Interventions to Promote Breastfeeding

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Interventions to Promote Breastfeeding

• Report for the Healthy Start
• Research to Practice Workgroup
• Jennifer Carvalho Salemi

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Promoting Breastfeeding from a Social Ecological
Framework
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Overview of Interventions

• Macro-level
• Media and Social Marketing
• National Policies
• Maternity Leave
• Implementation of WHO code
• BFHI
• Organizational Level
• Hospital and Maternity Care Practices
• Workplace Support
• Interpersonal Level
• Peer support
• Professional support and encouragement
• Supportive home environment

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Evidence-base

• Limits to Evidence-base
• Paucity of good, well-designed research in this
  area
• Lack of funding
• Most studies are small-scale few large-scale
  RCTs
• Methodological limitations
• Statistical significance not included
• Data not conducive to clear interpretation
• Inconsistency in definitions and outcome measures
  (exclusive/non-exclusive breastfeeding)
• Problem with relying on RCTs for evidence of
  effectiveness
• Many promising strategies have not been formally
  evaluated
• RCTs not always feasible or ethical
• For example, RCT study of commercial discharge
  packets would be unethical in countries where all
  hospitals already adhere to the International
  Code

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Evidence-based practices

• Summary of evidence for interventions
• Evidence-based interventions for which evidence
  has been fully evaluated
• Promising interventions have an established
  history or strong rationale for their use, but
  that have not been formally evaluated in
  large-scale studies.
• Limited effectiveness interventions for which
  there is limited or no evidence to support their
  use.

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Recommendations for Action

• The predictors and barriers of breastfeeding are
  numerous and complex.
• Many potentially effective strategies have not
  and may not be studied in good-quality/ RCTs
• The Center for Disease Control and the US
  Department of Health and Human Services advocate
  the implementation of numerous interventions with
  limited evidence of effectiveness.
• CDC recommends that if they are used, an
  evaluation of their effectiveness be carried out
  before widely disseminating the intervention.

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Overview of Interventions

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Media and Social Marketing
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Description

• Media campaigns
• Social marketing
• Multi-faceted approaches that target not only
  women, but their support system as well.
• Ban on marketing of infant formula at health care
  facilities.

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Media and Social Marketing

• Rationale
• Present positive images of breastfeeding
• Normalize the concept of breastfeeding
• ? Infant formula companies distribute patient
  education packets in hospitals.
• Advertise formula and often contain free formula
  samples.
• Distribution in hospitals and maternity centers
  sends a message that formula feeding is
  encouraged by health care professionals
• ? Social marketing of BF counteracts marketing of
  infant formula

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Evidence-base practices

• Media campaigns that promote positive images of
  breastfeeding, especially television commercials,
  do improve attitudes towards breastfeeding and
  increase initiation rates.
• Hospital distribution of commercially produced
  education packets has been shown to decrease
  breastfeeding duration.
• Especially among groups most at-risk
• Primiparas
• Women with low levels of educational attainment
• Women who become ill after birth

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Promising practices

• Social Marketing Approach
• Identify the factors that influence
  infant-feeding decisions among women in the
  target audience
• Identify their support system husbands,
  boyfriends, health care providers
• Find out what motivates and deters them from
  encouraging women to breastfeed
• Use these results to develop marketing strategy
  that addresses the benefits and barriers that are
  important to this population of women.

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National International Policies

• WHO International Code of Marketing of
  Breast-milk substitutes
• Baby- Friendly Hospital Initiative
• Maternity Leave

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WHO International Code of Marketing of
Breast-milk substitutes

• Commonly referred to as the International Code
• Prohibits the promotion of formula in health care
  facilities, the distribution of free samples, and
  use of pictures idealizing artificial feeding.

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Baby Friendly Hospital Initative

• Goals
• To implement the Ten steps to successful
  breastfeeding
• To discontinue the marketing of breast-milk
  substitutes at hospitals and maternity wards
  (ensure compliance with the International Code)

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As of June, 2008 there are 64 Baby-Friendly
Hospitals and Birth Centers in the United States
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Ten steps to successful breastfeeding

• 1. Have a written breastfeeding policy that is
  routinely communicated to all health care staff.
• 2. Train all health care staff in skills
  necessary to implement this policy.
• 3. Inform all pregnant women about the benefits
  and management of breastfeeding.
• 4. Help mothers initiate breastfeeding within a
  half-hour of birth.
• 5. Show mothers how to breastfeed, and how to
  maintain lactation even if they should be
  separated from their infants.

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• 6. Give newborn infants no food or drink other
  than breast milk, unless medically indicated.
• 7. Practice rooming-in allow mothers and
  infants to remain together 24 hours a day.
• 8. Encourage breastfeeding on demand.
• 9. Give no artificial teats or pacifiers (also
  called dummies or soothers) to breastfeeding
  infants.
• 10. Foster the establishment of breastfeeding
  support groups and refer mothers to them on
  discharge from the hospital or clinic.

