Impact of baby-friendly hospital practices on breastfeeding in Hong Kong

Impact of baby-friendly hospital initiatives on breastfeeding outcomes: Systematic review and meta-analysis

BACKGROUND

The Baby-Friendly Hospital Initiative (BFHI) is a global effort promoting the Ten Steps to support breastfeeding in maternity-care facilities.

AIM

This study examined the effect of BFHI on breastfeeding outcomes, focusing on initiation rates, exclusive breastfeeding durations, and factors influencing its effectiveness.

METHODS

A systematic review and meta-analysis were conducted by searching nine databases (1991 to February 2024). Included studies were experimental, quasi-experimental, or observational studies, with sites implementing the full BFHI or at least three steps. Two reviewers independently screened studies, assessed risk of bias, and extracted data. Random-effects models were used for pooled results, with subgroup analyses based on BFHI status and country income level.

DISCUSSION

Eighty-six studies were included. Infants in BFHI hospitals were more likely to be exclusively breastfed at ≤ 3 months (OR= 1.77; 95 % CI: 1.37-2.29) and 3-6 months (OR= 1.82; 95 % CI: 1.26-2.61). Higher rates of any breastfeeding were observed at ≤ 3 months (OR= 1.48; 95 % CI: 1.17-1.87), 3-6 months (OR= 1.75; 95 % CI: 1.18-2.61) and at > 6 months (OR= 2.34; 95 % CI: 1.04-5.27).

CONCLUSIONS

BFHI implementation positively impacts breastfeeding outcomes, with both short- and long-term effects. Partial implementation also correlates with higher exclusive breastfeeding rates. Insignificant differences across income levels may reflect the limited number of studies in low-and middle- income countries. Further research with longer-term follow up is needed to confirm long-term effects.

Associations between breastfeeding and self-reported experience of the "10 Steps to Successful Breastfeeding": a cross-sectional and longitudinal study of maternity clinic practices in Cyprus

Objective

To assess the implementation of the "10 Steps for Successful Breastfeeding" and explore associations with any Breastfeeding (BF) and Exclusive Breastfeeding (EBF) initiation and continuation.

Methods

Implementation of the 10 Steps was assessed based on a consecutive sample of 568 mothers' self-reported experience across all public (N = 5) and 29 (of 35) private maternity clinics using the WHO/UNICEF BFHI questionnaire (Section 4) within the first 24-48 h after birth. BF and EBF were estimated within 48 h after birth as well as at 1st, 4th and 6th month based on a self-reported current status method. Associations with initiation and continuation of any BF and EBF up to the 6th month were explored in logistic regression after adjusting for potential confounders. Associations were explored with individual steps as well as the overall experience, operationalized as the sum score of full, partial or no implementation of each item, with the exception of Step 6 (exclusive breastfeeding).

Results

At mean score 6.2 (SD = 2.7), the overall 10 Steps experience was low (theoretical range 0-14), even among those who breastfed exclusively (M = 7.7, SD = 2.0). EBF and BF initiation and continuation showed a stepwise association with self-reported experience of the 10 Steps. Across quartiles of increasing scores within 48 h after birth, the prevalence of EBF was 7.5%, 14.4%, 19.0%, and 34.2%. Mothers who experienced full or partial implementation of Step 4 (i.e., early initiation with skin-to-skin) were more likely to continue BF and EBF up to the 4th month, while use of pacifiers (Step 9) was more likely to have an adverse effect on breastfeeding continuation and exclusivity.

Conclusion

The BFIH's "10 Steps" are associated with BF initiation while certain practices seem to be more strongly associated with exclusivity and continuation of breastfeeding up to the sixth month. While breastfeeding intention may determine the experience of the 10 Steps, this also suggests that maternity care practices can have a supportive role for mothers to succeed their intentions to BF and EBF.

Breastfeeding practices in Northeast China in 2008 and 2018: cross-sectional surveys to explore determinants over a decade

BACKGROUND

This study was conducted to investigate the prevalence and determinants of breastfeeding in 2008 and 2018, respectively, in Northeast China, where health service efficiency is at the lowest national level and regional data on breastfeeding are lacking. The influence of early initiation of breastfeeding on later feeding practices was specifically explored.

METHODS

Data from the China National Health Service Survey in Jilin Province in 2008 (n = 490) and 2018 (n = 491) were analysed. Multistage stratified random cluster sampling procedures were used to recruit the participants. Data collection was conducted in the selected villages and communities in Jilin. Early initiation of breastfeeding was defined as the proportion of children born in the last 24 months who were put to the breast within one hour after birth in both the 2008 and 2018 surveys. Exclusive breastfeeding was defined as the proportion of infants 0-5 months of age who were fed exclusively with breast milk in the 2008 survey; while defined as the proportion of infants 6-60 months of age who had been fed exclusively with breast milk within the first six months of life in the 2018 survey.

RESULTS

The prevalence of early initiation of breastfeeding (27.6% in 2008 and 26.1% in 2018) and exclusive breastfeeding during the first six months (< 50%) were low in two surveys. Logistic regression revealed that exclusively breastfeeding at six months was positively associated with early initiation of breastfeeding (OR 2.65; 95% confidence interval (CI) 1.65, 4.26) and negatively associated with caesarean section (OR 0.65; 95% CI 0.43, 0.98) in 2018. Continued breastfeeding at one year and timely introduction of complementary foods were associated with maternal residence and place of delivery, respectively, in 2018. Early initiation of breastfeeding was associated with mode and place of delivery in 2018 but residence in 2008.

CONCLUSION

Breastfeeding practices in Northeast China are far from optimal. The negative effect of caesarean section and positive effect of early initiation of breastfeeding on exclusive breastfeeding suggest that an institution-based approach should not be substituted by the community-based one in the formulation of breastfeeding strategies in China.

Improving breastfeeding support through the implementation of the Baby-Friendly Hospital and Community Initiatives: a scoping review

BACKGROUND

Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund, which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) grew out of step 10, with a focus on community-based implementation. The aim of this scoping review is to map and examine the evidence relating to the implementation of BFHI and BFCI globally.

