The value of a pilot study in breast-feeding research. The Effect of a Peer Counseling Program on Breastfeeding Initiation and Longevity in a Low-income Rural Population WIC-Based Interventions to Promote Breastfeeding Among African-American Women in Baltimore: Effects on Breastfeeding Initiation and Continuation Early diet of preterm infants and development of allergic or atopic disease: randomised prospective study. No effect of birth centre care on either duration or experience of breast feeding, but more complications: findings from a randomised controlled trial. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial Simulated home delivery in hospital: a randomised controlled trial Lactation counseling increases exclusive breast-feeding rates in Ghana. Breastfeeding training for health professionals and resultant changes in breastfeeding duration. Counselling on breastfeeding: assessing knowledge and skills. Prenatal Breastfeeding Education: Its Effect on Breastfeeding Among WIC Participants Protective effect of breast feeding against infection. The Latin American trial of psychosocial support during pregnancy: effects on mother's wellbeing and satisfaction. Latin American Network For Perinatal and Reproductive Research (LANPER). ABFAB. Attachment to the breast and family attitudes to breastfeeding. The effect of breastfeeding education in the middle of pregnancy on the initiation and duration of breastfeeding: a randomised controlled trial [ISRCTN21556494] Randomized controlled trial to determine effects of prenatal breastfeeding workshop on maternal breastfeeding self-efficacy and breastfeeding duration. Home breastfeeding support by health professionals: findings of a randomized controlled trial in a population of Italian women A Controlled Trial of the Father's Role in Breastfeeding Promotion Including expectant fathers in antenatal education programmes in Istanbul, Turkey Factors associated with breastfeeding at six months postpartum in a group of Australian women The initiation of lactation: the effect of early versus delayed contact for suckling on milk intake in the first week post-partum. A study in Chiang Mai, Northern Thailand. The effectiveness of antenatal education of Pakistani and Indian women living in this country. Volunteer peer counselors increase breastfeeding duration among rural low-income women. A breast feeding education and promotion program: Effects on knowledge, attitudes, and support for breast feeding Evaluation of a community-based intervention to increase breastfeeding prevalence. Effect of breastfeeding education on the feeding pattern and health of infants in their first 4 months in the Islamic Republic of Iran. Clinical interventions and outcomes of One-to-One midwifery practice. Breast-feeding training for health professionals and resultant institutional changes. A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community. The Effects of In-Hospital Lactation Education on Breastfeeding Practice Breastfeeding expectations versus reality: a clusterrandomised controlled trial Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers' wellbeing in a Mexican public hospital: a randomised clinical trial Effectiveness of breastfeeding peer counseling in a low-income, predominantly Latina population: a randomized controlled trial. Association of degree and timing of exposure to breastfeeding peer counseling services with breastfeeding duration. Randomised, controlled trial of efficacy of midwife-managed care Effect of early suckling on term neonates' core body temperature. Breast milk and neonatal necrotising enterocolitis Lactation and a reduced risk of premenopausal breast cancer. Two mid-pregnancy interventions to increase the initiation and duration of breastfeeding: a randomized controlled trial. Influences on breast-feeding by lower-income women: an incentive-based, partner-supported educational program. Can we increase breast feeding rates? A breast-feeding promotion and support program a randomized trial in The Netherlands. Reduced Risk of IDDM Among Breast-Fed Children: The Colorado IDDM Registry Breast-feeding rates among black urban low-income women: effect of prenatal education. A randomized, controlled trial of nurse-midwifery care. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial Randomized, Controlled Trial of a Prenatal and Postnatal Lactation Consultant Intervention on Duration and Intensity of Breastfeeding up to 12 Months Effect on rates of breast feeding of training for the Baby Friendly Hospital Initiative Dads as breastfeeding advocates: results from a randomized controlled trial of an educational intervention. Differential Response to Breastfeeding Peer Counseling Within a Low-Income, Predominantly Latina Population Effect of intervention on the rates of breastfeeding of very low birth weight newborns. The effect of a programme of organised and supervised peer support on the initiation and duration of breastfeeding: a randomised trial. Breastfeeding Attitudes, Intention, and Initiation in Low-Income Women: the Effect of the Best Start Program The use of a birthroom: a randomized controlled trial comparing delivery with that in the labour ward Mother's reactions to a skills-based breastfeeding promotion intervention. The Effect of Breastfeeding Education on Adolescent Beliefs and Attitudes: A Randomized School Intervention in the Canadian Ojibwa Community of Sagkeeng A randomised controlled trial in the north of England examining the effects of skin-to-skin care on breast feeding. Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. Effects of providing hospital-based doulas in health maintenance organization hospitals. Simple Antenatal Preparation to Improve Breastfeeding Practice: A Randomized Controlled Trial Breast-feeding in a low-income population. Program to increase incidence and duration. Randomized controlled trial of a prenatal and postnatal lactation consultant intervention on infant health care use. Implementing evidence-based practice: evaluation of an opinion leader strategy to improve breast-feeding rates. Randomised trial of infant sleep location on the postnatal ward Does Breastfeeding Education Affect Nursing Staff Beliefs, Exclusive Breastfeeding Rates, and Baby-Friendly Hospital Initiative Compliance? The Experience of a Small, Rural Canadian Hospital Companionship by a lay labour supporter to modify the clinical birth environment: long-term effects on mother and child. Office Prenatal Formula Advertising and Its Effect on Breast‐Feeding Patterns Comparison of the effect of two systems for the promotion of exclusive breastfeeding Postpartum positioning and attachment education for increasing breastfeeding: a randomized trial. Effect of early mother-baby close contact over the duration of exclusive breastfeeding. A randomised controlled trial comparing birthing centre care with delivery suite care in Adelaide, Australia Environmental factors and symptoms in infants at high risk of allergy. The effect of a culture-specific education program to promote breastfeeding among Vietnamese women in Sydney.
OBJECTIVE To test the integrity of a protocol for a r and omised controlled trial ( RCT ) to examine the effectiveness of skin-to-skin care compared to routine care on the initiation and duration of breast feeding and to provide data to be used in the power calculation for a proposed trial . DESIGN R and omised pilot study . SETTING Warrington Hospital , Cheshire , UK . PARTICIPANTS Women at 36 weeks ' gestation with healthy singleton pregnancies , who intended to breast feed , who had ' booked ' for care at Warrington Hospital and had given informed consent to participate . Twenty-eight women were r and omised in the pilot study . METHOD Women were r and omly allocated to receive either routine or skin-to-skin care following birth . The first breast feed was assessed using the Breast-feeding Assessment Tool ( BAT ) .  Mothers were followed up at discharge from hospital and again at four months to provide details of duration of breast feeding . FINDINGS 66 women were approached to participate in the trial and 44 consented ( 67 % consent rate ) . Twenty-eight women were r and omised in the study and 26 breast feeds were observed ( 93 % ) . The pilot study identified procedural changes that were required in the design of the main study , provided an estimate of recruitment rates and confirmed the previously calculated sample size . CONCLUSION The pilot study demonstrated that a large RCT of skin-to-skin versus routine care was feasible . This is an example of how a pilot study has the ability to identify unforeseen challenges in the conduct of the trial as well as allowing necessary changes to be made to the design that will increase the quality of the subsequent research Breastfeeding rates among low-income women in the east-south- central United States are among the lowest in the country . This study examined the effect of a peer counseling program on breastfeeding initiation and duration in a low-income rural population in West Tennessee . A postpartum survey and chart review were conducted with WIC clients at nine health departments . Response rate was 99 % ( 291/293 ) .  Breastfeeding initiation and duration at 6 weeks were increased in the peer counselor group ( n= 156 ) compared with women in the no-peer counselor group ( n= 135 ) ( 53 % vs. 33%,p<0.001 , and 26 % vs. 13%,p=0.006 , respectively ) . Multivariate analysis revealed that women in the peer counselor group were significantly more likely to initiate breastfeeding ( OR=2.43 , 95 % CI=1.23 - 4.67 ) and to be breastfeeding at 6 weeks ( OR=2.78 , 95 % CI=2.08 - 9.5 1 ) , than those in the no-peer counselor group We evaluated the single and combined effects of introducing a motivational video and peer counseling into four matched WIC clinics on breastfeeding initiation and continuation at 7 - 10 days among African-American WIC participants . Of the 242 women with complete data , 48 % initiated breastfeeding , but only 31 % were still breastfeeding at 7 - 10 days . Initiation was associated with cesarean delivery , infant feeding instruction , no artificial milk discharge pack , attending the peer counselor only-intervention site , and intention to breastfeed . Continuation was influenced by infant feeding instruction , no artificial milk discharge pack , and intention to breastfeed . Overall , trends toward a positive impact of the breastfeeding promotion activities were evident but weak , and largely gone by 7 - 10 days postpartum OBJECTIVE --To study the effect of early diet on the development of allergic reactions in infants born preterm . DESIGN --Two r and omised prospect i ve trails . In trail A infants were r and omly allocated banked donor milk or preterm formula as their sole diet or ( separately r and omised ) as a supplement to their mother 's expressed breast milk . In trial B infants were allocated term or preterm formula . A blind follow up examination was done 18 months after the expected date of birth . SETTING --Neonatal units of hospitals in Cambridge , Ipswich , King 's Lynn , Norwich , and Sheffield . Outpatient follow up . PARTICIPANTS --777 Infants with a birth weight less than 1850 g born during 1982 to 1984 . MAIN OUTCOME MEASURES --Development of eczema , allergic reactions to food or drugs , and asthma or wheezing by nine and 18 months after term . Whenever possible the observations were confirmed by rechallenge or clinical examination . RESULTS --At 18 months after term there was no difference in the incidence of allergic reactions between dietary groups in either trial . In the subgroup of infants with a family history of atopy , however , those in trial A who received preterm formula rather than human milk had a significantly greater risk of developing one or more allergic reactions ( notably eczema ) by 18 months ( odds ratio 3.6 ; 95 % confidence interval 1.4 to 9.1 ) . CONCLUSIONS --Feeding neonates on formulas based on cows ' milk , including those with a high protein content , did not increase the overall risk of allergy . Nevertheless , in the subgroup with a family history of atopy early exposure to cows ' milk increased the risk of a wide range of allergic reactions , especially eczema OBJECTIVE to study the effect of birth centre care on the duration of breast feeding , breast feeding complications , and women 's experiences of breast feeding .  DESIGN r and omised controlled trial . SETTING in-hospital birth centre at South Hospital , Stockholm , and st and ard obstetric care in the Greater Stockholm area . SUBJECTS 1230 women with expected date of birth between October 1989 and February 1992 , interested in participating in a birth centre trial , and meeting medical low-risk criteria . 617 women were allocated to the experimental group offered birth centre care ( EG ) , and 613 to the  control group offered  st and ard obstetric care ( CG ) . MAIN OUTCOME MEASURES duration of breast feeding , breast feeding complications such as sore nipples , engorgement , milk stasis , and mastitis , and women 's experiences of breast feeding . FINDINGS no difference was found between EG and CG in the duration of breast feeding . Ninety-three per cent in both groups were breast feeding exclusively two months post partum . The average number of months of breast feeding , exclusively or partly , when investigated one year after the birth was 8.6 in EG and 8.5 in CG . No difference was observed in women 's experiences of breast feeding , but rather more women in EG than in CG reported sore nipples , 36 % and 30 % respectively ( p = 0.03 ) , and milk stasis , 26 % and 19 % respectively ( p = 0.002 ) . CONCLUSIONS birth centre care had no effect on the duration of breast feeding , or on women 's experiences of breast feeding . Prenatal attitudes were probably more significant predictors of these outcomes than differences in the two modes of maternity care in this population of highly breast feeding-motivated women . The larger proportion of sore nipples and milk stasis in the EG might have been due to earlier discharge , or to midwives less skilled in assisting with breast feeding at the birth centre than in the postpartum wards BACKGROUND Most mothers breastfeed in Bangladesh , but they rarely practise exclusive breastfeeding . Hospital-based strategies for breastfeeding promotion can not reach them because about 95 % have home deliveries . We postulated that with the intervention of trained peer counsellors , mothers could be enabled to breastfeed exclusively for the recommended duration of 5 months . METHODS 40 adjacent zones in Dhaka were r and omised to intervention or control groups . Women were enrolled during the last trimester of pregnancy between February and December , 1996 . In the intervention group , 15 home-based counselling visits were scheduled , with two visits in the last trimester , three early postpartum ( within 48 h , on day 5 , between days 10 and 14 ) , and fortnightly thereafter until the infant was 5 months old . Peer counsellors were local mothers who received 10 days ' training . FINDINGS 363 women were enrolled in each group .  