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Hospital Maternity Care Practices
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Description

• Baby-Friendly Hospital Status
• Ten-steps to successful breastfeeding
• Compliance with WHO Intl Code of Marketing of
  Breast-milk Substitutes
• Structural changes (either as part of BFHI or
  stand alone)
• Rooming-in allowing mother and baby to room
  together 24-hrs/day
• Early skin-to-skin contact
• Restrictions on formula marketing
• Breastfeeding guidance soon after delivery
• Combined structural changes
• Training of health professionals
• To increase knowledge of the importance of
  breastfeeding
• To change professional practice in support of
  breastfeeding.

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Evidence-based practices

• Structural changes in hospital practices can be
  effective at increasing the initiation and
  duration of breastfeeding.
• Evidence-based practices include
• Baby-friendly initiatives (10 steps
  implementation)
• Structural changes (as part of BFHI or
  stand-alone)
• Early skin-to-skin contact
• Rooming-in
• Breastfeeding guidance soon after delivery
• Especially for primiparas
• Combined structural changes most effective
• Limiting formula marketing and commercial
  discharge packets
• Overall, evidence suggests that commercial
  discharge packets negatively affect exclusive
  breastfeeding
• Adverse effect on duration among women who are
  not sure of their intentions to continue
  breastfeeding
• Further research is needed to assess its impact
  on initiation and duration

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Promising Practices

• Training of health care professionals
• Most studies have methodological limitations
• Statistical significance not provided
• Incomplete information about content of training
• Further research is needed to determine best
  practices related to training health care
  professionals to provide effective breastfeeding
  support
• Bottom-line
• No evidence that training of HC professionals
  alone directly effects breastfeeding initiation
  or duration
• Yet, training is a pre-requisite for the success
  of other breastfeeding interventions
• For example Healthy Start initiatives home
  visits hospital and maternity care practices
  lactation support services

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Workplace Support

• Workplace support

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Rationale

• 70 of employed mothers who have children under 3
  years of age work full-time.
• African American women are more likely to return
  to work earlier and be employed in a workplace
  that is not supportive of breastfeeding.

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Description

• Workplace support
• Flexible work policies
• Paid maternity leave
• Flexible work hours
• Environment that encourages breastfeeding
• Facilities that enable mothers to continue to
  breastfeed or store milk for later feeding
  (private rooms, refrigeration)

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Evidence of effectiveness

• No trials have evaluated the effectiveness of
  workplace interventions in promoting
  breastfeeding among women returning to paid work
  after the birth of their child.
• Cochrane Review, 2008

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Recommendations from the DHHS Office on Womens
Health

• The workplace environment should enable mothers
  to continue breastfeeding as long as the mother
  and baby desire.

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Breastfeeding Support

• Professional Support
• Peer Counseling

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Description

• Breastfeeding support consists of education about
  technique and feeding, as well as psychological
  support.
• Lactation consultants
• One-on-one support in hospitals and clinic
• Home visits
• Telephone support
• Peer counseling

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Rationale

• In communities where breastfeeding is the norm,
  new mothers may have plenty of exposure to
  breastfeeding.
• In the United States, many mothers have not had
  this exposure, especially new mothers.
• Breastfeeding support can offer mothers
• Attachment and positioning techniques
• Education about exclusive and unrestricted
  breastfeeding
• Assistance in interpreting their babys behavior
• Confidence in their ability to breastfeed

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Evidence-based practices

• Breastfeeding support interventions, alone, may
  increase breastfeeding duration, but do not
  significantly effect initiation.
• Interventions that combine education and support
  are more effective than support alone.

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• Peer support programs were found to be effective
  at increasing breastfeeding initiation and
  duration rates among
• Women on low incomes
• Women who expressed an interest in breastfeeding
  and requested a peer counselor.
• Multifaceted interventions with peer support as
  a key component are effective at increasing both
  initiation and duration

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• Evidence suggests that support is most effective
  when offered to women soon after birth, without
  them having to request it.

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La Leche League
Group peer support Peer counseling Telephone
counseling Home visits
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Limited effectiveness

• Professional social support alone, without
  educational components was not found to
  significantly increase initiation rates.

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Education
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Description

• Prenatal, intrapartum, and postnatal education to
  increase the knowledge and self-efficacy of
  mothers
• Breastfeeding classes
• Small-group classes
• One-on-one sessions
• Breastfeeding literature and written materials
• Generally conducted by lactation specialists or
  nurses during prenatal sessions

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Evidence-based interventions

• Education on breastfeeding found to be the most
  effective stand-alone intervention for increasing
  the initiation and short-term duration of
  breastfeeding.
• Breastfeeding education most effective among
  disadvantaged populations with low rates of
  breastfeeding.
• Prenatal health education classes delivered in
  small groups or one-to-one can be effective at
  increasing initiation and duration rates

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Promising practices

• Individual breastfeeding guidance and support to
  increase self-efficacy may be more effective in
  increasing the duration of breastfeeding than
  written materials alone.

