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Modern contraceptive technologies such as combined oral contraceptives and intrauterine devices were developed in the late 1950s and introduced on a large scale in industrialized countries more than two decades ago. The inability of a health-service-based program to provide adequate family planning care demonstrated a need for family planning workers drawn from the community. This led to the development of Community Based Delivery (CBD) programs in which lay workers from the community use simplified procedures and provide family planning in a nonclinic setting. The chapter examines the health-related aspects of contraceptives used in CBD programs, especially with regard to the nature of the methods, safety considerations, simplified procedures needed to counsel and screen new clients, monitoring and support of users, and the requirements for supervision and referral. The consequences of family planning on health depend largely on the balance between contraceptive risks and benefits and the risks of childbearing.

BACKGROUND Comprehensive prenatal education on infant feeding is recommended by many United States health organizations because of the need to maximize maternal preparedness for managing lactation physiology. Ready, Set, BABY (RSB) is a curriculum developed for counseling women about breastfeeding benefits and management including education on optimal maternity care practices. We hypothesized that RSB would be acceptable to mothers and that mothers' strength of breastfeeding intentions would increase, and their comfort with the idea of formula feeding would decrease after educational counseling using the materials. We also hypothesized that mothers' knowledge of optimal maternity care practices would increase after participation. METHODS Materials were sent to a total of seven sites in the United States and Puerto Rico. Local health care practitioners completed training before counseling mothers with the curriculum. A pre- and postintervention questionnaire was administered to participants. Statistical analysis of results included paired t tests, Wilcoxon signed-rank tests, and McNemar's tests. RESULTS Four hundred and sixteen expectant women participated. In the pre- and postintervention comparison, maternal participation in RSB significantly improved Infant Feeding Intentions Scale scores (P

The Academy of Breastfeeding Medicine is a worldwide organization of physicians dedicated to the promotion, protection, and support of breastfeeding and human lactation. Our mission is to unite into one association members of the various medical specialties with this common purpose.

Background: Insurance coverage for lactation management is proposed by the United States Affordable Care Act. International Board Certified Lactation Consultants (IBCLCs) are key providers of lactation services. In order to inform national discussion, this study examines the scope of insurance reimbursement of IBCLC services. Objectives: An email survey of US IBCLCs (N = 10 495) in March 2011 was used to explore frequencies of (1) submission—how often lactation consults were submitted to insurance providers for reimbursement and (2) recognition—the proportion of submitted charges recognized by insurance providers. Methods: Results (N = 2045) were analyzed to describe patterns of submission and recognition by IBCLC work setting, job classification, and reimbursement strategy. Results: Many survey respondents did not know their submission (41%) or recognition (57%) levels. Multiple strategies were used for reimbursement of IBCLC services with large variations in recognition between strategies. Overall, less than 15% reported high levels of submissions to insurance providers. Moreover, of submitted encounters, only 4% were consistently recognized by insurance providers. Inpatient hospital IBCLCs were least likely to have consults recognized (3%), and private community IBCLCs were most frequently recognized (32%). Compared with using IBCLC credentials for submitting an encounter, using another clinical license was the most successful strategy for achieving recognition of IBCLC consults (crude risk ratio, 1.44; 95% confidence interval, 1.04-2.01; P = .02). Conclusion: IBCLCs provide key care to a vulnerable population. However, we found that these services are not consistently reimbursed. IBCLCs poorly communicate their health care activities to insurance providers, but insurance providers also inconsistently recognize and reimburse IBCLC care.

Objectives (a) to apply an organisation-level, pre-implementation theory to identify and describe factors that may impact hospitals' readiness to achieve the Ten Steps and (b) to explore whether/how these factors vary across hospitals. Design a multisite, descriptive, qualitative study of eight hospitals that used semi-structured interviews of health-care professionals. Template analyses identified factors that related to organisation-level theory. Cross-site comparative analyses explored how factors varied across hospitals. Setting thirty-four health-care professionals from eight North Carolina hospitals serving low-wealth populations. The hospitals are participating in a quality improvement project to support the implementation of the Ten Steps. This study occurred during the pre-implementation phase. Findings several factors emerged relating to collective efficacy (i.e., the shared belief that the group, as a whole, is able to implement the Steps) and collective commitment (i.e., the shared belief that the group, as a whole, is committed to implementing the Steps) to implement the Ten Steps. Factors relating to both constructs included ‘staff age/experience,' ‘perceptions of forcing versus supporting mothers,' ‘perceptions of mothers' culture,' and ‘reliance on lactation consultants.' Factors relating to commitment included ‘night versus day shift,' ‘management support,' ‘change champions,' ‘observing mothers utilize breastfeeding support.' Factors relating to efficacy included ‘staffing,' ‘trainings,' and ‘visitors in room.' Commitment-factors were more salient than efficacy-factors among the three large hospitals. Efficacy-factors were more salient than commitment-factors among the smaller hospitals. Key conclusions and implications for practice interventions focused on implementing the Ten Step may benefit from improving collective efficacy and collective commitment. Potential approaches could include skills-based, hands-on training highlighting benefits for mothers, staff, and the hospital, and addressing context-specific misconceptions about the Steps.