METHODS

This scoping review was conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria followed the Population, Concepts, Contexts approach. All articles were screened by two reviewers, using Covidence software. Data were charted according to: country, study design, setting, study population, BFHI steps, study aim and objectives, description of intervention, summary of results, barriers and enablers to implementation, evidence gaps, and recommendations. Qualitative and quantitative descriptive analyses were undertaken.

RESULTS

A total of 278 articles were included in the review. Patterns identified were: i) national policy and health systems: effective and visible national leadership is needed, demonstrated with legislation, funding and policy; ii) hospital policy is crucial, especially in becoming breastfeeding friendly and neonatal care settings iii) implementation of specific steps; iv) the BFCI is implemented in only a few countries and government resources are needed to scale it; v) health worker breastfeeding knowledge and training needs strengthening to ensure long term changes in practice; vi) educational programmes for pregnant and postpartum women are essential for sustained exclusive breastfeeding. Evidence gaps include study design issues and need to improve the quality of breastfeeding data and to perform prevalence and longitudinal studies.

CONCLUSION

At a national level, political support for BFHI implementation supports expansion of Baby-Friendly Hospitals. Ongoing quality assurance is essential, as is systematic (re)assessment of BFHI designated hospitals. Baby Friendly Hospitals should provide breastfeeding support that favours long-term healthcare relationships across the perinatal period. These results can help to support and further enable the effective implementation of BFHI and BFCI globally.

How midwives and nurses experience implementing ten steps to successful breastfeeding: a qualitative case study in an Indonesian maternity care facility

BACKGROUND

The in-hospital stay following childbirth is a critical time for education and support of new mothers to establish breastfeeding. The WHO/UNICEF 'Ten Steps to Successful Breastfeeding (Ten Steps)' was launched globally in 1989 to encourage maternity services to educate and support mothers to breastfeed. The strategy is effective, however its uptake within health systems and facilities has been disappointing. We aimed to understand midwives' and nurses' experiences of implementing the Ten Steps in an Indonesian hospital.

METHODS

This qualitative study was conducted in an Indonesian hospital which has been implementing the Ten Steps since the hospital's establishment in 2012. Fourteen midwives and nurses participated in a focus group in January 2020. Data were analyzed using thematic analysis.

RESULTS

We identified five themes that represented midwives' and nurses' experiences of implementing the Ten Steps in this Indonesian maternity unit: 1) Human rights of child and mother, 2) Dependency on precarious leadership, 3) Lack of budget prioritization, 4) Fragmented and inconsistent implementation of the Ten Steps across the health system, and 5) Negotiating with family, community and culture. The results highlighted a dependency on local hospital champions and a lack of budget prioritization as barriers to implementation, as well as health system gaps which prevented the enablement of mothers and families to establish and maintain breastfeeding successfully in Indonesian maternity services.

CONCLUSIONS

As Indonesia has one of the largest populations in South East Asia, it is an important market for infant milk formula, and health services are commonly targeted for marketing these products. This makes it especially important that the government invest strongly in Ten Steps implementation. Continuity of care within and across the health system and leadership continuity are key factors in reinforcing its implementation. The study findings from this Indonesian maternity care facility re-emphasize WHO recommendations to integrate the Ten Steps into national health systems and increase pre-service education on breastfeeding for health care professionals.

A mixed-methods study on the association of six-month predominant breastfeeding with socioecological factors and COVID-19 among experienced breastfeeding women in Hong Kong

Background

In the past decade, various breastfeeding policies were implemented in Hong Kong, including changes in perinatal guidelines in public hospitals, adoption of the Baby-Friendly Hospital Initiative (BFHI), provision of guidelines for the marketing of formula milk, penalisation of discrimination towards breastfeeding, and extension of the statutory maternity leave. Meanwhile, the COVID-19 pandemic brought new challenges and opportunities to breastfeeding practices. Infection control measures in public hospitals included the cancellation of antenatal classes, hospital tours, and postnatal classes; suspension of perinatal visiting periods; and compulsory separation of COVID-19 positive mothers from newborns. In addition, work-from-home policies were widely implemented. This study aimed to identify the associated factors of six-month predominant breastfeeding (PBF), and to evaluate the impact of COVID-19 on breastfeeding practice.

Methods

This study was conducted from 1 March 2021 to 7 April 2021 using a mixed-methods approach. An electronic questionnaire was distributed to members of breastfeeding or parenting groups who have had breastfeeding experience in the past 10 yrs. Logistic and linear regression analyses were conducted to identify factors associated with six-month PBF both in general and during the pandemic period. A qualitative content analysis was conducted using an inductive approach.

Results

The study included 793 participants. Giving birth in a public hospital (OR 2.21; 95% CI 1.46, 3.34) and breastfeeding support from family and friends (OR 1.28; 95% CI 1.05, 1.57) were significantly associated with six-month PBF, even during COVID-19. Factors associated with the self-rated impact of COVID-19 on breastfeeding include working from home, the perceived immunological benefits of breastfeeding, and the wish to avoid breastfeeding or expressing breast milk in public premises. Furthermore, breastfeeding practice in public hospitals was more likely to be affected by the busyness of staff, while private hospitals had worse rooming-in practices and staff who had inadequate breastfeeding knowledge.

Conclusions

Giving birth in a public hospital and having breastfeeding support from family and friends were associated with six-month PBF. Furthermore, COVID-19 in Hong Kong had an overall positive impact on six-month PBF. Further studies should investigate the impact of hospital practices and the COVID-19 pandemic on breastfeeding behaviours.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00484-7.

Effects of baby-friendly practices on breastfeeding duration in China: a case-control study

BACKGROUND

The Baby-Friendly Hospital Initiative is generally considered an effective way to promote breastfeeding. Although China has the largest number of baby-friendly hospitals in the world, research on baby-friendly practices in China is limited, and the rate of exclusive breastfeeding (EBF) at 6 months, 20.7%, compared to the 2025 global goal of 50% is low. It is, therefore, important to determine the factors that remain significant barriers to EBF in China. To explore how the key baby-friendly practices affect EBF duration in China, we used a case-control study to compare the effects of baby-friendly-related practices on both EBF and non-breastfeeding (NBF) mothers at 3 months and to investigate the effects of both single and comprehensive baby-friendly practices in promoting EBF duration at 3 months, which is one step toward EBF at 6 months.

