like I Was a Part of Trying to Keep My Baby Alive": Perspectives of Hispanic and Non-Hispanic Black Mothers in Providing Milk for Their Very Preterm Infants

Background: Compared with non-Hispanic white, Hispanic and non-Hispanic black mothers of very preterm infants are less likely to provide mother's milk at the point of hospital discharge; the perspectives of these mothers are poorly understood. Objectives: To examine the perceived barriers and facilitators of providing milk for very preterm infants during the hospitalization among Hispanic and non-Hispanic black mothers. Materials and Methods: We conducted 23 in-depth, semistructured interviews of English and Spanish-speaking Hispanic and non-Hispanic black mothers that initiated milk production for their very preterm infants, ≤1,750 g at birth. Following thematic saturation, results were validated through expert triangulation and member checking. Results: Twelve mothers were Hispanic, where three were English speaking and nine were Spanish speaking. Eleven mothers were non-Hispanic black and English speaking. We found themes pertaining to general experiences: (1) Breastfeeding intent impacts mothers' success in providing milk throughout the hospitalization; (2) Pumping milk for a hospitalized infant is repetitive, exhausting, and does not elicit the same emotional connection as breastfeeding; (3) Hospital providers are an important source of support, when sufficient time is spent to address ongoing issues; (4) Providing milk creates a unique sense of purpose when mothers otherwise feel a lack of control; and we found themes pertaining to the experiences of Hispanic and non-Hispanic black mothers: (1) Breastfeeding as a cultural norm influences mothers' intent to initiate and continue breastfeeding; (2) Hospital staff are viewed as more supportive when interactions and treatment are perceived as racially/ethnically unbiased and (3) when communication occurs in the primary language; and (4) Mother-infant separation creates logistical challenges that negatively impact ongoing milk production. Conclusions: While providing milk for a hospitalized very preterm infant is exhausting, and logistically challenging, Hispanic and non-Hispanic black mothers are inspired to do so because of their intent to breastfeed, support from hospital providers, and feelings of purpose.

Breast is BEST: Increasing Health-Care Provider Knowledge and Confidence

BACKGROUND

Breastfeeding is recognized as the ideal source of nutrition for infants. However, several barriers to successful breastfeeding have been identified. Possibly one of the most significant barriers is the lack of health-care provider-related support and promotion of breastfeeding.

OBJECTIVE

The purpose of this study was to recognize the barriers to breastfeeding, ways health-care providers can assist patients in overcoming those barriers, and increase breastfeeding knowledge and confidence of health-care providers to better promote and manage breastfeeding clients.

METHODS

Study participants included: physicians, advanced practice nurses, and nurses. The American Academy of Pediatrics (AAP) Breastfeeding Residency Curriculum was utilized in the study, and participants were also educated on and encouraged to apply ACOG's Perinatal Practice Guidelines.

RESULTS

There was an overall increase of 19.2% in health-care provider knowledge scores and a 23% increase in confidence scores. There was also a 15.6% increase in documentation of early prenatal breastfeeding counseling.

CONCLUSIONS

The results and significance of the study provide evidence that once health-care providers are knowledgeable and confident in promoting breastfeeding, clients will be better equipped to successfully breastfeed.

IMPLICATIONS FOR NURSING

Breastfeeding success rates among mothers can be greatly improved through active support from health-care providers.

Australian general practitioners' knowledge, attitudes and practices towards breastfeeding

The aim of this study was to explore the knowledge, attitudes and practices of established general practitioners (GPs) in relation to breastfeeding. 10 GPs in the Australian Nepean Blue Mountains Health District were interviewed and the interviews transcribed and analyzed thematically. Emergent themes from each interview were identified and then compared between and across the 10 interviews. Five themes emerged following the analysis: breastfeeding knowledge and training; attitudes towards breastfeeding; GPs' role in relation to breast feeding; GPs' practices; influence of male gender. All the GPs interviewed had positive attitudes towards breastfeeding, however they were often lacking in knowledge and conviction to be able to provide strong support to women during their breastfeeding journey. Some reported ambivalence in their encouragement of breastfeeding due to their desire to maintain a good relationship with women who chose not to feed this way. Nine of the GPs had little or no formal breastfeeding training and relied mainly on personal experience. Their clinics did not provide formal breastfeeding support including a written breastfeeding friendly policy and most GPs were not proactive in creating such an environment. We hope that the results from this study will assist in developing breastfeeding policies and professional education to support GPs in this role.

Important Role of Medical Training Curriculum to Promote the Rate of Human Milk Feeding

The rate of human milk feeding has been decreasing despite the diverse efforts of many physicians and nurses, as well as numerous professional organizations and various international health institutions. The number of physicians and nurses who can provide proper guidance for human milk feeding and offer appropriate knowledge and techniques to allow the most beneficial and convenient manner of breastfeeding is quite deficient. It is suggested that physicians and nurses be trained to teach and educate about the medical importance of human milk feeding to lactating mothers. This can be accomplished through systemic changes in medical education and clinical practice. However, the curricula of medical schools in Korea do not provide enough education and training to effect an increase in human milk feeding. The author strongly recommends that the educational objectives for medical schools and resident training offer more education and training concerning so that they are well aware of breastfeeding basics and techniques, and have ability to solve lactation-associated clinical problems.

The Influence of Smoking on Breast feeding Among Women Who Quit Smoking During Pregnancy

INTRODUCTION

Understanding factors related to breast-feeding intention, initiation, duration, and weaning among women who quit smoking as a result of pregnancy may inform interventions to increase breast-feeding rates among women who smoke.

METHODS

Women (N = 300) who quit smoking as a result of pregnancy and enrolled in a postpartum relapse prevention trial were interviewed about breast-feeding intention prior to delivery. Breast-feeding initiation, duration, reasons for weaning, and relapse to smoking were assessed at 12-weeks postpartum.

