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

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.

Perspective: Supporting Maternal Efforts to Provide Optimal Infant Nutrition in the Post-Partum Setting

Supporting optimal newborn nutrition and the positive maternal-infant relationship while encouraging safe sleep practices are essential components of maternal and newborn care in the hospital setting following birth. Breastfeeding is widely recognized as the best practice to support the nutritional needs and well-being of the infant, and recommendations have been developed by the WHO, the American Academy of Pediatrics (AAP), and the United States Centers for Disease Control to encourage and successfully support breastfeeding efforts before hospital discharge. The 10 Steps to Successful Breastfeeding, developed and promoted by the WHO, form the basis of the Baby-Friendly Hospital Initiative (BFHI) and have become the international framework for public health initiatives to promote breastfeeding. An evaluation of hospital performance implementing the 10 steps through the process of "Baby-Friendly Designation" (BFD) has been suggested by many breastfeeding advocates as the optimal pathway to attain the goals of the BFHI. However, the WHO has recognized that BFD may not be an appropriate goal in all settings, and indicated, as part of their updated 2018 guidance, that "facilities may make changes in their policies and procedures to obtain the designation, but these changes are not always sustainable, especially when there are no regular monitoring systems in place." In addition, unintended associated issues regarding newborn safety and maternal dissatisfaction with some of the 10 steps have emerged. This perspective discusses the challenges faced by hospitals attempting to implement the BFHI 10 steps and suggests potential solutions to make progress in those efforts with or without BFD and also the efforts needed to support formula feedings when appropriate.

Breastfeeding experiences of patients in baby-friendly certified hospital settings: protocol for a scoping review

INTRODUCTION

The Baby-friendly Hospital Initiative is a global programme that is meant to support breastfeeding within organisations. Most of the current literature is focused on implementation and uptake of the programme; however, little is known about the patient experience of breastfeeding within these settings. By exploring this current gap in the literature, we may discover important contextual elements of the breastfeeding experience. The objective of this protocol is to provide a framework for a scoping review where we aim to understand the extent and type of evidence in relation to the patient experience of breastfeeding in Baby-friendly Hospital Initiative (BFHI)-certified settings.

METHODS AND ANALYSIS

The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. The databases to be searched for relevant literature include MEDLINE, Embase, PsycINFO, CINAHL and Scopus in April 2023. A grey literature scan will include reviewing documents from professional organisations/associations. For all sources of evidence that meet the inclusion criteria, data will be extracted and presented in a table format. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Participants in this review will include any individual who delivered their baby in a BFHI-certified setting. Exploring the patient experience will involve reviewing their subjective perceptions of events related to breastfeeding. These events must occur in a BFHI-certified hospital, and therefore, home births and other outpatient settings will be excluded.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review protocol or the final review. Knowledge gained from this research will be disseminated through the primary author's PhD dissertation work, as well as manuscript publications and conference presentations.

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.

The Effect of Breastfeeding in the First Hour and Rooming-In of Low-Income, Multi-Ethnic Mothers on In-Hospital, One and Three Month High Breastfeeding Intensity

Despite the known benefits of exclusive breastfeeding, the value of Baby-Friendly Hospital Interventions in increasing breastfeeding rates has been challenged, particularly the interventions of breastfeeding in the first hour of life and rooming-in. This study aimed to measure the association of breastfeeding in the first hour of life and rooming-in with high breastfeeding intensity of low-income, multi-ethnic mothers intending to breastfeed. A prospective, longitudinal cohort study was performed on 149 postpartum mothers who intended to breastfeed their infants. Structured interviews were performed at birth and one and three months. Breastfeeding intensity was defined as the percentage of all feedings that were breast milk, and high breastfeeding intensity was defined as a breastfeeding intensity >80%. The data were analyzed by chi-square, t-test, binary logistic regression analysis, and multivariate logistic regression analysis. Breastfeeding in the first hour was associated with increased high breastfeeding intensity in the hospital (AOR = 11.6, 95% CI = 4.7-28.6) and at one month (AOR = 3.6, 95% CI = 1.6-7.7), but not at three months. Rooming-in was associated with increased high breastfeeding intensity in the hospital (AOR 9.3, 95% CI = 3.6-23.7) and at one month (AOR = 2.4 (1.1-5.3) and three months (AOR 2.7, 95% CI 1.2-6.3). Breastfeeding in the first hour and rooming-in are associated with increasing breastfeeding and should be incorporated into practice.

Encouraging and Reinforcing Safe Breastfeeding Practices during the COVID-19 Pandemic

AIM

Promote safe breastfeeding during the pandemic.

METHODS

All participants were encouraged to request safe breastfeeding education from their prenatal provider. Pregnant mothers received appropriate breastfeeding and COVID-19 safe breastfeeding education in line with the CDC's COVID-19 breastfeeding guidelines. Data were obtained from 39 mothers attending Nashville General Hospital pediatric well-baby clinics (Group I: from December 2019 to June 2020) and 97 pregnant women attending prenatal clinics (Group II: from July 2020 to August 2021).

RESULTS

The participants' ages ranged from 15 to 45 years, with a mean of 27.5 ± 6.2. The women in both groups were similar in age, education, employment, and breastfeeding experience. They were equally unlikely to use face masks at home even while receiving guests or holding their babies. Although 121 (89.0%) women claimed face mask use while shopping, the rate for never doing so was 7 (18.0%) vs. 8 (8.3%) (p < 0.006) for Groups I and II, respectively. Safe practices included limited outing (66 (48.5%)), sanitized hands (62 (45.6%)), restricted visitors (44 (32.4%)), and limited baby outing (27 (19.9%)), and 8 (8.3%) in Group II received COVID-19 vaccinations. About half described fair and accurate COVID-19 safe breastfeeding knowledge, but 22 (30.1%) of them claimed they received no information. Breastfeeding contraindication awareness for Groups I and II were as follows: cocaine = 53.8% vs. 37.1%, p < 0.06; HIV = 35.9% vs. 12.4%, p < 0.002; breast cancer = 17.9% vs. 16.5%; and COVID-19 with symptoms = 28.2% vs. 5.2%, p < 0.001. The information source was similar, with family, friends, and media accounting for 77 (56.6%) of women while doctors, nurses, and the CLC was the source for 21 (15.4%) women. Exclusive breastfeeding one month postpartum for Groups I and II was 41.9% and 12.8% (p < 0.006), respectively.

CONCLUSION

The mothers were not more knowledgeable regarding breastfeeding safely one year into the COVID-19 pandemic. Conflicting lay information can create healthy behavior ambivalence, which can be prevented by health professionals confidently advising mothers to wear face masks when breastfeeding, restricting visitors and outings, and accepting COVID-19 vaccination. This pandemic remains an open opportunity to promote and encourage breastfeeding to every mother as the default newborn feeding method.

