Challenging the utility of 24-hour recall of exclusive breast feeding in Japan.

INTRODUCTION: WHO recommends exclusive breast feeding from birth to 6 months. However, to monitor populations, it recommends using the proportion of infants under 6 months who were exclusively breastfed during the previous 24 hours. To assess the usefulness of 24-hour recall, we (1) compared the prevalence of exclusive breast feeding measured by since-birth recall to the prevalence measured by 24-hour recall and (2) quantified each indicator's association with WHO-recommended, well-established methods for in-hospital breastfeeding support. METHODS: We conducted two online surveys of mothers in Japan (total n=4247) who had a healthy singleton delivery in the previous 25 months. They reported on their breast feeding (a) from birth to 5 months; or (b) during the previous 24 hours, for those with infants under 5 months; or (c) both, for those who participated in the initial survey and also in the follow-up survey. All mothers also reported on their in-hospital support. The strength of each indicator's association with provision of in-hospital support was quantified as the area under the curve (AUC). RESULTS: The prevalences of exclusive breast feeding by since-birth recall were 4.4% (first survey) and 2.5% (second survey). By 24-hour recall, the prevalence appeared to be 29.8%. More in-hospital support was moderately well associated with more exclusive breast feeding measured by since-birth recall: AUC 0.72 (95%CI 0.66 to 0.78). That association is consistent with the known benefits of in-hospital support. In contrast, when exclusive breast feeding was measured by 24-hour recall, its association with in-hospital support appeared to be extremely weak: AUC 0.59 (95% CI 0.54 to 0.65). CONCLUSION: Using 24-hour recall substantially overestimates the prevalence of exclusive breast feeding since birth, and it conceals the benefits of in-hospital breastfeeding support. To monitor population achievement of exclusive breast feeding for the first 6 months, or to evaluate breastfeeding interventions, 24-hour recall of exclusive breast feeding should not be used alone.

Influence of the COVID-19 pandemic on breastfeeding support for healthy mothers and the association between compliance with WHO recommendations for breastfeeding support and exclusive breastfeeding in Japan.

Background: Professional breastfeeding support contributes to maternal and child health. However, the influence of the current coronavirus disease 2019 (COVID-19) pandemic on breastfeeding support has not been carefully examined. Therefore, we assessed maternal breastfeeding intention and professional breastfeeding support before and during the pandemic. We further examined the association of compliance with World Health Organization (WHO) recommendations for professional breastfeeding support with exclusive breastfeeding during the pandemic. Methods: This cross-sectional, internet-based, questionnaire study analyzed data from 484 healthy women with live singleton births between 15 October 2019 and 25 October 2020 in Japan. A delivery before 5 March 2020 was classified as a before-pandemic delivery (n = 135), and a delivery after 6 March 2020 was a during-pandemic delivery (n = 349). Among the ten breastfeeding support steps recommended by the WHO, we assessed the five steps that are measurable by maternal self-report and would likely exhibit variability. Receipt of a free formula sample or invitation to a free sample campaign by the time of survey was also asked. Infant feeding status at the time of the survey was measured among women with infants younger than 5 months, which was a subgroup of mothers who delivered during the pandemic. Mothers were asked what was given to infants during the 24 h before the survey and when nothing other than breast milk was given, the status was classified as exclusive breastfeeding. Results: While 82.2% of women with a delivery before the pandemic intended to breastfeed, the rate was 75.6% during the pandemic (p = 0.120). The average number of breastfeeding support steps received was 3.24 before the pandemic but it was 3.01 during the pandemic (p = 0.069). In particular, rooming-in was less frequent (39.3% before vs. 27.8% during the pandemic, p = 0.014). Among mothers with infants younger than 5 months who had a delivery during the pandemic (n = 189), only 37.0% (n = 70) reported exclusively breastfeeding during the 24 h before completing the survey. Multiple logistic regression analysis indicated that receiving support for all five steps was positively associated with exclusive breastfeeding during the 24 h before the survey (adjusted odds ratio 4.51; 95% CI [1.50-13.61]). Receipt of a free formula sample or invitation to a free sample campaign was negatively associated with exclusive breastfeeding (adjusted odds ratio 0.43; 95% CI [0.19-0.98]). Other factors related to non-exclusive breastfeeding were older maternal age, lower education level, primiparity, and no breastfeeding intention. Conclusions: The pandemic weakened breastfeeding support for healthy women in Japan; however, support practice that adhered to WHO recommendations appeared to be effective during the pandemic.