RESULTS

The majority of pregnant former smokers intended to breastfeed (68%), and actual rates of breast feeding were higher (74%). Among women who initiated breast feeding, weaning before 2 months was common (41%). For most women (69%), smoking had no effect on breast-feeding decisions. Among the 31% of women who reported that smoking influenced their feeding decisions, 83% indicated that they did not smoke or decreased smoking frequency in order to breastfeed while 17% did not breastfeed or quit breast feeding in order to smoke. Women who decided to forgo breast feeding to smoke were significantly more likely to have a high school education or less (p < .001) and to be African American (p < .0001) than those who had other reasons not to breastfeed.

CONCLUSIONS

Most women who quit smoking during pregnancy initiate breast feeding, and the majority report smoking did not influence feeding decisions. Importantly, among women for whom smoking did influence feeding decisions, most reported changing smoking behavior to enable breast feeding. Interventions to increase breast-feeding initiation and duration may decrease postpartum relapse and improve maternal and infant health.

IMPLICATIONS

This study extends the literature on women's perception of the influence of smoking on breast feeding by assessing breast-feeding intent, initiation, duration, and reasons for weaning longitudinally among women who quit smoking as a result of pregnancy. The results support a need for additional research to determine the effectiveness of breast feeding supports as a component of interventions to reduce postpartum smoking relapse.

Medical Directors of Breastfeeding Programs at Academic Medical Centers: Duties and Challenges

INTRODUCTION

An emerging trend in Academic Medical Centers (AMCs) is to coordinate breastfeeding care, research, and trainee education through "medical director" positions. Little is known about their duties, supports, and challenges.

OBJECTIVE

To determine the duties and challenges of directors of breastfeeding medicine in AMCs.

METHODS

A survey was distributed four times over a 3-month period to three listservs with a total of 860 members. Physicians directing breastfeeding programs or services at AMCs were included. Participants were asked about details of their employment, time distribution of the position, their role in education, billing practices, and major hurdles.

RESULTS

Thirty-two physicians responded to the survey: 25 from the United States, and seven international. Only 22% of respondents had formal job descriptions and only 31% reported being paid for their breastfeeding work. Most positions were created in the past 10 years (75%), were housed in Departments of Pediatrics (75%), and provided clinical services for breastfeeding in inpatient and outpatient settings. Ninety-one percent of respondents educated trainees and provided oversight of lactation consultants. Major hurdles included difficulties with billing for services, lack of protected time and personal reimbursement, lack of formal structure and job descriptions, and lack of buy-in at the institutional and sometimes governmental levels.

CONCLUSIONS

Medical Directors of Breastfeeding Services may be increasingly prevalent in AMCs and are engaged in inpatient and outpatient clinical work, trainee education, and lactation consultant oversight. Both financial and structural hurdles were reported by those holding these positions.

Reflections of Black Women Who Choose to Breastfeed: Influences, Challenges and Supports

OBJECTIVES

Black women continue to have the lowest rates of breastfeeding. Of those who choose to breastfeed up to half cease nursing within the first few days or months postpartum. This study identified factors that influence and challenge Black women who choose to breastfeed, and supportive strategies that facilitate successful breastfeeding experiences.

METHODS

Four focus groups were conducted in 2013 with 16 self-identified Black women aged 21-46 (M = 31.35 years), with 11-18 (M = 14.94) years of education, and were either pregnant or had given birth to an infant within the prior 5 years (range of pregnancies 1-7; M = 2.44). A standard set of questions guided discussions. Data saturation occurred after three groups. All discussions were audiotaped and transcribed. Qualitative methods were used to identify categories and subthemes. Reviewers met periodically to resolve ambiguities and coding discrepancies. Member checking was conducted.

RESULTS

Four major categories emerged: Balancing the influences: People, myths, and technology; Being in the know; Critical periods; and, Supportive Transitions. Most women experienced little help with breastfeeding from health providers or systems. More influential was the interplay of family members,myths and the internet "as my friend". Role models and personalized support were noted as important but lacking among Black women. Patient profiling, experienced by some of the women, impacted breastfeeding choices.

CONCLUSIONS

Black women such as our participants are critical partners as we develop systems of care to decrease disparities and increase Black women's successes in breastfeeding. Findings underscore the importance of having diverse, readily available, user-friendly, culturally sensitive options for Black women who choose to breastfeed.

Impact of an Educational Intervention on Breastfeeding Counseling Behavior of OB/GYN Residents

BACKGROUND

Breastfeeding counseling has been shown to increase the initiation and duration of breastfeeding. The American Congress of Obstetricians and Gynecologists calls for all healthcare workers to educate and encourage women to choose breastfeeding. Despite these recommendations, the reported incidence of prenatal breastfeeding discussions varies widely. Lack of physician education has been speculated to be one of the contributing factors.

OBJECTIVE

To assess the impact of a breastfeeding educational intervention on the knowledge and counseling behaviors of OB/GYN resident physicians.

STUDY DESIGN

Resident physicians in a university-based OB/GYN program were given two lectures on the benefits of breastfeeding and common lactation issues. The residents completed a knowledge test before and after the educational intervention. Resident behaviors were assessed through patient surveys after the initial prenatal visit (n = 79 and n = 81 before and after the educational sessions, respectively). The responses were then analyzed by comparing binomial proportions before and after the intervention.

RESULTS

Patient surveys showed that the educational intervention resulted in statistically significant increases in the rate of general discussion from 62% to 79% (p = 0.017) and discussion of breast changes that occur during pregnancy from 41% to 57% (p = 0.037). There was a positive trend for breastfeeding promotion from 58% to 72% (p = 0.08) and for breast exams from 42% to 56% (p = 0.08). The median score on resident's knowledge assessment test increased marginally from 20 to 20.5 out of 28 questions after the educational intervention.

CONCLUSION

Our study showed that a brief educational intervention on breastfeeding had a meaningful impact on OB/GYN resident physician counseling behavior.

