Office prenatal formula advertising and its effect on breast-feeding patterns

Academy of Breastfeeding Medicine Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Period (Revised 2024)

Background: The Academy of Breastfeeding Medicine revised the 2015 version of this clinical protocol to review the evidence and provide recommendations related to breastfeeding promotion in the prenatal period. Key Information: Promoting and normalizing breastfeeding in the prenatal period can improve breastfeeding outcomes including initiation and duration of breastfeeding. Ideally, prenatal interventions should be a part of a comprehensive longitudinal breastfeeding support program. Recommendations: Clinicians or other health workers should discuss breastfeeding at each prenatal visit. Counseling topics should include the health benefits of breastfeeding versus not breastfeeding, the basics of breastfeeding (e.g., physiology, positioning), what to expect of hospital-based and immediate postpartum breastfeeding support (i.e., Baby-Friendly Ten Steps), and the risks of unnecessary supplementation. Medical, anatomical, and other risk factors for breastfeeding challenges should be identified, and targeted anticipatory guidance should be given. Prenatal counseling should include distribution of structured breastfeeding education at low literacy levels and in the parent's preferred language. Counseling should be culturally sensitive and patient-centered, including family members when appropriate. Prenatal support may integrate various health workers (e.g., medical doctors, midwives, community health workers, lactation consultants, among others) and include various modalities including telecommunication. Enhancing breastfeeding education for prenatal care providers is also imperative. Additional themes related to implementation of recommendations for specific populations are also reviewed.

Health and nutrition claims for infant formula: international cross sectional survey

OBJECTIVES

To review available health and nutrition claims for infant formula products in multiple countries and to evaluate the validity of the evidence used for substantiation of claims.

DESIGN

International cross sectional survey.

SETTING

Public facing and healthcare professional facing company owned or company managed formula industry websites providing information about products marketed for healthy infants delivered at full term in 15 countries: Australia, Canada, Germany, India, Italy, Japan, Nigeria, Norway, Pakistan, Russia, Saudi Arabia, South Africa, Spain, the United Kingdom, and the United States in 2020-22.

MAIN OUTCOME MEASURES

Number and type of claims made for each product and ingredient. References cited were reviewed and risk of bias was assessed for registered clinical trials using the Cochrane risk of bias tool, and for systematic reviews using the Risk Of Bias in Systematic reviews tool.

RESULTS

757 infant formula products were identified, each with a median of two claims (range from 1 (Australia) to 4 (US)), and 31 types of claims across all products. Of 608 products with ≥1 claims, the most common claim types were "helps/supports development of brain and/or eyes and/or nervous system" (323 (53%) products, 13 ingredients), "strengthens/supports a healthy immune system" (239 (39%) products, 12 ingredients), and "helps/supports growth and development" (224 (37%) products, 20 ingredients). 41 groups of ingredients were associated with ≥1claims, but many claims were made without reference to a specific ingredient (307 (50%) products). The most common groups of ingredients cited in claims were long chain polyunsaturated fatty acids (278 (46%) products, 9 different claims); prebiotics, probiotics, or synbiotics (225 (37%) products, 19 claims); and hydrolysed protein (120 (20%) products, 9 claims). 161/608 (26%) products with ≥1 claims provided a scientific reference to support the claim-266 unique references were cited for 24 different claim types for 161 products. The reference types most frequently cited were clinical trials (50%, 134/266) and reviews (20%, 52/266). 28% (38/134) of referenced clinical trials were registered, 14% (19/134) prospectively. 58 claims referred to 32 registered clinical trials, of which 51 claims (27 trials) related to a randomised comparison. 46 of 51 claims (90%) referenced registered clinical trial outcomes at high risk of bias, and all cited systematic reviews and pooled analyses, carried a high risk of bias.

CONCLUSIONS

Most infant formula products had at least one health and nutrition claim. Multiple ingredients were claimed to achieve similar health or nutrition effects, multiple claims were made for the same ingredient type, most products did not provide scientific references to support claims, and referenced claims were not supported by robust clinical trial evidence.

Birth and newborn care policies and practices limit breastfeeding at maternity facilities in Vietnam

The prevalence of early and exclusive breastfeeding in Vietnam remains sub-optimal. The objective of this study was to determine factors associated with early initiation of breastfeeding (EIBF) and exclusive breastfeeding for the first 3 days after birth (EBF3D). We conducted a population-based, cross-sectional survey of 726 mothers with children aged 0-11 months in two provinces and one municipality from May to July 2020. Multinomial logistic regression was used to examine factors associated with EIBF and EBF3D. The prevalence of EIBF was 39.7% and EBF3D 18.0%. The EIBF prevalence is positively associated with immediate and uninterrupted skin-to-skin contact (SSC) for 10-29 min (aOR: 2.55; 95% CI: 1.49, 4.37), 30-59 min (aOR: 4.15; 95% CI: 2.08, 8.27), 60-80 min (aOR: 4.35; 95% CI: 1.50, 12.6), or ≥90 min (aOR: 5.87; 95% CI: 3.14, 10.98). EIBF was negatively associated with cesarean birth (aOR: 0.24; 95% CI: 0.11, 0.51), bringing infant formula to the birth facility (aOR: 0.49; 95% CI: 0.30, 0.78), purchased it after arrival (aOR: 0.37; 95% CI: 0.24, 0.60), or did both (aOR: 0.43; 95% CI: 0.21, 0.89). EBF3D was negatively associated with cesarean section birth (aOR: 0.15; 95% CI: 0.06, 0.39), vaginal birth with episiotomy (aOR: 0.40; 95% CI: 0.18, 0.88), bringing formula to the maternity facility (aOR: 0.03; 95% CI: 0.01, 0.07), purchased it after arrival (aOR: 0.02; 95% CI: 0.01, 0.06) or did both (aOR: 0.04; 95% CI: 0.02, 0.10). Receiving counseling from any source was not significantly associated with early breastfeeding practices. Policy and health service delivery interventions should be directed at eliminating infant formula from birthing environments, reducing unnecessary cesarean sections and episiotomies, providing immediate and uninterrupted SSC for all births, and improving breastfeeding counseling and support.