Background Exclusive breastfeeding for 6 months and continued breastfeeding for at least 1 year is recommended by all major health organizations. Whereas 74.6 percent of mothers initiate breastfeeding at birth, exclusivity and duration remain significantly lower than national goals. Empirical evidence suggests that exposure to infant formula marketing contributes to supplementation and premature cessation. The objective of this study was to explore how women interpret infant formula advertising to aid in an understanding of this association. Methods Four focus groups were structured to include women with similar childbearing experience divided according to reproductive status: preconceptional, pregnant, exclusive breastfeeders, and formula feeders. Facilitators used a prepared protocol to guide discussion of infant formula advertisements. Authors conducted a thematic content analysis with special attention to women's statements about what they believed the advertisements said about how the products related to human milk (superior, inferior, similar) and how they reported reacting to these interpretations. Results Participants reported that the advertisements conveyed an expectation of failure with breastfeeding, and that formula is a solution to fussiness, spitting up, and other normal infant behaviors. Participants reported that the advertisements were confusing in terms of how formula-feeding is superior, inferior or the same as breastfeeding. This confusion was exacerbated by an awareness of distribution by health care practitioners and institutions, suggesting provider endorsement of infant formula. Conclusions Formula marketing appears to decrease mothers' confidence in their ability to breastfeed, especially when provided by health care practitioners and institutions. Therefore, to be supportive of breastfeeding, perinatal educators and practitioners could be more effective if they did not offer infant formula advertising to mothers. (BIRTH 40:2 June 2013)

The Ten Steps to Successful Breastfeeding outline maternity practices that protect, promote, and support breastfeeding and serve as the foundation for the Baby-Friendly Hospital Initiative. Research aim: This systematic review describes interventions related to Step 3 of the Ten Steps, which involves informing pregnant women about the benefits and management of breastfeeding. Our main objective was to determine whether prenatal clinic- or hospital-based breastfeeding education increases breastfeeding initiation, duration, or exclusivity.The electronic databases MEDLINE and CINAHL were searched for peer-reviewed manuscripts published in English between January 1, 2000, and May 5, 2016. Bibliographies of relevant systematic reviews were also screened to identify potential studies.Thirty-eight studies were included. The research studies were either randomized controlled trials or quasi-experimental studies conducted in developed or developing countries. Findings suggest that prenatal interventions, delivered alone or in combination with intrapartum and/or postpartum components, are effective at increasing breastfeeding initiation, duration, or exclusivity where they combine both education and interpersonal support and where women's partners or family are involved. However, varying study quality and lack of standardized assessment of participants' breastfeeding intentions limited the ability to recommend any single intervention as most effective.Future studies should test the strength of maternal breastfeeding intentions, assess the role of family members in influencing breastfeeding outcomes, compare the effectiveness of different health care providers, and include more explicit detail about the time and full cost of different interventions.

Objectives. The Ten Steps to Successful Breastfeeding is a proven approach to support breastfeeding in maternity settings; however, scant literature exists on the relative impact and interpretation of each step on breastfeeding. We assessed the Ten Steps and their relationship with in-hospital breastfeeding rates at facilities serving low-wealth populations and explored the outcomes to identify step-specific actions. Methods. We present descriptive and nonparametric comparisons and qualitative findings to examine the relationship between the Ten Steps and breastfeeding rates from each hospital using baseline data collection. Results. Some steps (1-policy, 2-training, 4-skin-to-skin, 6-no supplements, and 9-no artificial nipples, followed by 3-prenatal counseling, 7-rooming-in) reflected differences in relative baseline breastfeeding rates between settings. Key informant interviews revealed misunderstanding of some steps. Conclusions. Self-appraisal may be less valid when not all elements of the criteria for evaluating Step implementation may be fully understood. Limited exposure and understanding may lead to self-appraisal errors, resulting in scores that are not reflective of actual practices. Nonetheless, the indication that breastfeeding rates may be better mirrored by a defined subset of steps may provide some constructive insight toward prioritizing implementation activities and simplifying assessment. These issues will be further explored in the next phase of this study.

There has been a significant increase in the number of published peer-reviewed articles on breastfeeding over the last two decades. However, in part because of the lack of clear or consistent definitions used in these publications, generalization and comparison of findings have been difficult, and interpretation of findings is often limited. This study was undertaken to examine this issue by assessing if and what definitions of breastfeeding have been used in a variety of relevant journals and the source of those definitions.An iterative systematic approach was used to select articles for review from major breastfeeding and health-related journals. Articles were reviewed for use of breastfeeding terminology, descriptors (e.g., exclusive, partial), and full definitions. Descriptive analysis was carried out using Excel (Microsoft(®), Redmond, WA). A flow chart was developed to examine sources of definitions in use.Descriptors are seen 68% of the time, and full definitions are only offered in slightly more than a quarter (28%) of the articles. Among those journals that are primarily dedicated to breastfeeding research, 43-64% included descriptors, and 20-29% included definition of the descriptor. The pediatric journal included a high percentage with descriptors (77%), but only 18% were defined further. Among the other journals, there was a wide range (0-60%) with descriptors but fewer providing definitions. Only 26 articles offered a definition, and of these, 21 articles included a citation. Most derived from the Interagency Group for Action on Breastfeeding and World Health Organization definitional schemas.There remains a need by journals for increased requirement of inclusion of breastfeeding definitions and by researchers of attention to their use. For this to occur, there must first be the reconfirmation and/or development of a set of consistently utilized definitions that are applicable for the study of behaviors, support interventions, and health outcomes for both the mother and of the child. Therefore, an inclusionary international Working Group Process Approach is recommended, similar to that used in 1988, with confirmation and dissemination by all major organizations and agencies.

