Impact of Baby‐Friendly Hospital Practices on Breastfeeding in Hong Kong

Abstract: Background: The World Health Organization (WHO) developed the Baby‐Friendly Hospital Initiative to improve hospital maternity care practices that support breastfeeding. In Hong Kong, although no hospitals have yet received the Baby‐Friendly status, efforts have been made to improve breastfeeding support. The aim of this study was to examine the impact of Baby‐Friendly hospital practices on breastfeeding duration. Methods: A sample of 1,242 breastfeeding mother‐infant pairs was recruited from four public hospitals in Hong Kong and followed up prospectively for up to 12 months. The primary outcome variable was defined as breastfeeding for 8 weeks or less. Predictor variables included six Baby‐Friendly practices: breastfeeding initiation within 1 hour of birth, exclusive breastfeeding while in hospital, rooming‐in, breastfeeding on demand, no pacifiers or artificial nipples, and information on breastfeeding support groups provided on discharge. Results: Only 46.6 percent of women breastfed for more than 8 weeks, and only 4.8 percent of mothers experienced all six Baby‐Friendly practices. After controlling for all other Baby‐Friendly practices and possible confounding variables, exclusive breastfeeding while in hospital was protective against early breastfeeding cessation (OR: 0.61; 95% CI: 0.42–0.88). Compared with mothers who experienced all six Baby‐Friendly practices, those who experienced one or fewer Baby‐Friendly practices were almost three times more likely to discontinue breastfeeding (OR: 3.13; 95% CI: 1.41–6.95). Conclusions: Greater exposure to Baby‐Friendly practices would substantially increase new mothers’ chances of breastfeeding beyond 8 weeks postpartum. To further improve maternity care practices in hospitals, institutional and administrative support are required to ensure all mothers receive adequate breastfeeding support in accordance with WHO guidelines. (BIRTH 38:3 September 2011)     

Effect of Operative Delivery in the Second Stage of Labor on Breastfeeding Success

Abstract: Background: Operative delivery rates are currently rising in many countries, but the effects of this factor on the initiation and duration of breastfeeding are unclear. The purpose of this study was to evaluate breastfeeding success after instrumental vaginal delivery or cesarean section at full dilatation, and to investigate whether timing of discharge after operative delivery affects breastfeeding rates. Methods: A prospective cohort study was conducted of 393 women with term, singleton, live, cephalic pregnancies who required delivery in theater during the second stage of labor between February 1999 and February 2000. Postal questionnaires were mailed to participants at 6 weeks and 1 year. Logistic regression models were used to explore the relationships between infant feeding and mode of delivery, controlling for factors previously correlated with breastfeeding success. Results: Rates of exclusive breastfeeding at discharge and 6 weeks postpartum were 70 and 44 percent, respectively. No significant differences occurred when instrumental vaginal delivery was compared with cesarean section, adjusted OR 0.84 (95% CI 0.50, 1.41) and 1.15 (95% CI 0.69, 1.93) respectively. Breastfeeding rates after failed instrumental delivery were similar to those after immediate cesarean section, adjusted OR 0.99 (95% CI 0.72, 1.38) and 1.28 (95% CI 0.91, 1.78). Women who had a longer in‐patient stay after cesarean section were more likely to achieve exclusive breastfeeding at hospital discharge (78% vs 66%, p = 0.03). Conclusions: Method of operative delivery in the second stage of labor does not appear to influence initiation or duration of exclusive breastfeeding. A longer inpatient stay may help cesarean‐delivered women to initiate breastfeeding. (BIRTH 30:4 December 2003)     

Planned Place of Birth in New Zealand: Does it Affect Mode of Birth and Intervention Rates Among Low‐Risk Women?

