Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Other Education, Partner-Level Intervention, Technology-Based Support,

Intervention Description: One modifiable risk factor amenable to intervention is partner support. Having women work as a team with their co-parents to meet their breastfeeding goals have been found to improve breastfeeding outcomes. eHealth resources have been found to be accessible and feasible ways to provide breastfeeding education yet, the best way to design breastfeeding interventions for mothers and their co-parents is not known. Couples allocated to the eHealth study condition (SC1) were provided with access to a previously created, publicly available eHealth breastfeeding co-parenting website, which they could access independently throughout the perinatal period. Couples allocated to the Available Resources Only condition were informed that they could assess breastfeeding resources generally available in the community. Among couples randomized to the SC1, information was collected regarding participation in the virtual meeting and use of the eHealth resource which was assessed at all follow-up time points.

Intervention Results: Breastfeeding rates were high in both groups (SC1 63% and SC2 57% ‘exclusive’ 6 months) and (SC1 71% and SC2 78% ‘any’ 12 months) and not statistically significantly different. High scores were found in both groups in secondary outcome measures. Generally available breastfeeding resources were used in both groups with websites being used often and rated as most helpful. SC1 rated the eHealth resource provided to them highly.

Conclusion: The findings suggest both mothers and their co-parents should be targeted in breastfeeding education and web-based resources designed to meet their needs.

Study Design: RCT

Setting: Online

Population of Focus: Expectant women planning to breastfeed for the first time and their co-parents

Sample Size: 113 expectant women and 104 of their co-parents

Age Range: Adults 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): Educational Material, Individual Supports, Social Supports, Lactation Consultant

Intervention Description: The current statement updates the evidence for this conclusion and serves as a basis for AAP publications that detail breastfeeding management and infant nutrition, including the AAP Breastfeeding Handbook for Physicians,2 AAP Sample Hospital Breastfeeding Policy for Newborns,3 AAP Breastfeeding Residency Curriculum,4 and the AAP Safe and Healthy Beginnings Toolkit.

Intervention Results: Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice. The American Academy of Pediatrics reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Medical contraindications to breastfeeding are rare. Infant growth should be monitored with the World Health Organization (WHO) Growth Curve Standards to avoid mislabeling infants as underweight or failing to thrive. Hospital routines to encourage and support the initiation and sustaining of exclusive breastfeeding should be based on the American Academy of Pediatrics-endorsed WHO/UNICEF “Ten Steps to Successful Breastfeeding.” National strategies supported by the US Surgeon General’s Call to Action, the Centers for Disease Control and Prevention, and The Joint Commission are involved to facilitate breastfeeding practices in US hospitals and communities. Pediatricians play a critical role in their practices and communities as advocates of breastfeeding and thus should be knowledgeable about the health risks of not breastfeeding, the economic benefits to society of breastfeeding, and the techniques for managing and supporting the breastfeeding dyad. The “Business Case for Breastfeeding” details how mothers can maintain lactation in the workplace and the benefits to employers who facilitate this practice.

Conclusion: Research and practice in the 5 years since publication of the last AAP policy statement have reinforced the conclusion that breastfeeding and the use of human milk confer unique nutritional and nonnutritional benefits to the infant and the mother and, in turn, optimize infant, child, and adult health as well as child growth and development. Recently, published evidence-based studies have confirmed and quantitated the risks of not breastfeeding. Thus, infant feeding should not be considered as a lifestyle choice but rather as a basic health issue. As such, the pediatrician’s role in advocating and supporting proper breastfeeding practices is essential and vital for the achievement of this preferred public health goal.

Study Design: N/A

Setting: N/A

Data Source: N/A

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Peer Counselor, Educational Material, Home Visits

Intervention Description: To assess the efficacy of peer counseling to promote exclusive breastfeeding (EBF) among low-income inner-city women in Hartford, Conn.

Intervention Results: Significantly more mothers in the control group had not initiated breastfeeding compared to mothers in the intervention group (RR= 2.48; 95% CI: 1.04-5.90)

Conclusion: Well-structured, intensive breastfeeding support provided by hospital and community-based peer counselors is effective in improving exclusive breastfeeding rates among low-income, inner-city women in the United States.

Study Design: RCT

Setting: 3 clinic teams providing prenatal care at the Women’s Ambulatory Health Services Clinic of Hartford Hospital (CT)

Population of Focus: First stage: Recruited mothers attending the prenatal clinic on mornings of 4 predetermined weekdays who were ≥ 18 years old, ≤ 32 weeks gestational age (GA), healthy, and did not have medical conditions likely to impair successful breastfeeding Second stage: Recruited mothers considering breastfeeding who planned to deliver at Hartford Hospital, and to stay in the area for three months after delivery, living in a household earning < 185% of the federal poverty level, and available to be contacted via telephone. Third stage (Postpartum): Recruited mothers free of any medical condition that would prevent her from exclusively breastfeeding with newborns at least 36 weeks GA, weighing ≥ 2500 gm, with no complications requiring treatment in the NICU, and Apgar scores of ≥ 6 at 1 and 5 minutes.

Data Source: Medical records and mother self-report

Sample Size: Randomized • Intervention (n=90) • Control (n=92) Stage 3 Screening After Delivery • Intervention (n=77) • Control (n=85)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Peer Counselor, Educational Material, Telephone Support, PROFESSIONAL_CAREGIVER, Education/Training (caregiver)

Intervention Description: In efforts to improve breeastfeeding rates, WIC established the Breastfeeding peer Counselor program (BFPC) model to improve breastfeeding rates among participants. The Upstate New York WIC BFPC program (UNYWIC BFPC) began with volunteers who provided support to WIC participants referred to BFPC services. The BFPCs completed Loving Support training. BFPC contacts included telephone, in-person (WIC clinic or home), and mailings.

Intervention Results: Mothers who accepted BFPC referrals and had at least 1 phone conversation or in-person contact had a significant 35% to 164% increased odds of positive BF outcomes. Mailings did not significantly improve outcomes.

Conclusion: The Special Supplemental Nutrition Program for Women, Infants, and Children may need to identify barriers to BF duration and implement interventions in communities with low BF rates. Future studies may benefit from evaluating the impact of combined in-person support and phone contacts during the prenatal and postpartum periods on BF outcomes.

Study Design: Secondary data analysis

Setting: The Upstate New York WIC Breastfeeding Peer Counselor program

Population of Focus: WIC-enrolled mothers with live singleton births who accepted a Breastfeeding Peer Counselor program referral

Sample Size: 2,149 mothers

Age Range: 5 day old infants (prenatal and postnatal contact with mothers)

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Materials, Other Education, Technology-Based Support, COMMUNITY, Social Media, Social Supports,

Intervention Description: This study investigates the experiences of women using a social media Facebook group for breastfeeding support and attempts to explore whether it has aided in extended breastfeeding success. In addition, it aims to explore the value of social cognitive theory (SCT) in explaining these experiences. Qualitativ, audio-recorded, semi-structured interviews were conducted from eight women who were members of a private Facebook group.

Intervention Results: A number of themes were identified from the women's experiences, with analysis uncovering the superordinate theme 'increased self-efficacy' which provided an understanding of how the group impacted women's experiences and aided them in breastfeeding success. The sub-themes of education, accessibility, online community, normalization, and extended goals provided a more detailed understanding of how self-efficacy was increased through group membership.

Conclusion: The symbiotic relationship between members of a social media group facilitates greater breastfeeding success and a longer duration of breastfeeding through the central concept of the SCT: reciprocal determinism. Therefore, it is posited that the SCT is a suitable theory of behaviour change which can potentially be used to develop interventions aiming to increase breastfeeding rates and duration.

Study Design: Qualitative study (exploratory, deductive approach)

Setting: Social media platform: Private Facebook group

Population of Focus: Women who were members of a private Facebook group

Sample Size: 8 women

Intervention Components (click on component to see a list of all articles that use that intervention): Technology-Based Support, Educational Material, PATIENT_CONSUMER

Intervention Description: 1) Determine if using the Mother’s Milk Messaging™ app improved aspects of breastfeeding and breastfeeding rates and 2) Describe engagement as well as themes from the qualitative feedback on the app.

Intervention Results: There were a total of 346 participants in the trial, with 227 in the Intervention (n = 154 group 1 and n = 156 group 2) and 119 in the control group. Because of minimal Facebook activity, the two intervention groups 1 and 2 were combined. There were no differences in breastfeeding exclusivity and duration. (NS). Women in the intervention arm reported significantly higher confidence with breastfeeding and perceived social support to the control group (p < .05). Greater than 80% registered the app and those that engaged with the app had higher scores with time. Mothers appreciated receiving text messages and videos with reliable information. No harm was reported in this study.

Conclusion: MMM increased confidence with breastfeeding and with gathering social supports. Exclusively BF was high in all participants. Mothers perceived it as useful and dependable especially the texting.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Peer Counselor, Educational Material, Group Education, Home Visits, Telephone Support

Intervention Description: Evaluated the single and combined effects of introducing a motivational video and peer counseling into four matched WIC clinics on breastfeeding initiation and continuation at 7-10 days among African-American WIC participants.

Intervention Results: Significant differences in the percentage of women initiating breastfeeding in the video (50%), peer counselor (62%), and video + peer counselor (52%) groups vs control group (26%)

Conclusion: Overall, trends toward a positive impact of the breastfeeding promotion activities were evident but weak, and largely gone by 7-10 days postpartum.

