Shared decision‐making for infant feeding and care during the coronavirus disease 2019 pandemic

Despite decades of research establishing the importance of breastfeeding, skin‐to‐skin contact and mother–infant closeness, the response to the coronavirus disease 2019 (COVID‐19) pandemic has underscored the hidden assumption that these practices can be dispensed with no consequences to mother or child. This article aims to support shared decision‐making process for infant feeding and care with parents and health care providers during the unprecedented times of the pandemic. It proposes a structure and rationale to guide the process that includes (1) discussing with parents evidence‐based information and the different options to feed and care for an infant and young child in the context of the pandemic as well as their potential benefits, risks and scientific uncertainties; (2) helping parents to recognize the sensitive nature of the decisions and to clarify the value they place on the different options to feed and care for their infant or young child; and (3) providing guidance and support needed to make and implement their decisions. A shared decision‐making process will help parents navigate complex feeding and care decisions for their child as we face the different stages of the COVID‐19 pandemic.     

Growth patterns and their contributing factors among HIV‐exposed uninfected infants

With expanded HIV treatment and prevention programmes, most infants born to HIV‐positive women are uninfected, but the patterns and determinants of their growth are not well described. This study aimed to assess growth patterns in a cohort of HIV‐exposed uninfected (HEU) infants who participated in an experimental HIV vaccine trial and to test for associations with maternal and infant factors, including in‐utero exposure to antiretroviral therapy (ART), mode of delivery, exclusive breastfeeding, mother''s education and receipt of the vaccine. Infants in the trial were seen at regular clinic visits from birth to 48 weeks of age. From the anthropometric measurements at these visits, weight‐for‐age z‐scores (WAZ), weight‐for‐length z‐scores (WLZ) and length‐for‐age z‐scores (LAZ) were computed using World Health Organization (WHO) software and reference tables. Growth patterns were investigated with respect to maternal and infant factors, using linear mixed regression models. From 94 infants included at birth, growth data were available for 75.5% at 48 weeks. The determinants of infant growth in this population are multifactorial: infant LAZ during the first year was significantly lower among infants delivered by caesarean section (p = 0.043); both WAZ and LAZ were depressed among infants with longer exposure to maternal ART (WAZ: p = 0.015; LAZ: p < 0.0001) and among infants of mothers with lower educational level (WAZ: p = 0.038; LAZ: p < 0.0001); the effect of maternal education was modified by breastfeeding practice, with no differences seen in exclusively breastfed infants. These findings inform intervention strategies to preserve growth in this vulnerable infant population.     

What are the determinants of low exclusive breastfeeding prevalence in China? A cross‐sectional study

Exclusive breastfeeding (EBF) status is far from the national target in China. To identify the modifiable factors associated with EBF of infants aged under 6 months in China. A cross‐sectional study was conducted in 12 provinces/municipalities across China in 2017–2018. We used multistage stratified cluster sampling and collected data through face‐to‐face interviews with mothers using an electronic questionnaire. Totally, 5287 pairs of mother–infant aged <6 months were investigated. The EBF prevalence was 29.2% (1544/5287). Mothers with correct knowledge of colostrum (adjusted odds ratio [AOR]:1.32, 95% confidence interval [CI]: 1.07, 1.62), EBF (AOR: 1.39, 95% CI: 1.06, 1.81) and the highest scores of perceptions for breastfeeding benefits (AOR: 1.36, 95% CI: 1.14, 1.61) were more likely to exclusively breastfeed. However, mothers with more frequent unwillingness of breastfeeding during the first month postpartum were less likely to practice EBF (AOR: 0.68, 95% CI: 0.52, 0.90). Infants having their first breast milk within 24 h of birth increased the odds of EBF (AOR: 2.41, 95% CI: 1.86, 3.13). Infants were less likely to be exclusively breastfed in the families in which the main caregiver was the grandmothers. Mothers without receiving infant formula feeding suggestions via the health facilities, media, or the Internet (AOR: 1.57, 95% CI: 1.33, 1.85) or without the experience of infant formula feeding in public (AOR: 1.45, 95% CI: 1.23, 1.72) might more likely to practice EBF. To acquire comprehensively correct knowledge and keep a positive attitude of breastfeeding for the mothers are crucial for improving the EBF prevalence. Family supports are potential interventions worth focusing on. Infant formula promotion remains a great barrier for EBF in China.     