Abstract: Background: Midwives providing care as lead maternity caregivers in New Zealand provide continuity of care to women who may give birth in a variety of settings, including home, primary units, and secondary and tertiary level hospitals. The purpose of this study was to compare mode of birth and intrapartum intervention rates for low‐risk women planning to give birth in these settings under the care of midwives. Methods: Data for a cohort of low‐risk women giving birth in 2006 and 2007 were extracted from the Midwifery Maternity Provider Organisation database. Mode of birth, intrapartum interventions, and neonatal outcomes were compared with results adjusted for age, parity, ethnicity, and smoking. Results: Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66–5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05–1.87; RR: 1.78, 95% CI: 1.31–2.42) than women planning to give birth in a primary unit. Conclusions: Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth. (BIRTH 38:2 June 2011)     

Factors Associated with Low Incidence of Exclusive Breastfeeding for the First 6 Months

ABSTRACT: Background: The identification of factors that are associated with early cessation of exclusive breastfeeding is important for defining strategies for the promotion of exclusive breastfeeding. The objective of this study was to identify the determinants of exclusive breastfeeding cessation before 6 months, including variables that generally receive little attention, such as the influence of grandmothers, breastfeeding technique, and sore nipples. Methods: This prospective study follows a cohort of 220 healthy mother‐baby pairs from birth to 6 months, living in Porto Alegre, Brazil. Data were collected at the maternity unit, during a home visit at 30 days, and by telephone interview at 60, 120, and 180 days. Breastfeeding technique was assessed and breasts examined at the maternity unit and during home visits. Cox regression was employed to estimate the degree of association between the variables and the outcome. Results: The following factors were associated with cessation of exclusive breastfeeding before 6 months: adolescent mother (hazard ratio [HR] = 1.48, 95% CI 1.01–2.17), fewer than six prenatal visits (HR = 1.60, 95% CI 1.10–2.33), use of a pacifier within the first month (HR = 1.53, 95% CI 1.12–2.11), and poor latch‐on (HR = 1.29, 95% CI 1.06–1.58 for each unfavorable parameter). Conclusions: Activities to promote exclusive breastfeeding should be intensified for adolescent mothers and for those whose prenatal care was less than ideal. These activities should reinforce the ill effects of pacifiers and should also include appropriate instruction for these mothers in correct breastfeeding technique. (BIRTH 34:3 September 2007)     

Impact of First Childbirth on Changes in Women’s Preference for Mode of Delivery: Follow‐up of a Longitudinal Observational Study

ABSTRACT: Background: A woman’s childbirth experience has an influence on her future preferred mode of delivery. This study aimed to identify determinants for women who changed from preferring a planned vaginal birth to an elective cesarean section after their first childbirth. Methods: This prospective longitudinal observational study involved two units that provide obstetric care in Hong Kong. A mail survey was sent to 259 women 6 months after their first childbirth. These women had participated in a longitudinal cohort study that examined their preference for elective cesarean section in the antenatal period of their first pregnancies. Univariate and multivariate analyses were performed to identify determinants for women who changed from preferring vaginal birth to elective cesarean section. Results: Twenty‐four percent (23.8%, 95% CI 18.4–29.3) of women changed from preferring vaginal birth to elective cesarean section after their first childbirth. Determinants found to be positively associated with this change included actual delivery by elective cesarean section (OR 106.3, 95% CI 14.7–767.4) intrauterine growth restriction (OR 19.5, 95% CI 1.1–353.6), actual delivery by emergency cesarean section (OR 8.4, 95% CI 3.4–20.6), higher family income (OR 3.2, 95% CI 1.1–8.8), use of epidural analgesia (OR 2.6, 95% CI 1.0–6.8), and higher trait anxiety score (OR 1.1, 95% CI 1.0–1.3). The most important reason for women who changed from preferring vaginal birth to elective cesarean section was fear of vaginal birth (24.4%). Conclusions: A significant proportion of women changed their preferred mode of delivery after their first childbirth. Apart from reducing the number of cesarean sections in nulliparous women, prompt provision of education to women who had complications and investigations into fear factors during vaginal birth might help in reducing women’s wish to change to elective cesarean section. (BIRTH 35:2 June 2008)     

