Evaluation of Ready, Set, BABY: A prenatal breastfeeding education and counseling approach.

BACKGROUND: Comprehensive prenatal education on infant feeding is recommended by many United States health organizations because of the need to maximize maternal preparedness for managing lactation physiology. Ready, Set, BABY (RSB) is a curriculum developed for counseling women about breastfeeding benefits and management including education on optimal maternity care practices. We hypothesized that RSB would be acceptable to mothers and that mothers' strength of breastfeeding intentions would increase, and their comfort with the idea of formula feeding would decrease after educational counseling using the materials. We also hypothesized that mothers' knowledge of optimal maternity care practices would increase after participation. METHODS: Materials were sent to a total of seven sites in the United States and Puerto Rico. Local health care practitioners completed training before counseling mothers with the curriculum. A pre- and postintervention questionnaire was administered to participants. Statistical analysis of results included paired t tests, Wilcoxon signed-rank tests, and McNemar's tests. RESULTS: Four hundred and sixteen expectant women participated. In the pre- and postintervention comparison, maternal participation in RSB significantly improved Infant Feeding Intentions Scale scores (P < 0.001) and knowledge of Baby-Friendly recommended maternity care practices (P < 0.001), while significantly decreasing comfort with the idea of formula feeding (P < 0.001). The education materials were positively rated by participants. CONCLUSIONS: The findings indicate that the approach of using RSB in prenatal counseling group classes or individual sessions improves breastfeeding intentions. Future testing is needed to determine the effectiveness of the materials for impacting breastfeeding outcomes.

Systematic Review of Evidence for Baby-Friendly Hospital Initiative Step 3.

BACKGROUND: The Ten Steps to Successful Breastfeeding outline maternity practices that protect, promote, and support breastfeeding and serve as the foundation for the Baby-Friendly Hospital Initiative. Research aim: This systematic review describes interventions related to Step 3 of the Ten Steps, which involves informing pregnant women about the benefits and management of breastfeeding. Our main objective was to determine whether prenatal clinic- or hospital-based breastfeeding education increases breastfeeding initiation, duration, or exclusivity. METHODS: The electronic databases MEDLINE and CINAHL were searched for peer-reviewed manuscripts published in English between January 1, 2000, and May 5, 2016. Bibliographies of relevant systematic reviews were also screened to identify potential studies. RESULTS: Thirty-eight studies were included. The research studies were either randomized controlled trials or quasi-experimental studies conducted in developed or developing countries. Findings suggest that prenatal interventions, delivered alone or in combination with intrapartum and/or postpartum components, are effective at increasing breastfeeding initiation, duration, or exclusivity where they combine both education and interpersonal support and where women's partners or family are involved. However, varying study quality and lack of standardized assessment of participants' breastfeeding intentions limited the ability to recommend any single intervention as most effective. CONCLUSION: Future studies should test the strength of maternal breastfeeding intentions, assess the role of family members in influencing breastfeeding outcomes, compare the effectiveness of different health care providers, and include more explicit detail about the time and full cost of different interventions.

Postpartum Sexuality and the Lactational Amenorrhea Method for Contraception.

This chapter reviews the literature on postpartum coital behavior, anovulatory and ovulatory bleeding episodes, and the methodology and efficacy of Lactational Amenorrhea Method and progesterone-only oral contraceptives. Of interest is the finding that breastfeeding women may resume coital behavior earlier postpartum, but report increased discomfort over time. The high efficacy of the Lactational Amenorrhea Method is confirmed and data illustrating possible relaxation of some criteria are presented. The conflicting guidance of CDC and WHO concerning immediate postpartum use of progestin-only methods is presented. The dearth of recent studies calls for new research on these topics.

Effect of primary care intervention on breastfeeding duration and intensity.

