Research On Supporting Breastfeeding and Skin-to-Skin

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Cochrane Library Special Collection: Enabling breastfeeding for mothers and babies

This Cochrane Special Collection of systematic reviews on Breastfeeding explores the kind of support that enables women to breastfeed. It found that women need sensitive, reliable and face-to-face guidance from pregnancy through to the first weeks and months of their babies’ lives, helping them to get breastfeeding off to a good start and continue to breastfeed in the long-term. Support is needed to prevent and treat physical problems, and to build confidence, particularly in communities where breastfeeding is no longer seen as the norm. With eight out of 10 women in the UK stopping breastfeeding before they want to, it is crucial that this evidence is used to protect and increase breastfeeding support. Read our blog on translating this evidence into action.

NIHR themed review: Better Beginnings – improving health for pregnancy

The National Institute for Health Research’s Better Beginnings report explores ways to improve health before, during and after pregnancy. It highlights the importance of tailored breastfeeding support, as well as skin-to-skin contact, in enabling women to breastfeed for as long as they wish.

Breastfeeding knowledge and duration

This American study of 2,935 women explored the relationship between mothers’ knowledge of breastfeeding recommendations and breastfeeding duration. Researchers found that one in five did not know current breastfeeding recommendations; they had a lower probability of breastfeeding and a higher risk of ceasing breastfeeding at any point.

Wallenborn, J, et al (2017), Knowledge of Breastfeeding Recommendations and Breastfeeding Duration: A Survival Analysis on Infant Feeding Practices II, Breastfeeding Medicine, doi:10.1089/bfm.2016.0170

Kangaroo mother care for preterm infants

A 20 year follow-up study of the impact of kangaroo care (KMC, or skin-to-skin contact) on preterm and low birthweight babies found significant, long-lasting social and behavioural protective effects even 20 years after the intervention. The effects of KMC at one year on IQ and home environment were still present 20 years later in the most fragile individuals, reflected by reduced school absenteeism and reduced hyperactivity, aggressiveness, externalization, and socio-deviant conduct of young adults. Neuroimaging showed larger volume of the left caudate nucleus in the KMC group.

Charpak, N (2016), Twenty-year Follow-up of Kangaroo Mother Care Versus Traditional Care. Pediatrics 139(1):e20162063

World Breastfeeding Trends Initiative (WBTi) UK Report 2016

November 2016 saw the launch of the first WBTi report for the UK. The report uses 10 key measures to identify how well breastfeeding is protected and supported in a particular country – it highlights the UK’s worryingly low breastfeeding rates and the importance of providing consistent support at every level – from hospital to home and community.

The World Breastfeeding Trends Initiative (WBTi) is a collaborative national assessment of the implementation of key policies and programmes from the WHO’s Global Strategy for Infant and Young Child Feeding. Unlike other assessments, the WBTi brings together the main agencies and organisations involved in aspects of IYCF in a particular country to work together to collect information, identify gaps and generate recommendations for action. This is the first WBTi assessment for the UK; the process is repeated every 3–5 years in order to track trends.

WBTi UK Report 2016

Effect of kangaroo care on physical growth and breastfeeding

This study of 110 neonates found that the use of kangaroo care improved the infants’ physical growth and increased breastfeeding rates.

Effect of Kangaroo Mother Care on physical growth, breastfeeding and its acceptability. Geeta Gathwala, Bir Singh, and Jagjit Singh, Trop Doct. 2010; 40(4): p. 199-202.

Benefits of skin-to-skin to baby and mother

A review of 34 studies found that skin-to-skin contact improved breastfeeding rates, infant cardio-respiratory stability and blood glucose levels.

Anderson GC, Moore E, Hepworth J, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.

Determinants of breastfeeding initiation and cessation among employed mothers

This prospective cohort study of 817 women in Minnesota found that the odds of breastfeeding initiation were higher for women who: held professional jobs, were primiparae, had a graduate degree and did not smoke prenatally. Women were also more likely to start and continue breastfeeding if they had family or friends who breastfed. Breastfeeding cessation was more common amongst women who returned to work within 6 months of giving birth. The authors conclude that future research should examine women’s awareness of employer policies regarding paid and unpaid leave.