UNICEF UK Baby Friendly Initiative: Providing,receiving and leading infant feeding care in a hospital maternity setting—A critical ethnography

Although breastfeeding is known to improve health, economic and environmental outcomes, breastfeeding initiation and continuation rates are low in the United Kingdom. The global WHO/UNICEF Baby Friendly Hospital Initiative (BFHI) aims to reverse declining rates of breastfeeding by shifting the culture of infant feeding care provision throughout hospital maternity settings. In the United Kingdom, the global BFHI has been adapted by UNICEF UK reflecting a paradigm shift towards the experiences of women and families using maternity services. This research used a critical ethnographic approach to explore the influence of the national UNICEF UK Baby Friendly Initiative (BFI) standards on the culture of one typical maternity service in England, over a period of 8 weeks, across four phases of data collection between 2011 and 2017. Twenty‐one staff and 26 service users were recruited and engaged in moderate‐level participant observation and/or guided interviews and conversations. Basic, organising and a final global theme emerged through thematic network analysis, describing the influence of the BFI on providing, receiving and leading infant feeding care in a hospital maternity setting. Using Antonovsky''s sense of coherence construct, the findings discussed in this paper highlight how the BFI offers ‘informational’ (comprehensible), ‘practical’ (manageable) and ‘emotional’ (meaningful) support for both staff and service users, strengthened by effective, local leadership and a team approach. This is juxtaposed against the tensions and demands of the busy hospital maternity setting. It is recommended that ongoing infant feeding policy, practice and leadership balance relational and rational approaches for positive infant feeding care and experiences to flourish.     

Remote provision of breastfeeding support and education: Systematic review and meta‐analysis

The Covid‐19 pandemic has led to a substantial increase in remotely provided maternity care services, including breastfeeding support. It is, therefore, important to understand whether breastfeeding support provided remotely is an effective method of support. To determine if breastfeeding support provided remotely is an effective method of support. A systematic review and meta‐analysis were conducted. Twenty‐nine studies were included in the review and 26 contributed data to the meta‐analysis. Remotely provided breastfeeding support significantly reduced the risk of women stopping exclusive breastfeeding at 3 months by 25% (risk ratio [RR]: 0.75, 95% confidence interval [CI]: 0.63, 0.90). There was no significant difference in the number of women stopping any breastfeeding at 4–8 weeks (RR: 1.10, 95% CI: 0.74, 1.64), 3 months (RR: 0.89, 95% CI: 0.71, 1.11), or 6 months (RR: 0.91, 95% CI: 0.81, 1.03) or the number of women stopping exclusive breastfeeding at 4–8 weeks (RR: 0.86, 95% CI: 0.70, 1.07) or 6 months (RR: 0.93, 95% CI: 0.85, 1.0). There was substantial heterogeneity of interventions in terms of mode of delivery, intensity, and providers. This demonstrates that remote interventions can be effective for improving exclusive breastfeeding at 3 months but the certainty of the evidence is low. Improvements in exclusive breastfeeding at 4–8 weeks and 6 months were only found when studies at high risk of bias were excluded. They are also less likely to be effective for improving any breastfeeding. Remote provision of breastfeeding support and education could be provided when it is not possible to provide face‐to‐face care.     