Peer counselling significantly improved breastfeeding practice s. For the primary outcome , the prevalence of exclusive breastfeeding at 5 months was 202/228 ( 70 % ) for the intervention group and 17/285 ( 6 % ) for the control group ( difference=64 % ; 95 % CI 57%-71 % , p>0.0001 ) . For the secondary outcomes , mothers in the intervention group initiated breastfeeding earlier than control mothers and were less likely to give prelacteal and postlacteal foods . At day 4 , significantly more mothers in the intervention group breastfed exclusively than controls . INTERPRETATION Peer counsellors can effectively increase the initiation and duration of exclusive breastfeeding . We recommend incorporation of peer counsellors in mother and child health programmes in developing countries Objectives To compare the outcome of two methods of  maternity care during the antenatal period and at delivery . One was to be midwife‐led for both antenatal care and delivery , the latter taking place in rooms similar to those in one 's own home to simulate home confinement . The other would be consultant‐led with the mothers labouring in the delivery suite rooms with resuscitation equipment for both mother and baby in evidence , monitors present and a delivery bed on which both anaesthetic and obstetric procedures could be easily and safely carried out Exclusive breast-feeding ( EBF ) rates remain low despite numerous health benefits associated with this behavior . We conducted a r and omized trial on the effect of lactation counseling on EBF , which controlled for the Hawthorne effect while also varying the timing of the intervention . Pregnant women attending prenatal clinics in Tema were r and omly assigned to 1 of 2 intervention groups ( IG ) or to a control group ( C ) , as follows : 1 ) EBF support given pre- , peri- , and postnatally ( IG1 ; n = 43 ) ; 2 ) EBF support given only peri- and postnatally ( IG2 ; n = 44 ) ; or 3 ) nonbreast-feeding health educational support ( C ; n = 49 ) that had an equal amount of contact with lactation counselors . Two educational sessions were provided prenatally , and 9 home follow-up visits were provided in the 6-mo postpartum period . Infant feeding data were collected monthly at the participant 's home . The 3 groups did not differ in sociodemographic characteristics . At 6 mo postpartum , 90.0 % in IG1 and 74.4 % in IG2 had exclusively breast-fed during the previous month . By contrast , only 47.7 % in C were doing so ( P = 0.008 ) . Similarly , the percentage of EBF during the 6 mo was significantly higher ( P = 0.02 ) among IG1 and IG2 ( 39.5 % ) than among C ( 19.6 % ) . The 100 % increase in EBF rates can be attributed to the lactation counseling provided . Additional prenatal EBF support may not be needed within a context of strong routine prenatal EBF education CONTEXT Promotion of breastfeeding in Brazilian maternity hospitals . OBJECTIVE To quantify changes in the breastfeeding duration among mothers served by hospitals exposed to the Wellstart-SLC course  , comparing them with changes among mothers attended by institutions not exposed to this course . DESIGN R and omized Institutional Trial . SETTING The effects of training on breastfeeding duration was assessed in eight Brazilian hospitals assigned at r and om to either an exposed group ( staff attending the Wellstart-SLC course ) or a  control group .  SAMPLE For each of the eight study hospitals , two cohorts of about 50 children were visited at home at one and six months after birth . The first cohort ( n = 494 ) was composed of babies born in the month prior to exposure to the Wellstart-SLC course , and the second cohort ( n = 476 ) was composed of babies born six months subsequent to this exposure . MAIN MEASUREMENTS Kaplan-Meier curves were plotted to describe the weaning process and log-rank tests were used to assess statistical differences among survival curves . Hazard ratio ( HR ) estimates were calculated by fitting Cox proportional hazard regression models to the data . RESULTS The increases in estimated , adjusted rates for children born in hospitals with trained personnel were 29 % ( HR = 0.71 ) and 20 % ( HR = 0.80 ) for exclusive and full breastfeeding , respectively . No changes were identified for total breastfeeding . CONCLUSION This r and omized trial supports a growing body of evidence that training hospital health professionals in breastfeeding promotion and protection results in an increase in breastfeeding duration Reported are the results of a r and omized controlled trial to assess the effectiveness of the WHO/UNICEF 40-hour course " Breastfeeding counselling : a training course " . The course was conducted in a maternity hospital which provides care to a low-income population in a metropolitan area in São Paulo , Brazil . Health workers from 60 health units were r and omly assigned to be either participants ( 20 ) or controls ( 40 ) , and their breastfeeding knowledge and skills were assessed before and immediately after the course , as well as 3 months later . Immediately after the course the participants ' knowledge of breastfeeding had increased significantly compared to controls . Both their clinical and counselling skills also improved significantly . When assessed 3 months later , the scores remained high with only a small decrease . The implementation of the course was also evaluated . The methods used were participatory observation , key interviews and focus group discussion . In the 33 sessions of the course , the average score was 8.43 out of 10 . Scores were highest for content and methodology of the theory sessions , and lowest for " use of time " , " clinical management of lactation " , and " discussion of clinical practice " .  " Breastfeeding counselling : a training course " therefore effectively increases health workers ' knowledge and their clinical and counselling skills for the support of breastfeeding . The course can be conducted adequately using the material and methodology proposed , but could be more satisfactory if the time allocated to exercises and clinical practice sessions were increased The effect of prenatal breastfeeding education on breastfeeding incidence and duration was determined among 31 prenatal WIC participants . The subjects , assigned to a control group  ( n= 17 ) or experimental group  ( n= 14 ) , received prenatal nutrition education through the WIC program . The experimental group received at least one breastfeeding education class . There was no significant difference in breastfeeding incidence between the groups , however , there was a significant difference in breastfeeding incidence by parity ( p<0.05 ) . There was a significantly higher percentage of women still breastfeeding at 3 and 4 months postpartum in the experimental versus the control group ( p<0.05 ) . The control group breastfed for 29.5 + 43.6 days , while the experimental group breastfed for 76 days + 104.3 ( p=.05 ) . Multiparous women who had bottle-fed previous children breastfed for a shorter duration ( 18 + 22 days ) than primiparous women ( 60 87 days ) ( p<.07 ) OBJECTIVE To assess the relations between  breast feeding and infant illness in the first two years of life with particular reference to gastrointestinal disease . DESIGN Prospect i ve observational study of mothers and babies followed up for 24 months after birth . SETTING Community setting in Dundee . PATIENTS 750 pairs of mothers and infants , 76 of whom were excluded because the babies were preterm ( less than 38 weeks ) , low birth weight ( less than 2500 g ) , or treated in special care for more than 48 hours . Of the remaining cohort of 674 , 618 were followed up for two years . INTERVENTIONS Detailed observations of infant feeding and illness were made at two weeks , and one , two , three , four , five , six , nine , 12 , 15 , 18 , 21 , and 24 months by health visitors . MAIN OUTCOME MEASURE The prevalence of gastrointestinal disease in infants during follow up . RESULTS After confounding variables were corrected for babies who were  breast fed for 13 weeks or more ( 227 ) had significantly less gastrointestinal illness than those who were bottle fed from birth ( 267 ) at ages 0 - 13 weeks ( p less than 0.01 ; 95 % confidence interval for reduction in incidence 6.6 % to 16.8 % ) , 14 - 26 weeks ( p less than 0.01 ) , 27 - 39 weeks ( p less than 0.05 ) , and 40 - 52 weeks ( p less than 0.05 ) . This reduction in illness was found whether or not supplements were introduced before 13 weeks , was maintained beyond the period of breast feeding itself , and was accompanied by a reduction in the rate of hospital admission . By contrast , babies who were breast fed for less than 13 weeks ( 180 ) had rates of gastrointestinal illness similar to those observed in bottle fed babies . Smaller reductions in the rates of respiratory illness were observed at ages 0 - 13 and 40 - 52 weeks ( p less than 0.05 ) in babies who were breast fed for more than 13 weeks . There was no consistent protective effect of breast feeding against ear , eye , mouth , or skin infections , infantile colic , eczema , or nappy rash . CONCLUSION Breast feeding during the first 13 weeks of life confers protection against gastrointestinal illness that persists beyond the period of breast feeding itself A r and omized controlled trial including 2235 women at high risk of low birthweight was conducted in four Latin American institutions . The objective of this trial was to evaluate a  psychosocial support intervention during pregnancy aim ed at improving perinatal health and mothers ' psychosocial conditions . The core of the intervention was four to six home visits where emotional support , counseling and strengthening of the woman 's social network was provided . Outcomes were measured at 36 weeks of pregnancy , post-partum and 40 days after delivery . The intervention was not successful in either altering women 's perception of social support and satisfaction with the reproductive experience , as well as maternal and newborn 's health care . It is concluded that although high levels of psychosocial distress during pregnancy may play an independent role in determining adverse pregnancy outcomes , this adverse effect does not appear to be ameliorated by psychosocial interventions conducted only during pregnancy , particularly those of a magnitude that can be realistically implemented ( in content and frequency ) at public care services in most developing countries Background It has proven difficult to reach World Health Organization ( WHO ) recommendations that infants be exclusively breastfed from birth to six months of age [ 1 , 2 ] , yet there is limited knowledge about interventions that are effective in increasing breastfeeding initiation and duration . Particularly lacking is evidence about how to maintain breastfeeding rates in countries which already have a high initiation of breastfeeding . This study aims to determine whether mid-pregnancy breastfeeding education  , with a focus on either attitudes to breastfeeding or on technical aspects of breastfeeding , has an effect on rates of breastfeeding initiation and duration . Secondary aims of the study are to : explore what factors might affect the duration of breastfeeding and evaluate the interventions from the participant and childbirth facilitator perspectives . Methods / Design A r and omised controlled trial ( RCT ) design will be used . Women having their first baby , and planning to give birth as public patients at the Royal Women 's Hospital ( RWH ) , Melbourne , will be approached at 18–20 weeks of pregnancy and invited to participate in the study . Participants will be r and omly allocated to a control group or one of two group interventions : a previously design ed and trialled tool to teach practical aspects of breastfeeding or an exploration of family attitudes to breastfeeding . The latter was developed and piloted by the investigators in conjunction with the group facilitators , prior to trial commencement . The interventions are planned to take place at 20–25 weeks . Data will be collected by question naire at recruitment , at interview in hospital after the birth and by telephone interview six months later . Medical/obstetric outcomes will be obtained from the medical record . The sample size ( 972 ) was calculated to identify an increase in breastfeeding initiation from 75 to 85 % and an increase from 40 to 50 % in breastfeeding at six months OBJECTIVE To determine the effects of a prenatal breastfeeding workshop on  maternal breastfeeding self-efficacy and breastfeeding duration . DESIGN R and omized controlled trial . SETTING Large tertiary hospital in Ontario , Canada . PARTICIPANTS 110 primiparous women expecting a single child , an uncomplicated birth , and planning to breastfeed . INTERVENTION 2.5-hour prenatal breastfeeding workshop based on adult learning principles and self-efficacy theory . MAIN OUTCOME MEASURE Maternal breastfeeding self-efficacy and the numbers of days and amount of breastfeeding were measured at four and eight weeks postpartum . RESULTS / DATA ANALYSIS : Over time , maternal breastfeeding self-efficacy scores increased in both groups . Women who attended the workshop had higher self-efficacy scores and a higher proportion were exclusively breastfeeding compared to women who did not attend the workshop . There was little difference in the average number of days of breastfeeding , but the intervention group had less weaning . CONCLUSIONS The workshop increased maternal breastfeeding self-efficacy and exclusive breastfeeding Aim : We conducted a r and omized controlled trial to assess the effectiveness of a support intervention delivered by health professionals to increase the rate and duration of breastfeeding . Methods : A r and omized controlled intervention study was conducted in the period 2000–2001 among 605 mothers who had given birth in a public maternity ward located in the city of Rome , Italy . The intervention consisted of a home visit by a midwife from the maternity ward of the hospital . The outcome of the study was the infant 's feeding habits , assessed by a 24‐h recall . The effect of the intervention on the duration of breastfeeding was estimated by the Kaplan‐Meier method and by the Cox multivariate regression model . Results : According to intention‐to‐treat analysis , there was no significant difference between the intervention and the control group , after controlling for confounding factors ( hazard ratio ( HR ) 1.04 ; 95 % confidence interval ( 95 % CI ) : 0.85–1.26 ) . The duration of breastfeeding was shorter ( HR 1.61 ; 95 % CI : 1.13–2.31 ) for women in the intervention group who refused the obstetric visit Objective . To investigate whether supporting fathers to recognize the relevance of their role in the success of breastfeeding and teaching them how to prevent and to manage the most common lactation problems would result in more women breastfeeding . Methods . A controlled trial , in which the participating fathers were allocated in 2-month blocks to a child care training session , was conducted of 280 mothers considering breastfeeding and their 280 partners at a university obstetric department in Naples , Italy .  