Dagher, R, et al (2016), Determinants of breastfeeding initiation and cessation among employed mothers: a prospective cohort study, BMC Pregnancy and Childbirth, DOI: 10.1186/s12884-016-0965-1

Factors associated with infant feeding choices in the adolescent population

This study of 457 adolescent maternity patients at the University of Louisville Hospital found that involvement of the adolescents’ mothers or caregivers in feeding decisions was associated with a higher likelihood of deciding to bottle feed, whilst participation in early skin-to-skin contact was linked to a decision to breastfeed.

Godbout, J, et al (2016), Factors Associated with Infant Feeding Choices in the Adolescent Population, Journal of Human Lactation, doi: 10.1177/0890334416662629

What do women really want? Lessons for breastfeeding promotion and education

This study explored new mothers’ attitudes towards breastfeeding promotion and education to consider where improvements could be made. Mothers identified a need to move away from the perception that breastfeeding is best (rather than normal), an emphasis on wider values other than the health benefits of breastfeeding, and a message that every feed, rather than just 6 months exclusive breastfeeding, matters. Mothers also highlighted the need for promotion and education to target family members and wider society rather than simply mothers themselves, all of whom influenced both directly or indirectly the maternal decision and ability to breastfeed.

Brown, A, (2016), What Do Women Really Want? Lessons for Breastfeeding Promotion and Education. Breastfeeding Medicine, doi:10.1089/bfm.2015.0175

The influence of grandmothers on breastfeeding rates: a systematic review

Researchers reviewed studies into the influence that grandmothers could have on breastfeeding rates. Although data quality varied, they found some evidence that grandmothers who had had their own breastfeeding experience or were positively inclined towards breastfeeding had a beneficial impact on exclusive breastfeeding. They suggest that breastfeeding promotion programmes should include grandmothers to maximise impact.

Negin, J, et al (2016), The influence of grandmothers on breastfeeding rates: a systematic review. BMC Pregnancy and Childbirth, DOI: 10.1186/s12884-016-0880-5

Evaluation of the effectiveness of school-based breastfeeding education

A systematic review of relevant literature was conducted to identify scientifically rigorous studies on school-based interventions and promotion activities that focus on breastfeeding. The authors contend that school-based breastfeeding promotion programs hold promise for increasing knowledge of breastfeeding and support for breastfeeding, promoting positive attitudes, creating a culture where breastfeeding is the norm, and increasing future intentions to breastfeed.

Glaser, D.B. (2016) An Evaluation of the Effectiveness of School-Based Breastfeeding Education. Journal of Human Lactation. doi: 10.1177/0890334415595040.

The impact of a prenatal education video on rates of breastfeeding

This study aimed to determine whether a low-cost prenatal education video improves hospital rates of breastfeeding initiation and exclusivity in a low-income population. The results suggested that an educational breastfeeding video alone is ineffective in improving the hospital breastfeeding practices of low-income women. The authors conclude that increasing breastfeeding rates in this at-risk population likely requires a multi-pronged effort begun early in pregnancy or preconception.

Kellams, A.L. et al (2016) The Impact of a Prenatal Education Video on Rates of Breastfeeding Initiation and Exclusivity during the Newborn Hospital Stay in a Low-income Population. Journal of Human Lactation, doi: 10.1177/0890334415599402.

Breastfeeding among adolescent mothers: a systematic review of interventions from high-income countries

This study reviewed interventions designed to improve breastfeeding rates among adolescents. The authors recommend that more interventions should be developed and evaluated, and that interventions should include mothers and partners of adolescents to successfully promote breastfeeding among adolescent mothers.