Characteristics associated with the transition to partial breastfeeding prior to 6 months of age: Data from seven sites in a birth cohort study

The WHO recommends exclusive breastfeeding for the first 6 months of life. However, the transition of the infants'' diet to partial breastfeeding with the addition of animal milks and/or solids typically occurs earlier than this. Here, we explored factors associated with the timing of an early transition to partial breastfeeding across seven sites of a birth cohort study in which twice weekly information on infant feeding practices was collected. Infant (size, sex, illness and temperament), maternal (age, education, parity and depressive symptoms), breastfeeding initiation practices (time of initiation, colostrum and pre‐lacteal feeding) and household factors (food security, crowding, assets, income and resources) were considered. Three consecutive caregiver reports of feeding animal milks and/or solids (over a 10‐day period) were characterized as a transition to partial breastfeeding, and Cox proportional hazard models with time (in days) to partial breastfeeding were used to evaluate associations with both fixed and time‐varying characteristics. Overall, 1470 infants were included in this analysis. Median age of transition to partial breastfeeding ranged from 59 days (South Africa and Tanzania) to 178 days (Bangladesh). Overall, higher weight‐for‐length z‐scores were associated with later transitions to partial breastfeeding, as were food insecurity, and infant cough in the past 30 days. Maternal depressive symptoms (evaluated amongst 1227 infants from six sites) were associated with an earlier transition to partial breastfeeding. Relative thinness or heaviness within each site was related to breastfeeding transitions, as opposed to absolute z‐scores. Further research is needed to understand relationships between local perceptions of infant body size and decisions about breastfeeding.     

Infant feeding experiences and concerns among caregivers early in the COVID‐19 State of Emergency in Nova Scotia,Canada

The global emergency caused by the novel coronavirus (COVID‐19) pandemic has impacted access to goods and services such as health care and social supports, but the impact on infant feeding remains unclear. Thus, the objective of this study was to explore how caregivers of infants under 6 months of age perceived changes to infant feeding and other food and health‐related matters during the COVID‐19 State of Emergency in Nova Scotia, Canada. Four weeks after the State of Emergency began, between 17 April and 15 May 2020, caregivers completed this online survey, including the Perceived Stress Scale. Participants (n = 335) were 99% female and mostly White (87%). Over half (60%) were breastfeeding, and 71% had a household income over CAD$60,000. Most participants (77%) received governmental parental benefits before the emergency, and 59% experienced no COVID‐19‐related economic changes. Over three quarters of participants (77%) scored moderate levels of perceived stress. Common themes of concern included social isolation, COVID‐19 infection (both caregiver and infant), and a lack of access to goods, namely, human milk substitutes (‘infant formula’), and services, including health care, lactation support, and social supports. Most COVID‐19‐related information was sought from the internet and social media, so for broad reach, future evidence‐based information should be shared via online platforms. Although participants were experiencing moderate self‐perceived stress and shared numerous concerns, very few COVID‐19‐related changes to infant feeding were reported, and there were few differences by socio‐economic status, likely due to a strong economic safety net in this Canadian setting.     

Attitudes and experiences of employed women when combining exclusive breastfeeding and work: A qualitative study among office workers in Northern Ethiopia

Evidence from different countries shows that the level of support given to mothers who return to paid employment can significantly determine the duration of exclusive breastfeeding (EBF). However, little is known about how returning to work impacts Ethiopian women''s EBF practice. The aim of this study was to explore women''s attitudes and experiences of EBF when they returned to work. Mothers who had an infant of less than 12 months, working in government institutions in Tigray region, Ethiopia, were invited to participate in this study. Semi‐structured, face‐to‐face interviews were used to explore mothers'' perspectives of the factors that influenced EBF when they returned to work. The interview data were transcribed verbatim and thematically analysed. Twenty mothers were interviewed from 10 organizations. Three themes were identified from their accounts: mother''s knowledge, attitudes and practice towards breastfeeding; workplace context and employment conditions; and support received at home. Most participants were familiar with the benefits of EBF. Most participants reported that their colleagues had more positive attitudes towards breastfeeding than their managers. In almost all the workplaces, there was no specific designated breastfeeding space. Participants reported that close family members including husbands and mothers were supportive. Mothers'' knowledge and attitude towards breastfeeding, workplace and employment conditions and support received at home were found to be the main factors determining the duration of EBF among employed women. Participants reported that the overall support given to breastfeeding women from their employers was insufficient to promote EBF.     