The Impact of Formula Industry Marketing on Breastfeeding Rates in Native and Migrant Mothers

Introduction: Lifelong benefits of breastfeeding are far-reaching. However, optimal breastfeeding practices may be negatively affected by the marketing of different forms of breast milk substitutes. In addition, whether market factors have a different impact on migrants' breastfeeding practices when compared to natives has been poorly investigated. Objectives: Our study's aims are (1) to assess the effect of market factors on breastfeeding discontinuation (any and exclusive), (2) comparing migrant and native women. Methods: A longitudinal study was conducted within baMBINO, a nationwide project on perinatal health among migrant women in Portugal. Our final sample included 1,251 migrants and 1,150 natives recruited between April 2017 and March 2019 in 32 public maternities. Cox regression analysis was performed, adjusting for important confounders, and interactions were tested. Results: Market factors were associated with any and exclusive breastfeeding discontinuation. Participants receiving free formula samples from a health professional were more likely to stop exclusive breastfeeding (adjusted hazard ratios [aHR] = 1.37, 95% confidence intervals [95% CI] = 1.13-1.66, p = 0.002). Reporting exposure to formula discounts was associated with discontinuation of exclusive (aHR = 1.22, 95% CI = 1.09-1.38, p = 0.001) and any breastfeeding (aHR = 1.21, 95% CI = 1.00-1.46, p = 0.046). No interactions were found between being migrant and exposure to market factors. Conclusions: Market factors influence discontinuation of any and exclusive breastfeeding. The impact of marketing does not differ between native and migrant women.

Association between early essential newborn care and breastfeeding outcomes in eight countries in Asia and the Pacific: a cross-sectional observational -study

Objective

To explore the association between early essential newborn care (EENC) policy, practice and environmental interventions and breastfeeding outcomes.

Design

Cross-sectional observational study.

Setting

150 national, provincial and district hospitals implementing EENC in eight countries in East Asia and the Pacific.

Participants

1383 maternal interviews, chart reviews and environmental assessments during 2016 and 2017.

Main outcome measures

Exclusive breastfeeding (EBF), that is, feeding only breastmilk without other food or fluids since birth and before discharge, and, early breastfeeding initiation, that is, during skin-to-skin contact (SSC) with the mother without separation.

Results

Fifty-nine per cent of newborns initiated breastfeeding early and 83.5% were EBF. Duration of SSC showed a strong dose–response relationship with early breastfeeding initiation. SSC of at least 90 min was associated with 368.81 (95% CI 88.76 to 1532.38, p<0.001) times higher early breastfeeding. EBF was significantly associated with SSC duration of 30–59 min (OR 3.54, 95% CI 1.88 to 6.66, p<0.001), 60–89 min (OR 5.61, 95% CI 2.51 to 12.58, p<0.001) and at least 90 min (OR 3.78, 95% CI 2.12 to 6.74, p<0.001) regardless of delivery mode. Non-supine position (OR 2.80, 95% CI 1.90 to 4.11, p<0.001), rooming-in (OR 5.85, 95% CI 3.46 to 9.88, p<0.001), hospital breastfeeding policies (OR 2.82, 95% CI 1.97 to 4.02, p<0.001), quality improvement mechanisms (OR 1.63, 95% CI 1.07 to 2.49, p=0.02) and no formula products (OR 17.50, 95% CI 5.92 to 51.74, p<0.001) were associated with EBF.

Conclusion

EENC policy, practice and environmental interventions were associated with breastfeeding outcomes. To maximise the likelihood of early and EBF, newborns, regardless of delivery mode, should receive immediate and uninterrupted SSC for at least 90 min.

Advice to use infant formula and free samples are common in both urban and rural areas in China: a cross-sectional survey

OBJECTIVE

To examine the association between the place of residence and receiving free samples and advice to feed the baby with infant formula.

DESIGN

A cross-sectional study.

SETTING

The current study covered twelve counties/districts in China.

PARTICIPANTS

5112 mothers with infants aged 0-5·9 months.

RESULTS

About 16 % of the mothers received free samples of infant formula. During pregnancy, this likelihood was higher among mothers in small and medium cities (OR: 1·96; 95 % CI 1·14, 3·38) and non-poor rural counties (OR: 4·65; 95 % CI 1·65, 13·14) compared with mothers in big cities. During the hospital stay, it was lower in big cities. After discharge, it was lower in poor rural counties (OR: 0·14; 95 % CI 0·05, 0·41). About 26 % of the mothers were advised to feed their infants with infant formula. The likelihood of receiving advice to feed the baby with infant formula from hospitals was lower in non-poor (OR: 0·37; 95 % CI 0·21, 0·66) and poor rural counties (OR: 0·35; 95 % CI 0·13, 0·91) than in big cities. Mothers in non-poor rural counties were less likely to receive advice from traditional mass media (OR: 0·17; 95 % CI 0·06, 0·48), while mothers in small and medium cities were more likely to receive advice from modern mass media (OR: 1·84; 95 % CI 1·20, 2·80) compared with mothers in big cities.

CONCLUSIONS

The promotion strategy of infant formula varies from different places of residence in China. The study suggests the need to strengthen enforcement of relevant regulations, especially within health facilities and through modern mass media.