The World Health Organization (WHO)/UNICEF Baby-Friendly Hospital Initiative (BFHI) was developed to support the implementation of the Ten Steps for Successful Breastfeeding. The purpose of this study is to assess trends in the numbers facilities ever-designated "baby-friendly," to consider uptake of the new WHO/UNICEF BFHI materials, and to consider implications for future breastfeeding support.The national contacts from the 2006-2007 UNICEF BFHI update were recontacted, as were WHO and UNICEF officers worldwide, to ascertain the number of hospitals ever-designated "baby-friendly," presence of a government breastfeeding oversight committee, use of the new BFHI materials and, if yes, use of the new maternity or human immunodeficiency virus (HIV) materials.Seventy countries reporting in 2010-2011 and the updates from an additional 61 reporting in 2006-2007 (n=131, or 66% of the 198 countries) confirm that there are at least 21,328 ever-designated facilities. This is 27.5% of maternities worldwide: 8.5% of those in industrialized countries and 31% in less developed settings. In 2010, government committees were reported by 18 countries, and 34 reported using the new BFHI materials: 14 reported using the maternity care and 11 reported using the HIV materials.Rates of increase in the number of ever-certified "baby-friendly" hospitals vary by region and show some chronological correlation with trends in breastfeeding rates. Although it is not possible to attribute this increase to the BFHI alone, there is ongoing interest in Ten Steps implementation and in BFHI. The continued growth may reflect the dedication of ministries of health and national BFHI groups, as well as increasing recognition that the Ten Steps are effective quality improvement practices that increase breastfeeding and synergize with community interventions and other program efforts. With renewed interest in maternal/neonatal health, revitalization of support for Ten Steps and their effective institutionalization in maternity practices should be considered. Future updates are planned to assess ongoing progress and impact, and ongoing updates from national committees are welcome.

Many women in industrialized countries return to work while their children are infants. This is often associated with decreased breastfeeding duration or exclusivity. In order to better understand the breastfeeding support activities in childcare settings, studies were undertaken in settings with very different levels of infant mortality, breastfeeding, and breastfeeding support: Adelaide, Australia, and Wake County, North Carolina. The researchers collaborated to explore, contrast, and compare their baseline data.Available data on breastfeeding rates and infant mortality rates were explored for the two settings. In addition, the two childcare datasets were explored for common questions, and descriptive and χ(2) analyses were carried out.Similarities were found between the response from childcare settings providers in Australia and the United States. Rates of having at least one breastfeeding infant (70.6% vs. 66.3%), a place to breastfeed (90.7% vs. 95%), and a refrigerator for storage (100% vs. 100%) were similar for Adelaide and Wake County, respectively. Qualitative data from Adelaide also mirrored Wake County data in that providers in neither setting were actively promoting breastfeeding. However, the Adelaide data reflected significantly higher rates of encouragement (95.3% vs. 21.7%), written policy (77.8% vs. 20.8%), resource/materials distribution (76.6% vs. 1% and 93.8% vs. 17%), and training (44.4% vs. 13.9%).Childcare practices may reflect the environment of support, or lack thereof, for breastfeeding in the society as a whole. The similarities and differences seen in these settings may reflect both official guidance as well as the breastfeeding environment. There is much work to be done in the United States to come up to the same level of support for breastfeeding in child care and in other programs as is seen in Australia.

The U.S. Department of Agriculture's Supplemental Nutrition Program for Women, Infants, and Children (WIC) nutrition services provides supplemental nutrition and counseling to more than 50% of families with young children in the United States. Given the program's significant reach, as well as large differences in rates of breastfeeding among whites, African Americans, and Hispanics, we explored the associations among breastfeeding initiation, the availability of WIC-based breastfeeding support, and the racial/ethnic composition of WIC clients in North Carolina.An electronic survey gathered data on ongoing breastfeeding support activities from local WIC directors in North Carolina. North Carolina Pregnancy and Nutrition Surveillance System data provided racial/ethnic composition and breastfeeding initiation rates. Linear and logistic regression models were used to examine county-level associations among (1) racial/ethnic composition of clients, (2) breastfeeding initiation, and (3) availability of the identified WIC breastfeeding support services.Responses were received from 50 of the state's 100 counties and were generally representative of the state. Breastfeeding initiation by site was negatively associated with percentage of African American clients and positively associated with percentage of white or Hispanic clients (p0.05). The availability and intensity of breastfeeding support services varied widely, with 50% offering clinic-based services, 46% offering home visits, 38% offering peer counseling, and 76% offering some other form of counseling. The WIC sites with larger Hispanic populations were more likely to be providing a broad base of services, including clinic-based services, peer counseling, and home visits (p0.05); those with higher African American populations were significantly less likely to offer clinic-based breastfeeding support services (p0.05) and trended toward fewer services in general.Results confirmed previous findings of racial/ethnic disparities in breastfeeding rates. We also found that differences in the availability of breastfeeding support services were associated with the racial/ethnic composition of the catchment area. This apparent inequity in the availability of breastfeeding support services at different WIC sites may merit further exploration and may inform implementation of aspects of the U.S. Surgeon General's Call to Action to Support Breastfeeding.

Approximately half of all mothers of infants born in the United States receive services through the Special Supplemental Nutrition Program for Woman, Infants and Children (WIC). Although WIC promotes breastfeeding, data suggest that, despite advances in the last 2 decades, WIC participants are less likely to initiate breastfeeding, and much less likely to continue, than non-WIC participants, including the non-WIC participants who are eligible for WIC. WIC recently revised their food packages and enhanced the monetary value of the breastfeeding packages. While these changes are an important step in supporting WIC's efforts to promote breastfeeding, other major factors, such as participants' perceptions of the value of the packages and WIC's dependency on rebates from formula companies to fund a portion of the program, may dampen WIC's breastfeeding promotion and support efforts. There is great need for additional research on these issues.