Study Design: Cluster RCT

Setting: 4 WIC clinics in Baltimore, MD

Population of Focus: WIC eligible African American women starting prenatal care < 24 GA, with a singleton pregnancy, planning to keep the baby and stay in the clinic’s catchment area

Data Source: Mother self-report

Sample Size: Video (n=64) • Peer Counselor (n=55) • Video + Peer Counselor (n=66) • Control (n=57)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Materials, Other Education, Technology-Based Support, COMMUNITY, Social Media, Social Supports,

Intervention Description: The support offered to mothers after hospital discharge can be decisive in maintaining exclusive breastfeeding during the first 6 months post-partum. The objective of this study was to assess the impact on the duration of exclusive breastfeeding of a participatory intervention using an online social network--Facebook. A randomized clinical trial was performed involving 251 mother–child pairings in a university hospital in the Northeast of Brazil, 123 of which assigned to the intervention group and 128 to the control group. After hospital discharge, the intervention group was followed through a closed group of an online social network, where weekly posters were published on topics related to breastfeeding and an active communication was established with the mothers. The groups were interviewed monthly over the phone until the child reached 6 months of age.

Intervention Results: The exclusive breastfeeding frequencies were higher in the intervention group in all follow-up months, reaching 33.3% in the sixth month versus 8.3% in the control group. The median exclusive breastfeeding duration was 149 days (95% CI [129.6, 168.4]) in the intervention group and 86 days (95% CI [64.9, 107.1]) in the control group (P < 0.0001). The proportional risk of early interruption of exclusive breastfeeding was 0.38 (95% CI [0.28, 0.51], P < 0.0001).

Conclusion: This intervention had a positive impact on the duration and frequency of exclusive breastfeeding.

Study Design: Single-blind, RCT

Setting: Social media platform: Facebook

Population of Focus: Mother-child pairings assisted in the maternity ward of a Baby-Friendly Hospital who used Facebook

Sample Size: 251 mother-child pairings

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Other Education, Telephone Support, Technology-Based Support, COMMUNITY, Individual Supports,

Intervention Description: Pregnancy mobile apps are becoming increasingly popular, with parents-to-be seeking information related to their pregnancy and their baby through mobile technology. This increase raises the need for prenatal apps with evidence-based content that is personalized and reliable. The primary objective of this study is to assess whether the use of a health system–sponsored mobile app—Circle by Providence—aimed at providing personalized and reliable health information on pregnancy, postpartum recovery, and infant care is associated with improved health outcomes and increased healthy behaviors and knowledge among users.

Intervention Results: A total of 567 participants were enrolled in the study—167 in the app user group and 400 in the nonuser group. We found statistically significant differences between the two groups for certain behavior outcomes: subjects who used the app had 75% greater odds of breastfeeding beyond 6 months postpartum (P=.012), were less likely to miss prenatal appointments (P=.046), and were 50% more likely to exercise 3 or more times a week during pregnancy (P=.04). There were no differences in nutritional measures, including whether they took prenatal vitamins, ate 5 fruits or vegetables a day, or drank caffeine. We found no differences in many of the infant care outcomes; however, there was an increase in awareness of “purple crying.” Finally, there were no significant differences in measured clinical health outcomes, including cesarean births, length of hospital stays (in minutes), low birth weight infants, preterm births, small-for-gestational-age births, large-for-gestational-age births, and neonatal intensive care unit stays.

Conclusion: The use of the Circle app, which provides access to personalized and evidence-based health information, was associated with an increase in certain healthy behaviors and health knowledge, although there was no impact on clinical health outcomes. More research is needed to determine the impact of mobile prenatal apps on healthy pregnancies, clinical health outcomes, and infant care.

Study Design: Observational study using surveys and electronic medical records

Setting: Providence St. Joseph Health's Consumer Innovation Team launched app in Portland, Oregon and greater Seattle, Washington areas/Online

Population of Focus: Women with four or more prenatal encounters at one of the seven selected clinics that gave birth to a live infant at a Providence hospital in the past 4-6 months

Sample Size: 567 women (167 in the app user group and 400 in the comparison nonuser group)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): Educational Material, , PATIENT_CONSUMER

Intervention Description: The aim of this study was to pilot test the feasibility in a tertiary referral center for neonatal care of a post-natal educational intervention (the Diary) designed to provide mothers with basic information concerning newborn care and breastfeeding. Furthermore, we aimed to evaluate its effect on exclusive breastfeeding rates at discharge and at 48 h post-discharge, and on maternal perceived support during hospital stay, compared to standard care. A single-center two-phase interventional study was carried out from 1 December 2018 to 2 June 2019.

Intervention Results: The Diaries filled out and returned were 62.2%. Overall, mothers rated the information received through the Diary as “clear and comprehensive”. Exclusive breastfeeding rates at discharge resulted in being higher in Phase 1 than in Phase 2 (80.6% vs. 72.5%, p = 0.04), whereas no difference emerged in terms of exclusive breastfeeding rates at 48 h. In both phases, the median NPST total score (4.05) was high.

Conclusion: In conclusion, we propose a new instrument of in-hospital post-natal maternal education and, in line with the current literature, we support well-designed written educational materials to promote mothers’ knowledge and satisfaction with post-partum hospital assistance. Further studies that are multicentric and with a longer follow-up period are needed to evaluate the potential impact of the Diary on exclusive breastfeeding duration.

Intervention Components (click on component to see a list of all articles that use that intervention): Educational Material, Technology-Based Support, Telephone Support, PATIENT_CONSUMER

Intervention Description: This study was conducted to determine the effect of tele-education offered to mothers during the COVID-19 pandemic on breastfeeding success and perceived breastfeeding self-efficacy.

Intervention Results: It was determined that the tele-education given to mothers about breastfeeding during the COVID-19 pandemic increased breastfeeding success and perceived breastfeeding self-efficacy.

Conclusion: The researchers provided a 4-week long education and counseling service to mothers in the experimental group via direct phone calls and text messages. It was determined that the tele-education given to mothers about breastfeeding during the COVID-19 pandemic increased breastfeeding success and perceived breastfeeding self-efficacy.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Materials, Other Education, Technology-Based Support, COMMUNITY, Social Supports, Social Media

Intervention Description: In the United States, there are lower rates of breastfeeding among African American mothers, particularly those who are younger women. Recent epidemiological studies have shown a strong association of more aggressive types of breast cancer (estrogen receptor negative) among African American women, with a higher risk in African American women who did not breastfeed their children. This study aims to describe the process evaluation of recruitment and educational strategies to engage pregnant African American participants for a pilot study designed to determine whether social media messaging about breast cancer risk reduction through breastfeeding may positively influence breastfeeding rates.

Intervention Results: More than 3000 text messages were sent and received through WIC e-blasts and keyword responses from flyers. A total of 472 women were recruited through WIC e-blast, and 161 responded to flyers and contacts through the local health care network, community-based organizations, Facebook, and friend referrals. A total of 633 women were assessed for eligibility to participate in the study. A total of 288 pregnant African American women were enrolled, consented, and completed presurvey assessments (102.8% of the goal), and 22 participants attended focus groups or interviews reporting on their experiences with Facebook and the educational messages.

Conclusion: This process evaluation suggests that using electronic, smartphone apps with social media holds promise for both recruitment and conduct of health education intervention studies for pregnant African American women. Providing messaging and resources through social media to reinforce and educate women about breastfeeding and potentially provide lactation support is intriguing. Convenience (for researchers and participants) is an attribute of social media for this demographic of women and worthy of further research as an educational tool.

Study Design: Process evaluation

Setting: Social media platform: Facebook

Population of Focus: Pregnant African American women recruited through WIC

Sample Size: 472 women

Intervention Components (click on component to see a list of all articles that use that intervention): Educational Material

Intervention Description: To examine the associations of duration of exclusive breastfeeding with infections in the upper respiratory (URTI), lower respiratory (LRTI), and gastrointestinal tracts (GI) in infancy. This study was embedded in the Generation R Study, a population-based prospective cohort study from fetal life onward in the Netherlands. Rates of breastfeeding during the first 6 months (never; partial for <4 months, not thereafter; partial for 4-6 months; exclusive for 4 months, not thereafter; exclusive for 4 months, partial thereafter; and exclusive for 6 months) and doctor-attended infections in the URTI, LRTI, and GI until the age of 12 months were assessed by questionnaires and available for 4164 subjects.

Intervention Results: Compared with never-breastfed infants, those who were breastfed exclusively until the age of 4 months and partially thereafter had lower risks of infections in the URTI, LRTI, and GI until the age of 6 months (adjusted odds ratio [aOR]: 0.65 [95% confidence interval (CI): 0.51-0.83]; aOR: 0.50 [CI: 0.32-0.79]; and aOR: 0.41 [CI: 0.26-0.64], respectively) and of LRTI infections between the ages of 7 and 12 months (aOR: 0.46 [CI: 0.31-0.69]). Similar tendencies were observed for infants who were exclusively breastfed for 6 months or longer. Partial breastfeeding, even for 6 months, did not result in significantly lower risks of these infections.

Conclusion: Exclusive breastfeeding until the age of 4 months and partially thereafter was associated with a significant reduction of respiratory and gastrointestinal morbidity in infants. Our findings support health-policy strategies to promote exclusive breastfeeding for at least 4 months, but preferably 6 months, in industrialized countries.

Study Design: population-based prospective cohort study

Setting: Netherlands

Data Source: embedded in the Generation R Study, a population-based prospective cohort study from fetal life onward in the Netherlands

Sample Size: 4164 subjects

Age Range: Newborns 6-12 months

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Lactation Consultant, Educational Material, Assessment (PATIENT_CONSUMER)

Intervention Description: Primary prevention utilizing consistent visits with lactation professionals with a group of new mothers may efficiently address a care gap to meet breastfeeding goals. Mother-infant dyads attending a newborn care clinic for 6 weeks received feeding assessment and standard-of-care guidance from an Internationally Board-Certified Lactation Consultant (IBCLC). This study is an evaluation of a cost-effective easy-to-deliver strategy provided to an at-risk population attending a primary care clinic in the normal course of postnatal care.