Interventions for promoting the initiation of breastfeeding

BACKGROUND

Despite the widely documented risks of not breastfeeding, initiation rates remain relatively low in many high-income countries, particularly among women in lower-income groups. In low- and middle-income countries, many women do not follow World Health Organization (WHO) recommendations to initiate breastfeeding within the first hour after birth. This is an update of a Cochrane Review, first published in 2005.

OBJECTIVES

To identify and describe health promotion activities intended to increase the initiation rate of breastfeeding.To evaluate the effectiveness of different types of breastfeeding promotion activities, in terms of changing the number of women who initiate breastfeeding.To evaluate the effectiveness of different types of breastfeeding promotion activities, in terms of changing the number of women who initiate breastfeeding early (within one hour after birth).

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) and scanned reference lists of all articles obtained.

SELECTION CRITERIA

Randomised controlled trials (RCTs), with or without blinding, of any breastfeeding promotion intervention in any population group, except women and infants with a specific health problem.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial reports for inclusion, extracted data and assessed trial quality. Discrepancies were resolved through discussion and a third review author was involved when necessary. We contacted investigators to obtain missing information.

MAIN RESULTS

Twenty-eight trials involving 107,362 women in seven countries are included in this updated review. Five studies involving 3,124 women did not contribute outcome data and we excluded them from the analyses. The methodological quality of the included trials was mixed, with significant numbers of studies at high or unclear risk of bias due to: inadequate allocation concealment (N = 20); lack of blinding of outcome assessment (N = 20); incomplete outcome data (N = 19); selective reporting (N = 22) and bias from other potential sources (N = 17). Healthcare professional-led breastfeeding education and support versus standard care The studies pooled here compare professional health workers delivering breastfeeding education and support during the prenatal and postpartum periods with standard care. Interventions included promotion campaigns and counselling, and all took place in a formal setting. There was evidence from five trials involving 564 women for improved rates ofbreastfeeding initiation among women who received healthcare professional-led breastfeeding education and support (average risk ratio (RR) 1.43, 95% confidence interval (CI) 1.07 to 1.92; Tau² = 0.07, I² = 62%, low-quality evidence) compared to those women who received standard care. We downgraded evidence due to design limitations and heterogeneity. The outcome of early initiation of breastfeeding was not reported in the studies under this comparison. Non-healthcare professional-led breastfeeding education and support versus standard care There was evidence from eight trials of 5712 women for improved rates of breastfeeding initiation among women who received interventions from non-healthcare professional counsellors and support groups (average RR 1.22, 95% CI 1.06 to 1.40; Tau² = 0.02, I² = 86%, low-quality evidence) compared to women who received standard care. In three trials of 76,373 women, there was no clear difference between groups in terms of the number of women practicing early initiation of breastfeeding (average RR 1.70, 95% CI 0.98 to 2.95; Tau² = 0.18, I² = 78%, very low-quality evidence). We downgraded the evidence for a combination of design limitations, heterogeneity and imprecision (wide confidence intervals crossing the line of no effect). Other comparisonsOther comparisons in this review also looked at the rates of initiation of breastfeeding and there were no clear differences between groups for the following comparisons of combined healthcare professional-led education with peer support or community educator versus standard care (2 studies, 1371 women) or attention control (1 study, 237 women), breastfeeding education using multimedia (a self-help manual or a video) versus routine care (2 studies, 497 women); early mother-infant contact versus standard care (2 studies, 309 women); and community-based breastfeeding groups versus no breastfeeding groups (1 study, 18,603 women). None of these comparisons reported data on early initiation of breastfeeding.

AUTHORS' CONCLUSIONS

This review found low-quality evidence that healthcare professional-led breastfeeding education and non-healthcare professional-led counselling and peer support interventions can result in some improvements in the number of women beginning to breastfeed. The majority of the trials were conducted in the USA, among women on low incomes and who varied in ethnicity and feeding intention, thus limiting the generalisability of these results to other settings.Future studies would ideally be conducted in a range of low- and high-income settings, with data on breastfeeding rates over various timeframes, and explore the effectiveness of interventions that are initiated prior to conception or during pregnancy. These might include well-described interventions, including health education, early and continuing mother-infant contact, and initiatives to help mothers overcome societal barriers to breastfeeding, all with clearly defined outcome measures.

The Impact of Hospital Resources and Availability of Professional Lactation Support on Maternity Care: Results of Breastfeeding Surveys 2009-2014

BACKGROUND

Breastfeeding provides maternal and infant health benefits. Maternity care practices encompassed in the 10 Steps to Successful Breastfeeding are positively associated with improved breastfeeding outcomes. This study assessed changes in maternity care practices and lactation support.

MATERIALS AND METHODS

In 2009, 2011, and 2014, New York (NY) hospitals providing maternity care services were surveyed to assess the implementation of 9 of the 10 Steps to Successful Breastfeeding, professional lactation support, distribution of formula and discharge packs, and patient and hospital barriers to breastfeeding success. Generalized estimating equations were used to evaluate changes over time.

RESULTS

Surveys were completed by 138/138 (2009), 128/129 (2011), and 125/125 (2014) NY hospitals. During this time period, the percent of hospitals reporting implementation of Steps 2, 4, 6, or 9 increased, and the mean number of 9 steps implemented increased from 4.3 to 5.3. Hospitals distributing formula samples at discharge to breastfeeding mothers decreased significantly from 39 (32%) to 3 (2%). Professional lactation staffing ratios (N/1,000 births) of both International Board Certified Lactation Consultants and Certified Lactation Counselors increased between 2009 and 2011, but then decreased between 2011 and 2014. Reported barriers to breastfeeding support changed, with reductions in mixed messages from staff, but increases in lack of financial resources for breastfeeding support, inadequate prenatal education, mothers not being prepared, and family not being receptive to breastfeeding.

CONCLUSIONS

Between 2009 and 2014, NY hospitals reported increased barriers and a reduction in professional lactation support, which may have contributed to the limited improvements in breastfeeding support.