Maternal perceptions and experiences of breastfeeding support in Baby-Friendly hospitals: An integrative review

Background

The Baby-Friendly Hospital Initiative aims to improve breastfeeding by implementing the Ten Steps to Successful Breastfeeding (Ten Steps) into routine breastfeeding support in birth hospitals. Maternal perspective to breastfeeding support is important to consider as mothers and their infants are in the center of that support.

Objectives

To review and synthesize the existing literature on maternal perceptions and experiences of breastfeeding support in Baby-Friendly hospitals. A sub-aim was to describe differences in breastfeeding support between Baby-Friendly hospitals and non-Baby-Friendly hospitals from maternal perspective.

Data sources and review methods

An integrative literature review. A systematic literature search was conducted in October 2021 in five databases: PubMed, CINAHL, Cochrane, Scopus, Web of Science. Original peer-reviewed studies published in English exploring maternal viewpoints on breastfeeding support in Baby-Friendly hospitals were included. Two reviewers independently screened the titles (n=914), abstracts (n=226), and full texts (n=47). The review comprised of seventeen studies and includes both quantitative studies (n=14) and qualitative studies (n=3). Inductive content analysis and descriptive synthesis were conducted.

Results

Most studies (n=14) measured hospitals' compliance with the Ten Steps practices from maternal perspective. Mothers were provided with breastfeeding information and encouragement, however, a qualitative finding indicated that information focused on positive aspects of breastfeeding. Early skin-to-skin contact between the mother and infant was well facilitated although often not lasting more than 30 min. Breastfeeding was facilitated by practical support but according to findings of two qualitative studies, support was not always adequate to address mothers' problems with breastfeeding. Most mothers were exclusively breastfeeding during the hospital stay and no supplemental milk was offered to infant. Mothers were roomed-in together with their infant and were mostly encouraged to breastfeed on demand. Differences between Baby-Friendly hospitals and non-Baby-Friendly hospitals were observed particularly for steps 6 and 9: supplementary feeding and pacifier use were less common in Baby-Friendly hospitals.

Conclusions

From the maternal perspective, breastfeeding support in the Baby-Friendly hospitals was mainly but not completely in adherence with the Ten Steps practices. Low compliance with some of the Ten Steps indicates a need for a more frequent assessment of the breastfeeding support practices and consideration of strategies facilitating a more sustainable implementation of the initiative. Regardless of some shortcomings with the breastfeeding support, mothers were mainly satisfied with the support in the hospital. Mothers in the Baby-Friendly hospitals perceived that breastfeeding support was more adherent to the Ten Steps compared to mothers in non-Baby-Friendly hospitals.

Increasing the exclusive breastfeeding rate in a private hospital in UAE through quality improvement initiatives

BACKGROUND

Mother's milk is the best, and ideal method for infant feeding. We found that this practice was not being followed in our hospital. A survey was conducted in the unit with regards to breastfeeding practices which revealed that most babies who were discharged from our nursery were on formula supplements. Our goal was to improve established breastfeeding rates in the unit by increasing the number of full-term healthy babies who were discharged on exclusive Breastfeeding.

METHOD

A project team was formed, and data were collected through direct observations and direct interviews with postnatal mothers. Exclusive Breastfeeding at discharge was defined as a baby being fully on breastfeed with no additional formula supplements for at least 12 hours prior to discharge. The primary outcome was to increase the percentage of babies being discharged on exclusive Breastfeeding. We used the FOCUS PDCA model to measure improvements and 8 PDCA cycles of 4 weeks duration were implemented to test the changes.

RESULTS

The interventions we put in place led to a considerable nine times overall improvement in the established breastfeeding rates. Among all the interventions, the most promising results were observed during the PDCA cycles involving staff education, the introduction of antenatal classes for mothers, skin to skin contact and rooming in.

CONCLUSION

Breastfeeding rates in the private sector with nursery services can be improved by reinforcing breastfeeding education for mothers in addition to training the maternal care staff, empowering them to promote and assist in breastfeeding.

Trends and Determinants in Breastfeeding among Korean Women: A Nationwide Population-Based Study

Many efforts have been launched to promote breastfeeding in Korea. However, breastfeeding trends and associated factors with breastfeeding in Korea remain unknown. This study aimed to examine trends and determinants in breastfeeding using the Korea National Health and Nutrition Examination Survey (KNHANES) (2010-2018). We analyzed data from the KNHANES V (2010-2012), VI (2013-2015), and VII (2016-2018). A total of 9232 women aged 19-49 years were included in this study. We performed multivariable logistic regression analyses to investigate breastfeeding prevalence trends and associated factors with breastfeeding. Compared to 2010-2012, the odds ratio associated with breastfeeding during 2013-2015 and 2016-2018 increased to 1.30 (95% confidence interval (CI): 1.11-1.51) and 1.40 (95% CI: 1.21-1.63), respectively. The breastfeeding rate was associated with 40-49 years (OR, 95% CI: 0.47, 0.34-0.64 compared to 19-29 years), richer and poorer income (1.20, 1.03-1.39 in richer group and 1.24, 1.05-1.46 in poorer group compared to richest group), education level (0.74, 0.65-0.86 in ≤12 years of education compared to ≥13 years of education), smoking status (1.77, 1.38-2.28 in non-smoking compared to smoking), and self-rated health (1.40, 1.14-1.70 in good and 1.20, 1.00-1.44 in average compared to bad). Education programs and policies such as the Baby-Friendly Hospital Initiative (BFHI) and mother-friendly workplaces are necessary to increase the rates of breastfeeding in these groups.

Factors associated with breast-feeding initiation and continuation in Canadian-born and non-Canadian-born women: a multi-centre study

OBJECTIVE

To identify factors associated with breast-feeding initiation and continuation in Canadian-born and non-Canadian-born women.

DESIGN

Prospective cohort of mothers and infants born from 2008 to 2012: the Canadian Healthy Infant Longitudinal Development (CHILD) Cohort Study.

SETTING

General community setting in four Canadian provinces.

PARTICIPANTS

In total, 3455 pregnant women from Vancouver, Edmonton, Winnipeg and Toronto between 2008 and 2012.

RESULTS

Of 3010 participants included in the current study, the majority were Canadian-born (75·5 %). Breast-feeding initiation rates were high in both non-Canadian-born (95·5 %) and Canadian-born participants (92·7 %). The median breast-feeding duration was 10 months in Canadian-born participants and 11 months in non-Canadian-born participants. Among Canadian-born participants, factors associated with breast-feeding initiation and continuation were older maternal age, higher maternal education, living with their partner and recruitment site. Rooming-in during the hospital stay was also associated with higher rates of breast-feeding initiation, but not continuation at 6-month postpartum. Factors associated with non-initiation of breast-feeding and cessation at 6-month postpartum were maternal smoking, living with a current smoker, caesarean birth and early-term birth. Among non-Canadian-born participants, maternal smoking during pregnancy was associated with lower odds of breast-feeding initiation and lower odds of breast-feeding continuation at 6 months, and older maternal age and recruitment site were associated with breast-feeding continuation at 6 months.