Intervention Results: The number and timing of IBCLC visits was correlated with EDB at 6 weeks PP. Maternal/infant dyads seen at day 3 had 2.5 times higher odds of EDB at 6 weeks than those not receiving IBCLC standard-of-care feeding assessment. Dyads seen at days 3 and 14 had 3.4 times higher odds of EDB than those with less follow-up. Bottle use correlated with decreased odds of AB at 6 weeks PP; similarly, dyads seen only at day 14 PP had decreased odds of EDB. When looking at timing of the first involvement, dyads seen at 3 days had higher odds of EDB than dyads first seen at day 14 PP.

Conclusion: This primary prevention strategy of early minimal intervention using an IBCLC increased the odds of EDB and AB at 6 weeks PP. These data support the conclusion that early feeding assessment the first 2 weeks PP with an IBCLC may increase breastfeeding at 6 weeks PP.

Study Design: Retrospective comparison cohort study

Setting: Hospital-affiliated primary care clinic serving the underinsured and uninsured in the community

Population of Focus: Mother-infant dyads attending a newborn care clinic

Sample Size: 640 mother-infant dyads

Age Range: Infants at 6 weeks postpartum

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Lactation Consultant, Provision of Breastfeeding Item, Group Education, Incentives, Professional Support, COMMUNITY, Individual Supports,

Intervention Description: The Canada Prenatal Nutrition Program (CPNP) aims to improve birth outcomes and promote and support breastfeeding among vulnerable women. Using charitable donations, the Parkdale Parents' Primary Prevention Project (5Ps) CPNP provides postnatal lactation support to its clients in addition to standard prenatal services (group education workshops, individualized support from public health nurses and dieticians, community referrals, snacks, two public transit tokens, grocery store gift card, self-serve food bank, and childcare). This lactation support program was designed and implemented by 5Ps CPNP staff and includes three components: 1) gift package of breastfeeding and infant care supplies; 2) IBCLC visits within 48 h of referral; and 3) double electric breast pump.

Intervention Results: Ninety-one percent of participants were born outside of Canada; 55% had incomes below the Low-Income Cut-Off; and 55% reported food insecurity. All participants initiated breastfeeding, 84% continued for 6 months and 16% exclusively breastfed for 6 months. Among breastfed infants, ≥76% received vitamin D supplementation. Approximately 50% of infants were introduced to solids before 6 months. Only high school education or less and food insecurity were associated with lower breastfeeding rates. Overall, 75% of participants received at least one visit with a lactation consultant and 95% of these received a breast pump.

Conclusion: This study provides initial evidence that postnatal lactation support can be delivered within a CPNP site, with high uptake by clients. While all participants initiated breastfeeding and 84% continued for 6 months, adherence to the recommended 6 months of exclusive breastfeeding was low. Further research is needed to better understand the barriers to exclusive breastfeeding and how to support this practice among vulnerable women.

Study Design: Evaluation data

Setting: A Canada Prenatal Nutrition Program site in Toronto

Population of Focus: Pregnant women in the catchment area

Sample Size: 199 women

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, Educational Material

Intervention Description: The aim of this study was to evaluate the effect of a breastfeeding support Internet intervention on breastfeeding outcomes on women living in regional Western Australia.

Intervention Results: Women enrolled in the intervention were significantly more likely to be exclusively breastfeeding at 6 months postpartum compared with control group participants. Those women experiencing breastfeeding problems were more likely to access the Internet.

Conclusion: This breastfeeding support intervention study demonstrated a positive effect on longer-term exclusive breastfeeding for those enrolled in the intervention group. Together with more traditional methods of support, the Internet provides another possible method for promoting positive long-term breastfeeding outcomes.

Study Design: QE: non-equivalent control group

Setting: Western Australia

Population of Focus: Women who delivered an infant without serious illness, could read and understand English, and lived in a regional area in western Australia6

Data Source: Mother self-report

Sample Size: Intervention (n=207) Control (n=207)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Home Visits, Lactation Consultants, Peer Counselor, Professional Support,

Intervention Description: Breastfeeding education and support are core services provided by WIC, and numerous policies and initiatives ensure breastfeeding support is provided throughout the prenatal period and first year postpartum. Site-level characteristics related to staffing, policies, and practices that support breastfeeding were collected for the WIC Infant and Toddler Feeding Practices Study-2 (WIC ITEPS-2). Study data included interviews with 27 WIC state agency representatives affiliated with study sites, site visits to all 80 sites to collect data on facilities and staffing and a one hour interview with a site supervisor or coordinator, and surveys with staff (n=802) working in each of the 80 sites during the period when participants were enrolled in the study.

Intervention Results: Five WIC site-level supports were significantly and independently associated with any and fully breastfeeding: access to breastfeeding peer counselors, access to International Board Certified Lactation Consultants, postnatal home visits, allowing any WIC staff member to provide breast pump education, and having a policy not to provide formula during the first 30 days postpartum. Likelihood of any and fully breastfeeding increased with each additional site-level support present (odds ratio = 1.09, 95% confidence interval, 1.06–1.12; and odds ratio = 1.26, 95% confidence interval, 1.21–1.31, respectively).

Conclusion: Positive associations between site-level supports and breastfeeding at 2, 6, and 12 months were observed. Additional research is needed to understand how site-level supports interrelate and whether specific combinations are more effective, and to identify variations in implementation of breastfeeding supports.

Study Design: Secondary analysis

Setting: WIC programs in 27 states

Population of Focus: Women enrolled in WIC for the first time for that pregnancy prenatally or before their infant was 2.5 months old in 80 WIC sites across 27 states and territories during the 20 week recruitment period

Sample Size: 1,235 mothers and their infants (80 WIC sites; 802 staff surveys)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Other Education, Telephone Support, Technology-Based Support, COMMUNITY, Individual Supports

Intervention Description: We assessed whether increased use of breastfeeding smartphone applications (apps) impacts breastfeeding rates for low-income women. Women were randomized to one of two novel apps: control app containing digital breastfeeding handouts and BreastFeeding Friend (BFF), an interactive app containing on-demand breastfeeding educational and video content. The BFF app was a novel smartphone app designed based on a cross-sectional breastfeeding survey and feeback from focus group of postpartum, low-income African American women. Specifically, a multidisciplinary team of lactation consultants, perinatologists, and neonatologists designed the BFF app. The educational content included interactive advice on overcoming breastfeeding challenges, educational content on breastfeeding benefits, normal infant behavior and maternal postpartum physiology, strategies to optimize breastfeeding and pumping at work or school, hyperlinks to on-demand videos with tips and troubleshooting for successful latching, common breastfeeding positions, and using and cleaning a breast pump, as well as links to resources. All participants were given a complimentary Android smartphone with assigned breastfeeding app preloaded by a telecom provider.

Intervention Results: In the RCT, BFF and control app median uses were 15 (interquartile range [IQR] 4–24) and 9 (IQR 5–19) (p = 0.1), respectively. Breastfeeding initiation did not differ with app usage (84.1% in highest quartile versus 78.2% for lowest quartile; p = 0.5). Rates of sustained and exclusive breastfeeding through 6 months were similar between groups. Among both groups, smartphone apps were the most preferred breastfeeding resource at 6 weeks. Low quartile users also preferred alternative online breastfeeding resources: >50% of all users preferred technology-based breastfeeding resources.

Conclusion: Increased usage of breastfeeding apps did not improve breastfeeding rates among low-income women. However, technology-based resources were the most preferred breastfeeding resource after hospital discharge, indicating ongoing development of technology-based interventions has potential to increase breastfeeding in this high-needs population. clinicaltrials.gov (NCT03167073).

Study Design: Secondary analysis of an RCT

Setting: Prenatal clinic serving women with Medicaid or no health insurance at an academic medical center/Online

Population of Focus: Pregnant women at approximately 36 weeks' gestation recruited during routine obstetric appointments

Sample Size: 169 women

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Other Education, Telephone Support, Peer Counselor, Lactation Consultant, Technology-Based Support, COMMUNITY, Individual Supports,

Intervention Description: LATCH -- Lactation Advice thru Texting Can Help is a pilot, web-based texting intervention designed to improve breastfeeding rates among mothers receiving WIC. The two-way texting intervention provided both evidence-based breastfeeding education through automated texts adn a mode for mothers to freely exchange texts with breastfeeding peer counselor (PC). In addition to providing breastfeeding education, the automated texts were personalized by addressing the mother by name and signed by the PC. These automatic personalized texts were sent out regularly both prenatally and in the immediate post-partum period to increase peer counselor points of contact with mom via text. The web-based texting platform allowed all text messages to be recorded, and thus, the on-site lactation consultants and WIC supervisors were able to monitor and supervise all text-based communication regularly.

Intervention Results: Primary outcomes included early post-partum (PP) contact and exclusive breastfeeding (EBF) rates at 2 weeks PP. Feasibility outcomes included text messaging engagement and mother's satisfaction with texting platform. Fifty-eight women were enrolled, 52 of whom were available for intention-to-treat analysis (n = 30 texting, n = 22 control). Contact between mothers and PCs within 48 hr of delivery was greater in the texting group (86.6% vs. 27.3%, p < .001). EBF rates at 2 weeks PP among participants in the texting intervention was 50% versus 31.8% in the control arm (p = .197). Intervention group mothers tended to be more likely to meet their breastfeeding goals (p = .06).

Conclusion: Participants were highly satisfied with the Lactation Advice thru Texting Can Help intervention, and findings suggest that it may improve early post-delivery contact and increase EBF rates among mothers enrolled in WIC who receive PC. A large, multicentre trial is feasible and warranted.

