Interventions to Promote Breastfeeding

1. Interventions to Promote Breastfeeding Report for the Healthy Start Research to Practice Workgroup Jennifer CarvalhoSalemi

2. Promoting Breastfeeding from a Social Ecological Framework

3. Overview of Interventions • Macro-level: • Media and Social Marketing • National Policies: • Maternity Leave • Implementation of WHO code • BFHI • Organizational Level: • Hospital and Maternity Care Practices • Workplace Support • Interpersonal Level • Peer support • Professional support and encouragement • Supportive home environment • Individual Level • Education and professional support to increase knowledge, skill, and self-efficacy

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

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

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

7. Overview of Interventions

8. Media and Social Marketing

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

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

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

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

13. National & International Policies WHO International Code of Marketing of Breast-milk substitutes Baby- Friendly Hospital Initiative Maternity Leave

14. WHO International Code of Marketing of Breast-milk substitutes Commonly referred to as the “International Code” Prohibits the promotion of formula in health care facilities, the distribution of free samples, and use of pictures idealizing artificial feeding.

15. Baby Friendly Hospital Initative Goals: To implement the “Ten steps to successful breastfeeding” To discontinue the marketing of breast-milk substitutes at hospitals and maternity wards (ensure compliance with the International Code)

16. As of June, 2008 there are 64 Baby-Friendly Hospitals and Birth Centers in the United States

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

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

19. Hospital & Maternity Care Practices

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

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

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

23. Workplace Support Workplace support

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

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

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

27. Recommendations from the DHHS Office on Women’s Health “The workplace environment should enable mothers to continue breastfeeding as long as the mother and baby desire.”

28. Breastfeeding Support Professional Support Peer Counseling

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

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

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

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

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

34. La Leche League Group peer support Peer counseling Telephone counseling Home visits

35. Limited effectiveness Professional social support – alone, without educational components– was not found to significantly increase initiation rates.

36. Education

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

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

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

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

41. Key Findings Prenatal Intrapartum Postnatal Infancy A combination of interventions is likely to be more effective than a stand-alone intervention. Interventions that expand all phases of pregnancy are more effective than those limited to one phase.

42. Effective Intervention Packages Peer support Media campaign Hospital or health sector structural changes (i.e. rooming-in) Health education activities Intervention “packages” that include a combination of the following components are usually most effective:

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

44. References Abdulwadud, O. A., & Snow, M. E. (2007). Interventions in the workplace to support breastfeeding for women in employment. Cochrane Database Syst Rev(3), CD006177. Anderson, G. C., Moore, E., Hepworth, J., & Bergman, N. (2003). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev(2), CD003519. Britton, C., McCormick, F. M., Renfrew, M. J., Wade, A., & King, S. E. (2007). Support for breastfeeding mothers. Cochrane Database Syst Rev(1), CD001141. Fairbank, L., O'Meara, S., Renfrew, M. J., Woolridge, M., Sowden, A. J., & Lister-Sharp, D. (2000). A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding. Health Technol Assess, 4(25), 1-171. Futuro, E. (2006). BFHI USA. Retrieved July 1, 2008, from http://www.babyfriendlyusa.org/ Gagnon, A. J. (2000). Individual or group antenatal education for childbirth/parenthood. Cochrane Database Syst Rev(4), CD002869. Guise, J. M., Palda, V., Westhoff, C., Chan, B. K., Helfand, M., & Lieu, T. A. (2003). The effectiveness of primary care-based interventions to promote breastfeeding: systematic evidence review and meta-analysis for the US Preventive Services Task Force. Ann Fam Med, 1(2), 70-78. Hector, D., & King, L. (2005). Interventions to encourage and support breastfeeding. N S W Public Health Bull, 16(3-4), 56-61. Howard, C., Howard, F., Lawrence, R., Andresen, E., DeBlieck, E., & Weitzman, M. (2000). Office prenatal formula advertising and its effect on breast-feeding patterns. Obstet Gynecol, 95(2), 296-303. Lindenberger, J. H., and Bryant, C. A. . (2000). Promoting Breastfeeding in the WIC Program: A Social Marketing Case Study. American Journal of Health Behavior, 24(1), 53–60. Renfrew, M. J., Dyson, L., Wallace, L., D'Souza, L., McCormick, F., & Spiby, H. (2005). The effectiveness of public health interventions to promote the duration of breastfeeding: Systematic r. Retrieved June 7, 2008. from www.nice.org.uk. Satcher, D. S. (2001). DHHS blueprint for action on breastfeeding. Public Health Rep, 116(1), 72-73. Shealy KR, L. R., Benton-Davis S, Grummer-Strawn LM. (2005). The CDC Guide to Breastfeeding Interventions. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Sikorski, J., & Renfrew, M. J. (2000). Support for breastfeeding mothers. Cochrane Database Syst Rev(2), CD001141. Sikorski, J., Renfrew, M. J., Pindoria, S., & Wade, A. (2002). Support for breastfeeding mothers. Cochrane Database Syst Rev(1), CD001141. Sikorski, J., Renfrew, M. J., Pindoria, S., & Wade, A. (2003). Support for breastfeeding mothers: a systematic review. Paediatr Perinat Epidemiol, 17(4), 407-417. World Health Organization. (1998). Evidence for the Ten Steps to Successful Breastfeeding. Geneva.

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