METHODS

Participants were recruited from four maternal and child health hospitals in western (Chongqing), eastern (Qingdao), southern (Liuzhou), and central China (Maanshan). A total of 421 mothers (245 in the EBF group, 176 in the NBF group) of infants aged 3 months were surveyed through a self-reported questionnaire from April 2018 to March 2019. The experience of baby-friendly practices and breastfeeding during hospitalization were assessed with yes/no questions. Socio-demographic factors that influenced breastfeeding at 3 months were analyzed using bivariate and multivariate logistic regression analyses.

RESULTS

Of mothers in the EBF group, 65.57% reported engaging in at least seven baby-friendly practices compared to 47.72% of mothers in the NBF group. Significantly more mothers in the EBF group engaged in baby-friendly practices than in the NBF group. These practices included "breastfeeding within one hour after birth" (74.29% vs. 59.09%), "breastfeeding on demand" (86.48% vs. 75.00%), and "never use a pacifier" (46.53% vs. 31.25%). After adjusting for confounding variables, we found that the mothers who engaged in fewer than seven baby-friendly practices were about 1.7 times less likely to breastfeed than were those who engaged in seven or more baby-friendly practices (odds ratio [OR] 1.720, 95% confidence interval [CI] 1.106, 2.667). Further, the mothers who did not breastfeed on demand were as likely to not breastfeed up to 3 months (OR 2.263, 95% CI 1.265, 4.049), as were mothers who did not breastfeed during hospitalization (OR 4.379, 95% CI 1.815, 10.563).

CONCLUSIONS

These data from hospitals in China suggest that higher compliance with baby-friendly practices may have a positive impact on EBF at 3 months, particularly in terms of promoting the implementation of breastfeeding on demand and breastfeeding during hospitalization in China.

Perceived enablers of exclusive breastfeeding by teenage mothers in Ghana

Background

Exclusive breastfeeding for the first 6 months can prevent diseases, boost immunity and improve quality of lives of infants. Ghana implemented programmes aimed at reaching the global target of increasing exclusive breastfeeding for the first 6 months to at least 50% by the year 2025. The country witnessed a decline in the overall rate of exclusive breastfeeding and an increase in the number of teenage mothers. Globally, teenage mothers are less likely to breastfeed than mothers of other age groups. Understanding enablers of exclusive breastfeeding by teenage mothers is important for any intervention aimed at improving exclusive breastfeeding rates and the quality of lives of infants.

Method

The study used a qualitative, exploratory, descriptive and contextual design, with focus groups. A total of six group discussions were conducted with 30 pregnant teenagers recruited from six public hospitals.

Results

Seven enablers emerged from the analysis of data. These included positive beliefs about the benefits of breast milk, family history of positive exclusive breastfeeding outcomes, support of the intimate partner, approval of closed-family members, expert opinions of antenatal care staff, teenage-oriented breastfeeding education and community-based breastfeeding education.

Conclusion

Health professionals and policy makers could learn from these enablers and use them to promote exclusive breastfeeding practices amongst teenage mothers in Ghana.

Using the Knowledge-to-Action Framework to understand experiences of breastfeeding guideline implementation: A qualitative study

AIM

To examine the perceptions and experiences of health care professionals and mothers in relation to the implementation of a breastfeeding clinical practice guideline (CPG).

BACKGROUND

Breastfeeding CPG applications remain limited, and qualitative studies have indicated the need to overcome the perception by professionals of difficulties in applying recommendations.

METHODS

A qualitative study was conducted in a Spanish public hospital that implemented the Registered Nurses´ Association of Ontario breastfeeding CPG from 2012 through 2015. Between May and August 2017, 27 semi-structured interviews were conducted with managers, with professionals in maternity and paediatric departments and with mothers. Deductive content analysis was performed following the stages in the Knowledge-To-Action (KTA) Framework.

RESULTS

We obtained five main categories: (a) problem as opportunity; (b) adequate context and adapted recommendations; (c) extent of implementation; (d) impact of results; and (e) knowledge use normalization.

CONCLUSIONS

The KTA Framework assists understanding of the participation of the main actors in breastfeeding CPG implementation.

IMPLICATIONS FOR NURSING MANAGEMENT

The nature of the interventions and the participation of managers, different professionals and mothers in a multi-unit setting generate a complex implementation process that reveals key factors to be taken into account in future CPG implementations.

Exposure to baby-friendly hospital practices and mothers' achievement of their planned duration of breastfeeding

BACKGROUND

Both breastfeeding intentions and exposure to baby-friendly hospital practices were found to be associated with a longer duration of breastfeeding. This study aims to examine the effect of exposure to baby-friendly hospital practices on mothers' achievement of their planned duration of breastfeeding.

METHODS

A total of 1011 mother-newborn pairs from the postnatal units of four public hospitals in Hong Kong were recruited. Sociodemographic data and breastfeeding intention data were collected via self-report questionnaires during the postnatal hospitalization and exposure to Baby-Friendly hospital practices were assessed through hospital records and maternal self-report. Breastfeeding status after hospital discharge was assessed through telephone follow-up for up to 12 months postnatal, or until participants were no longer breastfeeding.

RESULTS

Only 55% (n = 552) of study participants achieved their intended duration of breastfeeding. Participants with higher socioeconomic status, previous breastfeeding experience, and those who had lived in Hong Kong for less than 5 years, were more likely to achieve their planned duration of breastfeeding. Among baby-friendly hospital practices, feeding only breast milk during the hospitalization and providing information about breastfeeding support on discharge were associated with participants' achieving their individual breastfeeding intentions. After adjustment, when compared with women who experienced onebaby-friendly practice, participants who experienced six baby-friendly hospital practices were significantly more likely to achieve their planned duration of breastfeeding (adjusted odds ratio = 8.45, 95% confidence interval 3.03-23.6).