CONCLUSIONS

Although Canadian-born and non-Canadian-born women in the CHILD cohort have similar breast-feeding initiation rates, breast-feeding initiation and continuation are more strongly associated with socio-demographic characteristics in Canadian-born participants. Recruitment site was strongly associated with breast-feeding continuation in both groups and may indicate geographic disparities in breast-feeding rates nationally.

The impact of Baby Friendly Initiative accreditation: An overview of systematic reviews

Despite its reported benefits, breastfeeding rates are low globally, and support systems such as the Baby Friendly Initiative (BFI) have been established to support healthy infant feeding practices and infant bonding. Increasingly reviews are being undertaken to assess the overall impact of BFI accreditation. A systematic synthesis of current reviews has therefore been carried out to examine the state of literature on the effects of BFI accreditation. A systematic search of CINAHL, MEDLINE, Maternal and Infant Health, Scopus, the Cochrane Library and PROSPERO was undertaken. Study selection, data extraction and critical appraisal of included reviews using the AMSTAR-2 tool were undertaken by two authors, with disagreements resolved through discussion with the third author. Due to heterogeneity, a narrative synthesis of findings was applied. Fourteen reviews met the inclusion criteria. Overall confidence in the results of the review was rated as high for three reviews, low for two reviews and critically low for nine reviews. Most evidence suggests some increase in breastfeeding initiation, exclusivity and duration of breastfeeding, and one main trial suggests decreased gastrointestinal infection and allergic dermatitis in infants. However, overall certainty in the evidence was rated as very low across all outcomes due to concerns over risk of bias within and heterogeneity between the original studies. More contemporary, good-quality randomised controlled trials or well-controlled prospective comparative cohorts are required to better evaluate the impact of full BFI accreditation, with particular attention paid to the context of the research and to long-term maternal and infant health outcomes.

Human Milk for the Term Newborn

Human milk provides optimal nutrition for term newborns, but the prevalence of its use is below target, and risks have been identified. Infants of black mothers as well as term newborns admitted to the neonatal intensive care unit are at risk for not receiving human milk. To improve human milk intake, multiple individual-level interventions have been shown to be effective, but some popular system-level interventions are ineffective or harmful. Expressed milk and donor milk may be less beneficial than direct breastfeeding. Nuanced public policies can help support lactation while promoting individual choice and equity.

Maternity ward staff perceptions of exclusive breastfeeding in Finnish maternity hospitals: A cross-sectional study

INTRODUCTION

This study aimed to describe exclusive breastfeeding (EBF, Step 6 of the Baby-Friendly Hospital Initiative) in Finnish maternity hospitals and identify factors that promote or limit EBF.

METHODS

A cross-sectional study design was used, and data were collected from eight maternity hospitals in Finland during a 10-day period in May 2014. The staff completed questionnaires (n=1554) from separate work shifts. The data were analyzed using descriptive statistics, and chi-squared and Fisher's tests. Responses to open-ended questions were analyzed using content analysis.

RESULTS

Maternity ward staff reported that 72% (n=1105) of the infants were exclusively breastfed during their work shift. The strongest promoting factors of exclusive breastfeeding were: maternity ward staffs' profession and education in breastfeeding counselling; multiparity; vaginal delivery; early skin-to-skin contact between mother and infant; initial breastfeeding after birth; rooming-in; and initial success of breastfeeding. The use of a nipple shield, the need for additional breastfeeding counselling, and infants' blood tests were limiting factors to exclusive breastfeeding. Open-ended answers revealed that exclusive breastfeeding was mainly delayed because of medical issues for the mother or infant.

CONCLUSIONS

Finnish maternity hospitals could improve exclusive breastfeeding rates by focusing attention and resources on breastfeeding counselling and evidence-based maternity care practices related to immediate care after birth, promoting vaginal delivery, rooming-in and availability of skilled counselling.

Effects of a 'Baby-Friendly Hospital Initiative' on exclusive breastfeeding rates at a private hospital in Lebanon: an interrupted time series analysis

Background

Exclusive breastfeeding (EBF) through six months of age has been scientifically validated as having a wide range of benefits, but remains infrequent in many countries. The WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI) is one approach to improve EBF rates.

Methods

This study documents the implementation of BFHI at Clemenceau Medical Center (CMC), a private hospital in Lebanon, and analyzes data on EBF practices among CMC’s patients before, during, and after the implementation period. The process of launching the BFHI at CMC is discussed from the perspective of key stakeholders using the SQUIRE guidelines for reporting on quality improvement initiatives. As an objective measure of the program’s impact, 2,002 live births from July 2015 to February 2018 were included in an interrupted time series analysis measuring the rates of EBF at discharge prior to, during, and following the bundle of BFHI interventions.

Results

The steps necessary to bring CMC in line with the BFHI standards were implemented during the period between November 2015 and February 2016. These steps can be grouped into three phases: updates to hospital policies and infrastructure (Phase 1); changes to healthcare staff practices (Phase 2); and improvements in patient education (Phase 3). The baseline percentage of EBF was 2.4 % of all live births. Following the BFHI intervention, the observed monthly change in EBF in the “Follow-Up” period (i.e., the 24 months following Phases 1–3) was significantly increased relative to the baseline period (+ 2.0 % points per month, p = 0.006). Overall, the observed rate of EBF at hospital discharge increased from 2.4 to 49.0 % of all live births from the first to the final month of recorded data.

Conclusions

Meeting the BFHI standards is a complex process for a health facility, requiring changes to policies, practices, and infrastructure. Despite many challenges, the results of the interrupted time series analysis indicate that the BFHI reforms were successful in increasing the EBF rate among CMC’s patients and sustaining that rate over time. These results further support the importance of the hospital environment and health provider practices in breastfeeding promotion, ultimately improving the health, growth, and development of newborns.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03816-3.

Racial Disparities in Sustaining Breastfeeding in a Baby-Friendly Designated Southeastern United States Hospital: An Opportunity to Investigate Systemic Racism

Background: Racial disparities in breastfeeding rates persist in the United States with Black women having the lowest rates of initiation and continuation. A literature review attributes this to many factors-historical roles, cultural norms, lack of social support, and systemic racism in the health care and lactation support system. The Baby-Friendly Hospital Initiative (BFHI) is an evidence-based program to increase breastfeeding through standardized protocols, and, in a Southeastern U.S. academic center, it was associated with increased breastfeeding, but the effect on racial disparities in breastfeeding was unknown. Methods: Through an institutional Perinatal Information Systems database, breastfeeding rates were compared before and after BFHI implementation. Breastfeeding initiation, sustained breastfeeding 24-hours before discharge, and patient demographics were assessed. Results: After BFHI implementation, mothers were overall 1.17 (95% confidence interval: 1.13-1.19) times more likely to initiate breastfeeding. For Black mothers, breastfeeding initiation increased significantly from 52% to 66%, but they were significantly less likely to sustain in-hospital breastfeeding compared to nonBlack mothers (69.4% versus 84.6%, p < 0.0001). Several demographic and medical comorbidities were significantly associated with failure to sustain breastfeeding to hospital discharge. When controlling for these factors, the racial disparity persisted. Conclusions: Since BFHI implementation, the racial gap in breastfeeding initiation decreased, but a significant disparity remained for sustained in-hospital breastfeeding. This study highlights the success of the BFHI program, but in the context of the current literature, also reveals the need for further work to ensure interventions are culturally competent and delivered equitably to support sustained breastfeeding for Black women.