Breastfeeding Knowledge and Intent to Breastfeed

Objectives: Identify, synthesize, and critically review research on common barriers to successful breastfeeding and ways healthcare providers can assist patients in overcoming the barriers.

Methods: A search of databases and citations for evidence-based research published from 2001 to 2015 was conducted. Forty-nine articles were reviewed with 22 articles being discussed.

Results: Three major themes were identified: (a) characteristics of breastfeeding education in the prenatal setting, (b) primary care interventions to promote breastfeeding, and (c) healthcare provider education on breastfeeding.

Conclusions: Findings of this review collectively suggest the need to increase breastfeeding rates among women in the United States. To achieve this, there is great significance placed on healthcare providers implementing interventions to promote breastfeeding, which subsequently requires improving healthcare provider knowledge and self-confidence on breastfeeding.

ABM Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Setting, Revision 2015

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Differences in breastfeeding initiation by maternal diabetes status and race, Ohio 2006-2011

To examine breastfeeding trends at hospital discharge from 2006 to 2011 by diabetes status and to determine associations between diabetes status and breastfeeding. Ohio Vital Statistics birth certificate data from 2006 to 2011, including all singleton births to Ohio resident mothers of reproductive age (16-44 years), were used to analyze trends in breastfeeding by diabetes status [prepregnancy diabetes (PDM), gestational diabetes (GDM)]. Logistic regression was used to evaluate the relationship between breastfeeding at discharge and diabetes type. Because a significant interaction between diabetes status and race existed, the model was stratified by race. This study includes 803,222 Ohio births from 2006 to 2011. A significant, increasing trend of breastfeeding (P < .0001) existed among women with GDM (63-70 %) and no DM (62-69 %). GDM breastfeeding rates were frequently the highest, while women with PDM often had the lowest breastfeeding initiation rates, regardless of sample characteristic. In models stratified by race, Black women were often the least likely to breastfeed, but overweight or obese and diabetes were not associated with a decreased likelihood of breastfeeding as they were among White women. While breastfeeding rates have increased in Ohio, they have still not reached the Healthy People 2020 goals. Our study shows that breastfeeding initiation rates vary by diabetes status and race. This study can aid in tailoring breastfeeding intervention and counseling efforts to women least likely to initiate breastfeeding, such as women with pregnancy diabetes, to improve the health of both infants and mothers.

Maternal Report of Advice Received for Infant Care

BACKGROUND

Advice has been associated with increased adherence to recommended infant care practices, and may represent a modifiable factor to promote infant health.

METHODS

A stratified, 2-stage, clustered design, with oversampling of black and Hispanic mothers, was used to survey a nationally representative sample of 1031 mothers of infants aged 2 to 6 months. Survey questions assessed advice received from doctors, birth hospital nurses, family, and media regarding immunization, breastfeeding, sleep position, sleep location, and pacifier use. Weighted frequencies of no advice and advice consistent with recommendations were calculated to obtain prevalence estimates. Multivariable logistic regression analyses were performed to assess factors associated with receipt of recommendation consistent advice.

RESULTS

Although doctors were the most prevalent source of reported advice, ∼20% of mothers reported no doctor advice for breastfeeding or sleep position, and more than 50% reported no advice regarding sleep location or pacifier use. Reported advice from nurses was generally similar to doctors. The prevalence of any advice from family or media was 20% to 56% for nearly all care practices, and advice given was often inconsistent with recommendations. The only factors that were consistently associated with receipt of recommendation consistent advice were race/ethnicity and parity; black and Hispanic mothers and first-time mothers were more likely to report recommendation consistent advice.

CONCLUSIONS

Mothers commonly report receiving either no advice or recommendation inconsistent advice from each of the 4 sources we studied. By identifying care practices with low prevalence of recommendation consistent advice from potentially important advisors, our findings highlight opportunities for future intervention.

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.

Using the socio-ecological framework to determine breastfeeding obstacles in a low-income population in Tijuana, Mexico: healthcare services

BACKGROUND

In Mexico, breastfeeding rates are one of the lowest of Latin America, with 14.4% of infants under 6 months being exclusively breastfed. Previous studies indicate that lack of support from healthcare services is a serious obstacle to breastfeeding mothers in Mexico. Our objective was to identify the main obstacles to breastfeeding presented by the healthcare services in a low-income population in Tijuana, Mexico.

MATERIALS AND METHODS

We used a socio-ecological framework to determine factors affecting breastfeeding practices. In four low-income communities in Tijuana we conducted focus groups and interviews with mothers, fathers, grandparents, and key informants. Interview notes and focus group transcripts were then studied in-depth independently by three researchers. The primary analytic technique was constant comparison.

RESULTS

One hundred twenty-nine subjects participated in this study: six focus groups (n=53) and 51 interviews among mothers, fathers, and grandparents, as well as 25 interviews among key informants. Main healthcare service obstacles to breastfeeding were erroneous information, lack of training and supervision, negative attitudes, miscommunication between healthcare providers (HCPs) and patients, detrimental medical practices such as giving free formula at hospitals, and the conflict of interest between the infant food industry and the HCPs.

CONCLUSIONS

This study showed that women in low-income communities in Tijuana face multiple obstacles to breastfeeding presented by healthcare services. In order to increase breastfeeding rates, institutional and structural changes are required.

Characteristics of breastfeeding discussions at the initial prenatal visit

OBJECTIVE

To describe the observed characteristics of first prenatal visit breastfeeding discussions between obstetric providers and their pregnant patients.

METHODS

This analysis was part of a larger study involving 69 health care providers and 377 patients attending their initial prenatal visits at a single clinic. Audio recordings and transcripts from the first 172 visits (including 36 obstetric-gynecology residents, six nurse midwives, and five nurse practitioners) were reviewed for breastfeeding discussion occurrence, timing and initiator of discussions, and adherence to American College of Obstetricians and Gynecologists (College) prenatal breastfeeding guidelines. Descriptive statistics were used to characterize the sample and frequency of breastfeeding discussions. Logistic regression and χ tests were used to examine patterns in women's breastfeeding discussion preferences and discussion occurrence. Conversations were qualitatively analyzed for breastfeeding content.