Breastfeeding: What are the Barriers? Why Women Struggle to Achieve Their Goals

Despite recognized health benefits for both mothers and infants, significant disparities still exist in the rates of breastfeeding in the United States. Major organizations representing the health of women and children (including the Centers for Disease Control and Prevention [CDC], American Academy of Pediatrics [AAP], American Congress of Obstetrics and Gynecology [ACOG], American Academy of Family Physicians [AAFP], United Nations International Children's Emergency Fund (UNICEF), the World Health Organization [WHO], and the United States Public Health Service [PHS]) recommend exclusive breastfeeding, but statistics show that although many women initiate breastfeeding, few meet the recommended goals for duration and exclusivity. This article reviews the evidence related to barriers (prenatal, medical, societal, hospital, and sociocultural) that many mothers face, and explore the known barriers and the impact they have on a woman's ability to breastfeed her infant. Strategies will be discussed to address (and potentially overcome) some of the most common barriers women face along with a list of resources that can be useful in this effort. Gaps in care and areas that need further research will be noted. This article is targeted toward physicians and other healthcare providers who work with women and who can assist with and advocate for the removal of barriers and thereby improve the health of women and children by increasing the rates of breastfeeding initiation, duration, and exclusivity in the United States.

Pervasive promotion of breastmilk substitutes in Phnom Penh, Cambodia, and high usage by mothers for infant and young child feeding

In 2005, Cambodia passed the Sub-Decree on Marketing of Products for Infant and Young Child Feeding (no. 133) to regulate promotion of commercial infant and young child food products, including breastmilk substitutes. Helen Keller International assessed mothers' exposure to commercial promotions for breastmilk substitutes and use of these products through a cross-sectional survey among 294 mothers of children less than 24 months of age. Eighty-six per cent of mothers reported observing commercial promotions for breastmilk substitutes, 19.0% reported observing infant and young child food product brands/logos on health facility equipment and 18.4% reported receiving a recommendation from a health professional to use a breastmilk substitute. Consumption of breastmilk substitutes was high, occurring among 43.1% of children 0-5 months and 29.3% of children 6-23 months of age. Findings also indicated a need to improve breastfeeding practices among Phnom Penh mothers. Only 36.1% of infants 0-5 months of age were exclusively breastfed, and 12.5% of children 20-23 months of age were still breastfed. Children that received a breastmilk substitute as a prelacteal feed were 3.9 times more likely to be currently consuming a breastmilk substitute than those who did not. Despite restriction of commercial promotions for breastmilk substitutes without government approval, occurrence of promotions is high and use is common among Phnom Penh mothers. In a country with high rates of child malnutrition and pervasive promotions in spite of restrictive national law, full implementation of Cambodia's Sub-Decree 133 is necessary, as are policies and interventions to support exclusive and continued breastfeeding.

KEY MESSAGES

Despite prohibition without specific approval by the national government, companies are pervasively promoting breast-milk substitutes in Phnom Penh, particularly on television and at points of sale. Strengthened implementation and enforcement of Cambodia's subdecree 133 are needed to better regulate promotion in order to protect breastfeeding for the nutrition and health of infants and young children in Cambodia. Mothers who used a breast-milk substitute as a prelacteal feed were 3.9 times more likely to currently feed this same child a breast-milk substitute, as compared with mothers who did not provide breast-milk substitute as a prelacteal feed. Supporting breastfeeding among mothers after delivery is critical to establish and sustain optimal breastfeeding practices. Use of breast-milk substitutes is also very common among mothers of children under 2 years of age in Phnom Penh. We recommend promoting exclusive and continued breastfeeding as beneficial to children's health and development, and supporting policy and workplace environments that enable breastfeeding up to and beyond 24 months of age.

Point-of-sale promotion of breastmilk substitutes and commercially produced complementary foods in Cambodia, Nepal, Senegal and Tanzania

In order to assess the prevalence of point-of-sale promotions of infant and young child feeding products in Phnom Penh, Cambodia; Kathmandu Valley, Nepal; Dakar Department, Senegal; and Dar es Salaam, Tanzania, approximately 30 retail stores per site, 121 in total, were visited. Promotional activity for breastmilk substitutes (BMS) and commercially produced complementary foods in each site were recorded. Point-of-sale promotion of BMS occurred in approximately one-third of sampled stores in Phnom Penh and Dakar Department but in 3.2% and 6.7% of stores in Kathmandu Valley and Dar es Salaam, respectively. Promotion of commercially produced complementary foods was highly prevalent in Dakar Department with half of stores having at least one promotion, while promotions for these products occurred in 10% or less of stores in the other three sites. While promotion of BMS in stores is legal in Senegal, it is prohibited in Cambodia without prior permission of the Ministry of Health/Ministry of Information and prohibited in both Nepal and Tanzania. Strengthening legislation in Senegal and enforcing regulations in Cambodia could help to prevent such promotion that can negatively affect breastfeeding practices.

KEY MESSAGES

Even in countries such as Cambodia, Nepal and Tanzania where point-of-sale promotion is restricted, promotions of BMS were observed (in nearly one-third of stores in Phnom Penh and less than 10% in Dar es Salaam and Kathmandu). Limited promotion of commercially produced complementary foods was evident (less than 10% of stores had a promotion for such foods), except in Dakar Department, where promotions were found in half of stores. Efforts are needed to strengthen monitoring, regulation and enforcement of restrictions on the promotion of BMS. Manufacturers and distributors should take responsibility for compliance with national regulations and global policies pertaining to the promotion of breastmilk substitutes.