Sipsma, H.L. et al (2015). Breastfeeding among adolescent mothers: A systematic review of interventions from high-income countries. Journal of human lactation. vol. 31 no. 2 pp. 221-229

Interventions to improve breastfeeding outcomes

This study provided comprehensive evidence of the effect of interventions on early initiation, exclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health systems and services (ii) Home and family environment (iii) Community environment (iv) Work environment (v) Policy environment or a combination of any of above.

Results indicated that intervention delivery in combination of settings seemed to have higher improvements in breastfeeding rates. Greatest improvements in early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding rates, were seen when counselling or education were provided concurrently in home and community, health systems and community, health systems and home settings, respectively. Baby Friendly Hospital support at health system was the most effective intervention to improve rates of any breastfeeding.

Sinha, B. et al (2015). Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis. Acta Paediatrica, Special Issue: Impact of Breastfeeding on Maternal and Child Health. Volume 104, Issue Supplement S467, pages 114-134.

Fathers’ involvement in childcare and perceived skill as a parent

A study in the USA explored 152 first-time fathers’ perceived childcare skill during the transition to parenthood. Face-to-face interviews were carried out with fathers at one month and one year following the birth. Analyses examined the associations among fathers’ perceived skill and child care involvement related to a number of factors including breastfeeding, maternal gate-keeping, mothers’ work hours, fathers’ depressive symptoms, and fathers’ beliefs about responding to a crying child. The researchers found that breastfeeding at one month was not related to involvement or perceived skill. Maternal gate-keeping, however, was negatively associated with father involvement. Greater involvement at one month strongly predicted greater involvement at one year. The authors suggest that invoking breastfeeding as an impediment to father involvement could in fact be more of a pretext than a significant reason for decreased involvement.

Barry AA, Smith JZ, Deutsch FM et al (2011) Fathers’ Involvement in Child Care and Perceptions of Parenting Skill Over the Transition to Parenthood. Journal of Family Issues; 32:1500-1521

Co-parenting breastfeeding support and exclusive breastfeeding: a randomised controlled trial

This randomized controlled trial evaluated the effectiveness of a co-parenting intervention on exclusive breastfeeding among primiparous mothers and fathers. Couples were randomized to receive either usual care or a co-parenting breastfeeding support intervention. Follow-up of exclusive breastfeeding and diverse secondary outcomes was conducted at 6 and 12 weeks postpartum. It was found that this co-parenting intervention involving fathers resulted in significant improvements in breastfeeding duration, paternal breastfeeding self-efficacy, and maternal perceptions of paternal involvement and assistance with breastfeeding.

Abbass-Dick et al (2014). Co-parenting breastfeeding support and exclusive breastfeeding: A randomised controlled trial. Pediatrics, doi: 10.1542/peds.2014-1416

Structured breastfeeding programmes in maternity services shown to improve breastfeeding rates

A systematic review was carried out to evaluate outcomes of structured versus non-structured breastfeeding programmes in acute maternity care settings in supporting initiation and duration of exclusive breastfeeding. A ‘structured programme’ was deemed to be a programme which included a multifaceted approach to support breastfeeding that targeted change at organisational, service delivery and individual behaviour levels, for example implementation of the Baby Friendly Hospital Initiative.

Authors conducted an extensive literature review and included 26 articles in the study. They note that most studies found a statistically significant improvement in breastfeeding initiation following introduction of a structured breastfeeding programme, although effect sizes varied. The impact on the duration of exclusive breastfeeding and duration of any breastfeeding to 6 months was also evident, although not all studies found statistically significant differences.

The authors conclude that despite poor overall study quality, structured programmes compared with standard care positively influence the initiation and duration of both exclusive breastfeeding and any breastfeeding. The researchers recommend further high quality trials, particularly to evaluate the impact of programmes within the community setting.

Beake S, Pellowe C, Dykes F et al (2012). A systematic review of structured compared with non-structured breastfeeding programmes to support the initiation and duration of exclusive and any breastfeeding in acute and primary health care settings. Maternal and Child Nutrition. DOI: 10.1111/j.1740-8709.2011.00381.x

Influence of childcare arrangements on breastfeeding outcomes

This study of 18,050 infants observed the likelihood of breastfeeding for at least 4 months according to informal childcare (care by friends, grandparents, other relatives, etc.) and formal childcare (e.g. nurseries, crèches), compared to being cared for ‘only by a parent’ and also by socio-economic group.