RESULTS

Breastfeeding discussions were infrequent (29% of visits), brief (mean 39 seconds), and most often initiated by clinicians in an ambivalent manner. Sixty-nine percent of breastfeeding discussions incorporated any College breastfeeding recommendations. Breastfeeding was significantly more likely to be discussed by certified nurse midwives than residents (odds ratio 24.54, 95% confidence interval 3.78-159.06; P<.01), and certified nurse midwives tended to engage patients in more open discussions. Women indicating a preference for breastfeeding discussions at the first visit (n=19) were more likely to actually have the discussion (P<.001).

CONCLUSION

Observed breastfeeding education at the first prenatal visit was suboptimal. The causes and effect of this deficiency on breastfeeding outcomes remains an important point of investigation.

LEVEL OF EVIDENCE

: II.

Increased breastfeeding rates in black women after a treatment intervention

There has been a considerable increase in rates of breastfeeding in the United States. Despite these trends, black women continue to fall below medical recommendations. Impoverished and poorly educated women also have a comparatively lower rate of breastfeeding. Provider encouragement and supportive interventions increase breastfeeding initiation among women of all backgrounds. The data presented come from a three-site randomized controlled bilingual depression treatment trial from 2005 to 2011 that examined the comparative effectiveness of interpersonal psychotherapy and a parenting education program. Breastfeeding education and support were provided for the majority of participants in each intervention. Breastfeeding status was queried at postpartum week 4. We found higher rates of breastfeeding in black women compared with those reported in national surveys. The black breastfeeding rate did not significantly differ from that of white or Hispanic women. American-born black women were just as likely to breastfeed as American-born white women, both at significantly greater rates than American-born Hispanic women. We also found no differences in breastfeeding rate in poorly educated and impoverished women. These data must be seen against the backdrop of a significant intervention to treat depression. Because breastfeeding interventions have been shown to increase breastfeeding rates, the support provided in our study likely increased rates in groups that lag behind.

Association of family and health care provider opinion on infant feeding with mother's breastfeeding decision

In the United States, about 25% of women choose not to initiate breastfeeding, yet little is known about how opinions of individuals in a woman's support network influence her decision to breastfeed. In the 2005-2007 Infant Feeding Practices Study II, women completed questionnaires from the last trimester of pregnancy until 12 months postpartum. Mothers indicated prenatally their family members' and health care providers' opinion on how newborns should be fed: breastfed only, formula fed only, breast and formula fed, or no opinion/don't know. Breastfeeding initiation was determined by asking mothers around 4 weeks postpartum (n=2,041) whether they ever breastfed. Logistic regression was used to examine the association between mothers' perception of family members' and health care providers' opinion on how to feed the infant and the initiation of breastfeeding, adjusting for sociodemographic characteristics. Nearly 14% of mothers surveyed did not initiate breastfeeding. Mothers who believed their family members or health care providers preferred breastfeeding only were least likely not to initiate breastfeeding. Never breastfeeding was significantly associated with the following perceptions: the infant's father (odds ratio [OR]=110.4; 95% CI 52.0 to 234.4) or maternal grandmother (OR=15.9; 95% CI 7.0 to 36.0) preferred only formula feeding; the infant's father (OR=3.2; 95% CI 1.7 to 5.9) or doctor (OR=2.7; 95% CI 1.2 to 6.2) preferred both breast and formula feeding; and the infant's father (OR=7.6; 95% CI 4.5 to 12.7), maternal grandmother (OR=5.4; 95% CI 2.6 to 11.0), or doctor (OR=1.9; 95% CI 1.0 to 3.7) had no opinion/didn't know their feeding preference. The prenatal opinions of family members and health care providers play an important role in a woman's breastfeeding decisions after the infant's birth.

Breastfeeding behavior among adolescents: initiation, duration, and exclusivity

PURPOSE

Despite a substantial amount of evidence on breastfeeding among non-adolescent mothers, research and strategies uniquely designed to target adolescent mothers are critical because their rates of breastfeeding are disproportionately low and their transition to parenthood is often unlike that of older mothers. Literature to date, however, offers limited evidence for designing effective interventions. Therefore, we aimed to fill this gap in the literature by examining breastfeeding behaviors among a cohort of female adolescents as they transition to parenthood.

METHODS

Data were derived from a longitudinal cohort of pregnant adolescent females (ages 14-21 years) and their male partners, observed from pregnancy through 6 months postpartum. Means and frequencies were used to describe breastfeeding experiences, breastfeeding behaviors, and sociodemographic characteristics. We used multivariate logistic regression and Cox proportional hazards models to identify factors independently associated with breastfeeding initiation, exclusive breastfeeding, and breastfeeding duration.

RESULTS

Approximately 71% initiated breastfeeding. Intending to breastfeed, having had complications in labor and delivery, and lower social support were associated with greater odds of breastfeeding initiation. Of the adolescent mothers who initiated breastfeeding, 84% had stopped by 6 months postpartum; among those, average breastfeeding duration was 5 weeks. Participants who exclusively breastfed had longer breastfeeding duration, and participants who had experienced intimate partner violence had shorter breastfeeding duration. Obese women and women who had more difficulty breastfeeding had lower odds of exclusive breastfeeding.

CONCLUSIONS

Enhanced clinical support and the promotion of exclusive breastfeeding should be considered when designing interventions to improve breastfeeding rates among adolescent mothers.

Factors affecting the demarketing of breastmilk substitutes in Palestine

BACKGROUND

Although medical research has proven that breastfeeding is unparalleled in providing the ideal nutrition for infants, "the demarketing of breastmilk substitutes" is a little-known concept. This empirical study tackled the origin and definition of demarketing, examined the different factors affecting the demarketing of breastmilk substitutes in Palestine from the breastfeeding woman's point of view, and developed an appropriate model for the demarketing of breastmilk substitutes. The article subsequently concludes with recommendations for areas of further academic research in the World Health Assembly, for policy makers in Palestine, and for the breastfeeding women themselves.