Associations Among Lactation, Maternal Carbohydrate Metabolism, and Cardiovascular Health

In mammalian reproductive physiology, lactation follows pregnancy; growing evidence suggests that disruption of this physiology affects a woman's lifetime risk of metabolic disease. These differences may reflect lactation-induced mobilization of fat stores and modulation of maternal stress reactivity. In addition, confounders may play a role: women who breastfeed for long durations are more likely to engage in other healthy behaviors, and obesity and insulin resistance may interfere with breastfeeding physiology. These findings underscore the importance of evidenced-based care to enable women to achieve their infant feeding goals.

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.

Advertisements of follow-on formula and their perception by pregnant women and mothers in Italy

OBJECTIVE

To assess how follow-on formula milks for infants aged 6-12 months are presented to and understood by mothers.

DESIGN

A quantitative and qualitative cross-sectional study including (1) an analysis of advertisements in three magazines for parents; (2) in-depth semistructured qualitative interviews to pregnant women on their perception of two advertisements for follow-on formula and (3) self-administered questionnaires for mothers to explore their exposure to and perception of formula advertisements.

PARTICIPANTS

Eighty pregnant women 32-36 weeks of gestation with no previous children and 562 mothers of children <3 years old.

SETTING

Maternal and child health centres in eight cities of Italy.

RESULTS

Advertisements of formula (n=89) represented about 7% of all advertisements in the three magazines, the majority (58%) being for follow-on formula. Advertisements were parent-oriented, aimed at helping parents solve health problems of their babies or at eliciting good feelings, or both. The qualitative interviews to pregnant women showed inability to define the advertised products at first glance due to the ambiguity of the numeral 2 and the presumed age of the portrayed baby; this inability did not disappear after carefully viewing the advertisements and reading the text. When asked in the self-administered questionnaires whether they had ever come across advertisements of infant formula, 81% of mothers reported that they had, despite the legal inexistence of such advertisements, and 65% thought that it was for a product to be used from birth.

CONCLUSIONS

Advertisements of follow-on formula are perceived by pregnant women and mothers as promoting infant formula.

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.

Evaluating motivational interviewing to promote breastfeeding by rural Mexican-American mothers: the challenge of attrition

Although most Hispanic/Latino-American mothers initiate breastfeeding, duration and exclusivity of breastfeeding remain low. We explored whether a motivational interviewing (MI) intervention could help rural Mexican-American mothers continue breastfeeding. We used a two-group (MI intervention n = 26, attention control [AC] n = 27) repeated measures experimental design. Assessments and interventions occurred at 3 days, 2 weeks, and 6 weeks postpartum (time points when mothers are particularly vulnerable to discontinuing breastfeeding), with a final phone assessment at 6 months postpartum. We collected demographic data and measured intent to breastfeed for 6 months (intent question), self-efficacy (Breastfeeding Self-Efficacy Scale-Short Form), and collected breastfeeding information (breastfeeding assessment questionnaire). Independent t-tests and Mann Whitney U non-parametric tests were used to evaluate group differences (α = 0.05). High levels of attrition by week 6 impaired our ability to evaluate the potential of our MI intervention. No significant differences were found between groups for any of the outcome variables (intent to breastfeed for 6 months, breastfeeding self-efficacy, and duration of breastfeeding). Though the mothers intended to breastfeed for 6 months and were confident in their ability to do so, most did not breastfeed for 6 months. At 6 months, mothers receiving the MI intervention had breastfed an average of 90 days compared to 82 days for those receiving the AC sessions and 22% of the mothers in each group were still breastfeeding at some level. Because of the impact of attrition during this study, we discuss factors that contributed to attrition and approaches to lessen this problem in future studies. Such efforts may require a greater investment of time and resources and should be budgeted accordingly. Culturally appropriate interventions are needed to help rural Mexican-American mothers meet their breastfeeding goals, thus providing an opportunity to reduce their children's risk of multiple diseases and obesity. Only when we address these considerations will we have an opportunity to decrease health disparities, promote healthy behaviors, and be trusted health care partners.

The impact of cosmetic breast implants on breastfeeding: a systematic review and meta-analysis

BACKGROUND

Cosmetic breast augmentation (breast implants) is one of the most common plastic surgery procedures worldwide and uptake in high income countries has increased in the last two decades. Women need information about all associated outcomes in order to make an informed decision regarding whether to undergo cosmetic breast surgery. We conducted a systematic review to assess breastfeeding outcomes among women with breast implants compared to women without.

METHODS

A systematic literature search of Medline, Pubmed, CINAHL and Embase databases was conducted using the earliest inclusive dates through December 2013. Eligible studies included comparative studies that reported breastfeeding outcomes (any breastfeeding, and among women who breastfed, exclusive breastfeeding) for women with and without breast implants. Pairs of reviewers extracted descriptive data, study quality, and outcomes. Rate ratios (RR) and 95% confidence intervals (CI) were pooled across studies using the random-effects model. The Newcastle-Ottawa scale (NOS) was used to critically appraise study quality, and the National Health and Medical Research Council Level of Evidence Scale to rank the level of the evidence. This systematic review has been registered with the international prospective register of systematic reviews (PROSPERO): CRD42014009074.

RESULTS

Three small, observational studies met the inclusion criteria. The quality of the studies was fair (NOS 4-6) and the level of evidence was low (III-2 - III-3). There was no significant difference in attempted breastfeeding (one study, RR 0.94, 95% CI 0.76, 1.17). However, among women who breastfed, all three studies reported a reduced likelihood of exclusive breastfeeding amongst women with breast implants with a pooled rate ratio of 0.60 (95% CI 0.40, 0.90).

CONCLUSIONS

This systematic review and meta-analysis suggests that women with breast implants who breastfeed were less likely to exclusively feed their infants with breast milk compared to women without breast implants.