Cesarean and Vaginal Birth in Canadian Women: A Comparison of Experiences

Abstract: Background: Many publications have examined the reasons behind the rising cesarean delivery rate around the world. Women’s responses to the Maternity Experiences Survey of the Canadian Perinatal Surveillance System were examined to explore correlates of having a cesarean section on other experiences surrounding labor, birth, mother‐infant contact, and breastfeeding. Methods: A randomly selected sample of 8,244 estimated eligible women stratified primarily by province and territory was drawn from the May 2006 Canadian Census. Completed responses were obtained from 6,421 women (78%). Results: Three‐quarters of the women (73.7%) gave birth vaginally and 26.3 percent by cesarean section, including 13.5 percent with a planned cesarean and 12.8 percent with an unplanned cesarean. In addition to more interventions in labor, women who had a cesarean birth after attempting a vaginal birth had less mother‐infant contact after birth and less optimal breastfeeding practices. Conclusion: Findings from the Maternity Experiences Survey indicated that women who have cesarean births experience more interventions during labor and birth and have less optimal birthing and early parenting outcomes. (BIRTH 37:1 March 2010)     

Breastfeeding Patterns of Primiparous Mothers in Hong Kong

Abstract: Background: An understanding of patterns of breastfeeding is necessary for the effective implementation of breastfeeding promotion and intervention programs. In Hong Kong, little current data have been gathered on women's breastfeeding rates. The objective of this study was to determine how patterns of breastfeeding, maternal demographics, and maternal employment affect continuation of breastfeeding in primiparous women in Hong Kong. Method: A longitudinal self‐report survey was used to collect data when first‐time mothers (n = 218) were in the hospital, at 1, 3, 6, 9, and 12 months postpartum, or until they weaned their infant. All data (self‐report survey, demographic data, and follow‐up telephone surveys) were collected in Cantonese and then translated into English. Data were analyzed by determining, first, the influence of individual variables on the length of breastfeeding using a simple Cox regression analysis, and second, by grouping variables according to time sequence and entering them into a Cox regression model in 4 sequential phases. Results: Factors that were significantly associated with continuation of breastfeeding were maternal age (HR = 0.97; p = 0.048); attendance at a prenatal breastfeeding class (HR = 0.69; p = 0.020); intended weeks of breastfeeding (HR = 0.97; p < 0.001); breastfeeding score in hospital (HR = 0.99; p = 0.009); and length of exclusive breastfeeding (HR = 0.93; p < 0.001). Similar results were obtained in the multiphase Cox regression analysis; only the breastfeeding score in hospital became marginally insignificant (p = 0.053) after adjusting for demographics, prenatal, and other immediate postpartum factors. Conclusions: Short periods of exclusive breastfeeding and early supplementation were common in this sample. Unlike previous research, maternal employment was not a statistically significant factor in length of continued breastfeeding. Study findings show that multiple factors influence continued breastfeeding in Hong Kong, suggesting further areas for investigation. Changes in practice may improve continued and exclusive breastfeeding rates. (BIRTH 30:3 September 2003)     

Outcomes Associated with Planned Home and Planned Hospital Births in Low‐Risk Women Attended by Midwives in Ontario,Canada, 2003–2006: A Retrospective Cohort Study

Background: Midwives in Ontario, Canada, provide care in the home and hospital and are required to submit data for all births to the Ontario Ministry of Health database. The purpose of this study was to compare maternal and perinatal/neonatal mortality and morbidity and intrapartum intervention rates for women attended by Ontario midwives who planned a home birth compared with similar low‐risk women who planned a hospital birth between 2003 and 2006. Methods: The database provided outcomes for all women planning a home birth at the onset of labor (n = 6,692) and for a cohort, stratified by parity, of similar low‐risk women planning a hospital birth. Results: The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk [RR], 95% confidence intervals [CI]: 0.84 [0.68–1.03]). No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%; RR [95% CI]: 0.64 [0.56, 0.73]). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births. Conclusions: Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.     