Development of the breastfeeding support scale to measure breastfeeding support from lay and professional persons, and its predictive validity in Japan.

BACKGROUND: International and national organizations recommend exclusive breastfeeding for the first 6 months of life, but many women stop earlier. Lay and professional persons can support mothers' efforts to overcome breastfeeding difficulties. Considering breastfeeding support to comprise emotional support, practical help, and information offered to women who desire to breastfeed (by professionals, family members, and others), we developed and tested a scale to measure it in Japan. METHODS: A total of 31 items were generated by literature review and from the authors' clinical experiences. Those items were tested with 243 mothers who visited public health centers in Tokyo for their infant's health check-up 3 months after birth. Breastfeeding support and infant feeding status were then assessed 5 months after birth. All the data were collected by using self-administered questionnaires. RESULTS: On the basis of the results of factor analysis, the number of items was reduced to 11. There were three factors: support from breastfeeding peers and from people in specifically named healthcare professions, practical help, and support from people the mother can rely on to help meet emotional needs and address breastfeeding concerns. Internal-consistency reliability (alpha) of scores on the 11-item scale was 0.83 when measured 3 months postpartum and 0.85 when measured 5 months postpartum. Higher scores on the 11-item scale 3 months postpartum were associated with more breastfeeding exclusivity both at that time (Kruskal-Wallis test, chi-squared = 14.871, df = 3, n = 211, p = 0.002, eta-squared = 0.071) and also 5 months postpartum (Kruskal-Wallis test, chi-squared = 8.556, df = 3, n = 159, p = 0.036, eta-squared = 0.054). Further, the area under the Receiver Operating Characteristic curve was 0.73 (95% CI [0.57-0.88]), which indicates that scores on the 11-item scale 3 months postpartum may be useful to predict which mothers will be less exclusive in breastfeeding 5 months postpartum. In conclusion, scores on this 11-item scale were reasonably reliable and valid for measuring breastfeeding support provided by lay and professional persons to mothers in Japan. Further research is required to evaluate this scale's applicability in other settings.

The Influence of Breastfeeding Peer Support on Breastfeeding Satisfaction Among Japanese Mothers: A Randomized Controlled Trial.

BACKGROUND: Peer support may help mothers to feel satisfied with their breastfeeding and to continue breastfeeding. However, previous researchers have not examined the influence of peer support on the three breastfeeding-satisfaction domains. RESEARCH AIM: We aimed to examine the influence of telephone-based peer support on the following three domains of breastfeeding satisfaction among Japanese mothers: maternal satisfaction, perceived benefit to the infant, and lifestyle compatibility with breastfeeding. METHODS: Breastfeeding mothers were recruited at four maternity hospitals in Japan to participate in a randomized controlled trial. Data were collected 1 month and 4 months postpartum. Among all of the participants (N = 114), those in the intervention group (n = 60) received telephone-based peer support until 4 months postpartum, and participants in the control group (n = 54) received conventional support. Breastfeeding satisfaction was measured using the short version of the revised Japanese Maternal Breastfeeding Evaluation Scale. Generalized estimating equations and effect size analyses were used to examine the influence of the intervention. RESULTS: On the subscale measuring lifestyle compatibility, participants with peer support had a higher score than those without peer support: regression coefficient 1.54 (95% confidence interval [0.03, 3.04]). The effect size was 0.40 standard deviations among participants with low and mid-level scores at baseline. CONCLUSION: Although peer support did not change maternal satisfaction or perceived benefit to the infant, it did increase lifestyle compatibility with breastfeeding among these Japanese mothers. This is evidence in favor of increasing the use of peer support.

Development of the revised Japanese Maternal Breastfeeding Evaluation Scale, short version.