Compliance with the International Code of Marketing of breast-milk substitutes: an observational study of pediatricians' waiting rooms

Abstract The importance of breastmilk as a primary preventative intervention is widely known and understood by most healthcare providers. The actions or non-actions that heathcare providers take toward promoting and supporting breastfeeding families make a difference in the success and duration of breastfeeding. Recognizing this relationship, the World Health Organization developed the International Code of Marketing of Breast-milk Substitutes (the Code), which defines best practices in breastfeeding promotion, including physicians' offices. The pediatric practices' waiting rooms are often a family's first experience with pediatric care. The specific aims of this study were to describe (1) Code compliance, (2) the demographic factors affecting the Code compliance, and (3) the amount and type of breastfeeding-supportive materials available in the pediatricians' waiting rooms. An observational cross-sectional design was used to collect data from 163 (82%) of the pediatric practices in Maricopa County, Arizona. None of the 100 waiting rooms that had any materials displayed (61%) was found to be completely Code compliant, with 81 of the offices having formula-promotional materials readily available. Waiting rooms in higher income areas offered more non-Code-compliant materials and gifts. Breastfeeding support information and materials were lacking in all but 18 (18%) offices. A positive relationship (t97=-2.31, p=0.02) occurred between the presence of breastfeeding educational materials and higher income areas. We were able to uncover some practice-related patterns that impact families and potentially undermine breastfeeding success. To move current practices toward breastfeeding-friendly physicians' offices, change is needed.

ABM Clinical Protocol #5: Peripartum breastfeeding management for the healthy mother and infant at term, revision 2013

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.

Knowledge, attitudes and practices regarding infant feeding among HIV-infected pregnant women in Gaborone, Botswana: a cross-sectional survey

OBJECTIVES

To assess knowledge, attitudes and practices regarding infant feeding among HIV-positive pregnant women in Gaborone, Botswana, and factors that influence their infant feeding choices.

DESIGN

A cross-sectional study.

METHODS AND STUDY SETTING

A questionnaire survey of 96 HIV-positive pregnant women attending four public infectious disease control clinics in Gaborone, Botswana.

RESULTS

Only about half of the study participants had knowledge about prevention of mother-to-child transmission (PMTCT) services related to breastfeeding, and very few (19.8%) chose to breastfeed their infants exclusively. Results of multiple logistic regression analysis showed that receiving infant feeding counselling as part of the PMTCT programme was significantly associated with a decision to exclusively breastfeed (OR (95% CI) 5.38 (1.83 to 15.81)). Similarly, HIV-positive pregnant women who received breastfeeding counselling through the PMTCT programme had higher knowledge of PMTCT practices related to appropriate infant feeding (OR (95% CI) 5.91 (1.06 to 34.31)). Women who did not express concern about HIV stigma had significantly higher knowledge of PMTCT practices related to infant feeding (OR (95% CI) 5.91 (1.69 to 15.56)). Knowledge of PMTCT practices related to breastfeeding was negatively associated with the belief that breastfeeding could transmit HIV to the baby (OR (95% CI) 9.73 (3.37 to 28.08)).

CONCLUSIONS

Knowledge, attitudes and practices related to breastfeeding among HIV-positive pregnant women need further improvement, and the PMTCT programme should strengthen infant feeding counselling services to assist HIV-positive mothers in making informed and appropriate decisions regarding infant feeding.

Understanding women's interpretations of infant formula advertising

BACKGROUND

Exclusive breastfeeding for 6 months and continued breastfeeding for at least 1 year is recommended by all major health organizations. Whereas 74.6 percent of mothers initiate breastfeeding at birth, exclusivity and duration remain significantly lower than national goals. Empirical evidence suggests that exposure to infant formula marketing contributes to supplementation and premature cessation. The objective of this study was to explore how women interpret infant formula advertising to aid in an understanding of this association.

METHODS

Four focus groups were structured to include women with similar childbearing experience divided according to reproductive status: preconceptional, pregnant, exclusive breastfeeders, and formula feeders. Facilitators used a prepared protocol to guide discussion of infant formula advertisements. Authors conducted a thematic content analysis with special attention to women's statements about what they believed the advertisements said about how the products related to human milk (superior, inferior, similar) and how they reported reacting to these interpretations.

RESULTS

Participants reported that the advertisements conveyed an expectation of failure with breastfeeding, and that formula is a solution to fussiness, spitting up, and other normal infant behaviors. Participants reported that the advertisements were confusing in terms of how formula-feeding is superior, inferior or the same as breastfeeding. This confusion was exacerbated by an awareness of distribution by health care practitioners and institutions, suggesting provider endorsement of infant formula.

CONCLUSIONS

Formula marketing appears to decrease mothers' confidence in their ability to breastfeed, especially when provided by health care practitioners and institutions. Therefore, to be supportive of breastfeeding, perinatal educators and practitioners could be more effective if they did not offer infant formula advertising to mothers.

Association of health profession and direct-to-consumer marketing with infant formula choice and switching

BACKGROUND

Infant formula is marketed by health professionals and directly to consumers. Formula marketing has been shown to reduce breastfeeding, but the relation with switching formulas has not been studied. Willingness to switch formula can enable families to spend less on formula.

METHODS

Data are from the Infant Feeding Practices Study II, a United States national longitudinal study. Mothers were asked about media exposure to formula information during pregnancy, receiving formula samples or coupons at hospital discharge, reasons for their formula choice at infant age 1 month, and formula switching at infant ages 2, 5, 7, and 9 months. Analysis included 1,700 mothers who fed formula at infant age 1 month; it used logistic regression and longitudinal data analysis methods to evaluate the association between marketing and formula choice and switching.