N C Med J. September/October 2010, Volume 71, Number 5 When one looks at many preventive health practice norms, one might conclude that North Carolina has a unique “health care personality.” The norms in North Carolina do not quite fit with regional norms in the southeastern United States, nor do they align with those of the Mid-Atlantic states. North Carolina’s attitudes, trends, and practices related to the protection, promotion, and support of breastfeeding are no exception. North Carolina has a special set of issues that affect trends and practices in breastfeeding and vary across the state. Breastfeeding is sometimes referred to as the “homeless intervention.” It has no commercial home. It is neither entirely a women’s issue nor entirely a children’s issue. Breastfeeding is not a one-time thing, like an immunization or a pill; rather, it demands a 24/7 commitment on the part of new parents who have many things to learn. However, it is a mistake to think of breastfeeding as simply a lifestyle choice. In the United States, we once considered avoidance of smoking, use of a seat belt or a bike helmet, and regular exercise to be lifestyle choices with no real public health impact. However, we have been persuaded by data on health and survival, as well as by the social and health care costs of nonadherence to public health recommendations, to value these preventive health behaviors and to support them with social marketing campaigns, insurance incentives, and even laws to increase acceptance and to promote behavior change. These considerations also apply to breastfeeding. Breastfeeding is a vital preventive health practice and an issue for all who care about health, whether from a clinical, business, or personal viewpoint. The support, or lack thereof, for breastfeeding has measurable implications in terms of lifelong health and wellness for North Carolinians.

Background: Most infant feeding studies present infant formula use as “standard” practice, supporting perceptions of formula feeding as normative and hindering translation of current research into counseling messages supportive of exclusive breastfeeding. To promote optimal counseling, and to challenge researchers to use exclusive breastfeeding as the standard, we have reviewed the scientific literature on exclusive breastfeeding and converted reported odds ratios to allow discussion of the “risks” of any formula use. Methods: Studies indexed in PubMed that investigated the association between exclusive breastfeeding and otitis media, asthma, types 1 and 2 diabetes, atopic dermatitis, and infant hospitalization secondary to lower respiratory tract diseases were reviewed. Findings were reconstructed with exclusive breastfeeding as the standard, and levels of significance calculated. Results: When exclusive breastfeeding is set as the normative standard, the re-calculated odds ratios communicate the risks of any formula use. For example, any formula use in the first 6 months is significantly associated with increased incidence of otitis media (OR: 1.78, 95% CI: 1.19, 2.70 and OR: 4.55, 95% CI: 1.64, 12.50 in the available studies; pooled OR for any formula in the first 3 mo: 2.00, 95% CI: 1.40, 2.78). Only shorter durations of exclusive breastfeeding are available to use as standards for calculating the effect of “any formula use” for type 1 diabetes, asthma, atopic dermatitis, and hospitalization secondary to lower respiratory tract infections. Conclusions: Exclusive breastfeeding is an optimal practice, compared with which other infant feeding practices carry risks. Further studies on the influence of presenting exclusive breastfeeding as the standard in research studies and counseling messages are recommended. (BIRTH 37:1 March 2010)

Objectives. We sought to assess whether breastfeeding-related hospital practices reported by mothers were associated with achievement of their intentions to exclusively breastfeed. Methods. We used data from Listening to Mothers II, a nationally representative survey of 1573 mothers who had given birth in a hospital to a singleton in 2005. Mothers were asked retrospectively about their breastfeeding intention, infant feeding at 1 week, and 7 hospital practices. Results. Primiparas reported a substantial difference between their intention to exclusively breastfeed (70%) and this practice at 1 week (50%). They also reported hospital practices that conflicted with the Baby-Friendly Ten Steps, including supplementation (49%) and pacifier use (45%). Primiparas who delivered in hospitals that practiced 6 or 7 of the steps were 6 times more likely to achieve their intention to exclusively breastfeed than were those in hospitals that practiced none or 1 of the steps. Mothers who reported supplemental feedings to their infant were less likely to achieve their intention to exclusively breastfeed: primiparas (adjusted odds ratio [AOR] = 4.4; 95% confidence interval [CI] = 2.1, 9.3); multiparas (AOR = 8.8; 95% CI = 4.4, 17.6). Conclusions. Hospitals should implement policies that support breastfeeding with particular attention to eliminating supplementation of healthy newborns.

Physicians commonly state the concern that, if they promote breastfeeding, they may “impose guilt upon those who do not breastfeed.” This article explores the genesis of this fear, who may benefit from this construct, and the terminology of guilt, shame, and loss. The article also explores the responsibility for both lactation failure and associated shame, considering the roles and responsibilities of physicians, the media, and society as a whole. An alternative construct for the guilt is offered, based on the consideration that the woman experiences lack of breastfeeding as a loss at some level, conscious or subconscious, and whether the choice to not breastfeed is her decision or imposed. Proposed approaches for acting to prevent and to treat shame and guilt are presented. J Hum Lact. 24(1):80-84.

This chapter reviews the literature on postpartum coital behavior, anovulatory and ovulatory bleeding episodes, and the methodology and efficacy of Lactational Amenorrhea Method and progesterone-only oral contraceptives. Of interest is the finding that breastfeeding women may resume coital behavior earlier postpartum, but report increased discomfort over time. The high efficacy of the Lactational Amenorrhea Method is confirmed and data illustrating possible relaxation of some criteria are presented. The conflicting guidance of CDC and WHO concerning immediate postpartum use of progestin-only methods is presented. The dearth of recent studies calls for new research on these topics.

After contraceptive use, breast-feeding duration is the major determinant of the birth interval length. Three methods of estimating births averted by breast-feeding, and the increase in contraceptive use needed to substitute for breast-feeding, are presented. Method 1 simply utilizes Bongaarts’ Ci, and the other two are based on mean birth intervals with and without breast-feeding. Estimates for each method are derived for six countries with DHS surveys from the mid-1990s: Burkina Faso, Uganda, India, Indonesia, Brazil and Peru. The estimated percentage of additional births that would occur if there were no breast-feeding ranged from 1–4% in Brazil to about 50% in Burkina Faso and Uganda, reflecting very low breast-feeding in Brazil and very high levels in the sub-Saharan African nations. Strengths and limitations of the three methods are considered.