CONCLUSIONS

Nearly half of participants did not achieve their planned breastfeeding duration. Exposure to baby-friendly hospital practices, especially in-hospital exclusive breastfeeding and providing breastfeeding support information upon hospital discharge may help more mothers to achieve their individual breastfeeding goals.

Breastfeeding Outcomes Among WIC-Participating Infants and Their Relationships to Baby-Friendly Hospital Practices

Background: Breastfeeding rates among low-income children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) lag behind national rates. In Los Angeles County (LAC), recent efforts have been made to increase the number of Baby-Friendly designated hospitals. This study examines changes in Baby-Friendly hospital practices, breastfeeding outcomes, and their relationships with Baby-Friendly hospital status among WIC-enrolled children in LAC. Methods: Cross-sectional data from the triennial LAC WIC Survey (2008 through 2017) were analyzed (n = 6,449) to examine changes in Baby-Friendly hospital practices over time, and differences in breastfeeding outcomes by specific Baby-Friendly hospital practices. Multivariate logistic regression was used to evaluate the relationship between the number of Baby-Friendly hospital practices that mothers met and any and exclusive breastfeeding outcomes. Results: In 2017, mothers surveyed were more likely to engage in Baby-Friendly hospital practices compared with 2008. Any and exclusive breastfeeding outcomes at 1 and 3 months significantly increased since 2014, and breastfed infants were more likely to have mothers who participated in Baby-Friendly hospital practices. The more Baby-Friendly hospital practices mothers met, the better the breastfeeding outcomes. However, there is room for improvement in the uptake of Baby-Friendly hospital practices in Baby-Friendly hospitals. Conclusion: Effort is needed to ensure Baby-Friendly hospitals have support to continuously comply with all steps to maintain Baby-Friendly designation, and non-Baby-Friendly hospitals have support to incorporate these practices into hospital protocols.

Baby-friendly hospital practices are associated with duration of full breastfeeding in primiparous but not multiparous Iranian women

There is evidence that the Baby-Friendly Hospital Initiative (BFHI) results in improved breastfeeding outcomes in Western countries, but little is known of its impact in Middle-Eastern countries. This study investigated the impact of BFHI practices on duration of full breastfeeding in a cohort of 700 Iranian mothers recruited between June 2014 and March 2015 from maternity hospitals in Shiraz and followed-up prospectively for 6 months. At baseline, mothers self-reported exposure to 7 of the BFHI Ten Steps to Successful Breastfeeding (Steps 3 to 9). Data on breastfeeding outcomes were collected at baseline, 1, 3, 4, and 6 months postpartum. Cox regression analysis was conducted to determine the impact of individual and cumulative BFHI Steps on the duration of full breastfeeding, defined as the number of weeks since discharge that an infant received only breast milk and no complementary formula or food. Mothers reported experiencing on average 3.9 (SD 1.13, range 1 to 7) Steps, and only 28% of infants were fully breastfed at 6 months. There was a protective inverse relationship for primiparous (p for trend = .022) but not multiparous mothers (p for trend = .069), between the number of Steps a woman was exposed to and the likelihood of her discontinuing full breastfeeding within 6 months postpartum. Greater exposure to BFHI practices potentially could increase primiparous mothers' chances of fully breastfeeding to 6 months. Continual monitoring of the BFHI Steps and repeated education of healthcare staff are required to ensure that Iranian mothers receive adequate breastfeeding support.

Women’s experiences of formula feeding their infants: an interpretative phenomenological study

Objective

This study aimed to explore the experiences of women in the process of formula feeding their infants. The World Health Organization has emphasized the importance of breastfeeding for infant health. After decades of breastfeeding promotions, breastfeeding rates in Hong Kong have been rising consistently; however, the low continuation rate is alarming. This study explores women’s experiences with formula feeding their infants, including factors affecting their decision to do so.

Methods

A qualitative approach using an interpretative phenomenological analysis (IPA) was adopted as the study design. Data were collected from 2014 to 2015 through individual in-depth unstructured interviews with 16 women, conducted between 3 and 12 months after the birth of their infant. Data were analyzed using IPA.

Results

Three main themes emerged as follows: (1) self-struggle, with the subthemes of feeling like a milk cow and feeling trapped; (2) family conflict, with the subtheme of sharing the spotlight; and (3) interpersonal tensions, with the subthemes of embarrassment, staring, and innocence. Many mothers suffered various stressors and frustrations during breastfeeding. These findings suggest a number of pertinent areas that need to be considered in preparing an infant feeding campaign.

Conclusions

The findings of this study reinforce our knowledge of women’s struggles with multiple sources of pressure, such as career demands, childcare demands, and family life after giving birth. All mothers should be given assistance in making informed decisions about the optimal approach to feeding their babies given their individual situation and be provided with support to pursue their chosen feeding method.

Compliance With WHO/UNICEF BFHI Standards in Croatia After Implementation of the BFHI

BACKGROUND

The primary goal of the Baby-Friendly Hospital Initiative (BFHI) is to create conditions in maternity facilities that enable women to initiate and sustain the practice of breastfeeding exclusively. Research aim: This study aimed to determine hospital practices and breastfeeding rates before and after BFHI implementation and assess compliance with UNICEF/World Health Organization (WHO) standards for seven of the BFHI's Ten Steps to Successful Breastfeeding ( Ten Steps).

METHODS

Mothers of healthy, term infants ( N = 1,115) were recruited from the postnatal ward of the University Hospital of Split, Croatia, between February 2008 and July 2011 and followed for 12 months in a repeated-measures, prospective, longitudinal, three-group, nonequivalent, cohort study. Breastfeeding rates, hospital practices-including seven of the Ten Steps-and maternal sociodemographic data were collected.

RESULTS

Parts of all seven Ten Steps that were assessed improved significantly post-BFHI. Step 3 ("antenatal education") showed the least improvement, whereas Step 7 ("rooming-in"; 2.6% pre-BFHI vs. 98.5% post-BFHI) and Step 9 ("no pacifiers/teats"; 21.8% pre-BFHI vs. 99.4% post-BFHI) showed the greatest improvement. Six months after Baby-Friendly designation, only Steps 7 and 9 were in full compliance with UNICEF/WHO standards. In-hospital, exclusive-breastfeeding rates rose markedly ( p < .001), but no change occurred in breastfeeding rates at 3, 6, or 12 months.