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Limited Effectiveness

• Non-interactive methods of breastfeeding
  education such as written materials have limited
  impact on initiation rates when used alone.
• No educational interventions were found to
  significantly impact duration up to 6 months

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Key Findings

• A combination of interventions is likely to be
  more effective than a stand-alone intervention.
• Interventions that expand all phases of pregnancy
  are more effective than those limited to one
  phase.

Prenatal
Intrapartum
Postnatal
Infancy
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Effective Intervention Packages

• Intervention packages that include a
  combination of the following components are
  usually most effective

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Recommendations

• The best way to develop an effective intervention
  is to
• Combine interventions
• Support breastfeeding before, during, and after
  pregnancy.

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References

• Abdulwadud, O. A., Snow, M. E. (2007).
  Interventions in the workplace to support
  breastfeeding for women in employment. Cochrane
  Database Syst Rev(3), CD006177.
• Anderson, G. C., Moore, E., Hepworth, J.,
  Bergman, N. (2003). Early skin-to-skin contact
  for mothers and their healthy newborn infants.
  Cochrane Database Syst Rev(2), CD003519.
• Britton, C., McCormick, F. M., Renfrew, M. J.,
  Wade, A., King, S. E. (2007). Support for
  breastfeeding mothers. Cochrane Database Syst
  Rev(1), CD001141.
• Fairbank, L., O'Meara, S., Renfrew, M. J.,
  Woolridge, M., Sowden, A. J., Lister-Sharp, D.
  (2000). A systematic review to evaluate the
  effectiveness of interventions to promote the
  initiation of breastfeeding. Health Technol
  Assess, 4(25), 1-171.
• Futuro, E. (2006). BFHI USA. Retrieved July 1,
  2008, from http//www.babyfriendlyusa.org/
• Gagnon, A. J. (2000). Individual or group
  antenatal education for childbirth/parenthood.
  Cochrane Database Syst Rev(4), CD002869.
• Guise, J. M., Palda, V., Westhoff, C., Chan, B.
  K., Helfand, M., Lieu, T. A. (2003). The
  effectiveness of primary care-based interventions
  to promote breastfeeding systematic evidence
  review and meta-analysis for the US Preventive
  Services Task Force. Ann Fam Med, 1(2), 70-78.
• Hector, D., King, L. (2005). Interventions to
  encourage and support breastfeeding. N S W Public
  Health Bull, 16(3-4), 56-61.
• Howard, C., Howard, F., Lawrence, R., Andresen,
  E., DeBlieck, E., Weitzman, M. (2000). Office
  prenatal formula advertising and its effect on
  breast-feeding patterns. Obstet Gynecol, 95(2),
  296-303.
• Lindenberger, J. H., and Bryant, C. A. . (2000).
  Promoting Breastfeeding in the WIC Program A
  Social Marketing Case Study. American Journal of
  Health Behavior, 24(1), 5360.
• Renfrew, M. J., Dyson, L., Wallace, L., D'Souza,
  L., McCormick, F., Spiby, H. (2005). The
  effectiveness of public health interventions to
  promote the duration of breastfeeding Systematic
  r. Retrieved June 7, 2008. from www.nice.org.uk.
• Satcher, D. S. (2001). DHHS blueprint for action
  on breastfeeding. Public Health Rep, 116(1),
  72-73.
• Shealy KR, L. R., Benton-Davis S, Grummer-Strawn
  LM. (2005). The CDC Guide to Breastfeeding
  Interventions. Atlanta U.S. Department of Health
  and Human Services, Centers for Disease Control
  and Prevention.
• Sikorski, J., Renfrew, M. J. (2000). Support
  for breastfeeding mothers. Cochrane Database Syst
  Rev(2), CD001141.
• Sikorski, J., Renfrew, M. J., Pindoria, S.,
  Wade, A. (2002). Support for breastfeeding
  mothers. Cochrane Database Syst Rev(1), CD001141.
• Sikorski, J., Renfrew, M. J., Pindoria, S.,
  Wade, A. (2003). Support for breastfeeding
  mothers a systematic review. Paediatr Perinat
  Epidemiol, 17(4), 407-417.
• World Health Organization. (1998). Evidence for
  the Ten Steps to Successful Breastfeeding.
  Geneva.

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• No single intervention or group can succeed in
  meeting the challenge implementing the strategy
  thus calls for increased political will, public
  investment, awareness among health workers,
  involvement of families and communities, and
  collaboration between governments,
• international organizations and other concerned
  parties that will ultimately ensure that all
  necessary action is taken.
• -- World Health Organization, 2003