Interventions to Promote Breastfeeding
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Transcript of Interventions to Promote Breastfeeding
Report for the Healthy Start Research to Practice Workgroup
Jennifer Carvalho SalemiJuly 15, 2008
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
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.
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.”
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.
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
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.
WHO International Code of Marketing of Breast-milk substitutes
Baby- Friendly Hospital InitiativeMaternity Leave
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.
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)
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.
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.
Baby-Friendly Hospital Status1. Ten-steps to successful breastfeeding2. 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.
• 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
Workplace support
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.
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)
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
“The workplace environment should enable mothers to continue
breastfeeding as long as the mother and baby desire.”
Professional SupportPeer Counseling
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
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
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.
Peer support programs were found to be effective at increasing breastfeeding initiation and duration rates among:Women on low incomesWomen 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
Evidence suggests that support is most effective when offered to women soon after birth, without them having to request it.
Group peer supportPeer counseling
Telephone counselingHome visits
Professional social support – alone, without educational components– was not found to significantly increase initiation rates.
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
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
Individual breastfeeding guidance and support to increase self-efficacy may be more effective in increasing the duration of breastfeeding than written materials alone.
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
A combination of interventions is likely to be more effective than a stand-alone intervention.
Interventions that expand all phases of pregnancy are more effective than those limited to one phase.
Prenatal Intrapartum Postnatal Infancy
Intervention “packages” that include a combination of the following components are usually most effective:
Peer support
Media campaign
Hospital or health sector structural changes (i.e.
rooming-in)
Health education activities
The best way to develop an effective intervention is to:• Combine interventions• Support breastfeeding before, during, and
after pregnancy.
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.
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