Study Design: Pilot RCT

Setting: WIC breastfeeding programs at a hospital-based primary care center and a federally qualified community health center/Cell phone

Population of Focus: Pregnant women at 18-30 weeks gestation from local WIC breastfeeding peer counselor programs

Sample Size: 52 women (30 texting and 22 control)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Educational Material, Other Education, Telephone Support

Intervention Description: The purpose of this study was to compare breastfeeding duration in mothers after delivery who were assigned randomly to a behavioral educational intervention vs enhanced usual care.

Intervention Results: Mothers in the intervention arm breastfed for a longer duration than did the control subjects (median, 12.0 vs 6.5 weeks, respectively; P = .02) Mothers in the intervention arm were less likely to quit breastfeeding over the first 6 months after delivery (hazard ratio, 0.79; 95% confidence interval, 0.65-0.97).

Conclusion: A behavioral educational intervention increased breastfeeding duration among low-income, self-identified black and Latina mothers during the 6-month postpartum period.

Study Design: RCT

Setting: Large tertiary hospital in New York City, NY

Population of Focus: Black and Latina women ≥18 years old, who had infants with birthweights ≥ 2500 gm and 5- minute Apgar scores ≥ 7

Data Source: Mother self-report

Sample Size: Randomized • Intervention (n=270) • Control (n=270) 6-Month Follow-Up • Intervention (n=214) • Control (n=209)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Professional Support,

Intervention Description: The aim of this study is to investigate the effectiveness of indivdualized intervention compared with routine care in improving rates of exclusive breastfeeding. We provided individual antenatal breastfeeding education and postnatal lactation support to intervention group. Control group received routine care. More specifically, the intervention consisted of individual antenatal breastfeeding education and postnatal lactation support. Participants were visited by a researcher at hospital admission. At the time of admission, the researcher used the breastfeeding attrition prediction scale and individualized the intervention based on the results. After delivery, researchers provided professional guidance for mothers. After discharge, researchers asked for monthly details of the breastfeeding situation and gave guidance by telephone follow-up after maternal hospital discharge to postpartum 4 months. They also received the same routine antenatal and postnatal obstretric care.

Intervention Results: We recruited 352 women of whom 176 were randomized to intervention group, 176 to control group. In total, 293 (83.2%) completed 4 months of follow-up. At discharge from hospital, 43.2% of women randomized to intervention group were exclusively breastfeeding compared with 30.0% of women in control group (relative risk 1.78; 95% confidence interval [CI] 1.12–2.82). At 4 months, 70.9% of women in the intervention group were exclusively breastfeeding compared with 46.2% of the women in the control group (2.84; 1.76–4.60). At discharge from hospital, 95.1% of women in the intervention group were breastfeeding on demand compared with 68.1% of women receiving routine care (9.00; 4.09–19.74). At 4 months, 94.6% of women in intervention group were breastfeeding on demand compared with 75.9% of women in the control group (5.57; 2.48–12.49).

Conclusion: The regular ongoing individualized antenatal education and postnatal support can effective increase the rates of exclusive breastfeeding from delivery to postpartum 4 months and change the breastfeeding behavior.

Study Design: RCT

Setting: Hospital in China

Population of Focus: Women > 34 weeks gestation recruited from from the obstetric admission office

Sample Size: 352 women (176 intervention group and 176 control group)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): Other Education, PATIENT_CONSUMER, Provision of Breastfeeding Item, Educational Material

Intervention Description: Community forum participants voted for an education and resource distribution program (using a baby box) to help reduce local infant mortality.

Intervention Results: The proportion of participants at the follow-up survey who reported bed-sharing most or all of the time (5.7%) was lower than those participants who had said they were likely or very likely to bed-share in the post-education survey (11.3%). Although nearly all participants (98.6%) in the post-education survey reported that they were likely to use the baby box, at the postpartum follow-up, 39.1% reported actual use of the baby box.

Conclusion: The program positively impacted self-reported likelihood of several health behaviors. A community-driven approach to maternal education and resource distribution may be beneficial in other cities.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational material, HEALTH_CARE_PROVIDER_PRACTICE, Quality Improvement/Practice-Wide Intervention, Hospital Policies, Provider Training/Education,

Intervention Description: The purpose of this system-wide quality improvement project was to create a breastfeeding-friendly pediatric practice. This breastfeeding support initiative was implemented at a multisite rural Illinois pediatric practice. The policy included: (a) breastfeeding promotion recommendations; (b) provider, nurse, and staff roles; (c) patient education and resources; and (d) breastfeeding-friendly atmosphere guidelines. An evidence-based breastfeeding policy was developed, staff education sessions were conducted, private lactation rooms were created, and breastfeeding photographs/posters were displayed throughout the offices. Lactation support services were publicized throughout the offices. Lactation support services were publicized via signs and social media postings.

Intervention Results: Overall breastfeeding rates were higher at each time point after implementation. Statistically significant increases occurred at the newborn and 1-month visits, with a modest improvement at 2 and 4 months.

Conclusion: This project demonstrated an improvement in breastfeeding duration rates. It is anticipated that this practice-wide standard of care change will promote breastfeeding throughout the first 12 months of life.

Study Design: Pre-post intervention

Setting: Multisite rural IL pediatric practice

Population of Focus: Mothers with breastfeeding infants from newborn to 4 months seen for well-child visits at a pediatric practice

Sample Size: 71 infants preintervention and 18 infants postintervention

Age Range: Newborn to infants 4 months old

Intervention Components (click on component to see a list of all articles that use that intervention): Educational Material, PATIENT/CONSUMER

Intervention Description: To determine whether a low-cost prenatal education video improves hospital rates of breastfeeding initiation and exclusivity in a low-income population.

Intervention Results: Exposure to the intervention did not affect breastfeeding initiation rates or duration during the hospital stay. The lack of an effect on breastfeeding initiation persisted even after controlling for partner, parent, or other living at home and infant complications (adjusted odds ratio [OR] = 1.05, 95% CI, 0.70-1.56). In addition, breastfeeding exclusivity rates during the hospital stay did not differ between the groups (P = .87).

Conclusion: This study suggests that an educational breastfeeding video alone is ineffective in improving the hospital breastfeeding practices of low-income women. Increasing breastfeeding rates in this at-risk population likely requires a multipronged effort begun early in pregnancy or preconception.

Study Design: RCT

Setting: University of Virginia Health System and the Virginia Commonwealth University Health System

Population of Focus: Women 24-41 weeks GA, income ≤185% FPL, English-speaking, with a singleton pregnancy, and no known contraindication to breastfeeding

Data Source: Medical record review

Sample Size: Intervention (n=249/174)3 Control (n=248/172)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Educational Material

Intervention Description: To equitably increase exclusive breastfeeding at hospital discharge among obstetrician/gynecologist resident service clients by 20% over 8 weeks. Design

Intervention Results: Rates of exclusive breastfeeding at hospital discharge were 7% at baseline and 13% after implementation. Rates of exclusive breastfeeding among Black clients were 0% at baseline and 16% after implementation. Clients demonstrated Baby-Friendly knowledge (teach-back average, 89%) but continued to supplement with formula, most often related to supply concerns (65%).

Conclusion: Intentionally equitable implementation of the Baby-Friendly steps may ameliorate racial disparities in breastfeeding during the early postpartum period. Preparing families to exclusively breastfeed should begin prenatally.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, Educational Material, Home Visits

Intervention Description: This study examined the effectiveness of a breast-feeding promotion program to increase the continuation of breast-feeding.

Intervention Results: The 3-month breast-feeding rate was 32% in the intervention and 38% in the control groups (OR = 0.79, 95% CI = 0.58-1.08).

Conclusion: The program was not effective. We discuss possible explanations from the design and execution of the trial and give some points for improvement of our program, such as the categories of caregivers involved and the number and duration of contacts after parturition.

Study Design: Cluster RCT

Setting: 10 maternity and child health centers within home health care organizations in Limburg

Population of Focus: Pregnant women who applied for maternity care in one of the participating centers who gave birth to infants ≥2000 g

Data Source: Mother self-report

Sample Size: • Intervention (n=5) • Control (n=5) N=clinics • Intervention (n=371) • Control (n=330) N=women

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Expert Support (Provider), Educational Material

Intervention Description: Sites were randomly assigned to receive an experimental intervention (n = 16) modeled on the Baby-Friendly Hospital Initiative of the World Health Organization and United Nations Children's Fund, which emphasizes health care worker assistance with initiating and maintaining breastfeeding and lactation and postnatal breastfeeding support, or a control intervention (n = 15) of continuing usual infant feeding practices and policies.

Intervention Results: Infants from the intervention sites were significantly more likely than control infants to be breastfed to any degree at 12 months (19.7% vs 11.4%; adjusted odds ratio [OR], 0.47; 95% confidence interval [CI], 0.32-0.69), were more likely to be exclusively breastfed at 3 months (43.3% vs 6.4%; P<.001) and at 6 months (7.9% vs 0.6%; P =.01), and had a significant reduction in the risk of 1 or more gastrointestinal tract infections (9.1% vs 13.2%; adjusted OR, 0.60; 95% CI, 0.40-0.91) and of atopic eczema (3.3% vs 6.3%; adjusted OR, 0.54; 95% CI, 0.31-0.95), but no significant reduction in respiratory tract infection (intervention group, 39.2%; control group, 39.4%; adjusted OR, 0.87; 95% CI, 0.59-1.28).

Conclusion: Our experimental intervention increased the duration and degree (exclusivity) of breastfeeding and decreased the risk of gastrointestinal tract infection and atopic eczema in the first year of life. These results provide a solid scientific underpinning for future interventions to promote breastfeeding.

Study Design: The Promotion of Breastfeeding Intervention Trial (PROBIT), a cluster-randomized trial conducted June 1996-December 1997 with a 1-year follow-up.

Setting: Thirty-one maternity hospitals and polyclinics in the Republic of Belarus.