Are childbirth location and mode of delivery associated with favorable early breastfeeding practices in hard to reach areas of Bangladesh?

BACKGROUND

Early initiation of breastfeeding within one hour of birth (EIBF) and no prelacteal feeding are WHO recommended practices for improving maternal and newborn health outcomes. Globally, EIBF can avert around 22% of newborn death. In recent years, Bangladesh has experienced increasing facility delivery coverage and cesarean section rates. However, the impact of these changes on early breastfeeding initiation in hard to reach areas (HtR) of the country is still poorly understood. Therefore, this study aimed to examine the independent associations between childbirth locations and mode of delivery with favorable early breastfeeding practices in four hard to reach areas of Bangladesh.

METHOD

We extracted data from a cross-sectional study conducted in four HtR areas of Bangladesh in 2017. A total of 2768 women, having birth outcomes in the past 12 months of the survey, were interviewed using structured questionnaires. EIBF and no prelacteal feeding were considered as favorable early breastfeeding practices. The categories of childbirth locations were defined by the place of birth (home vs. facility) and the delivery sector (public/NGO vs. private). The mode of delivery was categorized into vaginal delivery and cesarean section. Generalized linear models were used to test the independent associations while adjusting for potential confounders.

RESULTS

The prevalence of EIBF practices were 69.6%(95% CI:67.8-71.3); 72.2%(95% CI:67.8-71.3) among home births Vs 63.0%(95% CI:59.5%-66.4%) among facility births. Around 73.9% (95% CI:72.3-75.6) mother's in the study areas reported no-prelacteal feeding. Compared to home births, women delivering in the facilities had lower adjusted odds of EIBF (aOR = 0.51; 95%CI:0.35-0.75). Cesarean section was found to be negatively associated with EIBF (aOR = 0.20; 95%CI:0.12-0.35), after adjusting for potential confounders. We could not find any significant associations between the place of birth and mode of delivery with no prelacteal feeding.

DISCUSSIONS

This study found that facility births and cesarean deliveries were negatively associated with EIBF. Although the implementation of "Baby-Friendly Hospital Initiatives" could be a potential solution for improving EIBF and no prelacteal feeding practices, the challenges of reduced service availability and accessibility in HtR areas must be considered while devising effective intervention strategies. Future studies can explore potential interventions to promote early breastfeeding for facility births and cesarean deliveries in HtR areas.

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.

A comparison of exclusive breastfeeding in Belgian maternity facilities with and without Baby-friendly Hospital status

A retrospective cross-sectional study was carried out in Wallonia (the southern region of Belgium) in which a 20-question breastfeeding (BF) module was included in an immunization survey. The purpose of this paper is to compare exclusive breastfeeding (EBF) prevalences and BF practices for mothers giving birth in Baby-friendly Hospital Initiative (BFHI) and non-BFHI maternity facilities. A total of 557 mothers responded to BF questions when their child was 18-24 months old; 26.7% of them delivered in a BFHI maternity facility. At discharge, a larger proportion of children were exclusively breastfed if they were born in a BFHI maternity facility (76.5% vs. 65.8%, p = .02). The median duration of EBF (15.0 vs. 12.9 weeks, p = .3), and the proportion of children exclusively breastfed at 5 months (16.8% vs 15.8%, p = 1.0) were similar in both groups. Few mothers knew that EBF was recommended for the first 6 months of life (28.6% in BFHI vs 23.1% in non-BFHI, p = .2). For most groups of the population examined, the rates of BF tended to be higher in BFHI facilities, but many differences were not significant. More specifically, BFHI seemed to boost BF practices among mothers more likely to breastfeed, but the Initiative did not seem to trigger enhanced BF practices in mothers traditionally less likely to breastfeed (except for indifferent/negative partner's attitude and mothers of Belgian origin). Influencing the BF practices of mothers less likely to breastfeed requires a special attention with complementary actions in maternity facilities as well as in community services.

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.

Worldwide prevalence of mother-infant skin-to-skin contact after vaginal birth: A systematic review

BACKGROUND

Despite the World Health Organization's (WHO) recommendation for immediate skin-to-skin contact (SSC) after birth, separation of mothers and infants seems to be common practice in many hospitals. It is unknown how common the practice of SSC is worldwide. Therefore, we aimed to determine the reported prevalence of SSC for healthy mothers and infants immediately after normal birth.

METHODS

We systematically searched CINAHL, Medline, ProQuest Central, PubMed and the Cochrane Library for articles published between January 2007 and October 2017 using the keywords "kangaroo care" or "skin to skin contact" or "breastfeeding initiation" or "breast crawl" or "maternal infant contact" or "maternal newborn contact" or "baby friendly hospital initiative" or "ten steps for successful breastfeeding".

RESULTS

After an initial screening of 5266 records, 84 full text articles were assessed for eligibility, and 35 of these met the inclusion criteria. The studies were from 28 countries representing all six WHO world regions. There was a wide range in the practice of SSC for mother-infant dyads around the world: from 1% to 98%. Only 15 studies clearly defined SSC. Most of the studies were from high-income countries, and these reported higher rates of SSC than studies from low and middle-income countries.

CONCLUSION

There was a great heterogeneity in the definition of SSC as well as study designs, which makes cross-county comparison difficult. National studies reporting SSC rates are lacking. Future studies and guidelines to enhance SSC practice should include a standardised set of indicators and measurement tools that document SSC starting time and duration of SSC.

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

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

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.

Interventions promoting exclusive breastfeeding up to six months after birth: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The World Health Organization (WHO) recommends that mothers practice exclusive breastfeeding (EBF) of their infants for 6 months. Various breastfeeding support interventions have been developed to encourage mothers to maintain breastfeeding practices. Research aim: This study aims to review how effectively breastfeeding support interventions enable mothers to practice EBF for 6 months and to suggest the best intervention strategies.

METHODS

Six databases were searched, including MEDLINE, EMBASE, Cochrane, CINAHL, PsycINFO, and KoreaMed. The authors independently extracted data from journals written in English or Korean and published between January 2000 and August 2017. Randomized controlled trials (RCTs) reporting EBF until 6 months were screened.

RESULTS

A total of 27 RCTs were reviewed, and 36,051 mothers were included. The effectiveness of breastfeeding support interventions to promote EBF for 6 months was significant (odds ratio [OR] = 2.77; 95% confidence interval [CI]: 1.81-3.76). A further subgroup analysis of intervention effects shows that a baby friendly hospital initiative (BFHI) intervention (OR = 5.21; 95% CI: 2.15-12.61), a combined intervention (OR = 3.56; 95% CI: 1.74-7.26), a professional provider led intervention (OR = 2.76; 95% CI: 1.76-4.33), having a protocol available for the provider training program (OR = 2.87; 95% CI: 1.89-4.37) and implementation during both the prenatal and postnatal periods (OR = 3.32; 95% CI: 1.83-6.03) increased the rate of EBF for 6 months.