Family members’ infant feeding preferences,maternal breastfeeding exposures and exclusive breastfeeding intentions

BackgroundMaternal breastfeeding intentions are strongly associated with breastfeeding exclusivity and duration. Factors that affect new mothers’ exclusive breastfeeding intentions have not been adequately examined.ObjectiveThe purpose of this study was to examine the association between family member's infant feeding preferences, breastfeeding exposures, and womens’ exclusive breastfeeding intentions.Methods1277 breastfeeding mother-infant pairs were recruited from four public hospitals in Hong Kong. We used multiple logistic and linear regression models to explore the impact of the family members’ infant feeding preferences and breastfeeding exposures on exclusive breastfeeding intentions.Results78.1% mothers reported an intention to exclusively breastfeed, and the median intended duration of exclusive breastfeeding was 26 weeks. The husband's preference for breastfeeding (aOR = 1.67; 95% CI 1.20–2.31), previous breastfeeding experience (aOR = 1.56; 95% CI 1.10–2.23) and attendance at an antenatal breastfeeding class (aOR = 2.09; 95% CI 1.45–3.02) were all strongly associated with higher maternal intention to exclusively breastfeed. For every additional family member who preferred breastfeeding, the odds of intending to exclusively breastfeed increased by 32% (aOR1.32; 95% CI, 1.13–1.55). Similarly, the proportion of participants intending to exclusively breastfeed increased progressively with more breastfeeding exposures.ConclusionsIncluding fathers and other significant family members in antenatal breastfeeding education can help to maximize breastfeeding support for the new mother and encourage new mothers to exclusively breastfeed.     

Evaluation of a Student‐Nurse Doula Program: An Analysis of Doula Interventions and Their Impact on Labor Analgesia and Cesarean Birth

Introduction: The aim of this study was to describe specific doula interventions, explore differences in doula interventions by attending provider (certified nurse‐midwife vs obstetrician), and examine associations between doula interventions, labor analgesia, and cesarean birth in women receiving doula care from student nurses. Methods: A secondary analysis of data from the Birth Companions Program at the Johns Hopkins University School of Nursing was conducted using t tests, chi‐square statistics, and logistic regression models. Results: In the 648 births in the sample, doulas used approximately 1 more intervention per labor with certified nurse‐midwife clients compared to obstetrician clients. In multivariate analysis, the increase in the total number of interventions provided by doulas was associated with decreased odds of epidural (adjusted odds ratio [AOR] 0.92; 95% confidence interval [CI], 0.86‐0.98) and cesarean birth (AOR 0.90; 95% CI, 0.85‐0.95). When examined separately, a greater number of physical interventions was associated with decreased odds of epidural (AOR 0.85; 95% CI, 0.78‐0.92) and cesarean birth (AOR 0.80; 95% CI, 0.73‐0.88), but number of emotional/informational interventions was not. Discussion: Student nurses trained as doulas have the opportunity to provide a variety of interventions for laboring clients. An increase in the number of interventions, especially physical interventions, provided by doulas may decrease the likelihood of epidural use and cesarean birth.     

In‐Hospital Formula Supplementation of Breastfed Babies: A Population‐Based Survey

Abstract: Background: In‐hospital formula supplementation of breastfed newborns is commonplace despite its negative association with breastfeeding duration. Although several studies have described the use of formula supplementation, few have explored the factors that may be associated with its use. The aim of this study was to explore factors associated with in‐hospital formula supplementation using data from a large Australian population‐based survey. Methods: All women who gave birth in September and October 2007 in two Australian states were mailed questionnaires 6 months after the birth. Women were asked how they fed their baby while in hospital after the birth. Multivariable logistic regression was used to explore specified a priori factors associated with in‐hospital formula supplementation. Results: Of 4,085 women who initiated breastfeeding, 23 percent reported their babies receiving formula supplementation. Breastfed babies had greater odds of receiving formula supplementation if their mother was primiparous (adj. OR = 2.16; 95% CI: 1.76–2.66); born overseas and of non‐English‐speaking background (adj. OR = 2.03; 95% CI: 1.56–2.64); had a body mass index more than 30 (adj. OR = 2.27; 95% CI: 1.76–2.95); had an emergency cesarean section (adj. OR = 1.72; 95% CI: 1.3–2.28); or the baby was admitted to a special care nursery (adj. OR = 2.72; 95% CI: 2.19–3.4); had a birthweight less than 2,500 g (adj. OR = 2.02; 95% CI: 1.3–3.15) or was born in a hospital not accredited with Baby‐Friendly Hospital Initiative (BFHI) (adj. OR = 1.53; 95% CI: 1.2–1.94). Conclusions: The number of factors associated with in‐hospital formula supplementation suggests that this practice is complex. Some results, however, point to an opportunity for intervention, with the BFHI appearing to be an effective strategy for supporting exclusive breastfeeding. (BIRTH 38:4 December 2011)     