Data Source: N/A

Sample Size: 17 046 mother-infant pairs 16491 (96.7%) of which completed the entire 12 months of follow-up

Age Range: mother-infant pairs consisting of full-term singleton infants weighing at least 2500 g and their healthy mothers who intended to breastfeed

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Professional Support, HEALTH_CARE_PROVIDER_PRACTICE, Baby Friendly Hospital Initiative, COMMUNITY, Individual Supports,

Intervention Description: The Westside Healthy Start Program (WHS), located in Chicago, Illinois, developed an ongoing multilevel approach to breastfeeding promotion. Key elements of the WHS breastfeeding model include individual education and counseling from pregnancy to 6 months postpartum and partnership with a local safety-net hospital to implement the Baby Friendly Hospital Initiative and provide lactation support to delivering patients. All WHS participants receive general breastfeeding education from case managers throughout pregnancy (such as information about breastfeeding benefits) and one face-to-face visit from a BFC in the third trimester for more personalized and comprehensive support. WHS collaborates with the largest delivering hospital in the service area, a safety-net provider, to improve the breastfeeding environment and systems of care.

Intervention Results: In the year our model was implemented, 44.6% (49/110) of prenatal WHS participants reported that they planned to breastfeed, and 67.0% (183/273) of delivered partici- pants initiated. Among participants reaching 6 months postpartum, 10.5% (9/86) were breastfeeding. WHS also had 2667 encounters with women delivering at our partner hospital during breastfeeding rounds, with 65.1% of contacts initiating. Community data was not available to assess the efficacy of our model at the local level. However, WHS participants fared better than all delivering patients at our partner hospital, where 65.0% initiated in 2015.

Conclusion: Healthy Start programs are a promising vehicle to improve breastfeeding initiation at the individual and community level. Additional evaluation is necessary to understand barriers to duration and services needed for this population.

Study Design: Evaluation data

Setting: Westside Healthy Start program located in Chicago, IL

Population of Focus: Low-income, African-American women who are pregnant

Sample Size: 652 women

Age Range: Women <17 to 45 years old

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Materials, Other Education, Technology-Based Support, COMMUNITY, Social Media, Social Supports,

Intervention Description: Alongside increasing social media use worldwide, there is an expanding research focus on how social media use affects health behaviours, decisions and perceptions. The objective of this study was to systematically determine if and how breastfeeding is promoted and supported on the popular social media platform Instagram, which currently has over 700 million active users worldwide. To assess how Instagram is used to depict and portray breastfeeding, and how users share perspectives and information about this topic, we analysed 4,089 images and 8,331 corresponding comments posted with popular breastfeeding-related hashtags (#breastfeeding, #breastmilk, #breastisbest, and #normalizebreastfeeding).

Intervention Results: We found that Instagram is being mobilized by users to publicly display and share diverse breastfeeding-related content and to create supportive networks that allow new mothers to share experiences, build confidence, and address challenges related to breastfeeding. Discussions were overwhelmingly positive and often highly personal, with virtually no antagonistic content. Very little educational content was found, contrasted by frequent depiction and discussion of commercial products.

Conclusion: Instagram is currently used by breastfeeding mothers to create supportive networks and could potentially offer new avenues and opportunities to "normalize," protect, promote, and support breastfeeding more broadly across its large and diverse global online community.

Study Design: Qualitative study

Setting: Social media platform: Instgram

Population of Focus: Active Instagram users who shared perspectives and information about breastfeeding with popular breastfeeding-related hashtags

Sample Size: 4,089 images and 8,331 corresponding comments

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material,

Intervention Description: To evaluate the the impact of a standardized bundle of educational videos delivered via the bedside television to postpartum mothers on exclusive breastfeeding rates. The University of Minnesota Masonic Children's Hospital uses an interactive patient care tool called the GetWellNetwork, which is viewable through a patient's inroom television. The hospital's information technology team created a bidirectional interface to integrate the Epic electronic health record (EHR) with the interactive patient care tool; this allowed providers to place medical orders for educational videos to be viewed directly in patient's television screens. Once the order is placed, the patient receives a notification on their screen to view the video(s), and when they use their television remote to activate the video, it is documented in the EHR. The standard postpartum order set was updated to include orders assigning 4 breastfeeding discharge education videos to all mothers for viewing on their in-room televisions. These videos augmented existing breastfeeding support by providing education to mothers on topics including hand massage and manual expression, hands-on pumping, latch holds, and maximizing milk production.

Intervention Results: Our data set included 3115 newborns (1467 pre- and 1648 postintervention). In the postintervention year, the exclusive breastfeeding rate at discharge was 69.5% vs 68.4% preintervention (P value: .80). Most mothers (81.3%; 1339) watched all 4 videos, and 308 mothers (18.7%) watched none. The mothers who watched all 4 videos were more likely to breastfeed exclusively (72.7% vs 55.3%) and less likely to exclusively formula feed than the mothers who watched none (1.1% vs 19.8%; P < .0001).

Conclusion: There was no change in exclusive breastfeeding rates pre– versus post–video education intervention. However, most mothers watched all 4 videos, and those who did were significantly more likely to engage in any breastfeeding (98.9%) compared with those who watched none (80.2%) during the postpartum hospitalization.

Study Design: Retrospective chart review

Setting: University of Minnesota Masonic Children's Hospital

Population of Focus: Mothers with gave birth in the MN hospital pre- and post-intervention

Sample Size: 3115 live births (1467 pre- and 1648 post-intervention)

Age Range: Women ages 24-36 years

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Other Education, Telephone Support, Peer Counselor, Technology-Based Support, COMMUNITY, Individual Supports,

Intervention Description: The LATCH study was a multisite study designed to test the effectiveness of a 2-way text messaging intervention encouraging exclusive breastfeeding among women enrolled in WIC, combining in-person prenatal and postpartum breastfeeding education and support (breastfeeding peer counseling) with mobile health technology (text messaging). Four WIC BFPC sites in Connecticut participated in the study. The effectiveness of BFPCs was clearly established in the literature; thus, the text messaging intervention was designed to faciliate the BFPCs' work, not replace it.

Intervention Results: Lactation Advice Through Texting Can Help had a significant impact on early contact between participants and BFPCs (odds ratio = 2.93; 95% confidence interval, 1.35–6.37) but did not have a significant impact on EBF (odds ratio = 1.26; 95% confidence interval, 0.54–2.66).

Conclusion: Lactation Advice Through Texting Can Help has the potential to facilitate the work of BFPCs by shortening the time-to-first-contact with clients after giving birth. Research is needed to identify the level of breastfeeding support staff coverage that WIC clinics must have to meet the demand for services created by Lactation Advice Through Texting Can Help.

Study Design: Multisite, single-blind RCT

Setting: WIC breastfeeding peer counselor program/Cell phone

Population of Focus: Low-income women participating in the WIC BFPC program

Sample Size: 174 women

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Lactation Consultant, Provision of Breastfeeding Item, Group Education, NATIONAL, Policy/Guideline (National),

Intervention Description: Workplace breastfeeding resources (e.g., break times and private spaces) help working mothers exclusively breastfeed for 6 months. This study is one of the few studies to include and measure access to breastfeeding support such as breast pumps, worksite programs, educational materials, support groups, lactation consultants, and workplace policies. To meet the 6 month recommendation, employers can provide additional resources (i.e. lactation consultants and support groups) to help mothers transition back to work and continue breastfeeding. The ACA was an important first step for establishing minimum resources to support breastfeeding mothers; however, it needs to be expanded to cover all employer and workers.

Intervention Results: Fifty-two participants met the inclusion criteria for the study and completed the survey. Most of the participants in the study were White, college-educated women who worked in clerical or administration support and education occupations. Approximately 78.8% of the participants reported access to private spaces and 65.4% reported access to break times for breastfeeding. Fewer participants reported access to breast pumps, lactation consultants, and support groups.

Conclusion: There are gaps in access to workplace breastfeeding resources, but occupational health nurses can inform and help employers implement lactation resources to reduce breastfeeding disparities.

Study Design: Online, cross sectional survey

Setting: Policy

Population of Focus: Working mothers between the ages of 18 and 50 years old who gave birth in the previous two years

Sample Size: 52 women

Age Range: 18-50 year old women

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Midwife, Educational Material, Home Visits, Telephone Support

Intervention Description: To evaluate the effects of an extended midwifery support (EMS) programme on the proportion of women who breast feed fully to six months.

Intervention Results: Findings: there was no difference between the groups at six months postpartum for either full breast feeding [EMS 43.3% versus SMS 42.5%, relative risk (RR) 1.02, 95% confidence interval (CI) 0.87-1.19] or any breast feeding (EMS 63.9% versus SMS 67.9%, RR 0.94, 95%CI 0.85-1.04).

Conclusion: The EMS programme did not succeed in improving breast-feeding rates in a setting where there was high initiation of breast feeding. Breast-feeding rates were high but still fell short of national goals.

Study Design: RCT

Setting: King Edward Memorial Hospital (KEMH), Perth, Western Australia

Population of Focus: Women who gave birth at KEMH who intended to breastfeed

Data Source: Mother self-report

Sample Size: Randomized • Intervention (n=425) • Control (n=424) 6-Month Follow-Up • Intervention (n=393) Control (n=389)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, Educational Material, Group Education, Telephone Support

Intervention Description: The aim of this study was to evaluate the effectiveness of a multiphased midwifery intervention called the 'Milky Way' on any breastfeeding rates until six months.

Intervention Results: There were no significant differences in the antenatal baseline data between the groups. Compared to standard care, women in the Milky Way group had higher rates of breast feeding at one (83.7%, n=144 versus 61.3%, n=119, p<0.001), four (64.5%, n=111 versus 37.1%, n=72, p<0.001) and six months (54.3%, n=94 versus 31.4%, n=61 p<0.001).

Conclusion: Assignment to the Milky Way intervention was associated with significantly higher rates of breastfeeding compared with assignment to standard care only.