Sociocultural influences on infant feeding decisions among HIV-infected women in rural Kwa-Zulu Natal, South Africa

The promotion of exclusive breastfeeding for 6 months, followed by rapid transition to alternative food sources may be an important public health approach to the reduction of mother-to-child transmission of HIV through breastmilk. The basic ethical principle of 'informed choice' requires that HIV positive women are provided with adequate information about their options. However, information is only one factor that affects their decisions. The objective of this ethnographic study was to identify sociocultural influences on infant feeding decisions in the context of a large cohort study designed to assess the impact of a breastfeeding counselling and support strategy to promote exclusive breastfeeding on postnatal transmission of HIV in African women. Following an initial period of exploratory interviewing, ethnographic techniques were used to interview 22 HIV positive women about their views on infant feeding and health. Interviews were tape-recorded, transcribed and analysed with a text analysis program. Five themes of influences on feeding decisions emerged: (1) social stigma of HIV infection; (2) maternal age and family influences on feeding practices; (3) economic circumstances; (4) beliefs about HIV transmission through breastmilk; and (5) beliefs about the quality of breastmilk compared to formula. The study highlights the role of cultural, social, economic and psychological factors that affect HIV positive women's infant feeding decisions and behaviour.     

Guilt,shame, and postpartum infant feeding outcomes: A systematic review

Negative maternal affect (e.g., depression and anxiety) has been associated with shorter breastfeeding duration and poorer breastfeeding intention, initiation, and exclusivity. Other affective states, including guilt and shame, have been linked with formula feeding practice, though existing literature has yet to be synthesised. A narrative synthesis of quantitative data and a framework synthesis of qualitative and quantitative data were conducted to explore guilt and/or shame in relation to infant feeding outcomes. Searches were conducted on the DISCOVER database between December 2017 and March 2018. The search strategy was rerun in February 2020, together yielding 467 studies. The study selection process identified 20 articles, published between 1997 and 2017. Quantitative results demonstrated formula feeders experienced guilt more commonly than breastfeeding mothers. Formula feeders experienced external guilt most commonly associated with healthcare professionals, whereas breastfeeding mothers experienced guilt most commonly associated with peers and family. No quantitative literature examined shame in relation to infant feeding outcomes, warranting future research. The framework synthesis generated four distinct themes which explored guilt and/or shame in relation to infant feeding outcomes: ‘underprepared and ineffectively supported’, ‘morality and perceived judgement’ (breastfeeding), ‘frustration with infant feeding care’ and ‘failures, fears and forbidden practice’ (formula feeding). Both guilt and shame were associated with self‐perception as a bad mother and poorer maternal mental health. Guilt and shame experiences were qualitatively different in terms of sources and outcomes, dependent on infant feeding method. Suggestions for tailored care to minimise guilt and shame, while supporting breastfeeding, are provided.     

A nation‐wide study on the common reasons for infant formula supplementation among healthy,term, breastfed infants in US hospitals

In‐hospital infant formula supplementation of breastfed infants reduces breastfeeding duration, yet little is known about common reasons for infant formula supplementation. We examined the three most common reasons for in‐hospital infant formula supplementation of healthy, term, breastfed infants in the US reported by hospital staff. Hospital data were obtained from the 2018 Maternity Practices in Infant Nutrition and Care survey (n = 2045), which is completed by hospital staff. An open‐ended question on the top three reasons for in‐hospital infant formula supplementation was analyzed using thematic qualitative analysis and the frequencies for each reason were reported. The top three most common reasons for in‐hospital infant formula supplementation reported by hospital staff included medical indications (70.0%); maternal request/preference/feelings (55.9%); lactation management‐related issues (51.3%); physical but non‐medically indicated reasons (36.1%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%) and medical staff/institutional practices (4.7%). These findings suggest that a variety of factors should be considered to address unnecessary infant formula supplementation. Lactation management support delivered in a timely and culturally sensitive manner and targeted to mother‐infant dyads with potential medical and physical indications may reduce unnecessary in‐hospital infant formula supplementation.     