Support and advice about breastfeeding was provided to all of the mothers . Among the fathers of the intervention group , the training session included the management of breastfeeding ; among those of the control group , it did not . Primary outcome was the prevalence of full breastfeeding at 6 months . Secondary outcomes were the proportion of women who perceived their milk to be insufficient , who stopped breastfeeding because of problems , and who reported to have received help in breastfeeding management by their partners . Results The prevalence of full breastfeeding at 6 months was 25 % ( 35 of 140 ) in the intervention group and 15 % ( 21 of 140 ) in the control group and that of any breastfeeding at 12 months was 19 % ( 27 ) and 11 % ( 16 ) , respectively . Perceived milk insufficiency was significantly more frequent among the mothers of the control group ( 38 [ 27 % ] of 140 vs 12 [ 8.6 % ] of 140 ) , as well as breastfeeding interruption because of problems with lactation ( 25 [ 18 % ] of 140 vs 6 [ 4 % ] of 140 ) . Moreover , significantly more women in the intervention group reported receiving support and relevant help with infant feeding management from their partners ( 128 [ 91 % ] of 140 vs 48 [ 34 % ] of 140 ) . Among the women who had reported difficulties with lactation in the intervention and control groups ( 96 [ 69 % ] and 89 [ 64 % ] , respectively ) , the prevalence of full breastfeeding at 6 months was 24 % and 4.5 % , respectively . Conclusions Teaching fathers how to prevent and to manage the most common lactation difficulties is associated with higher rates of full breastfeeding at 6 months Abstract In this article we present the results of three studies investigating methods for including men in antenatal education in Istanbul , Turkey . Participants were first-time expectant parents living in low and middle-income areas . After a formative study on the roles of various family members in health during the period surrounding a first birth , an antenatal-clinic-based education programme for women and for couples was carried out as a r and omised , controlled study . Based on the results , separate community-based antenatal education programmes for expectant mothers and expectant fathers were tested . There was dem and among many pregnant women and some of their husb and s for including expectant fathers in antenatal education . In the short term , these programmes seemed to have positive effects on women and men 's reproductive health knowledge , attitudes and behaviours . In the clinic-based programme the positive effects of including men were mainly in the area of post-partum family planning , while in the community-based programme positive effects among men were also seen in the areas of infant health , infant feeding and spousal communication and support .  Free an tenatal education should be made available to all expectant mothers and when possible , men should be included , either together with their wives or in a culture such as that of Turkey , in separate groups . Résumé Trois etudes ont analysé des méthodes pour associer les hommes á l'éducation prénatale . Les participants , issus de quartiers à revenus faibles et moyens d'Istanbul , Turquie , attendaient leur premier enfant . Après une étude initiale des rôles en matiere de santé des membres de la famille pendant la période entourant une première naissance , un programme d'éducation a donné des soins prénatals en dispensaire aux femmes et aux couples , dans le cadre d'une etude aléatorie et contrôlée . En fonction des résultats , des programmes communautaires d'education prénatale , séparés pour les futurs péres et les futures mères , ont été testes . Beaucoup de femmes enceintes et quelques maris souhaitaient associer les futurs pères à l'éducation prénatale . A court terme , ces programmes semblaient avoir des effets positifs sur les connaissances , les attitudes et les comportements des hommes et des femmes en matière de santé génésique . Darts le programme mené au dispensaire , l'ínclusion des hommes avait des avantages touchant à la planification familiale post-partum , alors que les effets positifs du programme communautaire concernaient la santé infantile , 1'alimentation des nourrissons , la communication et le soutien entre époux . Une éducation prénatale gratuite devrait être proposée à toutes les futures mères et , lorsque c'est possible , les hommes devraient y être associés , soit avec leurs épouses soit , dans une culture comme celle de la Turquie , dans des groupes séparés . Resumen Tres investigaciones analizaron los métodos para incluir a los hombres en la educación prenatal en Estambul , Turquia . Los participantes eran parejas que vivían en Areas de bajos y medianos ingresos , quienes esperaban su primer bebé . Después de un estudio formativo acerca de los roles de los distintos integrantes de la familia en relación a la salud durante el período previo y posterior a un primer nacimiento , se implementó un estudio aleatorio controlado en la forma de un programa educativo  para mujeres y para parejas en una clínica prenatal . En base a los result ados , se probaron programas educativos prenatales comunitarios para mujeres embarazadas y sus parejas . Hubo una dem and a entre muchas de las mujeres embarazadas y algunos de sus esposos para incluir a los futures padres en la educación prenatal . A couo plazo , estos programas parecían tener efectos positivos en las actitudes , comportamientos y conocimientos de la salud reproductiva de las mujeres y los hombres . En el programa de la clinica , los efectos positivos de incluir a los hombres se notaban principalmente en el ámbito de la planificación familiar postparto , mientras que en el programa comunitario , se notaban además los efectos positivos en los ámbitos de la salud y la alimentacion infantil , el apoyo de los hombres a sus esposas y la comunicacíon con ellas . Se recomienda ofrecer educacion prenatal gratuita a todas las mujeres embarazadas y cu and o sea posible a los hombres , en conjunto con sus esposas o , en una cultura como la de Turquía , en grupos separados Background Despite high levels of breastfeeding initiation in Australia , only 47 percent of women are breastfeeding ( exclusively or partially ) six months later , with marked differences between social groups . It is important to identify women who are at increased risk of early cessation of breastfeeding . Methods Data from the three arms of a r and omised controlled trial were pooled and analysed as a cohort using logistic regression to identify which factors predicted women continuing to feed any breast milk at six months postpartum . The original trial included 981 primiparous women attending a public , tertiary , women 's hospital in Melbourne , Australia in 1999–2001 . The trial evaluated the effect of two mid-pregnancy educational interventions on breastfeeding initiation and duration . In the 889 women with six month outcomes available , neither intervention increased breastfeeding initiation nor duration compared to st and ard care . Independent variables were included in the predictive model based on the literature and discussion with peers and were each tested individually against the dependent variable ( any breastfeeding at six months ) . Results Thirty-three independent variables of interest were identified , of which 25 qualified for inclusion in the preliminary regression model ; 764 observations had complete data available . Factors remaining in the final model that were positively associated with breastfeeding any breast milk at six months were : a very strong desire to breastfeed ; having been breastfed oneself as a baby ; being born in an Asian country ; and older maternal age . There was an increasing association with increasing age . Factors negatively associated with feeding any breast milk at six months were : a woman having no intention to breastfeed six months or more ; smoking 20 or more cigarettes per day pre-pregnancy ; not attending childbirth education ; maternal obesity ; having self-reported depression in the six months after birth ; and the baby receiving infant formula while in hospital . Conclusion In addition to the factors commonly reported as being associated with breastfeeding in previous work , this study found a negative association between breastfeeding outcomes and giving babies infant formula in hospital , a high maternal body mass index , and self-reported maternal depression or anxiety in the six months after the baby was born . Interventions that seek to increase breastfeeding should consider focusing on women who wish to breastfeed but are at high risk of early discontinuation The effect of reducing the length of routine mother/infant separation following delivery on milk intake in the first week of life was examined prospect ively in 22 term infants in Chiang Mai , Northern Thail and . Infants were r and omly assigned to two groups : a late contact group ( control ) who followed routine hospital policy ( mean separation between mother and baby 25.1 h ) , and an early contact group ( experimental ) in which mother and baby were re-united as soon as possible following st and ard clinical observations ( mean separation after delivery of 3.6 h ) . Despite a difference of 22.4 in the mean age at which babies in the two groups were first suckled , no experimental difference was found in milk volume transfer over post-partum days 2 - 5 determined by test weighing at a morning feed with an integrating electronic balance . An observational study was performed concurrently , which showed that early contact group mothers were likely to have given 8 additional breast feeds during the extra 21.5 h they had with their infant Eighty-two Asian women ( mostly Muslims ) living in East London were prospect ively studied through their pregnancy and delivery . Their infants were assessed during the second year of life for growth , nutrition , morbidity , development and vaccination history . There was no increase in perinatal or infant mortality over the general population in the same borough , though there was increased infant morbidity , most commonly iron deficiency ( in 25 % ) , and one child with sub clinical rickets . One child had a genetic neurodegenerative disorder . The incidence of low birth weight babies was only slightly greater than that of the district as a whole , but after 1 year of age they were less well grown than the population studied by Tanner & Whitehouse . Sixty-four per cent of the women started to breast feed , but many also gave artificial milk and they usually ceased to breast feed earlier than most women in the same district . When half of the women were r and omly allocated to receive specialized education , with the others acting as controls , very few attended and little benefit was detected . Though the significance is doubtful , the infants of those educated did tend to be better grown ( especially in length ) , be less likely to have development well below average , have reduced morbidity and have more complete immunization schedules than those of the women not receiving education . This study shows no benefit due to antenatal education , but suggests that the children have advantages when their mothers have the drive to attend the education sessions BACKGROUND The purpose of this demonstration project was to test the effectiveness of a volunteer peer counseling program for promoting breastfeeding in a community . METHODS The two-year project was conducted in Iowa from September 1994 to September 1996 . Both intervention and control groups were rural low-income pregnant and postpartum women who qualified for the Women , Infants and Children 's ( WIC ) nutritional program . The intervention was initiated in two counties with 143 clients , of whom 72 completed the project . The control group was drawn from six counties that had received no significant breastfeeding promotion programs during the previous three years . The intervention was the assignment of trained volunteers with previous successful personal experience with breastfeeding as peer counselors  to low-income pregnant women . Both before and after the baby was born , the volunteers taught a series of in-home , one-to-one lessons about healthy diet and breastfeeding , and maintained informal contact to answer questions or help with concerns . RESULTS Women in the intervention group improved dietary intake when compared with the control group . Knowledge of breastfeeding and good nutrition improved slightly . Eighty-two percent of intervention compared with 31 percent of control group women initiated breastfeeding . Mean duration of breastfeeding for intervention and control group women was 5.7 and 2.5 weeks , respectively . At 4 weeks , 56 percent of intervention and 10 percent of control group women were still breastfeeding . CONCLUSION A volunteer peer counseling program that provides low-income women with role models , accurate information , support , and encouragement can increase the duration of breastfeeding , and thus contribute to healthier infants This study was undertaken to determine the effects of a partner-support , incentive-baed educational program on breast feeding knowledge , attitudes and support and to examine the relationship between feeding intentions and feeding behavior among low-income women . Women who expressed a willingness to participate in the intervention were r and omly assigned to “ intervention ” and “ usual breast feeding ” ( control ) groups . Sixty-eight primipara women , with expected due date s between May and December , 1992 , volunteered to participate in the study . Of these , 34 were r and omly assigned to each of the two groups . Approximately 81 percent of the women completed the study , leaving n=29 in the control group and n-26 in the intervention group . The intervention consisted of special incentives ( prizes ) for women and their partners to participate in several breast feeding education and promotion activities . Intervention group women and their partners experienced positive changes in breast feeding knowledge and attitudes . Furthermore , the intervention seemed to have influenced more women in the treatment group to breast feed despite their prenatal feeding intentions . In addition , the partners of intervention group women were perceived to be more supportive of , breast feeding than control group partners . These findings suggest that incentives , such as donated prizes , can be used to attract lower socioeconomic group women and their partners to breast feeding promotion interventions . Participation in such interventions can produce positive changes in breast feeding knowledge , attitudes , and support , and can have a dramatic effect in promoting breast feeding BACKGROUND The aim of the study was to determine whether peer counselling in the antenatal and post-natal period would increase the prevalence and duration of breastfeeding among low-income women in Glasgow . METHODS The study was design ed as a quasi-experimental evaluation of a community-based breastfeeding promotion programme . The intervention comprised peer counselling of pregnant women , support of breastfeeding mothers and local awareness-raising activities .  