SUBJECTS AND METHODS

An empirical study was conducted to collect the primary data using a questionnaire as a tool in order to test the hypotheses. The questionnaire was distributed to 400 breastfeeding women who were randomly selected from the population.

RESULTS

The findings proved that there is a relationship between independent variables (i.e., product, price, place, and promotion) and the dependent variable (i.e., demarketing of breastmilk substitutes) based on several reasons discussed thoroughly in this article.

CONCLUSIONS

Product, price, place, and promotion affect the demarketing of breastmilk substitutes in Palestine.

Donor human milk largely replaces formula-feeding of preterm infants in two urban hospitals

OBJECTIVE

To determine acceptance of donor human milk (DM) for feeding preterm infants and whether offering DM, alters mothers' milk (MM) feeding.

STUDY DESIGN

Infant feeding data were collected from medical records of 650 very preterm infants enrolled between 2006-2011 in two hospital level III neonatal intensive care units (NICUs) in Cincinnati, Ohio. The study was conducted during the implementation of a program offering 14 days of DM.

RESULT

From 2006-2011, any DM use increased from 8 to 77% of infants, largely replacing formula for the first 2 weeks of life; provision of MM did not change. DM was more likely to be given in the first 2 weeks of life, if infants never received MM or were >1000 g birth weight, but DM use did not differ by sociodemographic factors.

CONCLUSION

Offering DM dramatically increased human milk feeding and decreased formula use, but did not alter MM feeding in hospital.

Perspectives on promoting breastmilk feedings for premature infants during a quality improvement project

OBJECTIVE

This study investigated clinicians' perspectives during a quality improvement project to promote breastmilk feedings in premature infants.

STUDY DESIGN

From 2009 to 2010, 11 hospitals in the California Perinatal Quality Care Collaborative participated in a project to promote breastmilk feedings in premature infants. Audio recordings of monthly meetings held to encourage sharing of ideas were analyzed using qualitative methods to identify common themes related to barriers and solutions to breastmilk feeding promotion.

RESULTS

Two broad categories were noted: communication and team composition. Communication subthemes included (1) communication among hospital staff, including consistent documentation, (2) communication with family, and (3) communication between transfer hospitals. Team composition subthemes included (4) importance of physician buy-in and (5) integrated teams designed to empower leaders.

CONCLUSIONS

Optimizing communication among health professionals and parents and improving team composition may be key components of facilitating breastmilk feeding promotion in premature infants.

Long-term breastfeeding support: failing mothers in need

This qualitative study analyzes mothers' reports of breastfeeding care experiences from pregnancy through infancy. Most research on medical support for breastfeeding examines a specific practice or intervention during an isolated phase of care. Little is know about how mothers experience breastfeeding education and support from the prenatal period through their child's first year. A convenience sample of 75 black and white WIC participants with infants was recruited at three Maryland WIC agencies. In-depth interviews covered mothers' comprehensive experiences of breastfeeding education and support from pregnancy through the interview date. Most mothers received education or support from a medical professional prenatally, at the hospital, or during the child's infancy, but most also reported receiving no education or support at one or more of these stages. Mothers often felt provided education and support was cursory and inadequate. Some mothers received misinformation or encountered practitioners who were hostile or indifferent to breastfeeding. Mothers were not given referrals to available resources, even after reporting breastfeeding challenges. Mothers received inconsistent messages regarding breastfeeding within and across institutions. Mothers need consistent, sustained information and support to develop and meet personal breastfeeding goals. Medical professionals should follow guidelines issued by their own organizations as well as those from the US Surgeon General, Healthy People 2020, and the Baby Friendly Hospital Initiative. Prenatal, postnatal, and pediatric care providers should coordinate to provide consistent messages and practices within and across sites of care.

Establishing successful breastfeeding in the newborn period

The first days after delivery of a newborn infant are critical for breastfeeding establishment. Successful initiation and continuation-especially of exclusive breastfeeding-have become public health priorities, but it is fraught with many individual- and systems-level barriers. In this article, we review how hospital newborn services can be constructed or restructured to support the breastfeeding mother-infant dyad so that they can achieve high levels of breastfeeding success. Important positive and negative factors from the prenatal period, and the preparation for hospital discharge are also discussed.

Use of electronic communication by physician breastfeeding experts for support of the breastfeeding mother

BACKGROUND

Breastfeeding initiation and duration increase because of physician encouragement. However, many physicians have not received education on breastfeeding, and some may not have a supportive attitude or commitment to breastfeeding. Patients identify dissatisfaction with their current provider as a motivating factor in seeking health information on the Internet. This survey was performed to determine how many physicians with an interest and expertise in breastfeeding are being contacted for breastfeeding information over the Internet and to examine physicians' attitudes to these requests.

SUBJECTS AND METHODS

An e-mail describing the survey, inviting participation, and containing a link to the online questionnaire was posted on the Web site of the Academy of Breastfeeding Medicine and as well as on the Listserv of the American Academy of Pediatrics-Section on Breastfeeding. Information collected included physician training, successes and challenges related to providing breastfeeding medicine support by e-mail, and current level of e-mail communication with patients regarding breastfeeding issues.

RESULTS

One-fourth of physicians in our survey receive e-mails with questions about breastfeeding issues from patients with whom they have no preexisting relationships. More receive e-mail from known patients. This suggests that breastfeeding mothers seek expert information on the Internet. Over half of the physicians replied to e-mails individually and without any financial reimbursement.

CONCLUSIONS

Many breastfeeding mothers reach out to breastfeeding experts over the Internet. Our findings suggest that physicians who provide care to breastfeeding mothers need further education on breastfeeding to provide adequate support to their own patients.