A mixed methods systematic review exploring infant feeding experiences and support in women with severe mental illness

There are many benefits of breastfeeding to women and their infants but meeting the recommended 6 months of exclusive breastfeeding is likely to be more challenging for women with severe mental illness (SMI). This is the first systematic review that aims to examine evidence of (a) infant feeding outcomes in women with SMI and the factors associated with this, (b) the experiences of infant feeding and infant feeding support for women with SMI, (c) interventions for supporting infant feeding among these women and (d) health care professionals' attitudes toward supporting infant feeding in women with SMI. Mixed methods systematic review was carried out using the principles of Joanna Briggs Institute's (JBI) 'convergent integrated' methodology. CINAHL, PsycINFO, Medline and MIDIRS were used to search literature between 1994 and 2022. The quality of selected articles was assessed using JBI critical appraisal tools and thematic synthesis was undertaken to obtain findings. Eighteen papers were included in the final review. Women with SMI were less likely to initiate and continue breastfeeding than women without SMI. Several challenges with breastfeeding were highlighted, and while these were often linked to women's mental health difficulties, inconsistent advice from health care professionals and poor support with breastfeeding further compounded these challenges. This review highlights that policy and practice need to take into account the individual challenges women with SMI face when planning, initiating and maintaining breastfeeding. Education and training for health care professionals are needed to enable them to provide tailored infant feeding support to women with SMI, which reflects their individual needs.     

Effect of a baby‐friendly workplace support intervention on exclusive breastfeeding in Kenya

Exclusive breastfeeding (EBF) during the first 6 months of life is crucial for optimizing child growth, development and survival, as well as the mother''s wellbeing. Mother''s employment may hinder optimal breastfeeding, especially in the first 6 months. We assessed the effectiveness of a baby‐friendly workplace support intervention on EBF in Kenya. This pre‐post intervention study was conducted between 2016 and 2018 on an agricultural farm in Kericho County. The intervention targeted pregnant/breastfeeding women residing on the farm and consisted of workplace support policies and programme interventions including providing breastfeeding flexi‐time and breaks for breastfeeding mothers; day‐care centres (crèches) for babies near the workplace and lactation centres with facilities for breast milk expression and storage at the crèches; creating awareness on available workplace support for breastfeeding policies; and home‐based nutritional counselling for pregnant and breastfeeding women. EBF was measured through 24‐h recall. The effect of the intervention on EBF was estimated using propensity score weighting. The study included 270 and 146 mother–child dyads in the nontreated (preintervention) group and treated (intervention) group, respectively. The prevalence of EBF was higher in the treated group (80.8%) than in the nontreated group (20.2%); corresponding to a fourfold increased probability of EBF [risk ratio (RR) 3.90; 95% confidence interval (CI) 2.95–5.15]. The effect of the intervention was stronger among children aged 3–5 months (RR 8.13; 95% CI 4.23–15.64) than among those aged <3 months (RR 2.79; 95% CI 2.09–3.73). The baby‐friendly workplace support intervention promoted EBF especially beyond 3 months in this setting.     

Mother–infant interactions and infant intake during breastfeeding versus bottle‐feeding expressed breast milk

Bottle‐fed infants are at higher risk for rapid weight gain compared with breastfed infants. Few studies have attempted to disentangle effects of feeding mode, milk composition and relevant covariates on feeding interactions and outcomes. The objective of the present study was to compare effects of breastfeeding directly at the breast versus bottle‐feeding expressed breast milk on feeding interactions. Mothers with <6‐month‐old infants (n = 47) participated in two counterbalanced, feeding observations. Mothers breastfed their infants directly from the breast during one visit (breast condition) and bottle‐fed their infants expressed breast milk during the other (bottle condition). Masked raters later coded videos using the Nursing Child Assessment Parent–Child Interaction Feeding Scale. Infant intake was assessed. Mothers self‐reported sociodemographic characteristics, infant feeding patterns (i.e. percentage of daily feedings from bottles) and level of pressuring feeding style. Mother and infant behaviours were similar during breast and bottle conditions. Percent bottle‐feeding moderated effects of condition on intake (P = 0.032): greater percent bottle‐feeding predicted greater intake during the bottle compared with breast condition. Effects of feeding mode were not moderated by parity or pressuring feeding style, but, regardless of condition, multiparous mothers fed their infants more than primiparous mothers (P = 0.028), and pressuring feeding style was positively associated with infant intake (P = 0.045). Findings from the present study do not support the hypothesis that feeding mode directly impacts dyadic interaction for predominantly breastfeeding mothers and infants, but rather suggest between‐subject differences in feeding experiences and styles predict feeding outcomes for this population.     