Breastfeeding is known to demand use of maternal nutrient stores, but few comment on the positive health benefits of breastfeeding for the mother. Breastfeeding reduces the risk of postpartum blood loss by increasing the rate of uterine contraction, lowers the risk of postpartum blood loss by increasing the rate of utering contraction, lowers the risk of postpartum blood loss by increasing the rate of uterine contraction, lowers the risk of premenopausal breast cancer and also reduces the risk of ovarian cancer, reduces lifetime menstrual blood loss, may reduce rate or severity of infections, may reduce the risk of spinal and hip fracture after menopause, and may support bonding with the infant as well as an improved sense of self-esteem and success with mothering. This article reviews the literature on short- and long-term sequelae of breastfeeding for women.

9. Koupil I, Mann V, Leon DA, Lundberg U, Byberg L, Vagero D.Morningcortisoldoesnotmediatetheassociationofsizeatbirthwithbloodpressureinchildrenbornfromfull-termpregnancies.Clin Endocrinol (Oxf). 2005;62:661-6.10. Jones A, Godfrey KM, Wood P, Osmond C, Goulden P, Phillips DI.Fetal growth and the adrenocortical response to psychologicalstress. J Clin Endocrinol Metab. 2006;91:1868-71.11. Schmidt NA. Salivary cortisol testing in children. Issues ComprPediatr Nurs. 1998;20:183-90.12. Hanrahan K, McCarthy AM, Kleiber C, Lutgendorf S, Tsalikian E.Strategiesforsalivarycortisolcollectionandanalysisinresearchwith children. Appl Nurs Res. 2006;19:95-101.13. Dressendorfer RA, Strasburger CJ, Bidlingmaier F, Klug I,Kistner A, Siebler T, et al. Development of a highly sensitivenonisotopic immunoassay for the determination of salivary17-hydroxy-progesterone: reference ranges throughoutchildhood and adolescence. Pediatr Res. 1998;44:650-5.

Objectives. We determined the effectiveness of primary care–based, and pre- and postnatal interventions to increase breastfeeding. Methods. We conducted 2 trials at obstetrics and gynecology practices in the Bronx, New York, from 2008 to 2011. The Provider Approaches to Improved Rates of Infant Nutrition & Growth Study (PAIRINGS) had 2 arms: usual care versus pre- and postnatal visits with a lactation consultant (LC) and electronically prompted guidance from prenatal care providers (EP). The Best Infant Nutrition for Good Outcomes (BINGO) study had 4 arms: usual care, LC alone, EP alone, or LC+EP. Results. In BINGO at 3 months, high intensity was greater for the LC+EP (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.08, 6.84) and LC (OR = 3.22; 95% CI = 1.14, 9.09) groups versus usual care, but not for the EP group alone. In PAIRINGS at 3 months, intervention rates exceeded usual care (OR = 2.86; 95% CI = 1.21, 6.76); the number needed to treat to prevent 1 dyad from nonexclusive breastfeeding at 3 months was 10.3 (95% CI = 5.6, 50.7). Conclusions. LCs integrated into routine care alone and combined with EP guidance from prenatal care providers increased breastfeeding intensity at 3 months postpartum.

Background Although breastfeeding is almost universally accepted in the Democratic Republic (DR) of Congo, by the age of 2 to 3 months 65% of children are receiving something other than human milk. We sought to describe the infant feeding practices and determinants of suboptimal breastfeeding behaviors in DR Congo. Methods Survey questionnaire administered to mothers of infants aged ≤ 6 months and healthcare providers who were recruited consecutively at six selected primary health care facilities in Kinshasa, the capital. Results All 66 mothers interviewed were breastfeeding. Before initiating breastfeeding, 23 gave their infants something other than their milk, including: sugar water (16) or water (2). During the twenty-four hours prior to interview, 26 (39%) infants were exclusively breastfed (EBF), whereas 18 (27%), 12 (18%), and 10 (15%) received water, tea, formula, or porridge, respectively, in addition to human milk. The main reasons for water supplementation included “heat” and cultural beliefs that water is needed for proper digestion of human milk. The main reason for formula supplementation was the impression that the baby was not getting enough milk; and for porridge supplementation, the belief that the child was old enough to start complementary food. Virtually all mothers reported that breastfeeding was discussed during antenatal clinic visit and half reported receiving help regarding breastfeeding from a health provider either after birth or during well-child clinic visit. Despite a median of at least 14 years of experience in these facilities, healthcare workers surveyed had little to no formal training on how to support breastfeeding and inadequate breastfeeding-related knowledge and skills. The facilities lacked any written policy about breastfeeding. Conclusion Addressing cultural beliefs, training healthcare providers adequately on breastfeeding support skills, and providing structured breastfeeding support after maternity discharge is needed to promote EBF in the DR Congo.