OBJECTIVES: We determined the effectiveness of primary care-based, and pre- and postnatal interventions to increase breastfeeding. METHODS: We conducted 2 trials at obstetrics and gynecology practices in the Bronx, New York, from 2008 to 2011. The Provider Approaches to Improved Rates of Infant Nutrition & Growth Study (PAIRINGS) had 2 arms: usual care versus pre- and postnatal visits with a lactation consultant (LC) and electronically prompted guidance from prenatal care providers (EP). The Best Infant Nutrition for Good Outcomes (BINGO) study had 4 arms: usual care, LC alone, EP alone, or LC+EP. RESULTS: In BINGO at 3 months, high intensity was greater for the LC+EP (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.08, 6.84) and LC (OR = 3.22; 95% CI = 1.14, 9.09) groups versus usual care, but not for the EP group alone. In PAIRINGS at 3 months, intervention rates exceeded usual care (OR = 2.86; 95% CI = 1.21, 6.76); the number needed to treat to prevent 1 dyad from nonexclusive breastfeeding at 3 months was 10.3 (95% CI = 5.6, 50.7). CONCLUSIONS: LCs integrated into routine care alone and combined with EP guidance from prenatal care providers increased breastfeeding intensity at 3 months postpartum.

Implementing the ten steps to successful breastfeeding in multiple hospitals serving low-wealth patients in the US: innovative research design and baseline findings.

BACKGROUND: The Ten Steps to Successful Breastfeeding are maternity practices proven to support successful achievement of exclusive breastfeeding. They also are the basis for the WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI). This study explores implementation of these steps in hospitals that serve predominantly low wealth populations. METHODS: A quasi-experimental design with mixed methods for data collection and analysis was included within an intervention project. We compared the impact of a modified Ten Steps implementation approach to a control group. The intervention was carried out in hospitals where: 1) BFHI designation was not necessarily under consideration, and 2) the majority of the patient population was low wealth, i.e., eligible for Medicaid. Hospitals in the research aspect of this project were systematically assigned to one of two groups: Initial Intervention or Initial Control/Later Intervention. This paper includes analyses from the baseline data collection, which consisted of an eSurvey (i.e., Carolina B-KAP), Maternity Practices in Infant Nutrition and Care survey tool (mPINC), the BFHI Self-Appraisal, key informant interviews, breastfeeding data, and formatted feedback discussion. RESULTS: Comparability was ensured by statistical and non-parametric tests of baseline characteristics of the two groups. Additional findings of interest included: 1) a universal lack of consistent breastfeeding records and statistics for regular monitoring/review, 2) widespread misinterpretation of associated terminology, 3) health care providers' reported practices not necessarily reflective of their knowledge and attitudes, and 4) specific steps were found to be associated with hospital breastfeeding rates. A comprehensive set of facilitators and obstacles to initiation of the Ten Steps emerged, and hospital-specific practice change challenges were identified. DISCUSSION: This is one of the first studies to examine introduction of the Ten Steps in multiple hospitals with a control group and in hospitals that were not necessarily interested in BFHI designation, where the population served is predominantly low wealth, and with the use of a mixed methods approach. Limitations including numbers of hospitals and inability to adhere to all elements of the design are discussed. CONCLUSIONS: For improvements in quality of care for breastfeeding dyads, innovative and site-specific intervention modification must be considered.

Applying organisation theory to understand barriers and facilitators to the implementation of baby-friendly: A multisite qualitative study.

OBJECTIVES: (a) to apply an organisation-level, pre-implementation theory to identify and describe factors that may impact hospitals' readiness to achieve the Ten Steps and (b) to explore whether/how these factors vary across hospitals. DESIGN: a multisite, descriptive, qualitative study of eight hospitals that used semi-structured interviews of health-care professionals. Template analyses identified factors that related to organisation-level theory. Cross-site comparative analyses explored how factors varied across hospitals. SETTING: thirty-four health-care professionals from eight North Carolina hospitals serving low-wealth populations. The hospitals are participating in a quality improvement project to support the implementation of the Ten Steps. This study occurred during the pre-implementation phase. FINDINGS: several factors emerged relating to collective efficacy (i.e., the shared belief that the group, as a whole, is able to implement the Steps) and collective commitment (i.e., the shared belief that the group, as a whole, is committed to implementing the Steps) to implement the Ten Steps. Factors relating to both constructs included 'staff age/experience,' 'perceptions of forcing versus supporting mothers,' 'perceptions of mothers' culture,' and 'reliance on lactation consultants.' Factors relating to commitment included 'night versus day shift,' 'management support,' 'change champions,' 'observing mothers utilize breastfeeding support.' Factors relating to efficacy included 'staffing,' 'trainings,' and 'visitors in room.' Commitment-factors were more salient than efficacy-factors among the three large hospitals. Efficacy-factors were more salient than commitment-factors among the smaller hospitals. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: interventions focused on implementing the Ten Step may benefit from improving collective efficacy and collective commitment. Potential approaches could include skills-based, hands-on training highlighting benefits for mothers, staff, and the hospital, and addressing context-specific misconceptions about the Steps.