CONCLUSION

We suggest considering a multicomponent intervention as the primary strategy and implementing BFHI interventions within hospitals. Evidence indicates that intervention effectiveness increases when a protocol is available for provider training, when interventions are conducted from the pre- to postnatal period, when the hospital and community are connected, and when healthcare professionals are involved.

Practice-based interpretation of ultrasound studies leads the way to more effective clinical support and less pharmaceutical and surgical intervention for breastfeeding infants

BACKGROUND

breastfeeding optimises health outcomes for both mothers and infants. Although most women want to breastfeed, they report commencing infant formula because of nipple pain, unsettled infant behaviour, and infant growth concerns. To date, existing approaches to fit and hold ('latch and positioning') have been demonstrated not to help breastfeeding outcomes, and women report widespread dissatisfaction with the quality of support and conflicting advice they receive. Breast and nipple pain, difficulty with latching and sucking, fussing at the breast, back-arching, marathon feeds, excessively frequent feeds, poor weight gain, breast refusal, and crying due to poor satiety often signal suboptimal positional instability and impaired milk transfer, but may be misdiagnosed as medical conditions. Over the past two decades, there has been an exponential increase in numbers of infants being treated with medications, laser or scissors frenotomy, and manual therapy for unsettled behaviour and breastfeeding difficulty. New approaches to clinical breastfeeding support are urgently required.

METHOD AND RESULTS

we analyse the findings of a literature search of PubMed and MEDLINE databases for ultrasound studies measuring sucking in term and preterm infants. The findings demonstrate that the Stripping Action Model of infant suck during breastfeeding, and the resultant Structural Model of infant suck dysfunction, are inaccurate. Instead, ultrasound data demonstrates the critical role of intra-oral vacuum for milk transfer. We integrate these two-dimensional ultrasound results with clinical experience of the third dimension, volume, to propose a Gestalt Model of the biomechanics of healthy infant suck during breastfeeding. The Gestalt Model hypothesises that optimal intra-oral vacuums and breast tissue volumes are achieved when mother-infant positional stability eliminates conflicting intra-oral vectors, resulting in pain-free, effective milk transfer.

CONCLUSION

the Gestalt Model of the biomechanics of healthy infant suck during breastfeeding opens up the possibility of a new clinical method which may prevent unnecessary medical treatments for breastfeeding problems and related unsettled infant behaviour in early life.

Immediate postpartum levonorgestrel intrauterine device insertion and breast-feeding outcomes: a noninferiority randomized controlled trial

BACKGROUND

Immediate postpartum levonorgestrel intrauterine device insertion is increasing in frequency in the United States, but few studies have investigated the effect of early placement on breast-feeding outcomes.

OBJECTIVE

This study examined the effect of immediate vs delayed postpartum levonorgestrel intrauterine device insertion on breast-feeding outcomes.

STUDY DESIGN

We conducted this noninferiority randomized controlled trial at the University of Utah and the University of New Mexico Health Sciences Centers from February 2014 through March 2016. Eligible women were pregnant and planned to breast-feed, spoke English or Spanish, were aged 18-40 years, and desired a levonorgestrel intrauterine device. Enrolled women were randomized 1:1 to immediate postpartum insertion or delayed insertion at 4-12 weeks' postpartum. Prespecified exclusion criteria included delivery <37.0 weeks' gestational age, chorioamnionitis, postpartum hemorrhage, contraindications to levonorgestrel intrauterine device insertion, and medical complications of pregnancy that could affect breast-feeding. We conducted per-protocol analysis as the primary approach, as it is considered the standard for noninferiority studies; we also report the alternative intent-to-treat analysis. We powered the study for the primary outcome, breast-feeding continuation at 8 weeks, to detect a 15% noninferiority margin between groups, requiring 132 participants in each arm. The secondary study outcome, time to lactogenesis, used a validated measure, and was analyzed by survival analysis and log rank test. We followed up participants for ongoing data collection for 6 months. Only the data analysis team was blinded to the intervention.

RESULTS

We met the enrollment target with 319 participants, but lost 34 prior to randomization and excluded an additional 26 for medical complications prior to delivery. The final analytic sample included 132 in the immediate group and 127 in the delayed group. Report of any breast-feeding at 8 weeks in the immediate group (79%; 95% confidence interval, 70-86%) was noninferior to that of the delayed group (84%; 95% confidence interval, 76-91%). The 5% difference in breast-feeding continuation at 8 weeks between the groups fell within the noninferiority margin (95% confidence interval, -5.6 to 15%). Time to lactogenesis (mean ± SD) in the immediate group, 65.3 ± 25.7 hours, was noninferior to that of the delayed group, 63.6 ± 21.6 hours. The mean difference between groups was 1.7 hours (95% confidence interval, -4.8 to 8.2 hours), noninferior by log-rank test. A total of 24 intrauterine device expulsions occurred in the immediate group compared to 2 in the delayed group (19% vs 2%, P < .001), consistent with the known higher expulsion rate with immediate vs delayed postpartum intrauterine device insertion. No intrauterine device perforations occurred in either group.

CONCLUSION

Our results of noninferior breast-feeding outcomes between women with immediate and delayed postpartum levonorgestrel intrauterine device insertion suggest that immediate postpartum intrauterine device insertion is an acceptable option for women planning to breast-feed and use the levonorgestrel intrauterine device. Expulsion rates are higher with immediate postpartum levonorgestrel intrauterine device insertion compared to delayed insertion, but this disadvantage may be outweighed by the advantages of immediate initiation of contraception. Providers should offer immediate postpartum intrauterine device insertion to breast-feeding women planning to use the levonorgestrel intrauterine device.

Predictors of breastfeeding exclusivity and duration in a hospital without Baby Friendly Hospital Initiative accreditation: A prospective cohort study

AIM

The aim of this study was to investigate the maternity care factors associated with exclusive breastfeeding duration at three months and six months postpartum in a setting without BFHI accrediation.

METHODS

A prospective cohort design. Participants from one tertiary maternity hospital were eligible if they intended to exclusively breastfeed, had birthed a live, term baby; were breastfeeding at recruitment; were rooming-in with their baby; were healthy and well; and understood English. Participants completed an infant feeding survey using 24-h recall questions at three time-points. Data were analysed using descriptive statistics, bivariate analysis and regression modelling.