Background The Ten Steps to Successful Breastfeeding are maternity practices proven to support successful achievement of exclusive breastfeeding. They also are the basis for the WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI). This study explores implementation of these steps in hospitals that serve predominantly low wealth populations. Methods A quasi-experimental design with mixed methods for data collection and analysis was included within an intervention project. We compared the impact of a modified Ten Steps implementation approach to a control group. The intervention was carried out in hospitals where: 1) BFHI designation was not necessarily under consideration, and 2) the majority of the patient population was low wealth, i.e., eligible for Medicaid. Hospitals in the research aspect of this project were systematically assigned to one of two groups: Initial Intervention or Initial Control/Later Intervention. This paper includes analyses from the baseline data collection, which consisted of an eSurvey (i.e., Carolina B-KAP), Maternity Practices in Infant Nutrition and Care survey tool (mPINC), the BFHI Self-Appraisal, key informant interviews, breastfeeding data, and formatted feedback discussion. Results Comparability was ensured by statistical and non-parametric tests of baseline characteristics of the two groups. Additional findings of interest included: 1) a universal lack of consistent breastfeeding records and statistics for regular monitoring/review, 2) widespread misinterpretation of associated terminology, 3) health care providers’ reported practices not necessarily reflective of their knowledge and attitudes, and 4) specific steps were found to be associated with hospital breastfeeding rates. A comprehensive set of facilitators and obstacles to initiation of the Ten Steps emerged, and hospital-specific practice change challenges were identified. Discussion This is one of the first studies to examine introduction of the Ten Steps in multiple hospitals with a control group and in hospitals that were not necessarily interested in BFHI designation, where the population served is predominantly low wealth, and with the use of a mixed methods approach. Limitations including numbers of hospitals and inability to adhere to all elements of the design are discussed. Conclusions For improvements in quality of care for breastfeeding dyads, innovative and site-specific intervention modification must be considered.

OBJECTIVES: This study quantified the influence of employment, specifically a mother's employment away from her infant, on the use of breast milk substitutes in developing countries. METHODS: Data from the Demographic and Health Surveys were used to calculate the population attributable risk percentage for use of breast milk substitutes among women employed away from their babies in 15 countries for which suitable data were available. RESULTS: The estimated proportion of breast milk substitute use attributable to employment away from the baby ranged from 0.74% to 20.9% in the various countries. CONCLUSIONS: Employment is not the main determinant of breast milk substitute use. Efforts to improve breast-feeding can be safely targeted at the majority of women who are not employed away from their babies while nevertheless giving appropriate attention to the minority of new mothers who are employed away from their babies.

Data from many Demographic and Health Surveys I and II in developing countries were analyzed to determine the overlap between lactational amenorrhea and contraceptive use (nonhormonal methods) during the first 6 months postpartum. In Asia and the Near East region the level of double coverage during the first 3 months postpartum was 80% in Indonesia and Sri Lanka 60% in Thailand 50% in Egypt and 40% in Tunisia. In Africa the level of double coverage during the first 3 months postpartum was 80% or above for all countries studied except Sudan which did not have such data for 3 months postpartum. Double coverage remained high at 6 months postpartum (55% to

Objective: Lack of support for breastfeeding mothers has been consistently identified in the literature as a barrier for breastfeeding across racial and ethnic groups. Using a community-based participatory approach, academic and community-based partners conducted an iterative process to assess barriers, facilitators, and potential mediating interventions for breastfeeding in the African American community in Durham, North Carolina. Methods: Eight focus groups were conducted with African American mothers, fathers, and grandmothers. Researchers transcribed and coded each focus group and analyzed using ATLAS.ti 5.2. Patterns and themes that emerged informed the development of community stakeholder interviews; 41 interviews were conducted with community representatives. These findings informed the development of a support group pilot intervention. The pilot support groups were evaluated for increase in knowledge of attendees. Results: Focus group and community interviews indicate that African Americans may disproportionately experience inadequate support for breastfeeding. This lack of support was reported in the home, the workplace, among peers, and from health care providers. The pilot support groups resulted in increased knowledge of breastfeeding among group participants (odds ratio = 3.6; 95% confidence interval = 2.5-5.2). Conclusions: The findings from this research underscore the importance of a multilevel approach to breastfeeding support for African American women to address breastfeeding disparities.

This study assessed reported changes in clinical breastfeeding support practices following a three-day (approximately 24 hour) course. The course, presented at the Catholic University in Santiago, Chile, included the physiology of lactation and lactational infertility, related policy, clinical skills, the Lactational Amenorrhea Method (LAM), and program-related findings. A questionnaire was sent to all participants and an additional systematic sample was telephoned to assure a statistically valid sample. Sixty-nine percent of respondents reported changes in clinical practices resulting from attendance at the course. The results support the concept, now being advanced by the Baby-Friendly Hospital Initiative, that an 18-24 hour course can change clinical practices.

This year we are supporting and participating in activities in celebration of the 20th World Breastfeeding Week. This annual event is celebrated during the first week in August to commemorate the signing of the Innocenti Declaration, adopted at the World Health Organization/UNICEF Policymakers’ Meeting, ‘‘Breastfeeding in the 1990s: A Global Initiative,’’ held at the Spedale degli Innocenti, Florence, Italy, July 30–August 1, 1990. Thirty countries signed on, with the goal of reaching four operational targets by 1995: (1) appoint a national breastfeeding coordinator of appropriate authority and establish a multisectoral national breastfeeding committee composed of representatives from relevant government departments, nongovernmental organizations (NGOs), and health professional associations; (2) ensure that every facility providing maternity services fully practices all 10 of the Ten Steps to Successful Breastfeeding set out in the joint WHO/UNICEF statement ‘‘Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services’’; (3) take action to give effect to the principles and aim of all Articles of the International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly resolutions in their entirety; and (4) enact imaginative legislation protecting the breastfeeding rights of working women and established means for its enforcement. The Innocenti Declaration also called upon international NGOs to draw up action strategies for protecting, promoting, and supporting breastfeeding, support national situation analyses and development of goals, and en courage and support national authorities in planning, implementing, monitoring, and evaluating their breastfeeding policies. Mr. James Grant, then Director of UNICEF, called upon the NGO community to organize in this regard, and the World Alliance for Breastfeeding Action (WABA) was born. One of WABA’s first ground-breaking acts was to establish an annual World Breastfeeding Week: a time for action, a time for advocacy, a time for advancing support for breastfeeding. Each year, a different theme is chosen. This ongoing support, the increasing implementation of all four operational targets, the steady flow of evidence showing the vital importance of breastfeeding, and the fact that breastfeeding rates were shown to be responsive to programs of action, all contributed to a call for The Global Strategy for Infant and Young Child Feeding, which was endorsed by WBW 2012 image courtesy of WABA