Physician breastfeeding education leads to practice changes and improved clinical outcomes

BACKGROUND AND OBJECTIVES

Lack of physician knowledge about breastfeeding is associated with decreased initiation and continuation of breastfeeding by patients. We evaluated the effects of a breastfeeding education program on physicians' breastfeeding knowledge, attitudes, and beliefs, measured changes in clinical practice, and examined breastfeeding rates of patients of participating physicians.

STUDY DESIGN AND METHODS

Six breastfeeding sessions addressed breastfeeding problem-solving and counseling and specific clinical issues including mastitis, perceived insufficient milk, poor infant weight gain, and return to work. We measured physicians' breastfeeding knowledge, attitudes, and beliefs before and after curriculum implementation and also measured changes in practice. We analyzed breastfeeding rates of patients in the practice before, during, and after the intervention.

RESULTS

We studied 24 residents and 15 faculty members at the intervention site; there were 12 residents and nine faculty in a similar control program. Attendance at education sessions improved breastfeeding knowledge (p<0.01) and attitudes/beliefs (p=0.03). Participants identified 15 unique practice changes with a strong commitment to make these changes (4.7 on a 5-point scale) and fulfillment of practice change of 3.6. Participation in education sessions improved patients' rates of any breastfeeding at 4 and 6 months and of full breastfeeding at 4 months.

CONCLUSIONS

A breastfeeding education program at a semirural residency program improved physicians' breastfeeding knowledge. Implementation of practice changes was fair. Two years into the intervention, breastfeeding rates improved for patients of the physicians with high levels of participation in the program.

Breastfeeding support for African-American women in Louisiana hospitals

OBJECTIVE

This study determined the variation in hospital breastfeeding support for African-American women in Louisiana.

STUDY DESIGN

Data from the 2007-2008 Louisiana Pregnancy Risk Assessment Monitoring System (n=2,534) were used to determine the odds of African-American women's hospital experiences with breastfeeding-related services following delivery relative to women of all other races. SAS-callable SUDDAN software was used for analyses.

RESULTS

African-American women were 60% less likely than women of other races to initiate breastfeeding or pump milk (odds ratio=0.40, 95% confidence interval=0.31-0.52). Compared with women of other races, African-American mothers were less likely to receive breastfeeding instruction and support from healthcare professionals while in the hospital, including being less likely to receive phone numbers for support and less likely to have their baby remain in the hospital room with them. African-American mothers were also less likely to report that they breastfed while in-hospital or breastfed exclusively while in-hospital.

CONCLUSION

This study shows significant racial differences in initiation of breastfeeding and hospital experiences following delivery in Louisiana.

The human milk project: a quality improvement initiative to increase human milk consumption in very low birth weight infants

OBJECTIVE

Human milk has well-established health benefits for preterm infants. We conducted a multidisciplinary quality improvement effort aimed at providing at least 500 mL of human milk/kg in the first 14 days of life to very low birth weight (VLBW) (< 1,500 g) infants in the neonatal intensive care unit.

SUBJECTS AND METHODS

Improvement activities included antenatal consults with at-risk mothers, staff and parent education, a breast pump loaner program for uninsured/underinsured mothers, pump logs, establishment of a donor milk program, and twice-daily physician evaluation of infants' ability to tolerate feedings.

RESULTS

The number of infants receiving at least 500 mL of human milk/kg in their first 14 days of life increased from 50% to 80% within 11 months of implementation, and this increase has been sustained for 4 years. Infants who met the feeding goal because they received donor milk increased each year. Since September 2007, infants have received, on average, 1,111 mL of human milk/kg. Approximately 4% of infants did not receive any human milk. Respiratory instability was the most frequent physiological reason given by clinicians for not initiating or advancing feedings in the first 14 days of life.

CONCLUSIONS

Our quality improvement initiative resulted in a higher consumption of human milk in VLBW infants in the first 14 days of life. Other clinicians can use these described quality improvement methods and techniques to improve their VLBW babies' consumption of human milk.

High pregnancy-related anxiety and prenatal depressive symptoms as predictors of intention to breastfeed and breastfeeding initiation

BACKGROUND

Perinatal mood disorders affect up to 20% of women in the United States. Little is known about how disorders in maternal mood may affect rates of breastfeeding.

OBJECTIVE

To determine the impact of prenatal depressive symptoms and high pregnancy-related anxiety on (1) prenatal intention to breastfeed and (2) breastfeeding initiation.

METHODS

We prospectively followed 1436 pregnant women enrolled in the cohort study Project Viva. The main outcome measures were (1) mother's second trimester self-report of intention to use all or mostly formula in the first week of life and (2) failure to initiate breastfeeding. We defined prenatal depressive symptoms as a second trimester Edinburgh Postpartum Depression Scale (EPDS) score of > or =13 and high pregnancy-related anxiety as a "very much" response to three or more questions on a first trimester pregnancy anxiety scale.

RESULTS

Of the 1436 participants, 9% (n = 125) had prenatal depressive symptoms indicative of depression, and 10% (n = 141) reported high pregnancy-related anxiety; 11% (n = 159) intended to give mostly or only formula in the first week of life, and 86% (n = 1242) initiated breastfeeding. In multivariate analyses, women with prenatal depressive symptoms (OR 1.92, 95% CI 1.11, 3.33) and high pregnancy-related anxiety (OR 1.99, 95% CI 1.12, 3.54) were roughly two times more likely than women without these mood disorders to plan to formula feed. However, neither prenatal depressive symptoms (OR 1.06, 95% CI 0.61, 1.84) nor high pregnancy-related anxiety (OR 1.28, 95% CI 0.74, 2.20) was associated with failure to initiate breastfeeding.

CONCLUSIONS

In a healthcare setting highly supportive of breastfeeding, women with prenatal depressive symptoms and possibly those with high pregnancy-related anxiety were less likely to plan prenatally to breastfeed, although this tendency did not translate into lower breastfeeding initiation rates.