The study subjects were all women attending the antenatal booking clinic resident in either the intervention or control area . Data were collected by means of four self-completion question naires , two administered antenatally and two post-natally . The proportions intending to breastfeed or breastfeeding in the intervention and control groups were compared at each assessment and over time . RESULTS Of the 995 women enrolled in the study , data were available for analysis on 919 ( 92 per cent ) to 6 weeks postnatally . At booking , 18 per cent of the intervention group and 21 per cent of the control group stated an intention to breastfeed . At delivery , the proportions initiating breastfeeding were 23 per cent of the intervention subjects and 20 per cent of the controls , and by 6 weeks post-natally , the proportion providing any breast milk had declined to 10 per cent of the intervention group and 8 per cent of the control group . Using multivariate analysis to adjust for factors ( such as socio-economic status ) known to influence breastfeeding , the breastfeeding prevalence was significantly higher in the intervention group relative to the controls at delivery [ odds ratio ( OR ) 2.0 ; 95 per cent confidence interval ( CI ) 1.2 - 3.1 , p = 0.006 ] . By 6 weeks post-natally the difference between the two groups was not statistically significant ( OR 1.8 ; 95 per cent CI 1.0 - 3.4 , p=0.07 ) . CONCLUSIONS As the impact of the intervention was not sustained even for the modest duration of 6 weeks postnatally , it would be premature to justify widespread use of peer support programmes to increase the prevalence of breastfeeding in socially disadvantaged communities This quasi-experimental study was conducted in Shiraz , the Islamic Republic of Iran , on 120 pairs of mothers and infants in a maternity hospital that had a rooming-in programme . All 59 mothers in the study group received breastfeeding education , face-to-face , after delivery and during follow-up for 4 months in the mother and child health ( MCH ) centre or in their homes ; the remaining 61 mothers comprised the control group .  Exclusive breastfeeding rates were significantly higher in the study group ( 54 % ) than in the control group ( 6.5 % ) , but 5 % and 18 % of infants , respectively , in the study and control groups had stopped breastfeeding by the age of 4 months . The mean number of days of diarrhoea experienced by infants in the study group were significantly lower ( P < or = 0.004 ) than in the control group . At the end of 4 months , the mean weight and length of the infants were significantly higher ( both P < 0.05 ) in the study group than in the control group . The findings indicate that rooming-in is very important for promoting exclusive breastfeeding and that there is a need for continuous breastfeeding education of mothers BACKGROUND Changing Childbirth became policy for the maternity services in Engl and in 1994 and remains policy . One-to-One midwifery was implemented to achieve the targets set . It was the first time such a service had been implemented in the Health Service . An evaluation was undertaken to compare its performance with conventional maternity care . METHODS This was a prospect i ve comparative study of women receiving One-to-One care and women receiving the system of care that One-to-One replaced ( conventional care )  to compare achievement of continuity of carer and clinical outcomes . The evaluation took place in The Hammersmith Hospitals NHS Trust , the Queen Charlotte 's and Hammersmith Hospitals . This was part of a larger study , which included the evaluation of women 's responses , cost implication s , and clinical st and ards and staff reactions . The participants were all those receiving One-to-One midwifery practice ( 728 women ) , which was confined to two postal districts , and all women receiving care in the system that One-to-One replaced , in two adjacent postal districts ( 675 women ) , and expecting to give birth between 15 August 1994 and 14 August 1995 . Main outcome measures were achievement of continuity of care , rates of interventions in labour , length of labour , maternal and infant morbidity , and breastfeeding rates . RESULTS A high degree of continuity was achieved through the whole process of maternity care . One-to-One women saw fewer staff at each stage of their care , knew more of the staff who they did see , and had a high level of constant support in labour .  One-to-One practice was associated with a significant reduction in the use of epidural anaesthesia ( odds ratio ( OR ) 95 per cent confidence interval ( CI ) = 0.59 ( 0.44 , 0.80 ) ) , with lower rates of episiotomy and perineal lacerations ( OR 95 per cent CI = 0.70 ( 0.50 , 0.98 ) ) , and with shorter second stage labour ( median 40 min vs 48 min ) . There were no statistically significant differences in operative and assisted delivery or breastfeeding rates . CONCLUSIONS This study confirms that One-to-One midwifery practice can provide a high degree of continuity of carer , and is associated with a reduction in the rate of a number of interventions , without compromising safety of care . It should be extended locally and replicated in other services under continuing evaluation Assessed is a breast-feeding training course that was attended by health professionals at the Santos Lactation Center ( SLC ) , Santos , São Paulo , Brazil , as well as its impact on the implementation of breast-feeding programmes in maternity hospitals . Eight maternity hospitals were studied -- four were r and omly allocated to the experimental group and sent three health professionals to attend an 18-day course at SLC ; the remaining four institutions constituted the  control group . The compliance of all eight hospitals with WHO/UNICEF 's " Ten steps for successful breast-feeding " was determined using scores obtained before and 6 months after the training course . Institutions in the experimental group had an improved score , but those in the control group did not . The SLC training course was efficient since it enabled the participants to promote breast-feeding practice s. However , in order to succeed in implementing breast-feeding programmes , health professionals require also to develop skills to apply the knowledge they acquire in the course , as well as to involve the whole maternity unit team in the activities OBJECTIVE To assess the efficacy of peer counseling to promote exclusive breastfeeding ( EBF ) among low-income inner-city women in Hartford , Conn. DESIGN Participants recruited prenatally were r and omly assigned to either receive support for EBF from a peer counselor plus conventional breastfeeding support ( peer counseling group [ PC ] ) or only conventional breastfeeding support ( control group [ CG ] ) and followed through 3 months post partum . SETTING Low-income predominantly Latina community . PARTICIPANTS Expectant mothers , less than 32 weeks gestation and considering breastfeeding ( N = 162 ) . Intervention Exclusive breastfeeding peer counseling support offering 3 prenatal home visits , daily perinatal visits , 9 postpartum home visits , and telephone counseling as needed . MAIN OUTCOME MEASURES Exclusive breastfeeding rates at hospital discharge , 1 , 2 , and 3 months post partum ( n = 135 ) . RESULTS At hospital discharge , 24 % in the CG compared with 9 % in the PC had not initiated breastfeeding , with 56 % and 41 % , respectively , nonexclusively breastfeeding . At 3 months , 97 % in the CG and 73 % in the PC had not exclusively breastfed ( relative risk [ RR ] = 1.33 ; 95 % CI , 1.14 - 1.56 ) during the previous 24 hours . The likelihood of nonexclusive breastfeeding throughout the first 3 months was significantly higher for the CG than the PC ( 99 % vs 79 % ; RR = 1.24 ; 95 % CI , 1.09 - 1.41 ) . Mothers in the CG were less likely than their PC counterparts to remain amenorrheic at 3 months ( 33 % vs 52 % ; RR = 0.64 ; 95 % CI , 0.43 - 0.95 ) . The likelihood of having 1 or more diarrheal episode in infants was cut in half in the PC ( 18 % vs 38 % ; RR = 2.15 ; 95 % CI , 1.16 - 3.97 ) . CONCLUSION Well-structured , intensive breastfeeding support provided by hospital and community-based peer counselors is effective in improving exclusive breastfeeding rates among low-income , inner-city women in the United States The effectiveness of an in-hospital lactation education session on breastfeeding duration and satisfaction among postpartum women was investigated . In equal number , a total of 150 women were r and omly assigned to a st and ardized curriculum ( experimental group ) or a routine-care control group . No differences were found between the groups regarding breastfeeding duration , mother 's satisfaction level , or her perceived support . Item-scale analyses , however , were promising ( a=0 . 77 ) and a preliminary factor analysis suggested three underlying subscales : professional encouragement , satisfaction , and familial relationships . Based on a stepwise , multiple regression analysis three variables were related to length of breastfeeding experience , that is , level of satisfaction , educational level of the mother , and expected length of breastfeeding . Implication s of these results toward lactation education programs and further scale development are discussed Objective To evaluate the affect of an antenatal educational breastfeeding intervention on women 's breastfeeding duration Object To evaluate the effects of psychosocial support during labour , delivery and the immediate postpartum period provided by a female companion ( doula ) BACKGROUND Breastfeeding peer counseling has improved breastfeeding rates in developing countries ; however , its impact in this country has not been adequately evaluated . OBJECTIVE To evaluate the effectiveness of an existing , breastfeeding peer counseling program within the United States . DESIGN R and omized , prospect i ve , controlled trial in which participants were recruited prenatally and r and omly assigned to receive either routine breastfeeding education or routine breastfeeding education plus peer counseling . SETTING An urban hospital serving a large population of low-income Latinas . PARTICIPANTS Pregnant women ( < or = 26 weeks ' gestation ) were recruited from the hospital 's prenatal clinic . Inclusion criteria specified that participants be low income , be considering breastfeeding , have delivered a healthy , full-term singleton , and have access to a telephone . Intervention Breastfeeding peer counseling services included 1 prenatal home visit , daily perinatal visits , 3 postpartum home visits , and telephone contact as needed . MAIN OUTCOME MEASURES Breastfeeding rates at birth and 1 , 3 , and 6 months postpartum . RESULTS The proportion not initiating breastfeeding was significantly lower in the intervention group than among controls ( 8/90 [ 9 % ] vs 17/75 [ 23 % ] ; relative risk , 0.39 ; 95 % confidence interval , 0.18 - 0.86 ) . The probability of stopping breastfeeding also tended to be lower in the intervention group at both 1 month ( 36 % vs 49 % ; relative risk , 0.72 ; 95 % confidence interval , 0.50 - 1.05 ) and 3 months ( 56 % vs 71 % ; relative risk , 0.78 ; 95 % confidence interval , 0.61 - 1.00 ) . CONCLUSION These findings demonstrate that , in the United States , peer counselors can significantly improve breastfeeding initiation rates and have an impact on breastfeeding rates at 1 and 3 months post partum R and omized trials conducted in developing countries have demonstrated that breastfeeding peer counseling increases rates of breastfeeding initiation and improves the duration of breastfeeding ( Morrow et al. 1999 ; Haider et al. 2000 ) . We are conducting a r and omized community trial , design ed to evaluate the effectiveness of an existing  community-based breastfeeding peer counseling program serving mostly low income Latinas ( i.e. , women from Spanish-speaking countries in Latin America or the Caribbean ) in Hartford , CT . Preliminary data from this on-going study previously have shown that subjects r and omized to receive breastfeeding peer counseling  have a median breastfeeding duration one month greater than their counterparts who did not receive breastfeeding peer counseling  ( 1.75 mo vs. 0.8 mo , P<0.05 ) ( Chapman et al. 2002 ) . The objectives of this analysis are to : a ) report on a process evaluation of the program , focusing on actual coverage of pre- , peri- , and postnatal services ; and b ) determine if differences in the degree and timing of the exposure to breastfeeding peer counseling services are associated with breastfeeding duration BACKGROUND Midwife-managed programmes of care are being widely implemented although there has been little investigation of their efficacy . We have compared midwife-managed care with shared care ( ie , care divided among midwives , hospital doctors , and general practitioners ) in terms of clinical efficacy and women 's satisfaction . METHODS We carried out a r and omised controlled trial of 1299 pregnant women who had no adverse characteristics at booking ( consent rate 81.9 % ) . 648 women were assigned midwife-managed care and 651 shared care .  The research hypothesis was that compared with shared care , midwife-managed care would produce fewer interventions , similar ( or more favourable ) outcomes , similar complications , and greater satisfaction with care . Data were collected by retrospective review of case records and self-report question naires . Analysis was by intention to treat . FINDINGS Interventions were similar in the two groups or lower with midwife-managed care . For example , women in the midwife-managed group were less likely than women in shared care to have induction of labour ( 146 [ 23.9 % ] vs 199 [ 33.3 % ] ; 95 % CI for difference 4.4 - 14.5 ) . Women in the midwife-managed group were more likely to have an intact perineum and less likely to have had an episiotomy ( p = 0.02 ) , with no significant difference in perineal tears . Complication rates were similar . Overall , 32.8 % of women were permanently transferred from midwife-managed care ( 28.7 % for clinical reasons , 3.7 % for non- clinical reasons ) . Women in both groups reported satisfaction with their care but the midwife-managed group were significantly more satisfied with their antenatal ( difference in mean scores 0.48 [ 95 % CI 0.41 - 0.55 ] ) , intrapartum ( 0.28 [ 0.18 - 0.37 ] ) , hospital-based postnatal care ( 0.57 [ 0.45 - 0.70 ] ) , and home-based postnatal care ( 0.33 [ 0.25 - 0.42 ] ) . INTERPRETATION We conclude that midwife-managed care for healthy women , integrated within existing services , is clinical ly effective and enhances women 's satisfaction with maternity care The purpose of this study was to determine whether the practice of early suckling , through an effect on maternal behaviour , would improve neonatal temperature control .  