CONCLUSION

Full implementation of the BFHI was associated with significant improvement in hospital practices and in-hospital, exclusive-breastfeeding rates, but it did not affect breastfeeding rates postdischarge, emphasizing the vital role of community support. Baby-Friendly Hospital Initiative standards declined rapidly post-hospital designation, indicating the need for regular monitoring and reassessment as well as ongoing, effective training for hospital staff.

Effect on Baby-Friendly Hospital Steps When Hospitals Implement a Policy to Pay for Infant Formula

BACKGROUND

The Baby-Friendly Hospital Initiative requires hospitals to pay market price for infant formula. No studies have specifically examined the effect of hospitals paying for infant formula on breastfeeding mothers' exposure to Baby-Friendly steps.

OBJECTIVES

To investigate the effect of hospitals implementing a policy of paying for infant formula on new mothers' exposure to Baby-Friendly steps and examine the effect of exposure to Baby-Friendly steps on breastfeeding rates.

METHODS

We used a repeated prospective cohort study design. We recruited 2 cohorts of breastfeeding mother-infant pairs (n = 2470) in the immediate postnatal period from 4 Hong Kong public hospitals and followed them by telephone up to 12 months postpartum. We assessed participants' exposure to 6 Baby-Friendly steps by extracting data from the medical record and by maternal self-report.

RESULTS

After hospitals began paying for infant formula, new mothers were more likely to experience 4 out of 6 Baby-Friendly steps. Breastfeeding initiation within the first hour increased from 28.7% to 45%, and in-hospital exclusive breastfeeding rates increased from 17.9% to 41.4%. The proportion of mothers who experienced all 6 Baby-Friendly steps increased from 4.8% to 20.5%. The risk of weaning was progressively higher among participants experiencing fewer Baby-Friendly steps. Each additional step experienced by new mothers decreased the risk of breastfeeding cessation by 8% (hazard ratio = 0.92; 95% CI, 0.89-0.95).

CONCLUSION

After implementing a policy of paying for infant formula, breastfeeding mothers were exposed to more Baby-Friendly steps, and exposure to more steps was significantly associated with a lower risk of breastfeeding cessation.

Factors associated with breastfeeding duration and exclusivity in mothers returning to paid employment postpartum

Mothers who are employed postpartum are less likely to continue breastfeeding than mothers who are not formally employed. However, as postpartum employment is increasingly necessary for the majority of new mothers, it is important to investigate factors that influence the continuation of breastfeeding in employed mothers. A sample of 1,738 mothers who returned to paid employment postpartum were recruited from the obstetric units of four public hospitals in Hong Kong, and prospectively followed for 12 months or until their infant was weaned. More than 85 % of participants returned to formal employment within 10 weeks postpartum, with over 90 % of these employed full-time. About one-third of the participants (32 %) were able to combine breastfeeding and employment, with breastfeeding defined as continuing for more than 2 weeks after returning to work postpartum. Later return to work and higher maternal education were associated with new mothers being able to combine breastfeeding and employment. Later return to work, shorter working hours, parental childcare, and higher maternal education were also associated with less likelihood of weaning from any or exclusive breastfeeding. Improvements in employment-related conditions for mothers and additional support for lower educated mothers may be effective strategies to enable employed women to continue breastfeeding after their return to work.

Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review

The Baby-friendly Hospital Initiative (BFHI) is a key component of the World Health Organization/United Nations Children's Fund Global Strategy for Infant and Young Child Feeding. The primary aim of this narrative systematic review was to examine the impact of BFHI implementation on breastfeeding and child health outcomes worldwide and in the United States. Experimental, quasi-experimental and observational studies were considered eligible for this review if they assessed breastfeeding outcomes and/or infant health outcomes for healthy, term infants born in a hospital or birthing center with full or partial implementation of BFHI steps. Of the 58 reports included in the systematic review, nine of them were published based on three randomized controlled trials, 19 followed quasi-experimental designs, 11 were prospective and 19 were cross-sectional or retrospective. Studies were conducted in 19 different countries located in South America, North America, Western Europe, Eastern Europe, South Asia, Eurasia and Sub-Saharan Africa. Adherence to the BFHI Ten Steps has a positive impact on short-term, medium-term and long-term breastfeeding (BF) outcomes. There is a dose-response relationship between the number of BFHI steps women are exposed to and the likelihood of improved BF outcomes (early BF initiation, exclusive breastfeeding (EBF) at hospital discharge, any BF and EBF duration). Community support (step 10) appears to be essential for sustaining breastfeeding impacts of BFHI in the longer term.

Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis

AIM

To provide comprehensive evidence of the effect of interventions on early initiation, exclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health systems and services (ii) Home and family environment (iii) Community environment (iv) Work environment (v) Policy environment or a combination of any of above.

METHODS

Of 23977 titles identified through a systematic literature search in PUBMED, Cochrane and CABI, 195 articles relevant to our objective, were included. We reported the pooled relative risk and corresponding 95% confidence intervals as our outcome estimate. In cases of high heterogeneity, we explored its causes by subgroup analysis and meta-regression and applied random effects model.

RESULTS

Intervention delivery in combination of settings seemed to have higher improvements in breastfeeding rates. Greatest improvements in early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding rates, were seen when counselling or education were provided concurrently in home and community, health systems and community, health systems and home settings, respectively. Baby friendly hospital support at health system was the most effective intervention to improve rates of any breastfeeding.

CONCLUSION

To promote breastfeeding, interventions should be delivered in a combination of settings by involving health systems, home and family and the community environment concurrently.

Predictors of breastfeeding initiation in Hong Kong and Mainland China born mothers

BACKGROUND

In recent years there has been a steady influx of immigrants into Hong Kong from Mainland China, where breastfeeding patterns differ. Studies in other regions have found substantial differences in breastfeeding rates between native-born and immigrant mothers. The purpose of this study was to examine factors associated with breastfeeding initiation in Hong Kong born and Mainland China born mothers living in Hong Kong.