Breastfeeding practices after a counselling intervention for factory workers in Bangladesh

Breastfeeding may be particularly challenging for female factory workers who have long working hours and inadequate access to health information and care. In Chattogram, Bangladesh, a peer counselling intervention was undertaken to improve infant feeding practices of factory workers. Counselling started during pregnancy and continued until children were 18 months old. This article presents the results of a cross‐sectional survey undertaken during 2 weeks in March–April 2017, after the project''s conclusion. The aim was to compare breastfeeding practices, specifically early breastfeeding initiation and exclusive breastfeeding (EBF), among factory workers who had received peer counselling in the intervention areas (IA) with those of non‐counselled factory workers in the nearby comparison areas (CA). Six female interviewers, trained over 3 days, conducted interviews at the workers'' homes. Data were analysed to assess the association of peer counselling with infant feeding practices. Factory workers (N = 382) with infants between 0 and 18 months of age participated in the survey, in IA (n = 188) and in CA (n = 194). Although there were more health facility deliveries among the CA workers, only 43 (22%) of those workers had initiated breastfeeding within 1 h of birth versus 166 (88%) of the IA workers (p < .001). EBF prevalence on 24‐h recall in infants aged 0–6 months was only 7/83 (8%) for the CA workers versus 73/75 (97%) for IA workers (p < .001). The survey showed that breastfeeding practices of factory workers in the IA after the intervention were significantly better than those of factory workers in the CA.     

‘Is there any point in me doing this?’ Views and experiences of women in the Diabetes and Antenatal Milk Expressing (DAME) trial

The Diabetes and Antenatal Milk Expressing (DAME) randomised controlled trial (RCT) was conducted in 2011–2015, at six sites in Melbourne, Australia to explore the effect of advising women with diabetes in pregnancy to express breast milk from 36 weeks gestation. Infants whose mothers were randomised to express in pregnancy were more likely to be exclusively breast milk fed during their hospital stay, and there was no evidence of harm. This paper explores women''s views and experiences of antenatal expressing. In this two‐arm RCT, 635 women with diabetes in pregnancy who were otherwise of low medical risk were randomised at 36–37 weeks gestation to usual care (not expressing, n = 316), or the intervention, where women were advised to hand express for 10 min twice daily until birth (n = 319). Semistructured face‐to‐face interviews were conducted with 10 women who expressed antenatally. They were asked about their experiences of antenatal expressing, including how they felt about the overall experience, the amount of breast milk they expressed, making time to express, and their experience of breastfeeding. Thematic analysis of the in‐depth interviews identified six themes: (1) learning and adapting expressing, (2) feelings and sensations associated with expressing, (3) support, (4) dis/empowerment, (5) health, and (6) the value of breast milk. Women had both positive and negative experiences of antenatal expressing. If health professionals are advising antenatal expressing to women, it is important they understand the range of outcomes and experiences.     

A qualitative study exploring infant feeding decision‐making between birth and 6 months among HIV‐positive mothers