One hundred and sixty mothers having daytime spontaneous deliveries of healthy babies at term were r and omized into two groups . The treatment group were encouraged to put the baby to the breast immediately after delivery . In the control group , the baby was placed in a cot immediately after birth and breastfeeding occurred some time later at a time of the mother 's choice . Observations of the mother 's behaviour towards her baby and the baby 's core body temperature were recorded at 2 and 4 hours after birth and at 8 a.m. the next day . The early suckling group mothers were observed breastfeeding their babies more often than those of the control group . Significantly more of the control babies had temperatures below 36.5 degrees C at 8 a.m. the next day . Women of either group who were breastfeeding immediately prior to temperature recording were significantly less likely to have a baby with a low body temperature . It is concluded that a policy of early suckling , when compared with one of delayed contact , appears to reduce the incidence of low body temperature in the neonate In a prospect i ve multicentre study on 926 preterm infants formally assigned to their early diet , necrotising enterocolitis developed in 51 ( 5.5 % ) .  Mortality was 26 % in stringently confirmed cases . In exclusively  formula-fed  babies confirmed disease was 6 - 10 times more common than in those fed breast milk alone and 3 times more common than in those who received formula plus breast milk . Pasteurised donor milk seemed to be as protective as raw maternal milk . Among babies born at more than 30 weeks ' gestation confirmed necrotising enterocolitis was rare in those whose diet included breast milk ; it was 20 times more common in those fed formula only . Other risk factors included very low  gestational age , respiratory disease , umbilical artery catheterisation , and polycythaemia . In formula-fed but not breast-milk-fed infants , delayed enteral feeding was associated with a lower frequency of necrotising enterocolitis . With the fall in the use of breast milk in British neonatal units , exclusive formula feeding could account for an estimated 500 extra cases of necrotising enterocolitis each year . About 100 of these infants would die BACKGROUND The evidence of an association of lactation with a reduction in the  risk of breast cancer among women has been limited and inconsistent . The effect of lactation appears to be confined to premenopausal women with a history of long lactation , but most studies of this relation have been limited in statistical power . We conducted a multicenter , population -based , case-control study with a sample large enough for us to describe more precisely the association between lactation and the risk of breast cancer . METHODS Patients less than 75 years old who had breast cancer were identified from statewide tumor registries in Wisconsin , Massachusetts , Maine , and New Hampshire . Controls were r and omly selected from lists of licensed drivers if the case subjects were less than 65 years old , and from lists of Medicare beneficiaries if they were 65 through 74 years old . Information on lactation , reproductive history , and family and medical history was obtained by means of telephone interviews . After the exclusion of nulliparous women , 5878 case subjects and 8216 controls remained for analysis . RESULTS After adjustment for parity , age at first delivery , and other risk factors for breast cancer , lactation was associated with a slight reduction in the risk of breast cancer among premenopausal women , as compared with the risk among women who were parous but had never lactated ( relative risk , 0.78 ; 95 percent confidence interval , 0.66 to 0.91 ) ; the relative risk of breast cancer among postmenopausal women who had lactated , as compared with those who had not , was 1.04 ( 95 percent confidence interval , 0.95 to 1.14 ) . With an increasing cumulative duration of lactation , there was a decreasing risk of breast cancer among premenopausal women ( P for trend < 0.001 ) but not among postmenopausal , parous women ( P for trend = 0.51 ) . A younger age at first lactation was significantly associated with a reduction in the risk of premenopausal breast cancer ( P for trend = 0.003 ) . As compared with parous women who did not lactate , the relative risk of breast cancer among women who first lactated at less than 20 years of age and breast-fed their infants for a total of six months was 0.54 ( 95 percent confidence interval , 0.36 to 0.82 ) . CONCLUSIONS There is a reduction in the risk of breast cancer among premenopausal women who have lactated . No reduction in the risk of breast cancer occurred among postmenopausal women with a history of lactation BACKGROUND Despite high levels of breastfeeding initiation in Australia , only 46 percent of women are still breastfeeding ( exclusively or partially ) 6 months later , with marked differences between social groups . This study aim ed to determine the influence of mid-pregnancy breastfeeding education on the proportions of women breastfeeding at hospital discharge , and on the duration of breastfeeding . METHODS A r and omized controlled trial to compare two strategies for increasing the initiation and duration of breastfeeding was conducted , in which 981 primiparas who attended a public , tertiary women 's hospital in Melbourne , Australia , were r and omized to one of two interventions or to st and ard care ( 327 in each group ) . The interventions were a 1.5-hour class on practical aspects of breastfeeding using a previously tested tool ( Practical Skills ) , and two 1-hour classes exploring family and community attitudes toward , and experiences of , breastfeeding ( Attitudes ) . Both interventions took place in interactive small groups when women were in mid-pregnancy . Breastfeeding initiation was ascertained by interview 2 to 4 days after birth , and breastfeeding duration was assessed by telephone interview 6 months after birth . RESULTS Neither intervention increased breastfeeding initiation or duration compared with st and ard care . Rates at initiation were 97 percent ( 296/306 ) for the Practical Skills intervention , 95 percent ( 291/308 ) for the Attitudes intervention , and 96 percent ( 297/310 ) for st and ard care . Rates at 6 months were , respectively , 55 percent ( 162/297 ) , 50 percent ( 146/293 ) , and 54 percent ( 162/299 ) . CONCLUSIONS In setting s where breastfeeding initiation is already high , neither study intervention could be recommended as an effective strategy to increase breastfeeding initiation or duration OBJECTIVE To determine the effects of a partner-supported , incentive-based educational program on rates and duration of breast-feeding among low-income women . DESIGN Women who expressed a willingness to participate in the breast-feeding educational program  were r and omly assigned to one of two groups : an intervention group and a control group who received usual breast-feeding education . SETTING Clinics of the Special Supplemental Food Program for Women , Infants , and Children in Flagstaff , Ariz. SUBJECTS Sixty-eight primiparous pregnant women with expected due date s between May 1992 and December 1992 were willing to participate in the study . Of these , 34 were r and omly assigned to the intervention group and 34 to the control group . Approximately 81 % of the women completed the study : 29 in the control group and 26 in the intervention group . INTERVENTION The intervention consisted of special incentives ( prizes ) for women and their partners to participate in a breast-feeding class for expectant couples and an educational series on childbirth . Women were also encouraged to use a breast-feeding support program in which peers serve as role models . MAIN OUTCOME MEASURES The primary outcome measure was infant feeding method . Data were collected from mothers in both groups at the time of discharge from the hospital and at 2 weeks , 6 weeks , and 3 months postpartum . STATISTICAL ANALYSES PERFORMED Binomial proportional analyses of the feeding data were performed . RESULTS Women in the intervention group reported a higher percentage of breast-feeding at all measurement times . APPLICATIONS These findings suggest that incentives , such as donated prizes , can be used to attract primiparous women from lower socioeconomic groups , along with their partners , to participate in educational interventions design ed to promote breast-feeding . Participation by couples in breast-feeding promotion activities can dramatically increase the rate and duration of breast-feeding Breast feeding rates in Irel and have stagnated at around 33 % over the past 10 years . We aim ed to assess the effect of a simple intervention in late pregnancy on breast feeding rates . The study was r and omised and prospect i ve . In the intervention group a sheet illustrating eight positive aspects of breast feeding was presented to mothers at their 36 week antenatal visit . This information was reinforced with a question naire on the topic of breast feeding . The control group received a routine antenatal care . There were 98 mothers in the intervention group and 95 controls . A similar percentage in each group had medical cards . On discharge from hospital 31.5 % of controls and 43.9 % of the test group were breast feeding . This difference just failed to reach statistical significance ( P = 0.07 ) . The intervention , which took just three minutes of a medical student 's time , appeared to result in an improved breast feeding rate . Though the difference did not reach statistical significance , this reflects , in part , the small numbers in the study . About half of the women in the study indicated that no doctor had offered any advice on the choice of feeding . Since this minor intervention produced a good response , it would seem appropriate to adopt a more positive attitude in the promotion of breast feeding BACKGROUND In the Netherl and s , the initiation rate of breast-feeding ( BF ) was 80 % in 2002 , but only 35 % of the mothers continued to breast-feed for 3 months . This study examined the effectiveness of a breast-feeding promotion program to increase the continuation of breast-feeding . METHODS A cluster-r and omized intervention trial was used . Ten child health care centers in three regions of the home health care were r and omly allocated to the program or usual care . Elements in the program were health counseling , measures to enhance cooperation , early signaling of breast-feeding problems and continuity of care , and lactation consultancy .  Pregnant mothers who applied for home health care in the intervention or usual care regions were enrolled and were followed up from pregnancy until 6 months postpartum ( n = 683 ) . The primary outcome measure was the continuation of breast-feeding until at least 3 months . RESULTS The 3-month breast-feeding rate was 32 % in the intervention and 38 % in the control groups ( OR = 0.79 , 95 % CI = 0.58 - 1.08 ) . CONCLUSION The program was not effective . We discuss possible explanations from the design and execution of the trial and give some points for improvement of our program , such as the categories of caregivers involved and the number and duration of contacts after parturition The hypothesis that breast-feeding can provide protection against the development of  insulindependent diabetes mellitus ( IDDM )  and would , therefore , be less common among subjects with IDDM was tested with a retrospective design . Cases ( n = 268 ) were selected from the Colorado IDDM Registry and the Barbara Davis Center for Childhood Diabetes ( Denver , CO ) . Two control groups were recruited , one from physicians ' practice s throughout Colorado ( n = 291 ) and the second through r and om-digit dialing from the Denver area ( n = 188 ) . Cases were less likely to have been breast-fed than controls after adjustment for birth year , maternal age , maternal education , family income , race , and sex [ adjusted odds ratio ( OR ) = 0.70 ; 95 % confidence interval ( Cl ) = 0.50–0.97 ] . This finding was consistent for both control groups and by birth-year intervals . A greater decrease in risk of IDDM was seen among subjects who had been breast-fed to an older age ( for breast-feeding duration of ≥12 mo , adjusted OR = 0.54 , 95 % Cl = 0.27–1.08 ) . The amount of IDDM that might be explained by breast-feeding habits ( population percentage attributable risk ) ranged from 2 to 26 % , varying according to the breast-feeding prevalence reported in other studies . Replication of this work in different population s , controlled for the strong secular trends in breast-feeding habits , is critical before the hypothesis of protection is accepted Many factors are associated with low breast-feeding rates among black low-income women . This study examines whether , despite such factors , health professionals ' prenatal education of black poor women is associated with increased breast-feeding rates .  Black women born in the United States who attended a midwives prenatal clinic ( N = 159 ) were r and omly assigned to two types of prenatal education or were followed up in a control group . All women were interviewed on entry into the study and after delivery of their infants . Women assigned to group classes attended at least one session discussing myths , problems , and benefits of breast-feeding .  