Breastfeeding: population-based perspectives.

From a population perspective, the achievement of the goals of exclusive breastfeeding throughout the first 6 months of life and continued breastfeeding with the introduction of age-appropriate complementary feeding for infant feeding, women and families must be inspired and empowered to overcome health system, sociocultural, and economic/political barriers. This article discusses trends in breastfeeding, influences on the reacceptance of a breastfeeding norm, and breastfeeding as a social and public health issue. The goal is to create an enabling environment for optimal breastfeeding in health care and social norms, and to adjust the social and political realities to support an economic milieu that favors breastfeeding.

The extent that noncompliance with the ten steps to successful breastfeeding influences breastfeeding duration.

UNLABELLED: BACKGROUND, OBJECTIVES: The Ten Steps to Successful Breastfeeding are not, as yet, the norm in the United States. This study examined how noncompliance with each of the Steps, and combinations of 2 Steps, influence duration of breastfeeding at the breast. METHODS: Data were from the national Infant Feeding Practices Study II. The outcome was duration of any breastfeeding at the breast. Propensity scores modeled the probability of exposure to lacking 1 or more of the Ten Steps. Inverse probability weights controlled for confounding. Survival analyses estimated the relationship between the lack of a Step and breastfeeding duration. RESULTS: Lack of Step 6 (No human milk substitutes) was associated with shorter breastfeeding duration, compared with being exposed to Step 6 (10.5-wk decrease). Lack of both Steps 4 (Breastfeed within 1 hour after birth) and 9 (Pacifiers), together, was related to the greatest decrease in breastfeeding duration (11.8-wk decrease). The findings supported a dose-response relationship: being exposed to 6 Steps was related to the longest median duration (48.8 wk), followed by 4 or 5 Steps (39.8 wk), followed by 2 or 3 Steps (36.4 wk). CONCLUSIONS: Prevalent US maternity care practices do not, as yet, include all of the Ten Steps. This lack of care may be associated with poor establishment of the physiological feedback systems that support sustained breastfeeding. Breastfeeding at the breast is compromised when specific combinations of Steps are lacking. Efforts to increase implementation of specific Steps and combinations of Steps may be associated with increased duration of breastfeeding.

Definitions of breastfeeding: call for the development and use of consistent definitions in research and peer-reviewed literature.

BACKGROUND: There has been a significant increase in the number of published peer-reviewed articles on breastfeeding over the last two decades. However, in part because of the lack of clear or consistent definitions used in these publications, generalization and comparison of findings have been difficult, and interpretation of findings is often limited. This study was undertaken to examine this issue by assessing if and what definitions of breastfeeding have been used in a variety of relevant journals and the source of those definitions. MATERIALS AND METHODS: An iterative systematic approach was used to select articles for review from major breastfeeding and health-related journals. Articles were reviewed for use of breastfeeding terminology, descriptors (e.g., exclusive, partial), and full definitions. Descriptive analysis was carried out using Excel (Microsoft(®), Redmond, WA). A flow chart was developed to examine sources of definitions in use. FINDINGS: Descriptors are seen 68% of the time, and full definitions are only offered in slightly more than a quarter (28%) of the articles. Among those journals that are primarily dedicated to breastfeeding research, 43-64% included descriptors, and 20-29% included definition of the descriptor. The pediatric journal included a high percentage with descriptors (77%), but only 18% were defined further. Among the other journals, there was a wide range (0-60%) with descriptors but fewer providing definitions. Only 26 articles offered a definition, and of these, 21 articles included a citation. Most derived from the Interagency Group for Action on Breastfeeding and World Health Organization definitional schemas. DISCUSSION: There remains a need by journals for increased requirement of inclusion of breastfeeding definitions and by researchers of attention to their use. For this to occur, there must first be the reconfirmation and/or development of a set of consistently utilized definitions that are applicable for the study of behaviors, support interventions, and health outcomes for both the mother and of the child. Therefore, an inclusionary international Working Group Process Approach is recommended, similar to that used in 1988, with confirmation and dissemination by all major organizations and agencies.