Study Design: QE: pretest-posttest non-equivalent control group

Setting: Tertiary hospital in South Western Sydney Area Health Services

Population of Focus: Nulliparous women ≥19 years old with basic English literacy

Data Source: Mother self-report

Sample Size: Enrolled • Intervention (n=172) • Control (n=194) 6-Month Follow-Up • Intervention (n=149) • Control (n=189)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Materials, Other Education, Technology-Based Support, COMMUNITY, Social Media, Social Supports,

Intervention Description: The importance of support to breastfeeding success is well established, as are the difficulties many mothers face in accessing the support they need. With the majority of UK mothers now accessing social media for support, Breastfeeding Support Facebook (BSF) groups have increased exponentially. BSF groups vary in type (local or national/international) and in moderation—overseen by breastfeeding mothers and by midwives or trained lactation specialists. Some groups aimed at supporting mothers in a specific geographical area also have associated face-to-face groups, facilitated as either professional or peer support. Little is currently known about these specific local groups, their prevalence, impact or value to mothers. This paper examines mothers' experiences of using local BSF groups and why they value them as part of a larger study exploring the impact of midwife moderation on these groups. An online survey consisting of open and closed questions was completed by 2028 mothers.

Intervention Results: Findings identified that local BSF groups are widely used and highly valued for their connection with local face-to-face services and other mothers. They offer access to expertise and shared experience in a format mothers find convenient and timely, improving confidence and self-efficacy. Local BSF groups enable the formation of support networks and development of breastfeeding knowledge that mothers credit with increased well-being, motivation and breastfeeding duration. As such, they have the potential to add value to local face-to-face services and improve breastfeeding experiences and knowledge in communities.

Conclusion: The findings have important implications to support the development of integrated online interventions to improve public health.

Study Design: Qualitative study

Setting: Social media platform: Breastfeeding Support Facebook groups

Population of Focus: Mothers in the UK using local Breastfeeding Support Facebook groups

Sample Size: 2028 mothers

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Materials, Other Education, Technology-Based Support, COMMUNITY, Social Media, Social Supports,

Intervention Description: To date, most breastfeeding research on social media only focuses on content analysis, and there remains limited knowledge about the social networks of online communities (who interacts with whom), influencers in the breastfeeding space and the diffusion of evidence-based knowledge. This study, grounded in social network theory, aims to better understand the breastfeeding communication landscape on Twitter including determining the presence of a breastfeeding network, communities and key influencers. Further, we characterize influencer interactions, roles and the content being shared.

Intervention Results: The study revealed an overall breastfeeding social network of 3,798 unique individuals (users) and 3,972 tweets with commonly used hashtags (e.g., #breastfeeding and #normalizebreastfeeding). Around one third of users (n = 1,324, 34%) exchanged pornographic content (PC) that sexualized breastfeeding. The non-PC network (n = 2,474 users) formed 144 unique communities, and content flowing within the network was disproportionately influenced by 59 key influencers. However, these influencers had mostly inward-oriented interaction (% composition, E-I index: 47% professionals, -0.18; 41% interested citizens, -0.67; 12% companies, -0.18), limiting opportunities for evidence-based dissemination to the lay public.

Conclusion: Although more tweets about peer-reviewed research findings were sent compared with tweets about nonevidence-based lay recommendations, our findings suggest that it is the lay public who often communicated findings, which may be overcome through a targeted social network-based intervention.

Study Design: Outcome evaluation

Setting: Social media platform: Twitter

Population of Focus: Influencers in the breastfeeding space on Twitter

Sample Size: 3,798 unique individuals (users), 3,962 tweets

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Materials, Other Education, Technology-Based Support, COMMUNITY, Social Media, Social Supports,

Intervention Description: As recently highlighted by the National Academy of Sciences, there is a need for the scientific community (SC) to diffuse its findings to the public more effectively online, as means to counteract the spread of misinformation. In response to this call, we gathered data from Twitter for one month from major breastfeeding hashtags resulting in an interconnected social network (n = 3,798 users). We then identified 59 influencers who disproportionately influenced information flow using social network analysis. These influencers were from the SC (e.g. academics, researchers, health care practitioners), as well as interested citizens (IC) and companies. We then conducted an ego-network analysis of influencer networks, developed ego maps, and compared diffusion metrics across the SC, IC and company influencers. We also qualitatively analyzed their tweets (n = 711) to understand the type of information being diffused.

Intervention Results: Content analysis of tweets suggest IC are more active than the SC in diffusing evidence-based breastfeeding knowledge, with 35% of their tweets around recent research findings compared to only 12% by the SC. Nonetheless, in terms of outreach to the general public, the two-step networks of SC influences were more heterogenous than ICs (55.7 ± 5.07, 50.9 ± 12.0, respectively, P<0.001).

Conclusion: Collectively, these findings suggest SC influencers may possess latent potential to diffuse research and evidence- based practices. However, the research suggests specific ways to enhance diffusion.

Study Design: Outcome evaluation

Setting: Social media platform: Twitter

Population of Focus: Influencers from the scientific community using major breastfeeding hashtags on Twitter for a month

Sample Size: 59 influencers, 711 tweets

Intervention Components (click on component to see a list of all articles that use that intervention): Home Visits, PATIENT_CONSUMER, Educational Material,

Intervention Description: In this pilot study, the breastfeed care plus intervention program was implemented to support women and their families in breastfeeding success.

Intervention Results: Both interventions proved to be effective in improving the ‘perception of breastfeeding self-efficacy,' with higher scores being found in the experimental group (p < 0.001). The proportion of exclusive breastfeeding was also higher in the experimental group

Conclusion: The BCP intervention program, during the first 120 days postpartum, showed promissory results in improving ‘perception of breastfeeding self-efficacy’ compared to conventional care, favoring breastfeeding duration and exclusivity, and cumulative breastfeeding competence of women/families.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Other Education, Telephone Support, Technology-Based Support, COMMUNITY, Individual Supports

Intervention Description: To test the effects of weekly SMS for improving infant feeding practices and infant weight. SMS were sent automatically using a web-based SMS messaging platform from the time the participant enrolled in the study until the end (4 months later). Participants were randomized to receive SMS about infant's general health issues (control) or SMS for improving feeding practices (intervention) for 4 months. Intervention SMS were created with a focus on reinforcing WIC messages on breastfeeding, preventing overfeeding, delaying introduction of solid foods, and delaying and reducing baby juice comsumption. A total of 18 messages (1 per week for 4 months) were sent. All messages were written at a grade 5 level in Spanish for PR or English for HI.

Intervention Results: A total of 170 participants completed the study (n = 86 control and n = 84 intervention). Baseline characteristics were similar between groups. At the end, exclusive breastfeeding rates were similar between groups (67.4% control and 59.1% intervention). Introduction of other foods and beverages, addition of foods to the bottle, placing infants to sleep with milk bottles, caregiver's method and response to feeding infants and distractions while feeding infants were similar between groups. Also, weight status or rate of weight gain was similar between groups.

Conclusion: There were no significant improvements in feeding practices or in weight with the intervention. The timeline of the messages in relation to the targeted behavior may have affected the effectiveness of the intervention. Earlier dissemination of messages, higher level of intensity, longer intervention, additional contacts and inclusion of other caregivers may be needed to achieve the desired effects.

Study Design: Multisite RCT

Setting: WIC programs in Puerto Rico and Hawaii/Cell phone

Population of Focus: Caregivers of infants 0-2 months old participating in the WIC program

Sample Size: 170 participants (86 control and 84 intervention)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): Technology-Based Support, Educational Material, PATIENT_CONSUMER

Intervention Description: To examine the effectiveness of a mobile phone-based nutrition education intervention targeting pregnant and nursing mothers in six Sri Lankan divisional secretariat areas.

Intervention Results: A total of 996 pregnant and nursing mothers participated in the pre-assessment survey, of which 720 completed the post-assessment. Most were nursing mothers (84.2% pre- and 78.9% post-assessment). Participants provided positive feedback on the intervention. Knowledge/awareness (t = −18.70, p < 0.01) and attitudes (t = −2.00, p < 0.05) increased when exposed to the intervention. Favourable improvements in the practices were also observed. Mothers’ practices related to breastfeeding and 24-h dietary diversity showed a statistically significant improvement. However, social norms and behaviour intentions did not significantly improve. The qualitative component also revealed favourable responses.

Conclusion: The mobile intervention improved participants’ knowledge, awareness, attitude, and practices, but not social norms or behaviour intentions. This approach is recommended to be used on a larger scale in community settings. In addition, mobile technology could drive intervention in pandemic-related situations.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Materials, Other Education, Technology-Based Support, COMMUNITY, Social Media, Social Supports,

Intervention Description: Social media crosses socioeconomic and geographic lines and can inform and empower people, increase communication speed, and mobilize partnerships. Through the dissemination of standardized messages and graphics, social media can be optimized for the delivery of evidence-based nutrition information. In 2014, the USDA launched a mobile-responsive Web site to assist WIC staff in engaging participants and community partners. Resources included posters, brochures, videos, widgets, graphics, and BF peer counseling training. Recognizing the opportunity for spreading messages via social media, the Web site was enhanced with the addition of a social media toolkit for World Breastfeeding Week/National Breastfeeding Month (August, 2016). The goal of the project was to create sample graphics and messages based on the campaign that could be used by WIC agencies and partners to reach participants, eligible participants, and the public. Messages were developed using content from the Loving Support campaign materials and Loving Support Peer Counseling Training. Agencies were encouraged to link to the Loving Support Web site and use the hashtag #WICLovingSupport in their posts. Agencies could also customize the messages and graphics as needed to promote their own activities and events. The toolkit included Facebook covers and posts, Twitter headers and posts, a Twibbon, an Instagram post, and an e-card. A guide to using the toolkit with sample messages was created as well. The Figure shows sample images and messages.