Women assigned to individual prenatal counseling spoke with a pediatrician or nurse practitioner , who discussed breast-feeding topics similar to those covered in the classes . Women in the control group received no additional prenatal education . The three study groups had significantly different percentages of women who breast-fed ( controls 22 % , classes 46 % , individual sessions 53 % ) . Higher percentages of women in the study groups carried out their prenatal plans to breast-feed ( controls 50 % , classes 86 % , individual sessions 62 % ) or breast-fed despite prenatal plans to bottle-feed ( controls 10 % , classes 26 % , individual sessions 48 % ) . After multivariable analysis controlling for age , prenatal plans to breast-feed , prior breast-feeding experience , perceived support for breast-feeding , education , gravidity , and employment plans , women in intervention groups had a higher likelihood of breast-feeding than control subjects . These findings suggest that an increase in relatively simple , not-too-time-consuming educational efforts in institutions and offices serving black low-income women might yield significant narrowing of the gap in breast-feeding rates between white affluent women and black low-income women BACKGROUND In 1990 a pilot nurse-midwifery program  was implemented in a tertiary care hospital in a major western Canadian city . a r and omized , controlled trial was conducted to determine if , when maternal and newborn patient outcomes were compared , the midwifery program was as effective as traditional , low-risk health care available in the city . METHODS All low-risk women who requested and qualified for nurse-midwifery care  were r and omly assigned to an experimental or control group . RESULTS One hundred one women received care from nurse-midwives and 93 received st and ard care from either an obstetrician or family physician .  The rate of cesarean delivery in the nurse-midwife group was 4 percent compared with 15.1 percent in the physician group . The episiotomy rate , excluding cesarean deliveries , for the nurse-midwife group was 15.5 percent compared with 32.9 percent in the physician group . The rates of epidural anesthesia for pain relief in labor were 12.9 percent and 23.7 percent , respectively . Statistically significant differences were found ultrasound examinations , amniotomy , intravenous drug administration during labor , dietary supplements , length of hospital stay , and admission of infants to the neonatal intensive care unit . CONCLUSIONS The results clearly support the effectiveness of the pilot nurse-midwifery program and suggest that more extensive participation of midwives in the Canadian health care system is an appropriate use of health care dollars BACKGROUND Exclusive breastfeeding is recommended worldwide but not commonly practised . We undertook a r and omised controlled study of the efficacy of home-based peer counselling to increase the proportion of exclusive breastfeeding among mothers and infants residing in periurban Mexico City . METHODS Two intervention groups with different counselling frequencies , six visits ( 44 ) and three visits ( 52 ) , were compared with a control group ( 34 ) that had no intervention .  From March , 1995 , to September , 1996 , 170 pregnant women were identified by census and invited to participate in the study . Home visits were made during pregnancy and early post partum by peer counsellors recruited from the same community and trained by La Leche League . Data were collected by independent interview . Exclusive breastfeeding was defined by WHO criteria . FINDINGS 130 women participated in the study . Only 12 women refused participation . Study groups did not differ in baseline factors . At 3 months post partum , exclusive breastfeeding was practised by 67 % of six-visit , 50 % of three-visit , and 12 % of control mothers ( intervention groups vs controls , p<0.001 ; six-visit vs three-visit , p=0.02 ) . Duration of breastfeeding was significantly ( p=0.02 ) longer in intervention groups than in controls , and fewer intervention than control infants had an episode of diarrhoea ( 12 % vs 26 % , p=0.03 ) . INTERPRETATION This is the first reported community-based r and omised trial of breastfeeding promotion . Early and repeated contact with peer counsellors was associated with a significant increase in breastfeeding exclusivity and duration . The two-fold decrease in diarrhoea demonstrates the importance of breastfeeding promotion to infant health Objective . To determine whether an individualized , prenatal and postnatal , lactation consultant intervention result ed in increased cumulative intensity of breastfeeding up to 52 weeks . Design . The r and omized , nonblinded , controlled trial recruited women from prenatal care . Baseline prenatal interviews covered demographic data and breastfeeding experience , intention , and knowledge . Interviews at 1 , 2 , 3 , 4 , 6 , 8 , 10 , and 12 months after birth collected data on weekly feeding patterns , infant illness , and infant health care use . Setting . Two community health centers serving low-income , primarily Hispanic and /or black women . Participants . The analytic sample included 304 women ( intervention : n = 145 ; control : n = 159 ) with ≥1 postnatal interview . Intervention . Study lactation consultants attempted 2 prenatal meetings , a postpartum hospital visit , and /or home visits and telephone calls . Control subjects received the st and ard of care .  Outcome Measures . Cumulative breastfeeding intensity at 13 and 52 weeks , based on self-reports of weekly feeding , on a 7-level scale . Results . The intervention group was more likely to breastfeed through week 20 ( 53.0 % vs 39.3 % ) . Exclusive breastfeeding rates were low and did not differ according to group . In multivariate analyses , control subjects had lower breastfeeding intensity at 13 weeks ( odds ratio [ OR ] : 1.90 ; 95 % confidence interval [ CI ] : 1.13–3.20 ) and 52 weeks ( OR : 2.50 ; 95 % CI : 1.48–4.21 ) . US-born control subjects had lowest breastfeeding intensity at 13 weeks ( OR : 5.22 ; 95 % CI : 2.43–11.22 ) and 52 weeks ( OR : 5.25 ; 95 % CI : 2.44–11.29 ) . There were no significant differences in breastfeeding intensity among the US-born intervention , foreign-born intervention , and foreign-born control groups . Conclusions . This “ best- practice s ” intervention was effective in increasing breastfeeding duration and intensity . Breastfeeding promotion should focus on US-born women and exclusive breastfeeding Abstract Problem : Breastfeeding rates and related hospital practice s need improvement in Italy and elsewhere . Training of staff is necessary , but its effectiveness needs assessment . Context : Eight hospitals in different regions of Italy . Design : Controlled , non-r and omised study . Data collected in three phases . Training after the first phase in group 1 hospitals and after the second phase in group 2 . Strategies for change : Training of trainers and subsequent training of health workers with a slightly adapted version of the 18 hour Unicef course on breastfeeding management and promotion . Key measures for improvement : Hospital practice s , knowledge of 571 health workers  , and  breastfeeding rates at discharge , three , and six months in 2669 mother and baby pairs . Effects of change : After training hospitals improved their compliance with the “ ten steps to successful breast feeding , ” from an average of 2.4 steps at phase one to 7.7 at phase three . Knowledge scores of health professionals increased from 0.41 to 0.72 in group 1 ( training after phase one ) and from 0.53 to 0.75 in group 2 ( after phase two ) . The rate of exclusive breast feeding at discharge increased significantly after training : 41 % to 77 % in group 1 and 23 % to 73 % in group 2 , as did the rates of full ( exclusive plus predominant ) breast feeding at three months ( 37 % to 50 % in group 1 v 40 % to 59 % in group 2 ) and any breast feeding at six months ( 43 % to 62 % in group 1 v 41 % to 64 % in group 2 ) . Lessons learnt : Training for at least three days with a course including practical sessions and counselling skills is effective in changing hospital practice s , knowledge of health workers , and breastfeeding rates OBJECTIVE Recognizing that an expectant father may influence a mother 's decision to breast- or formula-feed , we tested the effectiveness of a simple , educational intervention that was design ed to encourage fathers to advocate for breastfeeding and to assist his partner if she chooses to breastfeed . STUDY DESIGN We conducted a r and omized controlled trial in which expectant fathers ( n = 59 ) were assigned r and omly to attend either a 2-hour intervention class on infant care and breastfeeding promotion ( intervention ) or a class on infant care only ( control group ) . The classes , which were led by a peer-educator , were interactive and informal and utilized different media to create an accessible environment for participants . Couples were recruited during the second trimester from a university obstetrics practice . RESULTS Overall , breastfeeding was initiated by 74 % of women whose partners attended the intervention class , as compared with 41 % of women whose partners attended the control class ( P = .02 ) . CONCLUSION Expectant fathers can be influential advocates for breastfeeding , playing a critical role in encouraging a woman to breastfeed her newborn infant This study aims to identify those most responsive to  breastfeeding peer counseling ( PC ) using data from a US-based r and omized trial . The authors ran a series of logistic regression models to identify differential responses to PC , using breastfeeding status at 0 , 1 , 3 , and 6 months postpartum as the dependent variables . Three subgroups were found to be most responsive to breastfeeding PC .  Multiparae receiving PC  were 6 times more likely to initiate breastfeeding than were multiparous controls ( odds ratio [ OR ] = 6.4 ; 95 % confidence interval [ CI ] = 1.9 - 20.8 ) . Similarly , those with uncertain prenatal breastfeeding intentions in the PC group were 7 times ( OR = 7.4 ; 95 % CI = 1.5 - 37.0 ) more likely to initiate breastfeeding than their control group counterparts . Among subjects partially breastfeeding on day 1 postpartum , those receiving PC were 12 times ( OR = 11.9 ; 95 % CI = 1.2 - 111.1 ) more likely to breastfeed through 3 months postpartum than were controls . These findings have important implication s to the Supplemental Food Program for Women , Infants and Children OBJECTIVE To describe an intervention to provide support and encouragement to mothers of preterm newborns and to evaluate its effect on breastfeeding rates in the first 6 months after hospital discharge . METHODS One hundred newborns and their mothers were selected consecutively and prospect ively according to order of birth . The mother-infant dyads were alternately assigned to one of two groups : one group received routine care ( routine group ) , and the other group received the intervention ( intervention group ) . The intervention consisted of individualized support in addition to the routine support provided in the Neonatology Service . Before delivery , one of the research ers was introduced to the mother and offered her information about the delivery . The research er was also present at delivery , made an early visit to the infant in the intensive care unit , provided constant support for the mother to express breast milk and to maintain lactation , gave the mother information about maternal and infant hospital discharge , and provided outpatient follow-up after discharge . RESULTS Thirty-six dyads completed the study . The characteristics of mothers and infants , as well as causes of exclusion , were similar in the two groups . In the routine group , 38.9 % of the infants were being breastfed at hospital discharge , and median breastfeeding duration was 54 days . In the intervention group , 80.5 % were being breastfed at discharge , and median breastfeeding duration was 91 days ( p<0.01 ) . CONCLUSIONS Simple support measures offered to mothers during hospitalization and outpatient follow-up had a very positive effect on breastfeeding rates BACKGROUND Peer support may improve  breastfeeding rates  but the evidence is inconclusive . Previous studies and review s recommend trials in different healthcare setting s. AIM To test if a specified programme of peer support affects the initiation and /or the duration of breastfeeding . DESIGN OF STUDY A two-group r and omised controlled trial of peer support for breastfeeding with evaluation of breastfeeding initiation and duration on an intention-to-treat basis . SETTING General practice in Ayrshire , Scotl and . METHOD Following informed consent , 225 women at 28 weeks gestation were allocated to control or peer support group by post-recruitment concealed allocation . All peer support and control group mothers received normal professional breastfeeding support . Additionally , those in the  peer support group still breastfeeding on return home from hospital had peer support until 16 weeks . RESULTS Thirty-five of the 112 ( 31 % ) women in the peer support group were breastfeeding at 6 weeks compared to 33/113 ( 29 % ) in the control group , a difference of 2 % ( 95 % confidence interval = -10 % to 14 % ) . The median breastfeeding duration for all women in the peer support group was 2 days compared to 1 day for the control group and the Kaplan-Meier survival plot shows the peer support group overall breastfeeding slightly longer than the control group , with no statistically significant difference by logrank test ( P = 0.5 ) . The median breastfeeding duration among primagravidae in the peer support group was 7 days , compared to 3 days for the control group . Among women who started to breastfeed the medians were 72 days in the peer support group and 56 days in the control group . These differences were not statistically significant . CONCLUSIONS Peer support did not increase breastfeeding in this population by a statistically significant amount This study compared breastfeeding attitudes , intention , and initiation among low-income women exposed or not exposed to the Best Start program .  A between- ( experimental vs control group ) and within-factor ( pretest vs posttest ) repeated measures design was employed . A nonprobability sample of 54 subjects was r and omly assigned to a control group ( n = 28 ) or an experimental group ( n = 26 ) . Using the Breastfeeding Attrition Prediction Tool , statistically significant group by time interaction effects were found for negative breastfeeding sentiment , positive breastfeeding sentiment , and breastfeeding control scales . Compared to the control group , the experimental group had significantly increased positive breastfeeding sentiment ( P < .01 ) , decreased negative breastfeeding sentiment ( P < .01 ) , and increased breastfeeding control ( P < .01 ) from pretest to posttest . Following exposure to the Best Start program , subjects in the experimental group showed statistically significantly higher breastfeeding intention and initiation than did those in the control group . Practical implication s are discussed . J Hum Lact . 