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.

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