Despite efforts to support breastfeeding for HIV‐positive mothers in South Africa, being HIV‐positive remains a barrier to initiating and sustaining breastfeeding. The aim was to explore decision‐making about infant feeding practices among HIV‐positive mothers in a rural and urban settings in KwaZulu‐Natal, South Africa. HIV‐positive pregnant women were purposively sampled from one antenatal clinic in each setting. A qualitative longitudinal cohort design was employed, with monthly in‐depth interviews conducted over 6 months postdelivery. Data were analysed using framework analysis. We report findings from 11 HIV‐positive women within a larger cohort. Participants were aged between 15 and 41 years and were all on antiretroviral therapy. Before delivery, nine mothers intended to exclusively breastfeed (EBF) for 6 months, and two intended to exclusively formula feed (EFF). Three mothers successfully EBF for 6 months, whereas four had stopped breastfeeding, and two were mixed breastfeeding by 6 months. Mothers reported receiving strong advice from health workers (HWs) to EBF and made decisions based primarily on HWs advice, resisting contrary pressure from family or friends. The main motivation for EBF was to protect the child from HIV acquisition, but sometimes fear of mixed feeding led to mothers stopping breastfeeding entirely. Infant feeding messages from HWs advice were frequently inadequate and out of date, and failed to address mothers' challenges. Minimal support was provided for EFF. In conclusion, HWs play a pivotal role in providing infant feeding support to HIV infected mothers, but need regular updates to ensure if advice is correct and appropriate.     

Determinants of infant feeding choices by Zambian mothers: a mixed quantitative and qualitative study

Choosing an infant feeding mode is complex for human immunodeficiency virus (HIV)-infected African women. We documented infant feeding choices by 811 mothers of infants aged less than 18 months enrolled in the Chilenje Infant Growth, Nutrition and Infection Study of fortified complementary or replacement foods. We also conducted 20 interviews and 4 focus group discussions among women and nurses to explore the issues in depth. Practices of most HIV-infected women did not closely follow national or international guidelines: 26% never initiated breastfeeding, and 55% were not breastfeeding by 6 months post partum. Women of lower socio-economic status and those not meeting criteria for safe replacement feeding were more likely to initiate breastfeeding, to continue longer and to stop at 6 months when provided with free food within the trial. Most HIV-negative women and women of unknown HIV status continued breastfeeding into the infant's second year, indicating limited 'spillover' of infant feeding messages designed for HIV-infected women into the uninfected population. Qualitative work indicated that the main factors affecting HIV-infected women's infant feeding decisions were the cost of formula, the advice of health workers, influence of relatives, stigma and difficulties with using an exclusive feeding mode. Rapidly changing international recommendations confused both mothers and nurses. Many HIV-infected women chose replacement feeding without meeting criteria to do this safely. Women were influenced by health workers but, for several reasons, found it difficult to follow their advice. The recently revised international HIV and infant feeding recommendations may make the counselling process simpler for health workers and makes following their advice easier for HIV-infected women.     

The impact of a package of behaviour change interventions on breastfeeding practices in East Java Province,Indonesia

Suboptimal infant young child feeding practices are frequently reported globally, including in Indonesia. This analysis examined the impact of a package of behaviour change interventions on breastfeeding practices in Malang and Sidoarjo Districts, East Java Province, Indonesia. The BADUTA study (which in the Indonesian Language is an acronym for BAwah DUa TAhun, or children aged less than 2 years) was an impact evaluation using a cluster‐randomized controlled trial with two parallel treatment arms. We conducted household surveys in 12 subdistricts from Malang and Sidoarjo. We collected information from 5175 mothers of children aged 0–23 months: 2435 mothers at baseline (February 2015) and 2740 mothers at endline (January to February 2017). This analysis used two indicators for fever and diarrhoea and seven breastfeeding indicators (early initiation of breastfeeding, prelacteal feeding, exclusive breastfeeding under 6 months, predominant breastfeeding, continued breastfeeding, age‐appropriate breastfeeding and bottle‐feeding). We used multilevel logistic regression analysis to assess the effect of the intervention. After 2 years of implementation of interventions, we observed an increased odds of exclusive breastfeeding under 6 months (adjusted odds ratio [aOR] = 1.85; 95% confidence interval [CI]: 1.35–2.53) and age‐appropriate breastfeeding (aOR = 1.39; 95% CI: 1.07–1.79) in the intervention group than in the comparison group, at the endline survey. We found significantly lower odds for prelacteal feeding (aOR = 0.52; 95% CI: 0.41–0.65) in the intervention than in the comparison group. Our findings confirmed the benefits of integrated, multilayer behaviour change interventions to promote breastfeeding practices. Further research is required to develop effective interventions to reduce bottle use and improve other breastfeeding indicators that did not change with the BADUTA intervention.