Continuity of Nursing Care and Its Link to Cesarean Birth Rate

ABSTRACT: Background: High cesarean birth rates are an international concern. The role of patterns of nursing care responsibility in preventing or contributing to cesarean births has been understudied. Our study sought to identify and describe indicators of continuity of nursing care responsibility during labor and to explore whether any association between these indicators and risk of cesarean birth could be identified empirically using an existing data set. Methods: We obtained a representative sample of low‐risk women giving birth in an intrapartum unit at a university hospital in Quebec, Canada, with approximately 3,700 births per year. To be considered for inclusion, women needed to have been primiparous, carrying singletons in vertex position, and at 37 weeks’ gestation or more. All women giving birth over a 13‐month period were assessed for eligibility using the hospital’s birth log. Data were extracted from the medical records of every second eligible birth, including information related to patterns of nursing care responsibility, maternal and infant characteristics, obstetric procedures, non–health‐related risk factors, and type of birth. Results: Data on all variables of interest were available for 467 women. These women were cared for by 1–17 nurses, care responsibility changed hands for them from 1 to 28 times, and the mean length of labor for which the same nurse was responsible for a woman ranged from 10 to 1,045 minutes. After controlling for length of labor, maternal age, maternal height, infant weight, gestational age, induction, type of rupture, and epidural analgesia, the odds ratio for cesarean birth due to number of nurses was 1.17 (95% CI 1.04, 1.32); 1 or more nurses switch per 2 hours (i.e., number of times care responsibilities changed hands), 1.04 (95% CI 0.62, 1.74); and 33 percent or more of the labor attended by the same nurse, 0.74 (95% CI 0.42, 1.30). Conclusions: An association was observed between number of nurses caring for a laboring woman and risk of cesarean delivery. Estimates of the association of other patterns of nursing care responsibility on cesarean birth were not sufficiently precise to draw conclusions. (BIRTH 34:1 March 2007)     

Maternal Temperature Elevation and Occiput Posterior Position at Birth Among Low‐Risk Women Receiving Epidural Analgesia

Introduction: To evaluate the relationship between maternal temperature elevation and occiput posterior position at birth as well as the association of fetal head position and temperature elevation on method of birth among women receiving epidural analgesia. Methods: We conducted a secondary analysis of data from the Fetal Orientation during Childbirth by Ultrasound Study (FOCUS), which used serial ultrasounds to evaluate the effect of epidural anesthesia on fetal position at birth in low‐risk women. The current analysis was limited to the 1428 study participants who received epidural analgesia. Results: In our population, 47% (n = 669) of women had a maximum intrapartum temperature greater than or equal to 99.6°F (37.6°C). The prevalence of fetal occiput posterior position at admission did not differ between women who later developed temperature elevations (24.4%) and those who did not (23.6%, P= .70). Women who developed an elevated temperature greater than or equal to 99.6°F (37.6°C) had an increased risk of occiput posterior fetal head position at birth regardless of the amount of temperature elevation (odds ratio [OR]= 2.0; 95% confidence interval [CI], 1.5‐2.8); the association persisted after control for potentially confounding factors (adjusted OR = 1.5; 95% CI, 1.1‐2.1). The cesarean birth rate among women with both temperature elevation and occiput posterior position at birth was more than 12 times the rate of women with neither risk factor (adjusted OR = 12.6; 95% CI, 7.5‐21.2). Discussion: Intrapartum temperature elevation among women receiving epidural analgesia, even if only to 99.6°F (37.6°C), is associated with approximately a 2‐fold increase in the occurrence of occiput posterior fetal head position at birth. Additionally, although this observational study cannot establish causal links, our findings suggest that the relationship between epidural‐related intrapartum temperature elevation and occiput posterior position at birth could contribute to an increased cesarean birth rate among women receiving epidural analgesia for pain relief in labor.     