FINDINGS

We recruited 424 participants of whom 84% (n=355) responded to the survey at 3-months and 79% (n=335) at 6-months. Women who avoided exposure to intrapartum opioid analgesia (e.g. intramuscular, intraveous or epidural) were more likely to be exclusively breastfeeding at 3-months postpartum (adjusted odds ratio (aOR) 2.09, 95% confidence interval (CI) 1.15-3.80, probability value (p) 0.016). The only other modifiable predictor of exclusive breastfeeding at 3-months was non-exposure to artificial formula on the postnatal ward (aOR 2.44, 95% CI 1.43-4.18, p<0.001). At 6-months postpartum, the rate of exclusive breastfeeding had reduced to 5% (n=16) which rendered regression modelling untenable.

DISCUSSION

Strategies to decrease exposure to opioid analgesia in birth settings and the use of infant formula on the postnatal ward may improve exclusive breastfeeding at three months.

CONCLUSION

Results suggest that both intrapartum and postpartum maternity care practices can predict long-term breastfeeding success.

Baby-Friendly Hospital designation has a sustained impact on continued breastfeeding

The Baby‐Friendly Hospital (BFH) Initiative has led to an increase in breastfeeding rates and duration worldwide. But little is known about whether the beneficial effects persist beyond a facility's designation as a BFH. To investigate the association of BFH designation (current, former, and never) and compliance with Baby‐Friendly (BF) practices on breastfeeding in Switzerland, this study combined nationwide survey data on breastfeeding with BFH monitoring data. In this cross‐sectional study, 1,326 children were born in 34 current (N = 508), 28 former (N = 425), and 34 never designated BFHs (N = 393). We compared exclusive and any breastfeeding according to BFH designation over the first year of life, using Kaplan‐Meyer Survival curves. Logistic regression models were applied to analyse breastfeeding prevalence, and Cox‐regression models were used for exclusive (0–6 months) and continued (6–12 months) breastfeeding duration. Average duration of exclusive breastfeeding (13.1 weeks, 95% confidence interval [12.0, 17.4]) and any breastfeeding (32.7 weeks, 95% confidence interval [30.5, 39.2]) were the longest for babies born in currently accredited BFHs. Exclusive breastfeeding was associated with high compliance with monitored BF practices in current BFHs and with the number of BF practices experienced in all hospitals. Continued breastfeeding was significantly longer when babies were born in current BFHs (cessation hazard ratio 0.60, 95% confidence interval [0.42, 0.84]) or in former BFHs (cessation hazard ratio 0.68, 95% confidence interval [0.48, 0.97]). Overall, the results support continued investment into BFHs, because babies born in current BFHs are breastfed the most and the longest, whereas a former BFH designation shows a sustained effect on continued breastfeeding.

Gestalt Breastfeeding: Helping Mothers and Infants Optimize Positional Stability and Intraoral Breast Tissue Volume for Effective, Pain-Free Milk Transfer

In the past decade, biological nurturing and activation of maternal and infant instincts after birth have constituted a major advance in clinical breastfeeding support. Yet, physiologic breastfeeding initiation is not enough to ensure ongoing pain-free and effective breastfeeding for many pairs. Current interventions, including "hands-off" mammalian approaches, do not improve breastfeeding outcomes, including in randomized controlled trials. Back-arching, difficulty latching or staying on the breast, and fussing at the breast are common signs of infant positional instability during breastfeeding. These cues are, however, often misdiagnosed as signs of medical conditions or oral connective tissue abnormalities, and underlying positional instability is not addressed. New clinical approaches are urgently required. This article offers a clinical approach to fit and hold (or latch and positioning)- gestalt breastfeeding, which aims to optimize positional stability and intraoral breast tissue volumes for pain-free effective breastfeeding. The word gestalt (pronounced "ger-shtolt") means a whole that is more than the sum of its parts. Gestalt breastfeeding builds on the theoretical foundations of complexity science, physiologic breastfeeding initiation, and new understandings of the biomechanics of infant suck elucidated in ultrasound studies. It also integrates simple psychological strategies from applied functional contextualism, popularly known as Acceptance and Commitment Therapy, empowering women to attend mindfully to breast sensations and their infant's cues. Gestalt breastfeeding can be reproduced for research purposes, including in comparison studies with oral surgery, and has the potential to improve breastfeeding outcomes.

Factors associated with the interruption of exclusive breastfeeding in infants up to 30 days old

Objective

To identify factors associated with the interruption of exclusive breastfeeding (EBF) in infants up to 30 days old.

Method

A cross-sectional study conducted at a university hospital in southern Brazil, from December 2014 to September 2015, with 341 infants up to 30 days old and their mothers. A semi-structured questionnaire was applied consisting of variables related to sociodemographic characteristics, obstetric history of the mother, companion's education, and data of the infant and of breastfeeding. Collected data were subjected to bivariate and multivariate analysis with the estimation of Prevalence Ratios (PR).

Results

The prevalence of EBF was 79.5%. The factors associated with the interruption of EBF were babies ≥ 21 days, who received formula supplementation at the hospital, women with difficulties breastfeeding after hospital discharge, and non-white.

Conclusion

the factors associated with EBF interruption can help health workers create actions for mothers with difficulties and prevent interruption of EBF.

The realization of BFHI Step 4 in Finland - Initial breastfeeding and skin-to-skin contact according to mothers and midwives

BACKGROUND

Breastfeeding and skin-to-skin contact are the best start for infant life. Breastfeeding ensures the best trajectory for development and growth while preventing many diseases later in life. It is recommended that initial breastfeeding occur during the first hour and that generally exclusive breastfeeding is adopted during the first six months.

OBJECTIVE

The aim of this study is to describe how initial breastfeeding and skin-to-skin contact (Step 4 of the BFHI) is implemented in Finnish maternity hospitals as well as to explain the factors connected to it. The information can be used to develop maternity care during the immediate postpartum period.

DESIGN

Cross-sectional study.

METHODS

The data were collected from mothers who had given birth as well as their midwives via questionnaire during the spring of 2014 during one week at eight maternity hospitals in Finland. The response rate was 59% for the new mothers (n=111), while it was 57% for the midwives (n=272). The data were analysed statistically and the open-ended questions in the questionnaire using content specifications.

FINDINGS

On the basis of the results, initial breastfeeding succeeded well after vaginal birth. Initial breastfeeding began, on average, at 41minutes of age and lasted for 51minutes. Of mothers, 87% regarded it a very positive experience. Initial breastfeeding was delayed mainly because of caesarean section and for reasons related to an infant's condition. Many background factors such as midwives' age, mothers' parity and the mode of childbirth were statistically significant in respect to the success of initial breastfeeding.

CONCLUSIONS

More attention should be placed on the initial breastfeeding of infants born by caesarean section and primiparous mothers.

Using Skin-to-Skin Contact to Increase Exclusive Breastfeeding at a Military Medical Center

Evidence shows that early formula supplementation leads to early weaning from exclusive breastfeeding. We implemented an evidence-based practice project on skin-to-skin contact (SSC) for healthy term newborns at a large military treatment facility in an effort to decrease formula supplementation in the early postpartum period. Military women face unique challenges when it comes to breastfeeding. SSC in the early postpartum period is an effective intervention to increase exclusive breastfeeding during the hospital stay and foster future positive breastfeeding outcomes. Through this project, staff knowledge of the benefits of SSC to women and newborns improved and the hospital's exclusive breastfeeding rate increased by 20 percent.