20(3):300 - 305 Summary . A r and omized controlled trial of two environments for delivery was conducted at Queen Charlotte 's Maternity Hospital . A total of 253 parous women expecting to have a labour ward delivery were invited to participate in the trial but only 148 agreed . These women were r and omly allocated to be delivered either with st and ard labour ward management ( n= 72 ) or in the birthroom — a small bedroom decorated in a homely manner , without facilities for epidural analgesia or electronic fetal monitoring ( n= 76 ) . Eleven women in the birthroom group and 10 in the labour ward group withdrew from the trial before labour and four were transferred from the birthroom to the labour ward when in labour . A question naire sent in the postnatal period to the women who completed the trial was returned by 80 % . In the birthroom group there was significantly ( i ) decreased admission‐to‐delivery interval ( ii ) less analgesia ( iii ) more freedom of movement ( iv ) less suturing ( v ) increased rooming‐in . No difference was found in the assessment of difficulty of labour nor in the method of subsequent infant feeding We interviewed women who participated in a breast-feeding promotion intervention study about whether and how participation affected their infant feeding choices , and if they would recommend such an intervention to others . The larger study , a r and omized controlled trial ( RCT ) of an individualized , pre- and post-natal lactation consultant ( LC ) intervention , enrolled 382 low-income primarily Black and Hispanic women in New York City . Twenty-one women completed qualitative exit interviews  for this study ( 11 from the Intervention group and 10 Controls ) . Several of the Controls stated that the post-partum study interviews were a source of support , and made them more conscious of how they fed their infant . The Intervention Group was asked about contacts with the study ' Mother-Baby specialist ' ( i.e. LC ) , including what was and was n't helpful . The Intervention Group participants described the Mother-Baby Specialist as key in their decision to initiate and maintain breastfeeding . They credit her direct skills and positive reinforcement with their confidence and perseverance to breastfeed . The success of the intervention is attributed to technical assistance from a trained lactation consultant within the context of a relationship built on encouragement , guidance and support Sagkeeng First Nation 's adolescent breastfeeding educational session  was evaluated using a r and omized pretest-posttest control group design . The intervention group received the session first ; the control group received the session following the posttest . A retention test to measure overall retained learning was given to all students 10 days later . Breastfeeding beliefs increased ( ± SD = 41.9 to 47.0 , P= .0047 ) from pretest to posttest for intervention subjects but not for controls . There were no changes in bottle-feeding beliefs or breastfeeding attitudes . There was an increase in breastfeeding beliefs from pretest to retention test for all students ( true treatment effect [ TTE ] = .85 st and ard deviation units [ SDU ] , P= .004 ) . Learning was gender specific , with females experiencing increases in breastfeeding beliefs ( TTE = 1.12 SDU , P= .004 ) , decreases in bottle-feeding beliefs ( TTE = –.77 SDU , P= .04 ) , and a trend to increased breastfeeding attitudes ( TTE = .41 SDU , NS ) . Males showed small , inconsistent learning effects . Learning occurred in the areas of health , convenience , cost , and decreased embarrassment OBJECTIVE to examine the effect of early skin-to-skin contact between mothers and their healthy full-term babies on initiation and duration of breast feeding . DESIGN a r and omised controlled trial comparing skin-to-skin with routine care . SETTING Warrington Hospital , Cheshire , UK . PARTICIPANTS 204 mother and baby pairs ; 102 r and omised to each group . OUTCOME MEASURES success of first breast feed , maternal satisfaction with skin-to-skin care and preference for future post-delivery care , baby-body temperature 1 hr after birth , partial or exclusive breast feeding at 4 months . FINDINGS in the skin-to-skin group , 89 out of 98 ( 91 % ) babies had a successful first feed compared with 82 out of 89 ( 83 % ) in the routine care group . The difference in the success rate was 8 % , 95 % confidence interval ( CI ) ( -1.6 % , 17.6 % ) ; chi(2)=2.7 ; df=1 ; P=0.10 . Forty-two out of 97 ( 43 % ) babies given skin-to-skin were partially or exclusively breast feeding at 4 months compared with 40 out of 100 ( 40 % ) of babies in the routine care group . The difference in breast-feeding rate at 4 months was 3.3 % , 95 % CI ( -10.3 % , 16.7 % ) ; chi(2)=0.22 ; df=1 ; P=0.64 . The mean temperature 1 hr after birth was higher with skin-to-skin than routine care . The difference in means was 0.15 degrees C ; 95 % CI ( 0.03 , 0.28 ) ; P=0.02 . A larger proportion of mothers ( 87/97 [ 90 % ] ) were very satisfied with skin-to-skin care , compared with 60 out of 102 ( 59 % ) in the control group ; 83 out of 97 ( 86 % ) of the mothers in the intervention group said that they would prefer to receive the same care in the future compared with 31 out of 102 ( 30 % ) mothers in the control group . CONCLUSIONS the difference between the groups in the success rate for the first breast feed and rates at 4 months was not statistically significant . However , mothers who had skin-to-skin contact enjoyed the experience , and most reported that they would choose to have skin-to skin care in the future . In this , the largest trial to date , previous concerns about baby-body temperature after skin-to-skin care were dispelled CONTEXT Current evidence that breastfeeding is beneficial for infant and child health is based exclusively on observational studies . Potential sources of bias in such studies have led to doubts about the magnitude of these health benefits in industrialized countries . OBJECTIVE To assess the effects of breastfeeding promotion on breastfeeding duration and exclusivity and gastrointestinal and respiratory infection and atopic eczema among infants . DESIGN The Promotion of Breastfeeding Intervention Trial ( PROBIT ) , a cluster-r and omized trial conducted June 1996-December 1997 with a 1-year follow-up . SETTING Thirty-one maternity hospitals and polyclinics in the Republic of Belarus . PARTICIPANTS A total of 17 046 mother-infant pairs consisting of full-term singleton infants weighing at least 2500 g and their healthy mothers who intended to breastfeed , 16491 ( 96.7 % ) of which completed the entire 12 months of follow-up . INTERVENTIONS Sites were r and omly assigned to receive an experimental intervention ( n = 16 ) modeled on the Baby-Friendly Hospital Initiative of the World Health Organization and United Nations Children 's Fund , which emphasizes health care worker assistance with initiating and maintaining breastfeeding and lactation and postnatal breastfeeding support , or a control intervention ( n = 15 ) of continuing usual infant feeding practice s and policies . MAIN OUTCOME MEASURES Duration of any breastfeeding , prevalence of predominant and exclusive breastfeeding at 3 and 6 months of life and occurrence of 1 or more episodes of gastrointestinal tract infection , 2 or more episodes of respiratory tract infection , and atopic eczema during the first 12 months of life , compared between the intervention and control groups . RESULTS Infants from the intervention sites were significantly more likely than control infants to be breastfed to any degree at 12 months ( 19.7 % vs 11.4 % ; adjusted odds ratio [ OR ] , 0.47 ; 95 % confidence interval [ CI ] , 0.32 - 0.69 ) , were more likely to be exclusively breastfed at 3 months ( 43.3 % vs 6.4 % ; P<.001 ) and at 6 months ( 7.9 % vs 0.6 % ; P = .01 ) , and had a significant reduction in the risk of 1 or more gastrointestinal tract infections ( 9.1 % vs 13.2 % ; adjusted OR , 0.60 ; 95 % CI , 0.40 - 0.91 ) and of atopic eczema ( 3.3 % vs 6.3 % ; adjusted OR , 0.54 ; 95 % CI , 0.31 - 0.95 ) , but no significant reduction in respiratory tract infection ( intervention group , 39.2 % ; control group , 39.4 % ; adjusted OR , 0.87 ; 95 % CI , 0.59 - 1.28 ) . CONCLUSIONS Our experimental intervention increased the duration and degree ( exclusivity ) of breastfeeding and decreased the risk of gastrointestinal tract infection and atopic eczema in the first year of life . These results provide a solid scientific underpinning for future interventions to promote breastfeeding OBJECTIVE To evaluate whether providing doulas  during hospital-based labor affects mode of delivery , epidural use , breast-feeding , and postpartum perceptions of the birth , self-esteem , and depression . METHODS This was a r and omized study of nullipara enrollees in a group-model health maintenance organization who delivered in one of three health maintenance organization-managed hospitals ; 149 had doulas , and 165 had usual care .  Study data were obtained from the mothers ' medical charts , study intake forms , and phone interviews conducted 4 - 6 weeks postpartum . RESULTS Women who had doulas had significantly less epidural use ( 54.4 % versus 66.1 % , P < .05 ) than women in the usual-care group . They also were significantly ( P < .05 ) more likely to rate the birth experience as good ( 82.5 % versus 67.4 % ) , to feel they coped very well with labor ( 46.8 % versus 28.3 % ) , and to feel labor had a very positive effect on their feelings as women ( 58.0 % versus 43.7 % ) and perception of their bodies ' strength and performance ( 58.0 % versus 41.0 % ) . The two groups did not differ significantly in rates of cesarean , vaginal , forceps , or vacuum delivery , oxytocin administration ; or breast-feeding , nor did they differ on the postpartum depression or self-esteem measures . CONCLUSION For this population and setting , labor support from doulas had a desirable effect on epidural use and women 's perceptions of birth , but did not alter need for operative deliveries OBJECTIVE : To address the impact of simple antenatal educational interventions on breastfeeding practice . METHODS : A r and omized controlled trial was carried out in a tertiary referral center from May 2002 to December 2004 . A r and om sample of eligible low-risk antenatal patients was recruited from clinics in the National University Hospital , Singapore . Group A received breastfeeding educational material and individual coaching from a lactation counselor . Group B received breastfeeding educational material with no counseling . Group C received routine antenatal care only . RESULTS : A total of 401 women were recruited . Mothers receiving individual counseling and educational material  practice d exclusive and predominant breastfeeding more often than mothers receiving routine care alone at 3 months ( odds ratio [ OR ] 2.6 , 95 % confidence interval [ CI ] 1.2–5.4 ) and 6 months ( OR 2.4 , 95 % CI 1.0–5.7 ) postpartum . More mothers practice d exclusive and predominant breastfeeding at 6 months among women receiving individual counseling compared with women exposed to educational material alone ( OR 2.5 , 95 % CI 1.0–6.3 ) . CONCLUSION : Where breastfeeding practice s are suboptimal , simple one-encounter antenatal education and counseling significantly improve breastfeeding practice up to 3 months after delivery . Provision of printed or audiovisual educational material is not enough . Health care workers should make every effort to have one face-to-face encounter to discuss breastfeeding with expectant mothers before they deliver . CLINICAL TRIAL REGISTRATION : Clinical Trials.gov , www . clinical trials.gov , NCT002770192 LEVEL OF EVIDENCE : OBJECTIVE To evaluate the efficacy of an intervention program to increase breast-feeding in a low-income , inner-city population . DESIGN A r and omized , nonblinded clinical control trial . Patients were followed up through pregnancy , delivery , and the first year of the infant 's life or until the time of weaning from the breast , whichever came first . SETTING The ambulatory care center for prenatal and pediatric care and the inpatient maternity unit of a primary care center that serves a low-income , inner-city population . PATIENTS There were a total of 108 patients : 51 were r and omized to the intervention group that received prenatal and postnatal lactation instruction from a lactation consultant , and 57 were r and omized to the control group that  received the st and ard of care at the institution . Patients in the control group were not seen by the lactation consultant . The two groups were similar demographically . INTERVENTION This program consisted of individual prenatal lactation consultation , daily rounds by the lactation consultant on the postpartum unit , and outpatient follow-up at 48 hours after discharge , at the time that the infant was 1 week of age , and at all future health supervision visits for infants up to 1 year of age . MAIN OUTCOME MEASURES The incidence and duration of breast-feeding . RESULTS There was a markedly higher incidence of breast-feeding in the intervention group , as compared with that of the control group ( 61 % vs 32 % , respectively ; P = .002 ) . The duration of breast-feeding was also significantly longer in the intervention group ( P = .005 ) . CONCLUSIONS This lactation program increased the incidence and duration of breast-feeding in our low-income cohort . We suggest that similar efforts that are applied to analogous population s may increase the incidence and duration of breast-feeding in low-income population s in the United States OBJECTIVE To determine whether infants of women r and omized to a prenatal and postpartum lactation support intervention  incur fewer otitis media- , respiratory tract- , or gastrointestinal-related visits than controls . DESIGN R and omized , unmasked controlled trial recruiting women from prenatal care setting s. Breastfeeding sensitive ( BFS ) illness visits for otitis media or respiratory tract or gastrointestinal complaints were obtained up to 12 months . SETTING Two urban community health centers . PARTICIPANTS Analytic sample of 338 low-income , primarily Hispanic and /or black mother-infant dyads ( n = 163 for the intervention group and n = 175 for the control group ) . INTERVENTION Study lactation consultants attempted 2 prenatal meetings , 1 postpartum hospital and /or home visit , and telephone calls as needed . Controls received the st and ard of care . MAIN OUTCOME MEASURES Combined outpatient and emergency department visits with illness and BFS illness diagnoses . RESULTS There was a significant interaction between treatment and Medicaid ; among those not receiving Medicaid , the number of otitis media visits was higher among controls ( P</=.03 ) . Visits for any illness and BFS , gastrointestinal , or respiratory tract illnesses did not differ by treatment group . Intervention group infants received more breast milk than controls , but exclusive breastfeeding rates remained low and did not differ between groups at any point . CONCLUSIONS Only the number of otitis media visits was reduced , in a subset of the intervention group . The intervention did not reduce visits for respiratory tract or gastrointestinal illness . Limited intervention contact and low exclusive breastfeeding rates may have attenuated intervention effects . Future interventions design ed to yield markedly increased breastfeeding rates may show greater effects in low-income multiethnic sample s. Health coverage for visits may moderate intervention effects OBJECTIVE The objective was to evaluate the effectiveness of  opinion leaders  in raising  breast-feeding rates .  