Human milk provides infants with antimicrobial, anti-inflammatory, and immunomodulatory agents that contribute to optimal immune system function. The act of breastfeeding allows important bacterial and hormonal interactions between the mother and baby and impacts the mouth, tongue, swallow, and eustachian tubes. Previous meta-analyses have shown that lack of breastfeeding and less intensive patterns of breastfeeding are associated with increased risk of acute otitis media, one of the most common infections of childhood. A review of epidemiologic studies indicates that the introduction of infant formula in the first 6 months of life is associated with increased incidence of acute otitis media in early-childhood. More recent research raises the issues of how long this increased risk persists, and whether lack of breastfeeding is associated with diagnosis of otitis media with effusion. However, many studies suffer from lack of study of younger populations and imprecise definitions of infant feeding patterns. These findings suggest that measures of the association between breastfeeding history and otitis media risk are sensitive to the definition of breastfeeding used; future research is needed with more precise and consistent definitions of feeding, with attention to distinctions between direct breastfeeding and human milk feeding by bottle.

The Academy of Breastfeeding Medicine is a worldwide organization of physicians dedicated to the promotion, protection, and support of breastfeeding and human lactation. In this Physician Focus, we describe the mission and activities of the Academy. We also highlight opportunities for physicians to participate.

This article provides a review of the definition of the term algorithm and examples of the usefulness of algorithms by paraprofessionals in family planning and other health fields. The few algorithms in the literature in use in the family planning field are reviewed and their potential in family planning training service delivery and management is discussed. A guide to the development of an algorithm is followed by 2 examples: 1) how an algorithm might be developed to handle a difficult counseling situation e.g. the introduction of contraceptives during lactation and 2) the development of an algorithm for supervision of data collection. This article is not an exhaustive review of medical algorithms but rather an attempt to lay the groundwork for future use of algorithms in family planning. The introduction of flow charts and diagrams audio-visual aids and booklets in and of themselves do little to improve programs; content and testing of these tools is most important. The carefully developed and tested algorithm might allow ongoing validation of content evaluation of training and services and improved management. There has been a recent trend toward the paramedicalization of family planning services in many countries. Training programs which were orginally developed for personnel with existing medical or management training and skills may not be appropriate for training these new cadres of personnel. These new cadres may benefit from increased use of algorithms for training as service delivery guidelines and for evaluation of paramedical workers in the family planning field.

Breast-feeding is today the major form of infant nutrition in the immediate postpartum period. Despite this, recent trends in modern life-styles have raised obstacles to successful lactation. These include infant illness and maternal responsibilities outside the home, both requiring separation from the mother. While the hormonal dynamics of infant suckling are understood, little is known about the effects of artificial methods of milk expression. A variety of breast pumps exist in the current US market which vary considerably in price and effectiveness. To understand better the ability of these pumps to assist women in the maintenance of lactation, the current study was undertaken to evaluate their effects on milk yield and prolactin and oxytocin release when compared to natural infant suckling. Twenty-three women who were exclusively breast-feeding their infants were randomly assigned to serially use several pumping methods, as well as infant suckling, with blood being taken at 10-minute intervals to determine the hormonal responses. The results reveal variability in the prolactin responses to the artificial pumping methods, with the greatest responses found with an electric pulsatile pump; these responses compare favorably with those of natural infant suckling. Other methods were less successful in causing prolactin elevations. No differences were seen among the methods in the oxytocin response. The results of this study demonstrate striking differences in the ability of breast-pumping methods to produce an acute and sustained prolactin rise in breast-feeding mothers. The large discrepancies found suggest the need for further studies in to enable women and health care providers to choose the most appropriate method for milk expression.(ABSTRACT TRUNCATED AT 250 WORDS)

Background The Baby-Friendly Hospital Initiative (BFHI) seeks to support breastfeeding initiation in maternity services. This study uses country-level data to examine the relationship between BFHI programming and trends in exclusive breastfeeding (EBF) in 14 developing countries. Methods Demographic and Health Surveys and UNICEF BFHI Reports provided EBF and BFHI data. Because country programs were initiated in different years, data points were realigned to the year that the first Baby-Friendly hospital was certified in that country. Pre-and post-implementation time periods were analyzed using fixed effects models to account for grouping of data by country, and compared to assess differences in trends. Results Statistically significant upward trends in EBF under two months and under six months, as assessed by whether fitted trends had slopes significantly different from 0, were observed only during the period following BFHI implementation, and not before. BFHI implementation was associated with average annual increases of 1.54 percentage points in the rate of EBF of infants under two months (p < 0.001) and 1.11-percentage points in the rate of EBF of infants under six months (p < 0.001); however, these rates were not statistically different from pre-BFHI trends. Conclusion BFHI implementation was associated with a statistically significant annual increase in rates of EBF in the countries under study; however, small sample sizes may have contributed to the fact that results do not demonstrate a significant difference from pre-BFHI trends. Further research is needed to consider trends according to the percentages of Baby-Friendly facilities, percent of all births occurring in these facilities, and continued compliance with the program.