RESULTS

Most mothers were exposed to both types of formula marketing. Mothers who received a sample of formula from the hospital at birth were more likely to use the hospital formula 1 month later. Mothers who chose formula at 1 month because their doctor recommended it were less likely to switch formula than those who chose in response to direct-to-consumer marketing. Mothers who chose a formula because it was used in the hospital were less likely to switch if they had not been exposed to Internet web-based formula information when pregnant or if they received a formula sample in the mail.

CONCLUSIONS

Marketing formula through health professionals may decrease mothers' willingness to switch formula.

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.

Evidence-based interventions to support breastfeeding

Considerable progress has been made in the past decade in developing comprehensive support systems to enable more women to reach their breastfeeding goals. Given that most women in the United States participate in some breastfeeding, it is essential that each of these support systems be rigorously tested and if effective replicated. Additional research is needed to determine the best methods of support during the preconception period to prepare women to exclusively breastfeed as a cultural norm.

Infant feeding practices and breastfeeding duration in Japan: A review

The Japanese health system places great emphasis on healthy development. However, the prevalence of Exclusive Breastfeeding at one month postpartum between 1980 and 2005 has remained unchanged, fluctuating between 42% and 49%. At the same time, the Any Breastfeeding prevalence has gradually increased from about 80% to 95%. In 2010, the latest national breastfeeding report showed that 'exclusive' and 'any' breastfeeding rates have improved. However, as the World Health Organization (WHO) definition of breastfeeding practices was not used in this study or in other national surveys, it is difficult to interpret these latest results. While the Japanese government has launched several promotion projects, there have been few studies and reviews of risk factors that influence breastfeeding duration. The objectives of this review were to summarise the factors that have influenced the duration of breastfeeding in Japan to provide information relevant to breastfeeding promotion programs. A search of electronic databases in Japanese and English was undertaken up to 2011. The inclusion criteria for this review were studies that focused on infant feeding practices and targeted Japanese mothers, fathers, or health professionals, but excluded mothers' friends and peer groups. In total, 12 articles were selected for the final analysis. Smoking status, low birth weight of infants and maternal perceptions of insufficient breast milk supply were negative influences on breastfeeding duration, while support from husbands/partners is associated with continued breastfeeding. Some factors that have been found to be associated with breastfeeding in other countries, including maternal age, family income, maternal educational levels, and living with grandparents of infants have not been confirmed in Japan. While the national breastfeeding rates were higher than other countries of similar health status, inconsistent knowledge of breastfeeding benefits and inappropriate hospital practices remain in Japan may be associated with increased the use of infant formula and reduced breastfeeding duration. Most of the studies reviewed were cross-sectional in design, with only a limited number of cohort studies. Also many published studies used small sample sizes. Cohort studies of infant feeding practices with larger sample sizes are required to monitor trends in rates and risk factors for breastfeeding outcomes.

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.

Is unimpeded marketing for breast milk substitutes responsible for the decline in breastfeeding in the Philippines? An exploratory survey and focus group analysis

Infant mortality and morbidity risk is linked to formula usage. The proportion of Filipino infant formula users rose 6% between 2003 and 2008. It is hypothesized this rise resulted from aggressive formula industry marketing. We conducted a household survey between April and December 2006 and focus groups in April-May 2007 in The Philippines to examine the association between mothers' exposure to advertising and other information sources and formula feeding decisions. Sixteen barangays (communities) were randomly selected from three purposively selected disadvantaged rural, urban and mixed municipalities. A total of 345 households had children under 24-months age: 114, 142 and 89 households from the rural, urban and mixed municipalities, respectively. In addition 38 respondents participated in 3 focus groups of 10-15 participants each, from three selected barangays. After adjusting for education and economic indicators logistic regression analysis showed that, children were more likely to be given formula if their mother recalled advertising messages, or a doctor, or mother or relative recommended it. Those using formula were 6.4 (1.8-23.1) times more likely to stop breastfeeding before 12 months. The focus groups described how television advertisements, doctors and medical representatives enticed them to use formula. We conclude that two factors were strongly associated with the decision to formula feed: self-reported advertising exposure, and physicians' recommendations.

Clinical protocol number #19: breastfeeding promotion in the prenatal setting

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.

Birthing ethics: what mothers, families, childbirth educators, nurses, and physicians should know about the ethics of childbirth

This article discusses current ethical issues associated with childbirth in the United States. It provides a review of moral problems and ethical choices made by parents and health-care professionals during the prenatal, intrapartum, and postpartum periods. Ethical issues are identified and framed through a "naturalized bioethics" approach, as recommended by Margaret Walker and her colleagues, Hilde Lindemann and Marian Verkerk. This approach critiques traditional bioethics and gives attention to everyday ethics and the social, economic, and political context within which ethical problems exist. This approach provides the reader with the tools needed to critically assess the way ethical problems are defined and resolved.

Influence of intention and self-efficacy levels on duration of breastfeeding for midwest rural mothers

OBJECTIVES

The purpose of this study was to explore the relationship of two modifiable factors (intention to breastfeed for 6 months and breastfeeding self-efficacy) with the duration of breastfeeding in primiparous women.

FINDINGS

Analyzed by logistic regression in a single prediction model, stronger intention (odds ratio = 1.89) and higher levels of self-efficacy at 2 weeks postpartum (odds ratio = 1.04) were significantly (p < .05) associated with an increased probability of breastfeeding for 6 months.

CONCLUSIONS

The combined influence of higher intention and self-efficacy increased the likelihood of breastfeeding for the recommended 6 months. Interventions to reinforce both should be designed and evaluated.