Implementing the Ten Steps for Successful Breastfeeding in hospitals serving low-wealth patients.

OBJECTIVES: The Ten Steps to Successful Breastfeeding is a proven approach to support breastfeeding in maternity settings; however, scant literature exists on the relative impact and interpretation of each step on breastfeeding. We assessed the Ten Steps and their relationship with in-hospital breastfeeding rates at facilities serving low-wealth populations and explored the outcomes to identify step-specific actions. METHODS: We present descriptive and nonparametric comparisons and qualitative findings to examine the relationship between the Ten Steps and breastfeeding rates from each hospital using baseline data collection. RESULTS: Some steps (1--policy, 2--training, 4--skin-to-skin, 6--no supplements, and 9--no artificial nipples, followed by 3--prenatal counseling, 7--rooming-in) reflected differences in relative baseline breastfeeding rates between settings. Key informant interviews revealed misunderstanding of some steps. CONCLUSIONS: Self-appraisal may be less valid when not all elements of the criteria for evaluating Step implementation may be fully understood. Limited exposure and understanding may lead to self-appraisal errors, resulting in scores that are not reflective of actual practices. Nonetheless, the indication that breastfeeding rates may be better mirrored by a defined subset of steps may provide some constructive insight toward prioritizing implementation activities and simplifying assessment. These issues will be further explored in the next phase of this study.

Early breastfeeding experiences of adolescent mothers: a qualitative prospective study.

BACKGROUND: Teen mothers face many challenges to successful breastfeeding and are less likely to breastfeed than any other population group in the U.S. Few studies have investigated this population; all prior studies are cross-sectional and collect breastfeeding data retrospectively. The purpose of our qualitative prospective study was to understand the factors that contribute to the breastfeeding decisions and practices of teen mothers. METHODS: This prospective study took place from January through December 2009 in Greensboro, North Carolina in the U.S. We followed the cohort from pregnancy until two weeks after they ceased all breastfeeding and milk expression. We conducted semi-structured interviews at baseline and follow-up, and tracked infant feeding weekly by phone. We analyzed the data to create individual life and breastfeeding journeys and then identified themes that cut across the individual journeys. RESULTS: Four of the five teenagers breastfed at the breast for nine days: in contrast, one teen breastfed exclusively for five months. Milk expression by pumping was associated with significantly longer provision of human milk. Breastfeeding practices and cessation were closely connected with their experiences as new mothers in the context of ongoing multiple roles, complex living situations, youth and dependency, and poor knowledge of the fundamentals of breastfeeding and infant development. Breastfeeding cessation was influenced by inadequate breastfeeding skill, physically unpleasant and painful early experiences they were unprepared to manage, and inadequate health care response to real problems. CONCLUSIONS: Continued breastfeeding depends on a complex interplay of multiple factors, including having made an informed choice and having the skills, support and experiences needed to sustain the belief that breastfeeding is the best choice for them and their baby given their life situation. Teenagers in the US context need to have a positive early breastfeeding experience, be able to identify and claim a reliable support system supportive of breastfeeding, and gain through their experience, a belief in their own agency and competency as mothers.

Global baby-friendly hospital initiative monitoring data: update and discussion.

