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.

ABM Position on Breastfeeding-Revised 2015.

The Academy of Breastfeeding Medicine is a worldwide organization of physicians dedicated to the promotion, protection, and support of breastfeeding and human lactation. Our mission is to unite into one association members of the various medical specialties with this common purpose.

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.

ABM Clinical Protocol #13: Contraception During Breastfeeding, Revised 2015.

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

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.

Infant feeding practices and determinants of poor breastfeeding behavior in Kinshasa, Democratic Republic of Congo: a descriptive study.

BACKGROUND: Although breastfeeding is almost universally accepted in the Democratic Republic (DR) of Congo, by the age of 2 to 3 months 65% of children are receiving something other than human milk. We sought to describe the infant feeding practices and determinants of suboptimal breastfeeding behaviors in DR Congo. METHODS: Survey questionnaire administered to mothers of infants aged ≤ 6 months and healthcare providers who were recruited consecutively at six selected primary health care facilities in Kinshasa, the capital. RESULTS: All 66 mothers interviewed were breastfeeding. Before initiating breastfeeding, 23 gave their infants something other than their milk, including: sugar water (16) or water (2). During the twenty-four hours prior to interview, 26 (39%) infants were exclusively breastfed (EBF), whereas 18 (27%), 12 (18%), and 10 (15%) received water, tea, formula, or porridge, respectively, in addition to human milk. The main reasons for water supplementation included "heat" and cultural beliefs that water is needed for proper digestion of human milk. The main reason for formula supplementation was the impression that the baby was not getting enough milk; and for porridge supplementation, the belief that the child was old enough to start complementary food. Virtually all mothers reported that breastfeeding was discussed during antenatal clinic visit and half reported receiving help regarding breastfeeding from a health provider either after birth or during well-child clinic visit. Despite a median of at least 14 years of experience in these facilities, healthcare workers surveyed had little to no formal training on how to support breastfeeding and inadequate breastfeeding-related knowledge and skills. The facilities lacked any written policy about breastfeeding. CONCLUSION: Addressing cultural beliefs, training healthcare providers adequately on breastfeeding support skills, and providing structured breastfeeding support after maternity discharge is needed to promote EBF in the DR Congo.

Recognition of International Board Certified Lactation Consultants by health insurance providers in the United States: results of a national survey of lactation consultants.

BACKGROUND: Insurance coverage for lactation management is proposed by the United States Affordable Care Act. International Board Certified Lactation Consultants (IBCLCs) are key providers of lactation services. In order to inform national discussion, this study examines the scope of insurance reimbursement of IBCLC services. OBJECTIVES: An email survey of US IBCLCs (N = 10 495) in March 2011 was used to explore frequencies of (1) submission--how often lactation consults were submitted to insurance providers for reimbursement and (2) recognition--the proportion of submitted charges recognized by insurance providers. METHODS: Results (N = 2045) were analyzed to describe patterns of submission and recognition by IBCLC work setting, job classification, and reimbursement strategy. RESULTS: Many survey respondents did not know their submission (41%) or recognition (57%) levels. Multiple strategies were used for reimbursement of IBCLC services with large variations in recognition between strategies. Overall, less than 15% reported high levels of submissions to insurance providers. Moreover, of submitted encounters, only 4% were consistently recognized by insurance providers. Inpatient hospital IBCLCs were least likely to have consults recognized (3%), and private community IBCLCs were most frequently recognized (32%). Compared with using IBCLC credentials for submitting an encounter, using another clinical license was the most successful strategy for achieving recognition of IBCLC consults (crude risk ratio, 1.44; 95% confidence interval, 1.04-2.01; P = .02). CONCLUSION: IBCLCs provide key care to a vulnerable population. However, we found that these services are not consistently reimbursed. IBCLCs poorly communicate their health care activities to insurance providers, but insurance providers also inconsistently recognize and reimburse IBCLC care.

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.

Understanding women's interpretations of infant formula advertising.

BACKGROUND: Exclusive breastfeeding for 6 months and continued breastfeeding for at least 1 year is recommended by all major health organizations. Whereas 74.6 percent of mothers initiate breastfeeding at birth, exclusivity and duration remain significantly lower than national goals. Empirical evidence suggests that exposure to infant formula marketing contributes to supplementation and premature cessation. The objective of this study was to explore how women interpret infant formula advertising to aid in an understanding of this association. METHODS: Four focus groups were structured to include women with similar childbearing experience divided according to reproductive status: preconceptional, pregnant, exclusive breastfeeders, and formula feeders. Facilitators used a prepared protocol to guide discussion of infant formula advertisements. Authors conducted a thematic content analysis with special attention to women's statements about what they believed the advertisements said about how the products related to human milk (superior, inferior, similar) and how they reported reacting to these interpretations. RESULTS: Participants reported that the advertisements conveyed an expectation of failure with breastfeeding, and that formula is a solution to fussiness, spitting up, and other normal infant behaviors. Participants reported that the advertisements were confusing in terms of how formula-feeding is superior, inferior or the same as breastfeeding. This confusion was exacerbated by an awareness of distribution by health care practitioners and institutions, suggesting provider endorsement of infant formula. CONCLUSIONS: Formula marketing appears to decrease mothers' confidence in their ability to breastfeed, especially when provided by health care practitioners and institutions. Therefore, to be supportive of breastfeeding, perinatal educators and practitioners could be more effective if they did not offer infant formula advertising to mothers.

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 support in child care: an international comparison of findings from Australia and the United States.

INTRODUCTION: Many women in industrialized countries return to work while their children are infants. This is often associated with decreased breastfeeding duration or exclusivity. In order to better understand the breastfeeding support activities in childcare settings, studies were undertaken in settings with very different levels of infant mortality, breastfeeding, and breastfeeding support: Adelaide, Australia, and Wake County, North Carolina. The researchers collaborated to explore, contrast, and compare their baseline data. METHODS: Available data on breastfeeding rates and infant mortality rates were explored for the two settings. In addition, the two childcare datasets were explored for common questions, and descriptive and χ(2) analyses were carried out. RESULTS: Similarities were found between the response from childcare settings providers in Australia and the United States. Rates of having at least one breastfeeding infant (70.6% vs. 66.3%), a place to breastfeed (90.7% vs. 95%), and a refrigerator for storage (100% vs. 100%) were similar for Adelaide and Wake County, respectively. Qualitative data from Adelaide also mirrored Wake County data in that providers in neither setting were actively promoting breastfeeding. However, the Adelaide data reflected significantly higher rates of encouragement (95.3% vs. 21.7%), written policy (77.8% vs. 20.8%), resource/materials distribution (76.6% vs. 1% and 93.8% vs. 17%), and training (44.4% vs. 13.9%). CONCLUSIONS: Childcare practices may reflect the environment of support, or lack thereof, for breastfeeding in the society as a whole. The similarities and differences seen in these settings may reflect both official guidance as well as the breastfeeding environment. There is much work to be done in the United States to come up to the same level of support for breastfeeding in child care and in other programs as is seen in Australia.