Researchers found that informal childcare was associated with a reduced likelihood of breastfeeding for all groups of mothers. Formal childcare arrangements were only associated with a reduced likelihood of breastfeeding if used full-time by more advantaged families. The researchers suggest that childcare centres offer a potential setting to promote breastfeeding, for example through offering storage of expressed milk and encouraging mothers to continue to breastfeed. The lower likelihood of being breastfed experienced by infants cared for by family, friends and neighbours was evident in all socio-economic groups.

The researchers therefore recommend that breastfeeding campaigns in the UK might be aimed at all members of society. Qualitative research into how childcare acts to facilitate or discourage breastfeeding for mothers from different socioeconomic groups may help to target policy and practice more effectively.

Pearce A, Li L, Abbas J et al (2012) Childcare use and inequalities in breastfeeding: findings from the UK Millennium Cohort Study. Arch. Dis. Child;  97(1): p. 39-42

Infant feeding decisions of socioeconomically deprived pregnant teenagers: the moral dimension

This study examined the infant feeding intentions of white pregnant teenagers living in a northern English inner city. The researchers found that breastfeeding was viewed as a morally inappropriate behaviour by most of the teenagers, with formula feeding being perceived as the appropriate behaviour. They conclude that existing breastfeeding promotion activities are likely to continue to fail to reach teenagers experiencing deprivation in England in the absence of effective strategies to change the underlying negative moral norms toward breastfeeding.

Dyson L, Green JM, Renfrew MJ et al. (2010) Factors influencing the infant feeding decision for socioeconomically deprived pregnant teenagers: the moral dimension.  Birth; 37: 141-9

Indices of multiple deprivation and breastfeeding support

This study of 216 mothers with a child between six and 24 months old found that breastfeeding duration was associated with socio-economic indicators and levels of multiple deprivation in both English and Welsh samples. The authors suggest that targeting women by their postcode is an effective, non-intrusive way of identifying women most at risk of low breastfeeding rates.

Brown AE, Raynor P, Benton D, Lee MD. Indices of Multiple Deprivation predict breastfeeding duration in England and Wales. Eur J Public Health 2010 Apr; 20(2):231-5. Epub 2009 Aug 10.

Antenatal confidence about and commitment to breastfeeding linked to breastfeeding success

This study of Caucasian and African American women in three major United States cities found that those mothers who were more likely to breastfeed successfully had confidence in the process of breastfeeding, confidence in their ability to breastfeed, and commitment to making breastfeeding work despite obstacles. The authors conclude that contrary to popular conceptions, breastfeeding appears to be a learned skill. Antenatal preparation appears to be crucial to the process; if mothers achieved a level of “confident commitment” before the birth, they were able to withstand lack of support by significant others and the common challenges that occurred as they initiated breastfeeding. Without the element of “confident commitment,” a decision to breastfeed appeared to fall apart once challenged.

Avery A, Zimmermann K, Underwood PW et al. (2009) Confident commitment is a key factor for sustained breastfeeding. Birth: 36; 141-8

Breastfeeding support: what works?

This literature review of articles published in Finnish, Swedish and English between the year 2000 and March 2006 examined the impact of breastfeeding support interventions. Researchers found that interventions started during pregnancy and continued into the postnatal period were more effective than interventions concentrating on a shorter period. The authors concluded that the Baby Friendly Hospital Initiative, practical hands-off teaching and the use of multiple education methods combined with support and encouragement, were effective approaches. Postnatally, home visits, telephone support and breastfeeding ‘centres’ combined with peer support were found to be effective.

Hannula L, Kaunonen M, Tarkka MT (2008) A systematic review of professional support interventions for breastfeeding. J Clin Nurs; 17 (9): 1132-43