BACKGROUND: The World Health Organization (WHO)/UNICEF Baby-Friendly Hospital Initiative (BFHI) was developed to support the implementation of the Ten Steps for Successful Breastfeeding. The purpose of this study is to assess trends in the numbers facilities ever-designated "baby-friendly," to consider uptake of the new WHO/UNICEF BFHI materials, and to consider implications for future breastfeeding support. MATERIALS AND METHODS: The national contacts from the 2006-2007 UNICEF BFHI update were recontacted, as were WHO and UNICEF officers worldwide, to ascertain the number of hospitals ever-designated "baby-friendly," presence of a government breastfeeding oversight committee, use of the new BFHI materials and, if yes, use of the new maternity or human immunodeficiency virus (HIV) materials. RESULTS: Seventy countries reporting in 2010-2011 and the updates from an additional 61 reporting in 2006-2007 (n=131, or 66% of the 198 countries) confirm that there are at least 21,328 ever-designated facilities. This is 27.5% of maternities worldwide: 8.5% of those in industrialized countries and 31% in less developed settings. In 2010, government committees were reported by 18 countries, and 34 reported using the new BFHI materials: 14 reported using the maternity care and 11 reported using the HIV materials. CONCLUSIONS: Rates of increase in the number of ever-certified "baby-friendly" hospitals vary by region and show some chronological correlation with trends in breastfeeding rates. Although it is not possible to attribute this increase to the BFHI alone, there is ongoing interest in Ten Steps implementation and in BFHI. The continued growth may reflect the dedication of ministries of health and national BFHI groups, as well as increasing recognition that the Ten Steps are effective quality improvement practices that increase breastfeeding and synergize with community interventions and other program efforts. With renewed interest in maternal/neonatal health, revitalization of support for Ten Steps and their effective institutionalization in maternity practices should be considered. Future updates are planned to assess ongoing progress and impact, and ongoing updates from national committees are welcome.

Breastfeeding and otitis media: a review of recent evidence.

Human milk provides infants with antimicrobial, anti-inflammatory, and immunomodulatory agents that contribute to optimal immune system function. The act of breastfeeding allows important bacterial and hormonal interactions between the mother and baby and impacts the mouth, tongue, swallow, and eustachian tubes. Previous meta-analyses have shown that lack of breastfeeding and less intensive patterns of breastfeeding are associated with increased risk of acute otitis media, one of the most common infections of childhood. A review of epidemiologic studies indicates that the introduction of infant formula in the first 6 months of life is associated with increased incidence of acute otitis media in early-childhood. More recent research raises the issues of how long this increased risk persists, and whether lack of breastfeeding is associated with diagnosis of otitis media with effusion. However, many studies suffer from lack of study of younger populations and imprecise definitions of infant feeding patterns. These findings suggest that measures of the association between breastfeeding history and otitis media risk are sensitive to the definition of breastfeeding used; future research is needed with more precise and consistent definitions of feeding, with attention to distinctions between direct breastfeeding and human milk feeding by bottle.

The Academy of Breastfeeding Medicine.

The Academy of Breastfeeding Medicine is a worldwide organization of physicians dedicated to the promotion, protection, and support of breastfeeding and human lactation. In this Physician Focus, we describe the mission and activities of the Academy. We also highlight opportunities for physicians to participate.

What are the risks associated with formula feeding? A re-analysis and review.