Prevalence and Factors Affecting Breastfeeding Among Aboriginal Women in Northwestern Ontario

ObjectiveTo evaluate breastfeeding outcomes among Aboriginal women and to determine variables affecting breastfeeding in the early postpartum period.DesignProspective cohort study.SettingTwo sites in Northwestern Ontario, Canada: a tertiary care center and a rural hospital.ParticipantsOne hundred thirty breastfeeding Aboriginal women agreed to participate in the study.MethodsAll women completed a baseline survey in hospital that included questions regarding demographic, prenatal, breastfeeding, obstetric, postpartum, and neonatal characteristics. Women were then telephoned at 4 and 8 weeks postpartum to complete additional questionnaires regarding infant feeding.ResultsLow rates of breastfeeding initiation (69%) and exclusive breastfeeding were identified at 4 (37.5%) and 8 (35.3%) weeks postpartum. Among those who initiated breastfeeding, duration rates at 4 (86%) and 8 weeks (78%) postpartum are comparable to other studies. Variables associated with any and exclusive breastfeeding at 8 weeks included the following: (a) household income, (b) intended breastfeeding duration, (c) plan to exclusively breastfeed, (d) perception of meeting their planned duration goal, and (e) higher breastfeeding self‐efficacy. Partner support was associated with any breastfeeding at 8 weeks but not exclusivity. Women who were breastfeeding exclusively in hospital (prevalence ratio [PR] = .48, 95% confidence interval [CI] [0.27, 0.86]), did not smoke (PR = 2.5, 95% CI [1.4, 4.3]) and/or use substances during pregnancy (PR = 4.5, 95% CI [1.5, 14]) were more likely to be breastfeeding exclusively at 8 weeks.ConclusionMany of the variables may be considered modifiable and amenable to intervention. Targeted interventions should be directed toward improving breastfeeding outcomes among Aboriginal women.     

Duration of breastfeeding in Swedish primiparous and multiparous women.

The aim of this study was to describe the effects of sociodemographic factors and maternity ward practices on the duration of breastfeeding in Swedish primiparas (n = 194) and multiparas (n = 294), consecutively selected from hospital birth files for 3 months, who responded to a questionnaire 9 to 12 months after childbirth. The impact of sociodemographic data and maternity ward practices on exclusive and any breastfeeding were examined. Smoking and supplementation without medical reasons influenced the duration of both exclusive and any breastfeeding negatively, whereas early first breastfeeding influenced the duration of both exclusive and any breastfeeding positively, and parity had no significant influence. Late hospital discharge influenced the duration of exclusive breastfeeding positively, and higher maternal age influenced the duration of any breastfeeding positively. These variables altogether explained 11.4% (P < .001) of the variance in the duration of exclusive breastfeeding and 8.2% (P < .001) of the duration of any breastfeeding.     

Breastfeeding Rates in Hong Kong: A Comparison of the 1987 and 1997 Birth Cohorts

ABSTRACT: Background: Low breastfeeding rates are an issue of international public health concern. Anecdotal reports suggest very low breastfeeding rates in Asia, but no population‐based studies have been conducted in the region. To determine the secular trend in breastfeeding practice in an Asian postindustrialized metropolitan community, we examined data from two population‐based birth cohorts of Hong Kong infants in 1987 and 1997. Methods: Annual population rates of breastfeeding initiation and duration were estimated from the birth cohorts, considering the change in breastfeeding rates over 10 years with correction for sociodemographic and birth characteristics. Factors associated with breastfeeding practice were identified using multivariate logistic regression modeling in a pooled analysis of individual data of both cohorts. Results: Overall, 26.8 percent of mothers initiated breastfeeding in 1987, and the rate increased to 33.5 percent in 1997. The rate would have been 27.4 percent in 1987 if the distributions of method of delivery, birthweight, birth order, maternal age, education, and employment status had been the same as in 1997. Only 7.6 percent of infants remained on the breast for more than 1 month in 1987 compared with 20.4 percent a decade later. Similarly, the rate for breastfeeding more than 3 months increased from 3.9 to 10.3 percent. Total breastfeeding duration was significantly longer in 1997 than 10 years earlier. Conclusions: This is the first systematic report of secular variations of breastfeeding rates in Asia. Hong Kong should set higher but realistic goals for breastfeeding that emphasize both initiation and maintenance. Given the wide latitude for improvement in terms of readily modifiable risk factors, such as smoking and cesarean section, these new goals should focus on improving rates in these targeted groups where breastfeeding rates are lowest. (BIRTH 29:3 September 2002)     