Intervention Results: The toolkit was launched on July 12, 2016 and received 4,319 page views by the end of August. Overall there were 9,432 downloads of all Loving Support materials and 29,745 page views to the Loving Support Web site. This was a 50% increase in page views and a 17% increase in downloads over the previous month, before the launch of the toolkit. Use of the toolkit continued since August with 1,507 page views between August, 2016 and February, 2017. The number of users for that same period was 5,007 (new and returning users). There were 2,342 downloads of social media graphics, with Facebook covers and posts, the e-card, and Instagram posts as the most downloaded items. The Twibbon campaign had 36 supporters. A TweetReach snapshot report from August 2 to August 6 (during World Breastfeeding Week) showed that the hashtag #WICLovingSupport had 60 tweets from 40 contributors, 287,820 accounts reached (the number of people who likely saw content), and 362,607 impressions (the number of times people likely reached).

Conclusion: Translating policy and guidance into action-oriented messages that WIC agencies can easily use and disseminate can increase the exposure of evidence-based nutrition messages. Although it is a relatively low-cost communication strategy, social media involves a high cost in time and attention needed to maintain an active presence.8 By providing a ready-to-go social media toolkit, the Food and Nutrition Service was able to offer consistent messaging, but it also reduced WIC staff workload and reached many people with information about BF promotion and support.

Study Design: Program evaluation

Setting: Social media platforms: Facebook, Twitter, and Instagram

Population of Focus: WIC staff

Sample Size: 5,007 new and returning users

Intervention Components (click on component to see a list of all articles that use that intervention): Educational Material, PATIENT_CONSUMER, ,

Intervention Description: Project Dads in Nutrition Education will strengthen the capacity of the Georgia Healthy Start program to integrate an evidence-based nutrition education program, breastfeeding education, and father engagement into its routine services.

Intervention Results: Changes in prepost survey assessment of participants’ nutrition literacy and eating behaviors; changes in prepost survey assessment of participants’ breastfeeding knowledge, attitudes, intent, initiation, and duration; and health and food diary collected 3 times (ie, at baseline, 3 months, and 6 months after enrollment).

Conclusion: Process evaluation throughout the study to document implementation. Generalized linear mixed modeling will be used to determine the impact of the intervention.

Intervention Components (click on component to see a list of all articles that use that intervention): Provider Training/Education, PATIENT_CONSUMER, HEALTH_CARE_PROVIDER_PRACTICE, Educational Material (Provider), Peer Counselor

Intervention Description: To evaluate changes in referrals to Women, Infants, and Children’s Supplemental Nutrition Program peer counselors, reported prenatal provider education and support, and breastfeeding outcomes (intention, initiation, 1-month duration of any and exclusive breastfeeding) after a prenatal breastfeeding promotion intervention.

Intervention Results: Pre-intervention (n = 71) and post-intervention (n = 70) participants were 49% Black, 61% publicly insured, and 16% uninsured. More post-intervention participants had > 1 Toolkit use (76%), peer counselor program referrals (60.0% post vs. 36.6% pre, p < .01), reported any breastfeeding intention (89% vs. 72%, p = .013), and intended to breastfeed for > 1 year (31% vs. 14%, p = .014). Post-intervention breastfeeding initiation and exclusivity were higher, but not significantly different. Post-intervention participants reported better prenatal breastfeeding supp

Conclusion: Implementing a prenatal Breastfeeding Toolkit, including facilitating peer counselor referral, was associated with increases in provider counseling, participants’ breastfeeding intentions, and uptake of peer counselors. Replicating this approach may reinforce efforts to support breastfeeding in similar practices serving women with lower incomes.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Educational Material, Group Education

Intervention Description: The rate of breastfeeding among immigrant Vietnamese women in Western countries is low compared to those in Vietnam. To counteract this trend, a language and culture specific education program was developed.

Intervention Results: Results suggested that the education program had significant effects on knowledge, attitudes, planned and actual behaviour towards breastfeeding. However, the effect did not sustain until 6 months postpartum.

Conclusion: Implications for nursing practice and further research are discussed.

Study Design: QE: non-equivalent control group

Setting: Western and South Western Sydney, New South Wales

Population of Focus: Vietnamese women who were at least 12 weeks pregnant

Data Source: Mother self-report

Sample Size: Intervention (n=108) Control (n=86)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Other Education, Telephone Support, Partner-Level Intervention, Technology-Based Support, COMMUNITY, Social Supports, Individual Supports,

Intervention Description: Social support for breastfeeding, in particular the support of an infant's father, has been identified as a crucial element for successful breastfeeding. Mobile health (mHealth) interventions employing digital technologies provide a rapidly evolving means of engaging fathers and providing them with information and support to address their needs related to both breastfeeding and transitioning to fatherhood. The Parent Infant Feeding Initiative (PIFI) was a 4-arm, randomized controlled trial conducted in Perth, Australia. The objective of this study was to determine the effectiveness of various father-focused breastfeeding interventions in terms of key infant feeding outcomes. The primary outcomes were duration of exclusive and any breastfeeding. The trial arms included a control group and 3 interventions, consisting of a face-to-face father-focused antenatal breastfeeding class facilitated by a male peer facilitator; Milk Man, a breastfeeding smartphone app designed specifically for fathers; and a combination of both interventions.

Intervention Results: A total of 1426 couples were recruited from public (443/1426, 31.1%) and private (983/1426, 68.9%) hospitals. Of these, 76.6% (1092/1426) of fathers completed the baseline questionnaire, 58.6% (836/1426) completed the 6-week follow-up questionnaire, and 49.2% (702/1426) completed the 26-week follow-up questionnaire. The average age of fathers who completed the baseline questionnaire was 33.6 (SD 5.2) years; the majority were born in Australia (76.4%) and had attended university (61.8%). There were no significant differences between the control and any of the intervention groups in any of the infant feeding outcomes or level of breastfeeding self-efficacy and postpartum partner support reported by mothers.

Conclusion: This study did not demonstrate that any intervention was superior to another or that any intervention was inferior to the standard care delivered in routine antenatal classes. Further studies are needed to test the effectiveness of these interventions in more socioeconomically diverse populations that are likely to benefit most from additional partner supports.

Study Design: RCT

Setting: Antenatal breastfeeding class/Online

Population of Focus: Couples from public and private hospitals in Perth, Australia

Sample Size: 1426 couples

Age Range: Adults 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Lactation Consultant, Telephone Support, Partner-Level Intervention, Professional Support,

Intervention Description: The study examines the effectiveness of a comprehensive, evidence-based, professional support intervention for breastfeeding that was implemented in the Netherlands: the Breastfeeding Support Program (BSP). The BSP tries to increase the proportion of mothers who breastfeed exclusively for six months or longer by positively influencing 1) the mother's attitude towards breastfeeding (by focusing on the positive effects of exclusive breastfeeding for 6 months or longer for mother and child), 2) the subjective norm (by explicitly involving the father and by forming a reliable source of support and positive messages about breastfeeding throughout the program), and 3) the mother's perceived behavioral control (by providing information, encouragement, and practical support to improve breastfeeding skills). The BSP combines both education and support, extends from pregnancy to the postnatal period, and uses a protocolled series of six individual consults delivered by an IBCLC. The sixth and final consult is held 10 weeks after delivery by telpehone and focuses on further support for returning to work.

Intervention Results: The effect of the BSP on survival rates for any and exclusive breastfeeding were significant while controlling for differences between the two groups at baseline (respectively HR = 0.34, p < .001 [95% CI = 0.18–0.61] and HR = 0.46, p < .001 [95% CI = 0.29–0.72]). Among mothers in the BSP group there was on average 66% less risk of cessation of any breastfeeding and on average 54% less risk of cessation of exclusive breastfeeding at any point in time compared to those in the control group.

Conclusion: The BSP appears to be an effective means to delay cessation of any and exclusive breastfeeding cessation and therefore to increase breastfeeding duration and exclusivity. This is an important finding, because earlier cessation of breastfeeding than desired is a common problem in many countries. Future research into the effectiveness of the BSP could consider random assignment to conditions and test the effectiveness of the intervention in other populations to investigate further whether wide-scale implementation of this intervention could be useful to promote breastfeeding.

Study Design: Quasi-experimental study

Setting: Breastfeeding Support Program in the Netherlands

Population of Focus: Pregnant women who were planning to breastfeed and who made a personal decision to enroll in the BSP

Sample Size: 138 women (66 mothers in the intervention group and 72 mothers in the control group)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Peer Counselor, Educational Material, Group Education, Incentives,

Intervention Description: The AMEN (originally "Avondale Moms Empowered to Nurse;" remaned to "All Moms Empowered to Nurse") project was the first Peer-to-Peer (Mom-to-Mom) breastfeeding education and support project in Avondale, a neighborhood in Hamilton County, Ohio. AMEN was designed to provide Peer-to-Peer (Mom-to-Mom) breastfeeding education and support, specifically for African American mothers living in neighborhoods of poverty, to increase breastfeeding initiation and duration. The peer support group typically met one to two times per month with the provision of childcare, transportation, refreshments, and grocery gift card incentives. Group activities included sharing of a breastfeeding topic of interest by Champion moms, various interactive activities (e.g., breastfeeding Jeopardy), and faciliated sharing by attendees, in addition to special guest presentations. With the COVID-19 pandemic, the group pivoted to the virtual world (Zoom) allowing even more mothers to join.

Intervention Results: Since May 2017, 67 AMEN support meetings have included 158 participants, with average attendance of 10 (range 5–19) per meeting. In addition to 8 Champions, 110 moms have attended, including 24% expecting mothers. Additional attendees include 13 family support persons, 23 guest speakers, and 12 from community outreach programs. Qualitative feedback from participants has been uniformly positive. Breastfeeding initiation rates have increased 12% in the initial neighborhood.