Background Workplace accommodations for breastfeeding mothers are an important step towards achieving United States Healthy People 2010 goals for continued breastfeeding. However, evidence suggests that some employers wishing to accommodate lactating mothers fear negative reactions from other workers. Methods This study conducted in February 2007, used descriptive statistics and linear regression to assess attitudes towards workplace breastfeeding/milk expression among employees (n = 407) of a large U.S. corporation providing a wide variety of workplace accommodations for lactating mothers. Results Overall, attitudes about the impact of breastfeeding on the work environment were favorable. Previous exposure to a co-worker who breastfed or expressed milk during the work day was associated with a positive attitude towards workplace breastfeeding, even after controlling for respondents' gender, length of employment and personal breastfeeding history. Conclusion These preliminary findings suggest that lactation accommodations did not have negative repercussions for other employees, and that a corporate environment designed to enable and encourage continued breastfeeding does not endanger positive attitudes towards breastfeeding in other employees.

The annual Breastfeeding and Feminism Symposia aim to reposition breastfeeding as a valued part of women's (re)productive lives and rights. The symposia are designed to raise the profile of breastfeeding within the women's advocacy and feminist studies' communities, and to increase recognition among breastfeeding supporters that breastfeeding promotion could receive more socio-political support by partnering with those concerned with women's reproductive health, rights and justice, women's economic advancement, and the elimination of social, economic and health inequities. The third symposium (2007) sought to build dialogue and increase communications between and among these diverse communities. The nine articles presented in this thematic series were selected by the journal editors, and represent the core discussions at the symposium. This editorial presents the areas of synergy and strategies for action that emerged from the discussions. These strategies and this thematic issue are intended to reassert the momentum that evolved among participants, and to stimulate involvement among individuals and organizations not in attendance in promoting breastfeeding as a women's reproductive health, rights and justice concern.

Background The purpose of this exploratory study was to examine Cambodian refugee mothers' infant feeding beliefs, practices, and decision making regarding infant feeding in the U.S. and to explore if a culturally-specific breastfeeding program is appropriate for this community. Methods A self-administered questionnaire and a 30 minute in-person interview were used to collect information from nine women. The audio-taped interviews were transcribed, answers compiled, and themes from each question identified. Results All participants practiced either traditional Cambodian diet (pregnancy and postpartum diet including, tnam sraa, herbs mixed with either wine or tea), traditional Cambodian rituals (like spung, amodified sauna) or both, despite having lived in the U.S. for many years. All nine women initiated breastfeeding, however eight women introduced infant formula while in hospital. Perceived low milk supply and returning to work were the main reasons cited for partial breastfeeding and early cessation of breastfeeding. Conclusion While causes of initiation of other foods are similar to those found in the U.S. as a whole, a culturally-specific Cambodian breastfeeding support program may help overcome some breastfeeding problems reported by Cambodian refugee mothers who have immigrated to the United States.

More than 60% of newborn infants in the US are now breast-fed a far higher percentage than the 22% of newborns breast-fed in the country in 1971. The authors conducted a study to identify the social and biomedical variables which influence the selection of infant feeding methods in the US and to provide guidelines for the choice of control variables in designing and interpreting studies which examine the influence of breast-feeding upon infant and child health. Data were drawn from the Child Health Supplement of the 1981 Health Interview Survey conducted by the National Center for Health Statistics. The survey is based upon nationally representative samples of the US population living in households. Relationships between demographic socioeconomic and health variables were studied for the sample of 2951 children under age 5 years as well as for Black and White women separately. The survey data offer evidence of the importance of social and health variables as selection factors for breast-feeding in the US. Ethnicity socioeconomic status and health of the mother and child as determined by indications of a difficult pregnancy and delivery and length of hospital stay were all associated with the initiation and duration of breast-feeding. Substantial interactions were also noted between ethnicity and health determinants of breast-feeding.

This article presents trends and differentials in exclusive breastfeeding patterns that occurred in developing settings during the 1990s and considers these trends in relation to the breastfeeding-support activities in that decade. Between 1990 and 2000, the data suggest that exclusive breast-feeding levels in the developing world increased 15% overall among infants younger than 4 months (from 46% to 53%) and among infants older than 6 months (from 34% to 39%). The increase in urban areas is of special note. Urban areas are presumed to be most susceptible to the ambient health system and social and commercial pressures against breastfeeding; the support activities of the 1990s (eg, the Baby-friendly Hospital Initiative and the International Code of Marketing of Breastmilk Substitutes) were developed to address these pressures. Given this, implementation of the Global Strategy for Infant and Young Child Feeding, which supports these proven interventions, should be effective in further increasing optimal breast-feeding practices.

Objectives. We investigated how, under various conditions, the risk of mother-to-child transmission of HIV through breastfeeding compares with the risk of death from artificial feeding. Methods. We developed a spreadsheet simulation model to predict HIV-free survival during 7 age intervals from 0 to 24 months for 5 different infant feeding scenarios in resource-poor settings. Results. Compared with artificial feeding, breastfeeding during the first 6 months by HIV-positive mothers increases HIV-free survival by 32 per 1000 live births. After 6 months, as the age-specific mortality rate and risk of death caused by replacement feeding both decline, replacement feeding appears to be safer. Conclusions. Under conditions common in countries with high HIV prevalence, replacement feeding by HIV-infected mothers should not be generally encouraged until after the infant is approximately 6 months old.

Much has been learned in the past 30 years concerning the physiological relationship of lactation and lactational infertility. Studies of maternal seemed to indicate that maternal nutritional status, parity and age were key.1 More recent work has indicated that characteristics of the infant feeding that may explain more of the difference.2,3,4 A recent study of the Lactational Amenorrhea Method (LAM) allowed study of the return of menses in two similar populations in urban Santiago Chile. Data from this prospective research were re-analyzed to assess patterns of breastfeeding and menses return.

The Lactational Amenorrhea Method for family planning, based on the physiology of lactational infertility, has undergone extensive clinical study. Concern remains, among clinicians and demographers alike, that this is a behavior-based method and is therefore unreliable. This study was undertaken to observe method use under conditions that would more approximate use outside of a research setting.