In‐Hospital Birth Center with the Same Medical Guidelines as Standard Care: A Comparative Study of Obstetric Interventions and Outcomes

Background: A challenge of obstetric care is to optimize maternal and infant health outcomes and the mother’s experience of childbirth with the least possible intervention in the normal process. The aim of this study was to investigate the effects of modified birth center care on obstetric procedures during delivery and on maternal and neonatal outcomes. Methods: In a cohort study 2,555 women who signed in for birth center care during pregnancy were compared with all 9,382 low‐risk women who gave birth in the standard delivery ward in the same hospital from March 2004 to July 2008. Odds ratios (OR) were calculated with 95% confidence interval (CI) and adjusted for maternal background characteristics, elective cesarean section, and gestational age. Results: The modified birth center group included fewer emergency cesarean sections (primiparas: OR: 0.69, 95% CI: 0.58–0.83; multiparas: OR: 0.34, 95% CI: 0.23–0.51), and in multiparas the vacuum extraction rate was reduced (OR: 0.42, 95% CI: 0.26–0.67). In addition, epidural analgesia was used less frequently (primiparas: OR: 0.47, 95% CI: 0.41–0.53; multiparas: OR: 0.25, 95% CI: 0.20–0.32). Fetal distress was less frequently diagnosed in the modified birth center group (primiparas: OR: 0.72, 95% CI: 0.59–0.87; multiparas: OR: 0.45, 95% CI: 0.29–0.69), but no statistically significant differences were found in neonatal hypoxia, low Apgar score less than 7 at 5 minutes, or proportion of perinatal deaths (OR: 0.40, 95% CI: 0.14–1.13). Anal sphincter tears were reduced (primiparas: OR: 0.73, 95% CI: 0.55–0.98; multiparas: OR: 0.41, 95% CI: 0.20–0.83). Conclusion: Midwife‐led comprehensive care with the same medical guidelines as in standard care reduced medical interventions without jeopardizing maternal and infant health. (BIRTH 38:2 June 2011)     

Cervical ripening with transcervical foley catheter and the risk of uterine rupture

OBJECTIVE: To estimate whether the rate of uterine rupture in patients with a previous cesarean delivery is related to labor induction and/or cervical ripening using transcervical Foley catheter. METHODS: Charts of all patients who had a trial of labor after a previous cesarean delivery in our institution between 1988 and 2002 were reviewed. The rates of successful vaginal birth after cesarean delivery and uterine rupture in patients with spontaneous labor (control group) were compared with those of patients who underwent a labor induction by means of amniotomy with or without oxytocin and patients who underwent a labor induction/cervical ripening using a transcervical Foley catheter. Logistic regression analysis was performed to adjust for confounding variables. RESULTS: Of 2479 patients, 1807 had a spontaneous labor, 417 had labor induced by amniotomy with or without oxytocin, and 255 had labor induced by using transcervical Foley catheter. The rate of successful vaginal birth after cesarean delivery was significantly different among the groups (78.0% versus 77.9% versus 55.7%, P <.001), but not the rate of uterine rupture (1.1% versus 1.2% versus 1.6%, P =.81). After adjusting for confounding variables, the odds ratio (OR) for successful vaginal birth after cesarean delivery was 0.68 (95% confidence interval [CI] 0.41, 1.15), and the OR for uterine rupture was 0.47 (95% CI 0.06, 3.59) in patients who underwent an induction of labor using a transcervical Foley catheter when compared with patients with spontaneous labor. CONCLUSION: Labor induction using a transcervical Foley catheter was not associated with an increased risk of uterine rupture.