Conclusion: Harnessing strength within the local community, Champion Breastfeeding Moms have successfully launched AMEN breastfeeding support groups in under-resourced African American urban neighborhoods, helping more mothers reach their breastfeeding goals.

Study Design: Mixed methods

Setting: Home visitation program, Every Child Succeeds, at Carmel Presbyterian Church in partnership with the Cincinnati Children's Hospital Medical Center in the Avondale neighborhood

Population of Focus: Participants in the AMEN peer support program

Sample Size: 67 support meetings with a total of 158 participants (8 champions, 110 mothers, 13 family support persons, 23 guest speakers, and 12 from community outreach programs)

Age Range: Not reported

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Materials, Other Education, Technology-Based Support, COMMUNITY, Social Media, Social Supports,

Intervention Description: Many women do not have adequate and consistent social support to help them deal with breastfeeding difficulties at home after childbirth. Millennial women (those born between 1980 and 1999) have a significant presence online, making internet-based sources of breastfeeding support a potentially far-reaching, cost-effective, and convenient innovation. Social media platforms (e.g., Facebook, YouTube, Twitter, LinkedIn, Pinterest, GooglePlus+, Tumblr, and Instagram) are internet-based applications that enable the creation and exchange of user-generated content that may provide an avenue of social support. Social media breastfeeding support groups (SMBSGs) provide a cost-efficient, immediate approach to gaining social support and education from vast populations with various sociodemographics. Using 17 SMBSGs, the study team explored the variables that lead to sustained, exclusive breastfeeding to 6 months for breastfeeding millennial women who follow SMBSGs.

Intervention Results: Using structural equation modeling, I examined relationships among personal factors; competing situational demands; social support; and confidence in, knowledge of, attitude toward, and sustainability of breastfeeding. Age, education, and competing work and family demands were all predictive of social support. Breastfeeding social support had a direct effect on participants’ breastfeeding confidence, knowledge, and attitudes (F = 4.96, R2 = .07, p < .002). Furthermore, within SMBSGs, exclusive breastfeeding to 6 months was reported to be three times (66%) greater than the U.S. national average (22%).

Conclusion: Interventions aimed at providing women with resources to gain breastfeeding social support, such as SMBSGs, may be vehicles to improve women’s confidence, knowledge, and attitudes and, therefore, increase the potential for exclusive breastfeeding to 6 months.

Study Design: Repeated measures, longitudinal, mixed-methods

Setting: Online social media support groups across 21 countries

Population of Focus: Convenience sample of exclusively breastfeeding millenial women who followed at least one of 17 social media breastfeeding support groups

Sample Size: 241 women

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Materials, Lactation Consultant, Other Education, Professional Support, HEALTH_CARE_PROVIDER_PRACTICE, Other (Provider Practice),

Intervention Description: A team-based, integrated lactation consultant (LC) and primary care provider (PCP) program improves breastfeeding rates in some outpatient settings, but only a limited number of studies have assessed efficacy in socioeconomically and racially diverse communities. The study intervention implemented routine LC/PCP visits for families at their first newborn visit to the FQHC following hospital discharge. A typical team-based visit was scheduled for 40 minutes with the RN/LC present for the entire visit and the PCP joining for about 10 minutes to examine the infant and coordinate the plan of care. The remaining 30 minutes was dedicated to lactation support, including addressing latch, milk supply, decreasing maternal pain, and breastfeeding anticipatory guidance.

Intervention Results: Among patients who initiated breastfeeding, those who received a LC/PCP visit were significantly more likely to be breastfeeding at 2 weeks (94% versus 80%, p = 0.004) and 4 months (68% versus 45%, p = 0.01). However, breastfeeding rates for the whole practice were not significantly different before and after implementation. Seventy-two percent of breastfeeding families saw a LC (n = 204). Median LC visit per breastfeeding patient was 1.18 (standard deviation [SD] +1.2). Patient survey reported that the three most commonly helpful aspects of the visit were “latch instruction” (60%), “breastfeeding questions answered” (80%) and “learning about massage and hand expression” (50%).

Conclusion: Team-based LC/PCP care is feasible at a FQHC. Patients found it helpful. Among families who initiated breastfeeding, receiving LC/PCP care was associated with increased breastfeeding duration through 4 months.

Study Design: Retrospective chart review

Setting: Federally Qualified Health Center in Cleveland, OH

Population of Focus: Women and infants receiving care at a Federally Qualified Health Center

Sample Size: Pre (n=197 women) and post (n=245 women)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Educational Material, Partner-Level Intervention

Intervention Description: A randomized controlled trial in which expectant fathers (n = 59) were assigned randomly to attend either a 2-hour intervention class on infant care and breastfeeding promotion (intervention) or a class on infant care only (control group). Couples were recruited during the second trimester from a university obstetrics practice.

Intervention Results: Overall, breastfeeding was initiated by 74% of women whose partners attended the intervention class, as compared with 41% of women whose partners attended the control class (P = .02).

Conclusion: Expectant fathers can be influential advocates for breastfeeding, playing a critical role in encouraging a woman to breastfeed her newborn infant.

Study Design: RCT

Setting: Johns Hopkins Hospital in Baltimore, MD

Population of Focus: Women who sought prenatal care at the resident and faculty practices

Data Source: Mother self-report

Sample Size: Intervention (n=27) Control (n=32)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Educational Material, Technology-Based Support, PATIENT_CONSUMER

Intervention Description: In response to the cessation of in-person prenatal education services during the COVID-19 pandemic, we adapted an evidence-based curriculum to a live virtual format entitled Ready, Set, Baby Live COVID-19 Edition (RSB Live).

Intervention Results: In a sample of 146 pregnant people, participation in RSB Live was associated with high levels of knowledge about the benefits of breastfeeding, early infant hunger cues, and recommended maternity care practices, as well as high levels of satisfaction with adaptations to the session’s content and virtual delivery. Participation was also associated with a significant increase in prenatal breastfeeding intention, a known predictor of breastfeeding outcomes.

Conclusion: This study supports live, virtual education with a standardized curriculum as an effective and acceptable means of providing prenatal education.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Educational Material, Other Education, Provision of Breastfeeding Item, PROVIDER/PRACTICE, Hospital Policies, Other (Provider Practice), POPULATION-BASED SYSTEMS, COMMUNITY, Other (Communities), Provider Training/Education

Intervention Description: A breastfeeding promotion program conducted on the Navajo reservation.

Intervention Results: Based on medical records review of feeding practices of all the infants born the year before (n = 988) and the year after (n = 870) the intervention, the program was extremely successful.

Conclusion: This combination of techniques, including qualitative and quantitative research into local definitions of the problem, collaboration with local institutions and individuals, reinforcement of traditional understandings about infant feeding, and institutional change in the health care system, is an effective way of facilitating behavioral change.

Study Design: QE: pretest-posttest

Setting: Shiprock, NM

Population of Focus: All mothers with infants born at the Shiprock hospital

Data Source: Medical record review

Sample Size: Preintervention (n=988) Postintervention (n=870)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Other Education, Home Visits,

Intervention Description: RCT to determine the effect of breastfeeding training on mothers’ knowledge, behaviors, and exclusive breastfeeding for 6 months. The training group received breastfeeding education during the prenatal and postnatal periods from the researcher. Besides the breastfeeding training that the pregnant women in the control group were provided by the hospital, they received education in the prenatal period about modern family planning methods. Prenatal training was provided to each pregnant woman in two lessons in a room allocated for training within the hospital. Each group consisted of 8-14 participants. Both groups were monitored through home visits in the 1st and 24th weeks postpartum. Postnatal training was provided within the first 24 h postpartum. The training lasted for at least 30 minutes and focused mostly on breastfeeding problems and breastfeeding techniques.

Intervention Results: The difference between the number of correct answers in pre- and posttest was higher in the training group (four questions) than in the control group (two questions) (p < .001). The number of mothers exclusively breastfeeding for 6 months was significantly higher in the training group (26.5%) than in the control group (3.3%) (p = .015). The median of the exclusive breastfeeding period was longer in the training group (5 months) than in the control group (4 months) (p = .013).

Conclusion: Training and supporting pregnant women and breastfeeding mothers on breastfeeding increased their knowledge, the period of exclusive breastfeeding, and the rate of 6-month exclusive breastfeeding.

Study Design: RCT

Setting: Outpatient OB/GYN clinics of a private baby-friendly hospital in the city center of Kayseri Province, Turkey

Population of Focus: Pregnant women in their 2nd or 3rd trimester attending the OB/GYN polyclinics of a baby-friendly hospital

Sample Size: 120 women (60 for training and 60 in the control groups)

Age Range: Women 20 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): Educational Material

Intervention Description: Pertinent studies were identified by a search of PubMed between January 1, 2008 and July 31, 2014. The random-effect model was used. Sensitivity analysis, subgroups analysis, and publication bias were conducted.

Intervention Results: Twenty-four articles with 27 studies involving 13,907 breast cancer cases were included in this meta-analysis. Pooled results suggested that breastfeeding was inversely [corrected] associated with the risk of breast cancer. The summary relative risk (RR) of breast cancer for the ever compared with never categories of breastfeeding was 0.613 (95% confidence interval [CI], 0.442-0.850). An inverse association was also found for the longest compared with the shortest categories of breastfeeding with the risk of breast cancer (RR=0.471; 95% CI, 0.368-0.602). No evidence of publication bias was found.

Conclusion: Findings from this meta-analysis suggest that breastfeeding, particularly a longer duration of breastfeeding, was inversely associated with risk of breast cancer.

Study Design: Meta-analysis

Setting: N/A

Data Source: PubMed

Sample Size: 13907

Age Range: N/A