An Internet-based education program improves breastfeeding knowledge of maternal-child healthcare providers

BACKGROUND AND OBJECTIVES

Breastfeeding rates in the United States remain below the Surgeon General's Healthy People 2010 goals. Encouragement of breastfeeding and education by maternal-child healthcare (MCH) providers (physicians, residents, and midlevel providers) improves breastfeeding initiation and duration. Surveys of MCH providers show lack of knowledge about breastfeeding. This study evaluated the effect of usage of "BreastfeedingBasics," a free Internet-based educational course, on the knowledge of MCH providers and evaluation of the baseline knowledge of course users.

METHODS

A before and after intervention study was done of MCH providers using the "BreastfeedingBasics" website between 1999 and 2008. Baseline knowledge and change in knowledge were assessed by computer-scored pretests and posttests.

RESULTS

Of 3,456 MCH providers enrolled, 2,237 (65%) completed one or more pretest. Total mean pretest/posttest scores were as follows: midlevel providers, 81%/89%; residents, 84%/93%; and physicians, 85%/92% (p < 0.001 among groups and between pretests and posttests). Mean pretest/posttest scores of the modules were as follows: Anatomy/Physiology, 79%/93%; Growth/Development, 72%/91%; Mother-Infant Couple (normal newborn), 82%/92%; and Breastfed Infant with Problems, 77%/91% (p < 0.001 for all). Specific topics with the lowest pretest scores and subsequent posttest scores were as follows (pretest/posttest): supplementation with vitamin D, 61%/93%; breastfeeding physiology, 38%/65%; growth of breastfed infants at 10 days, 80%/95%, 14 days, 72%/91%, and 3-4 months, 39%/84%; and stopping breastfeeding for maternal problems when not indicated, 69%/93% (p < 0.001 for all).

CONCLUSIONS

Use of an Internet-based educational program improved knowledge of MCH providers as measured by pretest and posttest scores. Knowledge of the growth of breastfed infants is particularly poor. Increasing knowledge is the first step in improving clinical practice that is necessary for increasing breastfeeding rates and duration.

Breastfeeding policies and practices in Canadian hospitals: comparing 1993 with 2007

BACKGROUND

The Baby-Friendly Hospital Initiative (BFHI) promotes the World Health Organization International Code of Marketing of Breast-milk Substitutes (WHO Code) and the WHO/UNICEF's Ten Steps to Successful Breastfeeding (Ten Steps). The purpose of this study is to describe and compare maternity hospitals' adherence to the BFHI in 1993 and 2007 for Canada and for each province and territory.

METHODS

A survey of all Canadian maternity hospitals was conducted in 1993 and 2007 on routine maternity care practices and policies including infant feeding.

RESULTS

The overall response rate was 91 percent (n = 523/572 hospitals) in 1993 and 92 percent (n = 323/353 hospitals) in 2007. Eighty-two percent (415/507) of hospitals in 1993 and 68 percent (198/292) in 2007 had exclusive contracts with formula companies. Fifty-eight percent (302/517) of hospitals in 1993 and 90 percent (289/322) in 2007 never gave breastfeeding mothers sample packs containing formula. Fifty-eight percent (296/507) in 1993 and 85 percent (273/321) in 2007 had written breastfeeding policies (Step 1); 97 percent (503/518) in 1993 and 99 percent (320/322) in 2007 allowed mothers to breastfeed, on cue, whenever the babies indicated an interest 24 hours a day (Step 8); 24 percent (126/519) in 1993 and 64 percent (206/321) in 2007 reported that they did not provide soothers (Step 9); 58 percent (297/513) in 1993 and 68 percent (215/316) in 2007 always offered information on breastfeeding support groups and/or advice at time of discharge (Step 10).

CONCLUSIONS

In the 14 years separating the two surveys, Canadian maternity hospitals substantially improved their implementation of the WHO Code and their adherence to the WHO/UNICEF Ten Steps.

[Prenatal breastfeeding information: survey in Pays de Loire, France]

OBJECTIVES

The main aim of this study was to evaluate how well expectant mothers were informed on breastfeeding by healthcare professionals. The secondary objective was to determine the factors associated with the initiation of breastfeeding.

POPULATION AND METHODS

The survey was conducted in a group of 500 women who had delivered at the Angers Hospital (France), based on a questionnaire filled out by the postpartum women during their hospital stay.

RESULTS

The rate of breastfeeding was 61.2%. More than a quarter (26.9%) of the women did not receive any prenatal breastfeeding information. The survey showed that 77.8% of the women had been informed of breastfeeding advantages for infants and 51.5% of breastfeeding advantages for themselves. Only 27.5% had received the advice of exclusive breastfeeding for 6months. Only 5.2% had been informed of the uselessness of breast preparation during pregnancy and a minority had been informed of correct and incorrect breastfeeding contraindications. Only 15.4% of fathers had been involved in a discussion on infant feeding practices during prenatal consultations. Only 4.8% of the women had come to prenatal classes on breastfeeding with a relative. The maternal factors positively associated with breastfeeding initiation were age between 25 and 34 years, non-French origin, a high socioeconomic status, being married, having been breastfed, and having previous experience with breastfeeding. Breastfeeding initiation was negatively associated with maternal smoking. All the factors concerning prenatal breastfeeding information in women were associated with the choice of breastfeeding.

CONCLUSION

This study pointed out the populations at risk of not breastfeeding. Breastfeeding information given to pregnant women by healthcare professionals may influence them on whether or not they choose to breastfeed their newborn. However, this survey showed that women are insufficiently informed on prenatal breastfeeding. Therefore, prenatal breastfeeding information should be improved.

Educational objectives and skills for the physician with respect to breastfeeding

The Academy of Breastfeeding Medicine is a worldwide organization of physicians dedicated to the promotion, protection and support of breastfeeding and human lactation. Our mission is to unite into one association members of the various medical specialties with this common purpose.