METHODS

We used a multi-center cross-sectional study design and recruited 2761 new mothers from the postnatal wards of all eight public hospitals in Hong Kong that offer obstetric services. We assessed breastfeeding status as well as various socio-demographic, maternal and birth characteristics. Chi-square tests and multivariable logistic regression were used to identify the predictors of breastfeeding initiation in Hong Kong born and Mainland China born participants.

RESULTS

80.3 % of Hong Kong and 81.1 % of Mainland Chinese born women initiated breastfeeding. In the fully adjusted models, multiparity (Odds Ratio [OR] 0.53, 95 % CI 0.43-0.66) and maternal smoking (OR 0.29, 95 % CI 0.18-0.45) were strongly associated with failure to initiate breastfeeding in both Hong Kong and Mainland China born participants. In Hong Kong born mothers, participants with lower maternal education and those who had a cesarean section were significantly less likely to breastfeed. For Mainland China born mothers, paternal smoking (OR 0.70, 95 % CI 0.49-0.99) and having a pregnancy-related health problem (OR 0.60, 95 % CI 0.38-0.94) were both additional risk factors for not breastfeeding.

CONCLUSION

This study has identified predictors of breastfeeding initiation in Hong Kong and Mainland China born mothers. Given the current high breastfeeding initiation rates among both groups, antenatal breastfeeding education and promotion programmes need to specifically intervene with sub-groups of pregnant women at risk for not breastfeeding so that their efforts are more strategic and cost-effective.

[Hospital practices and breastfeeding cessation risk within 6 months of delivery]

BACKGROUND

The impact of maternity ward practices on breastfeeding duration remains uncertain in France.

OBJECTIVE

This study aimed to determine whether compliance with an increasing number of Baby-Friendly Hospital Initiative recommended practices was associated with a decreasing risk for breastfeeding cessation within 6 months of delivery.

METHODS

We analyzed the original data from a prospective cohort study carried out in eight maternity centers in France in 2005-2006. A pediatrician or a midwife prospectively collected data on breastfeeding initiation within 1h of birth, rooming-in 24h a day, pacifier non-use, and giving breast milk only for 908 mothers who were breastfeeding at discharge.

RESULTS

Overall, 315 (34.7%), 309 (34.0%), 186 (20.5%), and 98 (10.8%) mothers experienced 4, 3, 2, or 0-1 maternity ward practices. The median breastfeeding duration was 18 weeks (25th-75th percentiles, 9 to >26), with 87.6% and 31.5% of mothers who were still breastfeeding by 4 and 26 weeks after delivery, respectively. After adjusting for study center and baseline characteristics, the hazard ratios of breastfeeding cessation associated with 3, 2, and 0-1 practices were 1.32 (95% confidence interval [CI], 1.06-1.64), 1.54 (95% CI, 1.20-1.98), and 1.59 (95% CI, 1.13-2.25) as compared with compliance with four practices (p for trend <0.001).

CONCLUSION

Although the causal interpretation for this relationship remains speculative, these findings support interventions aimed to implement or reinforce Baby-Friendly Hospital Initiative recommended practices in order to establish prolonged breastfeeding and decrease the risk for early cessation after discharge to home.

Reasons for initial formula supplementation of healthy breastfeeding newborns

In a retrospective review of 302 hospital charts, 38 percent of newborns whose mothers planned to exclusively breastfeed received formula before hospital discharge. Those breastfeeding infants who did not receive formula were significantly younger at first breastfeeding than infants who received formula. Significantly more infants born by cesarean (51 percent) received supplementation than those born vaginally (31 percent). Birth between 9 p.m. and 10 a.m. and a hospital stay for more than 24 hours increased odds of supplementation. Nurses can explore barriers to exclusive breastfeeding unique to their hospitals to develop strategies that facilitate breastfeeding support and decrease formula supplementation.

Maternal and Hospital Factors Associated with First-Time Mothers' Breastfeeding Practice: A Prospective Study

Continuity of breastfeeding is infrequent and indeterminate. Evidence is lacking regarding factors associated with breastfeeding at different postpartum time points. This prospective study investigated the change in, and correlates of, breastfeeding practices after delivery at a hospital and at 1, 3, and 6 months postpartum among first-time mothers. We followed a cohort of 300 primiparous mothers of Taiwan who gave birth at two hospitals during 2010-2011. Logistic and Cox regression analyses were performed to determine factors that were correlated with breastfeeding practices. In the study sample, the rate of exclusive breastfeeding during the hospital stay was 66%; it declined to 37.5% at 1 month and 30.2% at 3 months postpartum. Only 17.1% of women reported continuing breastfeeding at 6 months. Early initiation of breastfeeding, rooming-in practice, and self-efficacy were significantly related to exclusive breastfeeding during the hospital stay. After discharge, health literacy, knowledge, intention, and self-efficacy were positively and significantly associated with breastfeeding exclusivity. Later initiation (hazard ratio=1.53; 95% confidence interval, 1.05, 1.97), shorter intention (hazard ratio=1.42; 95% confidence interval, 1.13, 1.68), and self-efficacy (hazard ratio=0.98; 95% confidence interval, 0.96, 0.99) were important predictors of breastfeeding cessation within 6 months of delivery. Continuous breastfeeding practice for 6 months is challenging and difficult for new mothers. Results showed that factors related to breastfeeding varied over time after delivery. Interventions seeking to sustain breastfeeding should consider new mothers' needs and barriers at different times.

Antenatal education to increase exclusive breastfeeding: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of a professional one-to-one antenatal breastfeeding support and education intervention on the exclusivity and duration of breastfeeding.

METHODS

A total of 469 primiparous women who attended the antenatal clinics of two geographically distributed public hospitals in Hong Kong were randomized to receive either standard antenatal care or a one-to-one antenatal breastfeeding support and education session. The primary outcome was the prevalence of exclusive breastfeeding at 6 weeks postpartum. Secondary outcomes were the prevalence of exclusive breastfeeding at 3 and 6 months postpartum as well as the overall duration of any and exclusive breastfeeding across the first 6 months postpartum.