BACKGROUND AND OBJECTIVES: The Japanese Maternal Breastfeeding Evaluation Scale (JMBFES) was developed in 2013 based on the original Maternal Breastfeeding Evaluation Scale (MBFES). Mothers' abilities to incorporate breastfeeding into their daily life may influence their decision to continue or discontinue to breastfeed, but that version of the JMBFES had no questions to measure this important aspect of breastfeeding. Therefore, we sought to improve the JMBFES by incorporating questions measuring "lifestyle compatibility-incompatibility," and we conducted psychometric testing of the improved version. METHODS AND STUDY DESIGN: In this longitudinal study, the revised JMBFES was developed, and its reliability and validity was tested among 215 Japanese mothers. In the first survey, which was done three months after delivery, infant-feeding status and the prenatal intention regarding breastfeeding were measured. In the second survey, which was done two months later, the JMBFES questions were asked along with questions regarding infant-feeding status. We identified items that could be deleted while maintaining high reliability. Using regression models, we examined associations of JMBFES scores with breastfeeding intention and breastfeeding outcomes. RESULTS: All three subscales in the revised JMBFES had acceptable reliability (alpha >=0.78). The two "lifestyle compatibility-incompatibility" items (one new item and the one that had been deleted previously) belonged to the "potentially negative aspects" subscale. Scores on that subscale were not associated with breastfeeding intention. However, in both surveys, the mothers who were using formula reported more potential difficulties (p<=0.01). CONCLUSION: Results of validation testing and reliability testing indicate that the revised JBFEES can be used to measure breastfeeding satisfaction among Japanese mothers.

Is baby-friendly breastfeeding support in maternity hospitals associated with breastfeeding satisfaction among Japanese mothers?

While the World Health Organization's Baby-Friendly Hospital Initiative has increased breastfeeding duration and exclusivity, a survey found that only 8.5 % of maternity hospitals in 31 developed countries could be designated baby-friendly. Baby-friendly breastfeeding support is sometimes criticized as mother unfriendly. This study examined whether baby-friendly breastfeeding support was associated with breastfeeding satisfaction, duration, and exclusivity among Japanese mothers. In this cross-sectional study, 601 breastfeeding Japanese mothers completed questionnaires at their infants' 4-month health checkups at two wards in Yokohama, Japan; 363 were included in the analysis. Baby-friendly breastfeeding support was measured based on the WHO's "Ten Steps to Successful Breastfeeding." We measured satisfaction using two subscales of the Japanese version of the Maternal Breastfeeding Evaluation Scale. The association of baby-friendly support with maternal satisfaction was assessed using multiple linear regression, while the prevalence ratios (PRs) for breastfeeding were estimated using Poisson regression. Mothers were stratified by prepartum exclusive breastfeeding intention (yes, n = 256; no, n = 107). Mothers who experienced early skin-to-skin contact with their infants were more likely to report breastfeeding satisfaction than those who did not. Among mothers without exclusive breastfeeding intention, those who were encouraged to feed on demand were more likely to be breastfeeding without formula at 1 month (PR 2.66 [95 % CI 1.32, 5.36]) and to perceive breastfeeding as beneficial for their baby (regression coefficient = 3.14 [95 % CI 0.11, 6.17]) than those who were not so encouraged. Breastfeeding satisfaction was a useful measure of breastfeeding outcome. Early skin-to-skin contact and encouragement to feed on demand in the hospital facilitate breastfeeding satisfaction.

Development and psychometric testing of the Japanese version of the maternal breastfeeding evaluation scale.

BACKGROUND: Exclusive breastfeeding for 6 months after delivery is globally recommended as optimal infant feeding. However, if mothers evaluate their own breastfeeding by this standard, many might be disappointed because they fail to meet it. In contrast, the Maternal Breastfeeding Evaluation Scale (MBFES) measures mothers' satisfaction with breastfeeding regardless of the duration or exclusivity of breastfeeding. The MBFES has been used in Western countries, but not in Japan. OBJECTIVES: This study aimed to develop a Japanese version of the MBFES (the JMBFES) and to conduct psychometric testing among Japanese-speaking mothers in Japan. METHODS: The JMBFES was developed using forward translation, blind back-translation, panel discussion, and pilot testing. Breastfeeding Japanese mothers (n = 414) completed the JMBFES when their infants were 4 months old. For validation testing we used principal components analysis (promax rotation). We deleted items as necessary to improve reliability. We also used multiple linear regression to examine associations of JMBFES scores with breastfeeding intention and with breastfeeding outcomes. RESULTS: The analysis revealed subscales that were generally similar to the original 30-item MBFES. Reliability was satisfactory (Cronbach's alpha ≥ .77). Scores on the JMBFES and on most of its subscales were positively associated with both breastfeeding intention and breastfeeding outcomes. The subscale measuring potentially negative experiences was not statistically significantly associated with breastfeeding at 1 month, after adjustment for likely confounders. CONCLUSION: The results of reliability testing (Cronbach's alpha) and of validation testing indicate that the JMBFES can be used in Japan to explore mothers' satisfaction with breastfeeding.