Improving Exclusive Breastfeeding in an Urban Academic Hospital

BACKGROUND AND OBJECTIVE

Breastfeeding has many well-established health benefits for infants and mothers. There is greater risk reduction in health outcomes with exclusive breastfeeding (EBF). Our urban academic facility has had long-standing low EBF rates, serving a population with breastfeeding disparities. We sought to improve EBF rates through a Learning Collaborative model by participating in the Best Fed Beginnings project.

METHODS

Formal improvement science methods were used, including the development of a key driver diagram and plan-do-study-act cycles. Improvement activities followed the Ten Steps to Successful Breastfeeding.

RESULTS

We demonstrated significant improvement in the median adherence to 2 process measures, rooming in and skin-to-skin after delivery. Subsequently, the proportion of infants exclusively breastfed at hospital discharge in our facility increased from 37% to 59%. We demonstrated an increase in sustained breastfeeding in a subset of patients at a postpartum follow-up visit. These improvements led to Baby-Friendly designation at our facility.

CONCLUSIONS

This quality improvement initiative resulted in a higher number of infants exclusively breastfed in our patient population at "high risk not to breastfeed." Other hospitals can use these described methods and techniques to improve their EBF rates.

A Multifaceted Approach to Revitalizing the Baby-Friendly Hospital Initiative in Croatia

The Baby-Friendly Hospital Initiative (BFHI) was launched in Croatia in 1993. By 1998, 15 of 34 maternity facilities were designated "Baby-Friendly." Introduction of hospital bags, violating the International Code of the Marketing of Breastmilk Substitutes, led to a standstill in the BFHI. The aim of this article is to describe the successful reintroduction of the BFHI in Croatia between 2007 and 2015. After hospital bags were abolished in 2007, UNICEF Croatia undertook an assessment of BFHI implementation. All maternity facilities were invited by UNICEF and the Ministry of Health to join the renewed BFHI. UNICEF materials were translated and training for trainers, assessors, coordinators, and hospital staff held. By June 2015, 30 of 32 (94%) maternity facilities, providing care to 89% of newborns, were Baby-Friendly. Nine maternity hospitals have been renovated and 2 new hospitals have been built. Exclusive breastfeeding rates have risen 16% at 0 to 2 months (from 51% in 2007 to 67% in 2014) and 14% at 3 to 5 months (from 32% in 2007 to 46% in 2014). Fourteen "Breastfeeding-Friendly" primary care practices have been designated, 166 breastfeeding support groups are in operation, criteria for Mother-Friendly care are being piloted in 2 maternity facilities, and "Ten Steps in the Neonatal Intensive Care Unit" are being introduced. The BFHI provides an excellent opportunity for revitalizing breastfeeding protection, promotion, and support in all settings. Recognition and support of the BFHI by the Croatian government was crucial for implementing the BFHI, whereas the marketing practices of the breast milk substitutes industry are an ongoing challenge.

Nurses' Perspectives on the Process of Attaining Baby-Friendly Designation

The Baby-Friendly Hospital Initiative is a global initiative that aims to protect, promote, and support breastfeeding. This study explores and describes the process of attaining Baby-Friendly designation from nurses' perspectives. A purposive sampling design was used to recruit registered nurse participants in a large, safety-net, tertiary care facility. Data were collected via semistructured interviews and were analyzed using descriptive interpretative analysis. The following themes were revealed: Resistance, Culture, Investment in the Journey, Teamwork, and Source of Pride. Results indicate that comfortable yet antiquated practices led to fear of change and resistance. Initial culture shock was mediated by a successful education model, powerful experiences, and positive outcomes.

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.

The Baby-Friendly Hospital Initiative as an Intervention to Improve Breastfeeding Rates: A Review of the Literature

INTRODUCTION

The Baby-Friendly Hospital Initiative (BFHI) is considered to be an evidence-based program that improves breastfeeding outcomes, but primary research on the topic has been limited. The purpose of this review was to evaluate the literature and synthesize findings to determine the effectiveness of the BFHI as an intervention to improve breastfeeding initiation, duration, and exclusivity.

METHODS

A review of literature published from 1991 to October 2014 using MEDLINE, CINAHL, PsycINFO, and Web of Knowledge with the search term "Baby-Friendly Hospital Initiative." The 724 titles initially identified were reviewed using these inclusion criteria: English language, primary research, and available electronically or via interlibrary loan. Studies were excluded if they explicitly stated that they had omitted specific portions of the BFHI or did not fully implement the intervention; considered breastfeeding rather than the BFHI as an intervention; used the BFHI to improve neonatal intensive care unit outcomes specifically; or measured outcomes other than breastfeeding initiation, duration, or exclusivity. This yielded 25 studies for review.

RESULTS

There are more studies that support the BFHI as an intervention to increase breastfeeding than there are studies that demonstrate no effect of the intervention. However, design weaknesses, settings outside the United States, and disparate methods impede the ability to reach firm conclusions regarding the effectiveness of the BFHI in improving breastfeeding initiation, duration, and exclusivity rates in the United States.

DISCUSSION

Many of the studies regarding the effectiveness of the BFHI have been hampered by weak designs or methodologic limitations. Research conducted in the United States and employing experimental designs would help to more conclusively determine the effectiveness of the BFHI as an intervention to improve breastfeeding rates.

Postpartum Breastfeeding Promotion and Duration of Exclusive Breastfeeding in Western Nepal

BACKGROUND

Encouragement and skills provided to mothers during the postpartum period have been found to be successful in increasing exclusive breastfeeding rates. However, evidence from developing countries is limited. This study aimed to ascertain whether education and skill support provided by health workers during the postpartum period were associated with increased duration of exclusive breastfeeding in Western Nepal.

METHODS

A community-based prospective cohort study was conducted between January and October 2014, in the Rupandehi district of Nepal. Information on breastfeeding promotion provided by health workers after birth was collected from 649 mothers. The association between breastfeeding promotion and exclusive breastfeeding was investigated using multivariable Cox regression analysis.

RESULTS

Of the 649 mothers, 35 percent received all eight types of breastfeeding promotion advice, and 60 percent received six or more such types of advice. Breastfeeding promotion, such as "breastfeeding on demand" (hazard ratio [HR] 0.74 [95% CI 0.59-0.92]) and "not to provide pacifier or teats" (HR 0.82 [95% CI 0.68-0.97]), were significantly associated with a lower risk of exclusive breastfeeding cessation. The dose-response relationship was also significant for the number of advices received (HR 0.94 [95% CI 0.90-0.97]).

CONCLUSIONS

This study provides evidence that breastfeeding education and support immediately after childbirth could increase the duration of breastfeeding. The results suggest further attention to breastfeeding promotion in all maternity hospitals and birthing centers through skilled birth attendants.