RESULTS

The exclusive breastfeeding rate in the intervention group was 37.8% at 6 weeks postpartum compared with 36.4% in the standard care group (P=.77; 95% confidence interval [CI] -0.08 to 0.11). There were no significant differences between the two treatment groups in exclusive breastfeeding rates at 3 and 6 months or in the overall duration of any (hazard ratio [HR] 1.11, 95% CI 0.88-1.40] or exclusive breastfeeding (HR 0.96, 95% CI 0.79-1.17). The study had a least 80% power to detect a 50% increase in the rate of exclusive breastfeeding at 6 weeks postpartum.

CONCLUSION

In a setting with a high breastfeeding initiation rate, one-to-one antenatal breastfeeding support and education did not increase the exclusivity or duration of breastfeeding.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01648114.

Previous breastfeeding experience and duration of any and exclusive breastfeeding among multiparous mothers

BACKGROUND

High breastfeeding attrition rates have been attributed to a number of factors, but the effect of previous breastfeeding experience on subsequent breastfeeding duration has not been adequately investigated.

METHODS

In this study, 559 multiparous mothers were recruited and followed prospectively for 12 months or until the infant was weaned.

RESULTS

When compared with having previously breastfed for > 3 months, no previous breastfeeding experience (HR 3.24 [95% CI 2.37-4.42]) or a breastfeeding duration of ≤ 3 months (HR 2.56; 95% CI 2.05?3.20) substantially increased the risk of early weaning. Similarly, participants who had not exclusively breastfed (HR 1.82 [95% CI 1.46?2.26]) or who had exclusively breastfed for ≤ 2 months (HR 1.65 [95% CI 1.29?2.10]) were more likely to stop exclusive breastfeeding when compared with those who had exclusively breastfed for > 2 months. More than 40 percent of the participants who had previously breastfed for > 3 months had shorter current breastfeeding durations. The median decreases in any and exclusive breastfeeding for this group were 16.4 weeks and 13.1 weeks, respectively.

CONCLUSIONS

Multiparous women with no previous breastfeeding experience and those with a short duration of previous breastfeeding should be provided with greater support to promote a longer duration of breastfeeding. Multiparous women with a longer duration of breastfeeding should be strongly encouraged to meet or exceed this duration with their current infant.

Effect of a hospital policy of not accepting free infant formula on in-hospital formula supplementation rates and breast-feeding duration

Objective

To investigate the effect of public hospitals in Hong Kong not accepting free infant formula from manufacturers on in-hospital formula supplementation rates and breast-feeding duration.

Design

Prospective cohort study.

Setting

In-patient postnatal units of four public hospitals in Hong Kong.

Subjects

Two cohorts of breast-feeding mother–infant pairs (n 2560). Cohort 1 (n 1320) was recruited before implementation of the policy to stop accepting free infant formula and cohort 2 (n 1240) was recruited after policy implementation. Participants were followed prospectively for 12 months or until they stopped breast-feeding.

Results

The mean number of formula supplements given to infants in the first 24 h was 2·70 (sd 3·11) in cohort 1 and 1·17 (sd 1·94) in cohort 2 (P<0·001). The proportion of infants who were exclusively breast-fed during the hospital stay increased from 17·7 % in cohort 1 to 41·3 % in cohort 2 (P<0·001) and the risk of breast-feeding cessation was significantly lower in cohort 2 (hazard ratio=0·81; 95 % CI 0·73, 0·90). Participants who non-exclusively breast-fed during the hospital stay had a significantly higher risk of stopping any or exclusive breast-feeding. Higher levels of formula supplementation also increased the risk of breast-feeding cessation in a dose–response pattern.

Conclusions

After implementation of a hospital policy to pay market price for infant formula, rates of in-hospital formula supplementation were reduced and the rates of in-hospital exclusive breast-feeding and breast-feeding duration increased.

Applying a knowledge translation model to the uptake of the Baby Friendly Health Initiative in the Australian health care system

BACKGROUND

The Baby Friendly Hospital Initiative is a global, evidence-based, public health initiative. The evidence underpinning the Initiative supports practices promoting the initiation and maintenance of breastfeeding and encourages women's informed infant feeding decisions. In Australia, where the Initiative is known as the Baby Friendly Health Initiative (BFHI) the translation of evidence into practice has not been uniform, as demonstrated by a varying number of maternity facilities in each State and Territory currently accredited as 'baby friendly'. This variance has persisted regardless of BFHI implementation in Australia gaining 'in principle' support at a national and governmental level as well as inclusion in health policy in several states. There are many stakeholders that exert an influence on policy development and health care practices.

AIM

Identify a theory and model to examine where and how barriers occur in the gap between evidence and practice in the uptake of the BFHI in Australia.

RESULTS

Knowledge translation theory and the research to practice pipeline model are used to examine the identified barriers to BFHI implementation and accreditation in Australia.

CONCLUSION

Australian and international studies have identified similar issues that have either enabled implementation of the BFHI or acted as a barrier. Knowledge translation theory and the research to practice pipeline model is of practical value to examine barriers. Recommendations in the form of specific targeted strategies to facilitate knowledge transfer and supportive practices into the Australian health care system and current midwifery practice are included.

Predictors and consequences of in-hospital formula supplementation for healthy breastfeeding newborns

BACKGROUND

Although exclusive breastfeeding is recommended for the first 6 months, the use of breast milk substitutes is widespread around the world.

OBJECTIVES

To describe the patterns of infant formula supplementation among healthy breastfeeding newborns, to identify factors contributing to in-hospital formula supplementation, and to assess the dose-response relationship between the amount of in-hospital formula supplementation and the duration of any breastfeeding.

METHODS

A sample of 1246 breastfeeding mother-infant pairs was recruited from 4 public hospitals in Hong Kong and followed prospectively for 12 months or until weaned. Multiple logistic regression analysis was used to examine factors associated with in-hospital supplementation. Cox regression analysis was used to explore the impact of in-hospital supplementation on breastfeeding duration.