STUDY DESIGN A r and omized controlled trial of an opinion leader strategy in 18 hospitals in Central New York State compared mothers ' intention to breast-feed during baseline and study years . Multivariate logistic regression with a mixed model analyzed the effects on breast-feeding exclusively and on breast- and formula-feeding combined . RESULTS Obstetric clinicians had a high degree of knowledge about breast-feeding benefits and of perceived responsibility to recommend breast-feeding . Obstetricians , family practitioners , and midwives agreed on the person identified as the opinion leader , in each case an obstetrician who was chief of obstetrics or obstetrics-gynecology . Breast-feeding rates in hospitals with the opinion leader intervention did not differ significantly from those in control-group hospitals during the study year . CONCLUSION The opinion leader strategy in this case did not improve breast-feeding rates during the study year . Opinion leader strategies may make assumptions about clinician control that are not justified in situations such as breast-feeding Objective : To determine whether  postnatal mother – infant sleep proximity  affects breastfeeding initiation and infant safety . Design : R and omised non-blinded trial analysed by intention to treat . Setting : Postnatal wards of the Royal Victoria Hospital ( RVI ) , Newcastle upon Tyne , UK . Participants : 64 newly delivered mother – infant dyads with a prenatal intention to breastfeed ( vaginal deliveries , no intramuscular or intravenous opiate analgesics taken in the preceding 24 h ) . Intervention : Infants were r and omly allocated to one of three sleep conditions : baby in mother ’s bed with cot-side ; baby in side-car crib attached to mother ’s bed ; and baby in st and -alone cot adjacent to mother ’s bed  . Main outcome measures : Breastfeeding frequency and infant safety observed via night-time video recordings . Results : During st and ardised 4-h observation periods , bed and side-car crib infants breastfed more frequently than st and -alone cot infants ( mean difference ( 95 % confidence interval ( CI ) ) : bed v st and -alone cot = 2.56 ( 0.72 to 4.41 ) ; side-car crib v st and -alone cot = 2.52 ( 0.87 to 4.17 ) ; bed v side-car crib = 0.04 ( −2.10 to 2.18 ) ) . No infant experienced adverse events ; however , bed infants were more frequently considered to be in potentially adverse situations ( mean difference ( 95 % CI ) : bed v st and -alone cot = 0.13 ( 0.03 to 0.23 ) ; side-car crib v st and -alone cot = 0.04 ( −0.03 to 0.12 ) ; bed v side-car crib = 0.09 ( −0.03–0.21 ) ) . No differences were observed in duration of maternal or infant sleep , frequency or duration of assistance provided by staff , or maternal rating of postnatal satisfaction . Conclusion : Suckling frequency in the early postpartum period is a well-known predictor of successful breastfeeding initiation . Newborn babies sleeping in close proximity to their mothers ( bedding-in ) facilitates frequent feeding in comparison with rooming-in . None of the three sleep conditions was associated with adverse events , although infrequent , potential risks may have occurred in the bed group . Side-car cribs are effective in enhancing breastfeeding initiation and preserving infant safety in the postnatal ward The effectiveness of a breastfeeding education intervention consisting of a 11/2-hour m and ated session for all nursing staff , with an optional self-paced tutorial , was evaluated in a small rural Canadian hospital . The intervention was design ed to increase exclusive breastfeeding rates , create positive beliefs and attitudes among staff members , and increase compliance with the World Health Organization/UNICEF Baby-Friendly Hospital Initiative ( BFHI ) . Staff surveys and chart audits were conducted at both the intervention and control site hospitals prior to the intervention and 7 months after the intervention . Over a 7-month period , the intervention hospital experienced an increase in BFHI compliance ( 24.4 vs. 31.9 , P<.01 ) , breastfeeding beliefs ( 55.0 vs. 58.8 , P<.05 ) , and exclusive breastfeeding rates ( 31 % vs. 54 % of breastfed babies , P<.05 ) but no change in breastfeeding attitudes ( 44.0 vs. 44.9 , P=.80 ) . The control site experienced no change in BFHI compliance , beliefs , or attitudes but a significant decrease in exclusive breastfeeding rates ( 43 % vs. 0 % , P<.05 ) The birth of a  child  and adaptation to motherhood is generally accepted to be a stressful life event . During this time women may experience significant physiological , phycological and emotional changes in their lives Objective To compare the effect of formula company – produced material s about infant feeding to breast-feeding promotion material s without formula advertising on breast-feeding initiation and duration . Methods Five hundred forty-seven pregnant women were r and omized to receive either formula company ( commercial ; n = 277 ) or specially design ed ( research ; n = 270 )  educational packs about infant feeding at their first prenatal visit . Feeding method was determined at delivery . Breast-feeding duration of the 294 women who chose to breast-feed was ascertained at 2 , 6 , 12 , and 24 weeks . Survival analyses were used to evaluate continuous outcomes , and χ2 and logistic regression analyses were used to evaluate discrete outcomes . Results Breast-feeding initiation ( relative risk [ RR ] 0.93 , 95 % confidence interval [ CI ] 0.61 , 1.43 ) and duration after 2 weeks ( hazard ratio 1.19 , 95 % CI 0.86 , 1.64 ) were not affected . Women in the commercial group were more likely to cease breast-feeding before hospital discharge ( RR 5.80 , 95 % CI 1.25 , 54.01 ) and before 2 weeks ( adjusted odds ratio [ OR ] 1.91 , 95 % CI 1.02 , 3.55 ) . In subgroup analyses , women with uncertain goals for breast-feeding or goals of 12 weeks or less experienced shortened exclusive ( hazard ratio 1.53 , 95 % CI 1.06 , 2.21 ) , full ( hazard ratio 1.70 , 95 % CI 1.18 , 2.48 ) , and overall ( hazard ratio 1.75 , 95 % CI 1.16 , 2.64 ) breast-feeding duration when exposed to the commercial intervention . Conclusion Although breast-feeding initiation and long-term duration were not affected , exposure to formula promotion material s increased significantly breast-feeding cessation in the first 2 weeks . Additionally , among women with uncertain goals or breast-feeding goals of 12 weeks or less , exclusive , full , and overall breast-feeding duration were shortened . Educational material s about infant feeding should support unequivocally breast-feeding as optimal nutrition for infants ; formula promotion products should be eliminated from prenatal setting BACKGROUND Promotion of breastfeeding is an important child-survival intervention , yet little is known about which promotional strategies are the most effective . We aim ed to compare the effects on rates of breastfeeding of two systems for promotion of breastfeeding in Brazil -- a hospital-based system and the same system combined with a programme of home visits . METHODS In February , 2001 , maternity staff from two hospitals in Pernambuco , Brazil , were trained according to the Baby-Friendly Hospital Initiative ( BFHI ) . In a r and omised trial between March and August , 2001 , 350 mothers giving birth at these hospitals were assigned ten postnatal home visits to promote and support breastfeeding ( n=175 ) or no home visits ( n=175 ) . Breastfeeding practice s were studied on days 1 , 10 , 30 , 60 , 90 , 120 , 150 , and 180 by research ers unaware of group allocation . The primary outcome measure was the rate of exclusive breastfeeding from birth to 6 months . Analyses were by intention to treat . FINDINGS The hospital-training intervention achieved a high rate ( 70 % ) of exclusive breastfeeding in the hospitals , but this rate was not sustained at home and at 10 days of age only 30 % of infants were exclusively breastfed The patterns of exclusive breastfeeding in the two trial groups for days 10 - 180 differed significantly ( p<0.0001 ) , with a mean aggregated prevalence of 45 % among the group assigned home visits compared with 13 % for the group assigned none . INTERPRETATION The BFHI achieves high rates of exclusive breastfeeding in hospital ; however , in Brazil at least , the rates fall rapidly thereafter . Reliance on the BFHI as a strategy for breastfeeding promotion should be reassessed . A combination of promotional systems ( hospital-based and in the community ) is needed BACKGROUND Although lactation experts suggest that a correct positioning and attachment technique reduces breastfeeding problems and enhances long-term breastfeeding , evidence from r and omized trials is lacking . The objective of this study was to evaluate the effect of postpartum positioning and attachment education on breastfeeding outcomes in first-time mothers . METHOD A r and omized trial was performed in a public hospital in Adelaide , South Australia , where 160 first-time mothers were r and omly allocated to receive either structured one-to-one education ( experimental group ) or usual postpartum care ( control group ) within 24 hours of birth . The primary outcome was breastfeeding at 6 weeks and 3 and 6 months postpartum ; other outcomes were nipple pain and trauma in hospital and at 6 weeks and 3 and 6 months , and satisfaction with breastfeeding . RESULTS No significant differences occurred in breastfeeding rates between the groups at each endpoint , although a trend in the direction of lower rates was seen at each endpoint in the experimental group . This group reported less nipple pain on days 2 ( p = 0.004 ) and 3 ( p = 0.04 ) , but this was not sustained on follow-up . No differences were observed in nipple trauma in hospital or in self-reported nipple pain and /or trauma at the three endpoints . Experimental group women were less satisfied with breastfeeding at 3 and 6 months postpartum when using a one-item measure ; however , a multiple-item measure showed no significant differences at the three endpoints . CONCLUSIONS The intervention did not increase breastfeeding duration at any assessment time or demonstrate any differences between the groups on secondary outcomes . The trend toward lower breastfeeding rates in the experimental group suggests a need for a larger trial to evaluate whether or nor postpartum positioning and attachment education may negatively affect breastfeeding This is a prospect i ve study involving ninety-two lactating mother- infant pairs in the first six months of birth . They were followed-up up to six months for various perinatal factors determining the duration of exclusive breastfeeding .  Early postpartum mother-baby skin-to-skin contact had a powerful influence ( P<0.001 ) over the duration of exclusive breastfeeding  up to 4 - 6 months and was found to be more significant than early initiation of breastfeeding ( P<0.05 ) . Mode of delivery did not have any significant effect ( P<0.5 ) over the duration of exclusive breastfeeding . Thus health care centers can easily adopt a policy to allow few minutes of early postpartum mother-baby skin-to-skin contact and early initiation of breastfeeding to all vaginal as well as caesarian deliveries to promote breastfeeding Birthing centre care offers women with a low risk of complication in pregnancy an alternative to conventional care for the birthing of their baby It is important these two forms of care are appropriately assessed STUDY OBJECTIVE : To identify environmental determinants of six symptoms associated with allergic disease in infancy . DESIGN : Infants were participants in a prospect i ve r and omised controlled trial of feeding practice s in families with a history of atopy . SETTING : Infants were recruited in two maternity hospitals in S Wales and followed up in the community for 1 year . PARTICIPANTS : Mothers of 519 infants agreed to participate , but 36 were excluded ( mainly for moving home or failing to attend for follow-up ) , leaving 483 in the study ( 253 male , 230 female ) . Infants were followed up and examined for evidence of allergic disease at 3 , 6 , and 12 months . MEASUREMENTS AND MAIN RESULTS : At each examination , mothers were question ed about episodes of illness in the infant , and the data presented relate to ( reported and observed ) eczema and nasal discharge , and ( reported ) wheeze , prolonged colds , diarrhoea and vomiting . Mothers kept a diary with details of feeding for the first 6 months . All homes were visited by a nurse who took sample s of dust for dust mite antigen analysis . Extensive socio-demographic data were collected . None of the factors studied showed a convincing relationship with eczema . In a multiple logistic regression analysis breast feeding appeared to protect against wheeze , nasal discharge , colds , vomiting and diarrhoea . Having more siblings increased the likelihood of prolonged colds , and ( together with overcrowding ) of wheeze and nasal discharge . Maternal smoking and low social class were associated with wheeze , and house dust antigen with prolonged colds . Respiratory symptoms were associated with some aspects of housing but these could not be distinguished clearly from other social factors . Babies born in Autumn were at increased risk of wheeze , vomiting and diarrhoea . CONCLUSIONS : Environmental factors play an important part in determining risk of symptoms in potentially atopic babies . These factors are in principle open to manipulation The rate of breastfeeding among immigrant Vietnamese women in Western countries is low compared to those in Vietnam . To counteract this trend , a language and culture specific education program was developed . An experimental design was used to test the effectiveness of this program . The sample consisted of 182 prenatal Vietnamese women . Data collection included question naires and interviews . Results suggested that the education program had significant effects on knowledge , attitudes , planned and actual behaviour towards breastfeeding . However , the effect did not sustain until 6 months postpartum . Implication s for nursing practice and further research are discussed
BACKGROUND Despite the widely documented health benefits of breastfeeding , initiation rates remain relatively low in many high-income countries , particularly among women in lower income groups .
OBJECTIVES To evaluate the effectiveness of interventions which aim to encourage women to breastfeed  in terms of changes in the number of women who start to breastfeed .