Improving the use of human milk during and after the NICU stay

The feeding of human milk (milk from the infant's own mother; excluding donor milk) during the newborn intensive care unit (NICU) stay reduces the risk of costly and handicapping morbidities in premature infants. The mechanisms by which human milk provides this protection are varied and synergistic, and appear to change over the course of the NICU stay. The fact that these mechanisms include specific human milk components that are not present in the milk of other mammals means that human milk from the infant's mother cannot be replaced by commercial infant or donor human milk, and the feeding of human milk should be a NICU priority. Recent evidence suggests that the impact of human milk on improving infant health outcomes and reducing the risk of prematurity-specific morbidities is linked to specific critical exposure periods in the post-birth period during which the exclusive use of human milk and the avoidance of commercial formula may be most important. Similarly, there are other periods when high doses, but not necessarily exclusive use of human milk, may be important. This article reviews the concept of "dose and exposure period" for human milk feeding in the NICU to precisely measure and benchmark the amount and timing of human milk use in the NICU. The critical exposure periods when exclusive or high doses of human milk appear to have the greatest impact on specific morbidities are reviewed. Finally, the current best practices for the use of human milk during and after the NICU stay for premature infants are summarized.

Are 2 weeks of daily breastfeeding support insufficient to overcome the influences of formula?

OBJECTIVE

To evaluate the effectiveness of proactive telephone breastfeeding support in low-income, primiparous, primarily Latina women on 1) duration and exclusivity of breastfeeding, 2) satisfaction with feeding, 3) rationale for discontinuing breastfeeding and 4) health care utilization.

METHODS

Randomized controlled trial comparing usual care to 2 weeks of daily telephone calls by nurses by using culturally informed scripted protocols; and qualitative study of focused interviews on a sample of women in the intervention group (n = 40).

RESULTS

Breastfeeding duration and exclusivity rates, feeding method satisfaction, and reasons for stopping breastfeeding did not differ significantly between intervention (n = 161) and control (n = 180) groups, with 74% of both breastfeeding at 1 month and 28% and 37%, respectively, at 6 months. Insufficient milk supply was the main reason for stopping in both groups. Intervention infants were less likely to have a sick visit by 1 month (25%) than controls (35%, P = .05). Qualitative interviews revealed that the intervention was informative and helpful, with breastfeeding reported as healthier but harder; formula was a good alternative. Intervention mothers reporting < or =2 supplemental formula feedings on day 4 were more likely than mothers reporting > or =3 supplemental feedings to breastfeed at 1 month (odds ratio 7.7; 95% confidence interval 2.4-24.3).

CONCLUSIONS

Two weeks of daily telephone support did not increase breastfeeding duration but was associated with a decrease in sick visits in the first month. Early supplementation and the perception of formula as a good alternative to dealing with the breastfeeding difficulties appeared to be factors in failure of the intervention.

Cultural beliefs that may discourage breastfeeding among Lebanese women: a qualitative analysis

Background

Although the health benefits of breastfeeding are well established, early introduction of formula remains a common practice. Cultural beliefs and practices can have an important impact on breastfeeding. This paper describes some common beliefs that may discourage breastfeeding in Lebanon.

Methods

Participants were healthy first-time mothers recruited from hospitals throughout Lebanon to participate in a study on usage patterns of a telephone hotline for postpartum support. The hotline was available to mothers for the first four months postpartum and patterns of usage, as well as questions asked were recorded. Thematic analysis of the content of questions which referred to cultural beliefs and practices related to breastfeeding was conducted.

Results

Twenty four percent of the 353 women enrolled in the study called the hotline, and 50% of the calls included questions about breastfeeding. Mothers expressed concern about having adequate amounts of breast milk or the quality of their breast milk. Concerns that the mother could potentially harm her infant though breastfeeding were rooted in a number of cultural beliefs. Having an inherited inability to produce milk, having "bad milk", and transmission of abdominal cramps to infants through breast milk were among the beliefs that were expressed. Although the researchers live and work in Lebanon, they were not aware of many of the beliefs that are reported in this study.

Conclusion

There are a number of cultural beliefs that could potentially discourage breastfeeding among Lebanese women. Understanding and addressing local beliefs and customs can help clinicians to provide more culturally appropriate counselling about breastfeeding.

Breastfeeding knowledge, attitudes, and practices among providers in a medical home

OBJECTIVE

Breastfeeding offers numerous health advantages to children, mothers, and society. From obstetrics to pediatrics, breastfeeding dyads come in contact with a wide range of healthcare providers. The American Academy of Pediatrics (AAP) calls for pediatricians to support breastfeeding enthusiastically and for all children to have a medical home. We studied an inner-city healthcare system with a Dyson Community Pediatrics Training Initiative Model Medical Home clinic, to explore how a breastfeeding/baby-friendly medical home might be built upon this framework. We describe breastfeeding knowledge, attitudes, and practices among a full range of providers and healthcare system-level barriers to effective and coordinated breastfeeding services.

METHODS

We conducted eight focus groups using semistructured interviews: (1) pediatricians; (2) obstetricians; (3) pediatric nurses and allied health professionals; (4) obstetric nurses and allied health professionals; (5) 24-hour telephone triage answering service nurses; (6) public health nurses; (7) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) personnel; and (8) lactation consultants and peer counselors.

RESULTS

We identified gaps in providers' breastfeeding knowledge, counseling skills, and professional education and training. Providers' cultures and attitudes affect breastfeeding promotion and support. Providers used their own breastfeeding experiences to replace evidence-based knowledge and AAP policy statement recommendations for breastfeeding dyads. There were communication disconnects between provider groups. Providers underestimated their own, and overestimated others', influence on breastfeeding. The system lacked a coordinated breastfeeding mission.

CONCLUSIONS

This study illuminated key disconnectedness challenges (and, hence, opportunities) for a model medical home in fostering continuous, comprehensive, coordinated, culturally effective, and evidence-based breastfeeding promotion and support.