Marketing breastfeeding--reversing corporate influence on infant feeding practices

Breast milk is the gold standard for infant nutrition and the only necessary food for the first 6 months of an infant's life. Infant formula is deficient and inferior to breast milk in meeting infants' nutritional needs. The infant formula industry has contributed to low rates of breastfeeding through various methods of marketing and advertising infant formula. Today, in New York City, although the majority of mothers initiate breastfeeding (approximately 85%), a minority of infants is breastfed exclusively at 8 weeks postpartum (approximately 25%). The article reviews the practices of the formula industry and the impact of these practices. It then presents the strategic approach taken by the NYC Department of Health and Mental Hygiene and its partners to change hospital practices and educate health care providers and the public on the benefits of breast milk, and provides lessons learned from these efforts to make breastfeeding the normative and usual method of infant feeding in New York City.

Protection, promotion and support of breastfeeding in low-income countries

The rates of exclusive breastfeeding and the duration of breastfeeding fall short of what is recommended by the Global Strategy on Infant and Young Child Feeding worldwide. In low-income countries this is associated with a great excess of avoidable childhood death and disease. A higher degree of protection, promotion and support of breastfeeding has the potential to avert the death of about 1.3 million children per year and to prevent much of the associated individual and social sufferings. This paper presents some evidence about interventions that are effective to protect, promote and support breastfeeding in the health system and in the community. These interventions should not be implemented in isolation, but as part of an integrated and intersectoral programme, with a participatory approach that takes local cultural characteristics into account. Lack of political will is probably the most important factor associated with inadequate protection, promotion and support of breastfeeding.

Increasing breastfeeding rates in New York City, 1980-2000

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

Correlates of breastfeeding initiation in southeast Arkansas

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Baby-Friendly way: the best breastfeeding start

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

The effectiveness of primary care-based interventions to promote breastfeeding: systematic evidence review and meta-analysis for the US Preventive Services Task Force

PURPOSE

We wanted to systematically review whether primary care-based interventions improve initiation and duration of breastfeeding.

METHODS

Studies were found by searching MEDLINE (1966-2001), Health-STAR, the Cochrane Database of Systematic Reviews, the National Health Service Centre for Reviews and Dissemination Databases, and bibliographies of identified trials and review articles. Studies were included if they originated in the primary care setting and were conducted in a developed country, written in English, and contained a concurrent control group.

RESULTS

Thirty randomized and nonrandomized controlled trials and 5 systematic reviews of breastfeeding counseling were included. Educational programs had the greatest effect of any single intervention on both initiation (difference 0.23; 95% confidence interval [CI], 0.12-0.34) and short-term duration (difference 0.39; 95% CI, 0.27-0.50). Support programs conducted by telephone, in person, or both increased short-term (difference 0.11; 95% CI, 0.03-0.19) and long-term duration (difference 0.08; 95% CI, 0.02-0.16). In contrast, written materials such as pamphlets did not significantly increase breastfeeding. Data were insufficient to determine whether the combination of education with support was more effective than education alone.

CONCLUSIONS

Educational programs were the most effective single intervention. One woman would breast-feed for up to 3 months for every 3 to 5 women attending breastfeeding educational programs. Future research and policy should focus on translating these findings into more widespread practice in diverse primary care settings.

Position of the American Dietetic Association: nutrition and lifestyle for a healthy pregnancy outcome

It is the position of the American Dietetic Association that women of childbearing potential should maintain good nutritional status through a lifestyle that optimizes maternal health and reduces the risk of birth defects, suboptimal fetal growth and development, and chronic health problems in their children. The key components of a health-promoting lifestyle during pregnancy include appropriate weight gain; consumption of a variety of foods in accordance with the Food Guide Pyramid; appropriate and timely vitamin and mineral supplementation; avoidance of alcohol, tobacco, and other harmful substances; and safe food-handling. Prenatal weight gain within the Institute of Medicine (IOM) recommended ranges is associated with better pregnancy outcomes. The total energy needs during pregnancy range between 2,500 to 2,700 kcal a day for most women, but prepregnancy body mass index, rate of weight gain, maternal age, and physiological appetite must be considered in tailoring this recommendation to the individual. The consumption of more food to meet energy needs and the increased absorption and efficiency of nutrient utilization that occurs in pregnancy are generally adequate to meet the needs for most nutrients. However, vitamin and mineral supplementation is appropriate for some nutrients and situations. This statement also includes recommendations pertaining to use of alcohol, tobacco, caffeine, street drugs, and other substances during pregnancy; food safety; and management of common complaints during pregnancy and specific health problems. In particular for medical nutrition therapy, pregnant women with inappropriate weight gain, hyperemesis, poor dietary patterns, phenylketonuria (PKU), certain chronic health problems, or a history of substance abuse should be referred to a qualified dietetics professional.

Breastfeeding

A large and growing body of scientific evidence suggests that breastfeeding provides immediate and long-lasting health advantages for the mother and her infant. In the United States, breastfeeding rates currently are the highest recorded in 30 years, although premature weaning owing to the largely avoidable problems of breast pain and concern about adequate milk supply is still common. The advantages of breastfeeding will be more widely appreciated when all health care professionals acquire competence in evidence-based lactation management strategies. These strategies include helping women to position and attach their newborns correctly, encouraging frequent and effective feedings at the breast from birth onward, teaching new parents the signs of adequate milk intake, and providing the resources for promoting breastfeeding without the competition of commercial product promotion.

Implementing change: becoming baby-friendly in an inner city hospital

The Baby-Friendly Hospital Initiative of the United Nations Children's Fund and the World Health Organization dramatically raises breastfeeding rates when implemented. To date, only 27 of the 16,000 Baby-Friendly hospitals worldwide are located in the United States. Barriers to becoming Baby-Friendly in the United States include the strength of the infant formula industry, suboptimal clinician knowledge, and the need to implement significant change throughout an institution. This paper describes how Boston Medical Center, an inner-city teaching hospital in Boston with approximately 1800 births per year, overcame numerous obstacles and, in December 1999, became the first Baby-Friendly hospital in Massachusetts.