RESULTS

Of the total, 82.5% of newborns were supplemented in the hospital; one-half received formula within 5 hours of birth. Assisted vaginal delivery (odds ratio [OR] = 2.06, 95% confidence interval [CI] 1.03, 4.15), cesarean section (OR = 3.45, 95% CI 1.75, 6.80), and higher birth weight (OR = 1.56, 95% CI 1.12, 2.18) were positively associated with in-hospital formula supplementation, whereas initiating breastfeeding in the delivery room (OR = 0.55, 95% CI 0.33, 0.89) was associated with decreased likelihood of in-hospital supplementation. Any infant formula in the first 48 hours was associated with a shorter duration of breastfeeding (hazard ratio [HR] = 1.51, 95% CI 1.27, 1.80), but there was no dose-response effect.

CONCLUSION

In-hospital formula supplementation is common in Hong Kong hospitals and appears to be detrimental to breastfeeding duration. Continued efforts should be made to avoid the provision of infant formula to breastfeeding babies while in the hospital unless medically indicated.

Low prevalence of breastfeeding initiation within the first hour of life in a rural area of Sichuan Province, China

BACKGROUND

The World Health Organization recommends that newborn infants be breastfed within the first hour of life, a practice that improves infant health and reduces neonatal mortality. The objectives of this study were to report the rate of breastfeeding initiation within 1 hour of birth in Jiangyou, China, to determine its impact on "full breastfeeding" at discharge, and to investigate factors associated with early breastfeeding initiation.

METHODS

A prospective cohort study of infant feeding practices was undertaken during 2010 and 2011 in Jiangyou, 2 years after an earthquake caused extensive damage. A total of 695 mothers were recruited from hospitals and health centers and interviewed at discharge.

RESULTS

In this study, 9.1 percent of women began breastfeeding within 1 hour postpartum. Mothers who initiated breastfeeding early were more likely to be fully breastfeeding at discharge (OR 2.10, 95% CI 1.23-3.60). Multivariate logistic regression analysis revealed that giving birth at a health center was associated with delayed breastfeeding initiation (OR 0.11, 95% CI 0.04-0.32), whereas attending antenatal classes (OR 2.57, 95% CI 1.36-4.87) and receiving encouragement from hospital staff to initiate breastfeeding (OR 5.60, 95% CI 2.31-13.55) were correlated with putting the baby to the breast soon after delivery.

CONCLUSIONS

Early breastfeeding initiation rate was low and the use of prelacteal foods was widespread in Jiangyou. Early breastfeeding initiation was associated with higher "full breastfeeding" rates at discharge. It is important to educate doctors and nurses to assist mothers with early breastfeeding initiation and to discourage the use of non-breastmilk prelacteal feeds.

Baby-friendly hospital accreditation, in-hospital care practices, and breastfeeding

OBJECTIVES

To investigate the effect of Baby-Friendly Hospital Initiative (BFHI) accreditation and hospital care practices on breastfeeding rates at 1 and 4 months.

METHODS

All women who birthed in Queensland, Australia, from February 1 to May 31, 2010, received a survey 4 months postpartum. Maternal, infant, and hospital characteristics; pregnancy and birth complications; and infant feeding outcomes were measured.

RESULTS

Sample size was 6752 women. Breastfeeding initiation rates were high (96%) and similar in BFHI-accredited and nonaccredited hospitals. After adjustment for significant maternal, infant, clinical, and hospital variables, women who birthed in BFHI-accredited hospitals had significantly lower odds of breastfeeding at 1 month (adjusted odds ratio 0.72, 95% confidence interval 0.58-0.90) than those who birthed in non-BFHI-accredited hospitals. BFHI accreditation did not affect the odds of breastfeeding at 4 months or exclusive breastfeeding at 1 or 4 months. Four in-hospital practices (early skin-to-skin contact, attempted breastfeeding within the first hour, rooming-in, and no in-hospital supplementation) were experienced by 70% to 80% of mothers, with 50.3% experiencing all 4. Women who experienced all 4 hospital practices had higher odds of breastfeeding at 1 month (adjusted odds ratio 2.20, 95% confidence interval 1.78-2.71) and 4 months (adjusted odds ratio 2.93, 95% confidence interval 2.40-3.60) than women who experienced fewer than 4.

CONCLUSIONS

When breastfeeding-initiation rates are high and evidence-based practices that support breastfeeding are common within the hospital environment, BFHI accreditation per se has little effect on both exclusive or any breastfeeding rates.

Association between intrapartum interventions and breastfeeding duration

INTRODUCTION

Few women who reside in Hong Kong exclusively breastfeed, and one-half stop breastfeeding within the first few months. There is little research in this population on the association between intrapartum interventions and breastfeeding duration.

METHODS

A sample of 1280 mother-infant pairs were recruited from the obstetric units of 4 public hospitals in Hong Kong and followed prospectively for 12 months or until the infant was weaned. The outcome variables for this analysis were the duration of any and exclusive breastfeeding. Predictor variables were 4 intrapartum interventions: receipt of opioid pain medication, induction versus spontaneous labor, epidural administration, and mode of birth. We used Cox proportional hazards modeling to assess the impact of intrapartum interventions on the duration of any and exclusive breastfeeding, and we constructed Kaplan-Meier survival curves to evaluate the cumulative impact of multiple intrapartum interventions on breastfeeding outcomes.

RESULTS

Bivariate analysis showed that induction of labor (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.09-1.41), opioid pain medication (HR, 1.21; 95% CI, 1.06-1.37), and having an emergency cesarean birth (HR, 1.22; 95% CI, 1.01-1.48) were associated with a shorter duration of any breastfeeding. Induction of labor (HR, 1.23; 95% CI, 1.08-1.39) and having an emergency cesarean birth (HR, 1.25; 95% CI, 1.05-1.51) were associated with a shorter duration of exclusive breastfeeding. After controlling for known confounding variables, there was no longer any association between individual intrapartum interventions and the duration of any or exclusive breastfeeding. The median duration of breastfeeding for participants who experienced a natural birth with no intrapartum interventions was 9 weeks compared with 5 weeks for participants who experienced at least 3 intrapartum interventions.

DISCUSSION

Clinicians working with new breastfeeding mothers should focus on providing additional support to mothers who experience a difficult labor and birth with multiple interventions to improve their breastfeeding experiences.