BACKGROUND: Most infant feeding studies present infant formula use as 'standard' practice, supporting perceptions of formula feeding as normative and hindering translation of current research into counseling messages supportive of exclusive breastfeeding. To promote optimal counseling, and to challenge researchers to use exclusive breastfeeding as the standard, we have reviewed the scientific literature on exclusive breastfeeding and converted reported odds ratios to allow discussion of the 'risks' of any formula use. METHODS: Studies indexed in PubMed that investigated the association between exclusive breastfeeding and otitis media, asthma, types 1 and 2 diabetes, atopic dermatitis, and infant hospitalization secondary to lower respiratory tract diseases were reviewed. Findings were reconstructed with exclusive breastfeeding as the standard, and levels of signidicance calculated. RESULTS: When exclusive breastfeeding is set as the normative standard, the re-calculated odds ratios communicate the risks of any formula use. For example, any formula use in the first 6 months is significantly associated with increased incidence of otitis media (OR: 178, 95% CI: 1.19, 2.70 and OR: 4.55, 95% CI: 1.64, 12.50 in the available studies; pooled OR for any formula in the first 3 mo: 2.00, 95% CI: 140, 2.78). Only shorter durations of exclusive breastfeeding are available to use as standards for calculating the effect of 'any formula use' for type 1 diabetes, asthma, atopic dermatitis, and hospitalization secondary to lower respiratory tract infections. CONCLUSIONS: Exclusive breastfeeding is an optimal practice, compared with which other infant feeding practices carry risks. Further studies on the influence of presenting exclusive breastfeeding as the standard in research studies and counseling messages are recommended.

What are the risks associated with formula feeding? A re-analysis and review.

BACKGROUND: Most infant feeding studies present infant formula use as "standard" practice, supporting perceptions of formula feeding as normative and hindering translation of current research into counseling messages supportive of exclusive breastfeeding. To promote optimal counseling, and to challenge researchers to use exclusive breastfeeding as the standard, we have reviewed the scientific literature on exclusive breastfeeding and converted reported odds ratios to allow discussion of the "risks" of any formula use. METHODS: Studies indexed in PubMed that investigated the association between exclusive breastfeeding and otitis media, asthma, types 1 and 2 diabetes, atopic dermatitis, and infant hospitalization secondary to lower respiratory tract diseases were reviewed. Findings were reconstructed with exclusive breastfeeding as the standard, and levels of significance calculated. RESULTS: When exclusive breastfeeding is set as the normative standard, the re-calculated odds ratios communicate the risks of any formula use. For example, any formula use in the first 6 months is significantly associated with increased incidence of otitis media (OR: 1.78, 95% CI: 1.19, 2.70 and OR: 4.55, 95% CI: 1.64, 12.50 in the available studies; pooled OR for any formula in the first 3 mo: 2.00, 95% CI: 1.40, 2.78). Only shorter durations of exclusive breastfeeding are available to use as standards for calculating the effect of "any formula use" for type 1 diabetes, asthma, atopic dermatitis, and hospitalization secondary to lower respiratory tract infections. CONCLUSIONS: Exclusive breastfeeding is an optimal practice, compared with which other infant feeding practices carry risks. Further studies on the influence of presenting exclusive breastfeeding as the standard in research studies and counseling messages are recommended.

Exploring the impact of the Baby-Friendly Hospital Initiative on trends in exclusive breastfeeding.

BACKGROUND: The Baby-Friendly Hospital Initiative (BFHI) seeks to support breastfeeding initiation in maternity services. This study uses country-level data to examine the relationship between BFHI programming and trends in exclusive breastfeeding (EBF) in 14 developing countries. METHODS: Demographic and Health Surveys and UNICEF BFHI Reports provided EBF and BFHI data. Because country programs were initiated in different years, data points were realigned to the year that the first Baby-Friendly hospital was certified in that country. Pre-and post-implementation time periods were analyzed using fixed effects models to account for grouping of data by country, and compared to assess differences in trends. RESULTS: Statistically significant upward trends in EBF under two months and under six months, as assessed by whether fitted trends had slopes significantly different from 0, were observed only during the period following BFHI implementation, and not before. BFHI implementation was associated with average annual increases of 1.54 percentage points in the rate of EBF of infants under two months (p < 0.001) and 1.11-percentage points in the rate of EBF of infants under six months (p < 0.001); however, these rates were not statistically different from pre-BFHI trends. CONCLUSION: BFHI implementation was associated with a statistically significant annual increase in rates of EBF in the countries under study; however, small sample sizes may have contributed to the fact that results do not demonstrate a significant difference from pre-BFHI trends. Further research is needed to consider trends according to the percentages of Baby-Friendly facilities, percent of all births occurring in these facilities, and continued compliance with the program.