Ten Steps to Successful Breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trial

BACKGROUND

Optimisation of breastfeeding practices could reduce high mortality rates in children younger than 5 years, but in DR Congo, despite near-universal breastfeeding initiation and nine of ten children still breastfeeding at 1 year of age, exclusivity remains a difficulty. We assessed the effect on breastfeeding outcomes of a short-cut implementation of a programme called the Ten Steps to Successful Breastfeeding, the key component of the Baby-Friendly Hospital Initiative (BFHI).

METHODS

We did a cluster-randomised controlled trial and randomly assigned health-care clinics in Kinshasa, DR Congo, to standard care (control group), BFHI steps 1-9 (steps 1-9 group), or BFHI steps 1-9 plus additional support during well-child visits (steps 1-10 group) with computer-generated random numbers used to assign matched pairs to study groups. Mothers at these clinics who had given birth to one healthy baby during enrolment, and who expressed their intentions of visiting a well-baby session at the same clinic, were eligible and received the treatment assigned to their clinic. Mother-infant pairs were excluded if the mothers intended to attend well-baby clinic visits at a different health facility, or to travel before the child was aged at least 6 months. Participants and independent interviewers were masked to group assignment (ie, they were recruited after randomisaion and training of the clinic staff and were not informed of the study scheme), but clinical staff were unmasked. BFHI steps 1-9 and 1-10 were given by health-care staff trained with the WHO/UNICEF BFHI course. The primary outcomes were breastfeeding initiation within 1 h of birth and exclusive breastfeeding at age 14 and 24 weeks, assessed at face-to-face interviews in the clinic. Analysis was by intention to treat. Prevalence ratios (PR) were adjusted for cluster effects and baseline characteristics. This trial is registered at ClinicalTrials.gov, number NCT01428232, and is closed to new participants.

FINDINGS

Between May 24, and Aug 25, 2012, we randomly assigned two eligible clinics to control, two to BFHI steps 1-9, and two to BFHI steps 1-10. We enrolled 975 eligible mother-infant pairs (304 in the control group, 363 in the steps 1-9 group, and 308 in the steps 1-10 group). 230 (76%) of infants in the control group, 263 (72%) in the steps 1-9 group, and 220 (71%) in the steps 1-10 group were breastfed within 1 h of birth; these results did not differ significantly between groups. Prevalence of exclusive breastfeeding at age 14 weeks was 89 (29%) in the control group, 237 (65%) in the steps 1-9 group (adjusted PR 2·20, 95% CI 1·73-2·77), and 129 (42%) in the steps 1-10 group (1·40, 1·13-1·74). At age 24 weeks, the prevalence of exclusive breastfeeding was 36 (12%) in the control group, 131 (36%) in the steps 1-9 group (3·50, 2·76-4·43), and 43 (14%) in the steps 1-10 group (1·31, 0·91-1·89).

INTERPRETATION

In the setting of health-care clinics in DR Congo with a high proportion of mothers initiating breastfeeding, implementation of basic training in BFHI steps 1-9 had no additional effect on initiation of breastfeeding but significantly increased exclusive breastfeeding at 6 months of age. Additional support based on the same training materials and locally available breastfeeding support materials, offered during well-child visits (ie, step 10) did not enhance this effect, and might have actually lessened it.

[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.

The New Hampshire Ten Steps to Successful Breastfeeding Collaborative: A Statewide QI Initiative

BACKGROUND AND OBJECTIVE

Despite national recognition for their breastfeeding-friendly practices, many New Hampshire hospitals are still not achieving the Ten Steps to Successful Breastfeeding. To increase achievement of the Ten Steps in New Hampshire's birthing hospitals, facilitate Baby-Friendly Hospital Initiative (BFHI) designation for interested hospitals, and improve rates of in-hospital any and exclusive breastfeeding.

METHODS

After a 2010 needs assessment, we conducted 2 statewide workshops targeting 6 of the Ten Steps found to be most deficient among New Hampshire birthing hospitals. Eighteen of 20 hospitals attended at least 1 workshop, and 6 participated in an intensive collaborative. In 2013, we analyzed interval Ten Step achievement and in-hospital breastfeeding trends.

RESULTS

Staff education showed the greatest improvement, increasing step 2 achievement from 1 to 6 hospitals (P=.05). Although the number of hospitals implementing step 6 (breast milk only) and step 9 (no artificial nipples) increased, differences were not statistically significant. Intensive collaborative hospitals achieved an average of 1.5 new steps, whereas non-Baby Friendly hospitals lost 0.7 steps (P=.05). In-hospital breastfeeding rates increased in intensive collaborative hospitals and were significantly higher than those in non-Baby Friendly hospitals by the end of the study (any breastfeeding, 89% vs 73%, P=.03; exclusive breastfeeding, 84% vs 61%, P<.001).

CONCLUSIONS

A statewide improvement collaborative facilitated increases in Ten Step achievement and in-hospital breastfeeding for hospitals participating in an intensive collaborative. Active work in Ten Step implementation, including staff education, appears to be more effective in increasing in-hospital breastfeeding than does BFHI designation alone.

Predictors of discontinuing exclusive breastfeeding before six months among mothers in Kinshasa: a prospective study

Background

Although breastfeeding is common in Democratic Republic of the Congo, the proportion of women who exclusively breastfeed their babies up to 6 months remains low. This study aimed at identifying predictors of discontinuing exclusive breastfeeding before six months among mothers in Kinshasa.

Methods

A prospective study was carried out from October 2012 to July 2013 among 422 mother-child pairs recruited shortly after discharge from twelve maternities in Kinshasa and followed up to six months. Interviews were conducted at each woman’s house during the first week after birth, and at one, two, three, four, five and six months. Collected data included history of child’s feeding and mother’s socio-demographic and psychosocial characteristics. The Cox Proportional Model was used to identify predictors of discontinuing exclusive breastfeeding before six months.

Results

The median duration of exclusive breastfeeding was 10.9 weeks (Inter Quartile Range 4.3 to 14.9). At six months, 2.8 % of infants were exclusively breastfed. The factors independently associated with the discontinuation of exclusive breastfeeding before six months were: not confident in the ability to breastfeed [Adjusted hazard ratio (AHR) = 3.90; 95 % CI 1.66, 9.16)], no plan on the duration of EBF (AHR = 2.86; 95 % CI 1.91, 4.28), breastfeeding problems during the first week (AHR = 1.54; 95 % CI 1.13, 2.11), low level of breastfeeding knowledge (AHR = 1.52; 95 % CI 1.08, 2.15), and experienced less than five Baby-friendly practices during the maternity stay (AHR = 1.47; 95 % CI 1.05, 2.06).

Conclusions

Confidence in the ability to breastfeed and intention to exclusively breastfeed were the most important predictors of discontinuing exclusive breastfeeding before six months. To have a greater impact on the duration of exclusive breastfeeding, interventions should focus on these factors.

Electronic supplementary material

The online version of this article (doi:10.1186/s13006-015-0044-7) contains supplementary material, which is available to authorized users.