Breastfeeding: crucially important, but increasingly challenged in a market-driven world

Abstract Globally women continue to face substantial barriers to breastfeeding. The 2016 Lancet Breastfeeding Series identified key barriers and reviewed effective interventions that address them. The present study updates the evidence base since 2016 using a review of reviews approach. Searches were implemented using the Epistomenikos database. One hundred and fifteen reviews of interventions were identified and assessed for quality and risk of bias. Over half of reviews (53%) were high‐ or moderate quality, with the remaining low or critically low quality due to weaknesses in assessment of bias. A large portion of studies addressed high‐income and upper‐middle income settings, (41%), and a majority (63%) addressed health systems, followed by community and family settings (39%). Findings from reviews continue to strengthen the evidence base for effective interventions that improve breastfeeding outcomes across all levels of the social‐ecological model, including supportive workplace policies; implementation of the Baby‐Friendly Hospital Initiative, skin to skin care, kangaroo mother care, and cup feeding in health settings; and the importance of continuity of care and support in community and family settings, via home visits delivered by CHWs, supported by fathers', grandmothers' and community involvement. Studies disproportionately focus on health systems in high income and upper‐middle income settings. There is insufficient attention to policy and structural interventions, the workplace and there is a need for rigorous assessment of multilevel interventions. Evidence from the past 5 years demonstrates the need to build on well‐established knowledge to scale up breastfeeding protection, promotion and support programmes.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/mcn.13344

What works to protect, promote and support breastfeeding on a large scale: A review of reviews

Breastfeeding is the evolved human infant feeding norm, practiced historically and across cultures. Over the past 200 years, breastfeeding practices have eroded, reaching a nadir in the middle of the 20th century. Mobilization from grassroots social movements, with support from public health and medicine, has yielded a substantial rise in overall breastfeeding prevalence. However, timely initiation, exclusive breastfeeding, and duration of breastfeeding still lag behind global targets. Inadequate breastfeeding leads to substantial morbidity and approximately 600,000 child deaths and an additional 100,000 maternal deaths annually. Most women and pregnant people are physiologically able and desire to breastfeed, however, they face substantial barriers. Effective interventions address health systems, workplace policies, and engage communities and families. However, substantial work remains to implement fully supportive policies across multiple social sectors. Urgent action is needed to limit the pervasive influence of commercial milk formula (CMF) marketing in policy, healthcare, and on families to achieve more equitable outcomes. 

Overcoming barriers to breastfeeding.

http://www.thelancet.com/article/S0140673622019328/pdf

BACKGROUND
Mothers in low-income settings work in agricultural employment are challenged to meet breastfeeding (BF) recommendations. Recent legislation in Kenya mandates maternity leave and workplace supports, yet the relationship of these benefits with BF practices is poorly understood.


OBJECTIVES
We evaluated the associations with workplace-provided BF supports and BF practices among formally employed mothers in Kenya. The availability of supports was hypothesized to be associated with a higher prevalence and greater odds of exclusive breastfeeding (EBF).


METHODS
We conducted repeated cross-sectional surveys among formally employed mothers at 1-4 days, 6 weeks, 14 weeks, and 36 weeks (to estimate 24 weeks) postpartum in Naivasha, Kenya. We used logistic regression, adjusted for maternal age, education, physical burden of work, HIV status, and income, to evaluate associations between workplace supports and EBF practices.


RESULTS
Among formally employed mothers (n = 564), those who used onsite workplace childcare were more likely to practice EBF than those who used community- or home-based childcare at both 6 weeks (95.7% versus 82.4%, p = 0.030) and 14 weeks (60.6% versus 22.2%, p < 0.001; (aOR: 5.11, 95% CI: 2.3, 11.7). Likewise, at 14 weeks, among mothers who currently used daycares, a higher proportion who visited daycares at or near workplaces practiced EBF (70.0%) than those not visiting a daycare (34.7%, p = 0.005). EBF prevalence was higher among mothers with access to workplace private lactation spaces than those without such spaces (84.6% vs. 55.6%, p = 0.037), and among mothers who lived in workplace housing than those without onsite housing (aOR: 2.06, 95% CI: 1.25, 3.41).


CONCLUSIONS
Formally employed mothers in Kenya who have access to and use workplace-provided BF supports were more likely to practice EBF than mothers who lacked these supports. As the Kenya Health Act is implemented, lactation rooms, onsite housing and daycare, and transportation to visit children can support employed mothers' breastfeeding.

Access to Workplace Supports is Positively Associated with Exclusive Breastfeeding Among Formally Employed Mothers in Kenya.

Objective: To critically review the literature regarding workplace breast-feeding interventions and to assess their impact on breast-feeding indicators. Design:
 A systematic review and meta-analysis was conducted. Electronic searches for workplace intervention studies to support breast-feeding, without restriction on language or study design, were performed in PubMed, CENTRAL, CINAHL, Embase, Web of Science, Business Source Complete, ProQuest-Sociology and ProQuest-Social Science to 13 April 2020. A meta-analysis of the pooled effect of the programmes on breast-feeding indicators was conducted. Results:
 The search identified 10 215 articles; fourteen studies across eighteen publications met eligibility criteria. Programmes were delivered in the USA (n 10), Turkey (n 2), Thailand (n 1) or Taiwan (n 1). There were no randomised controlled trials. The pooled OR for exclusive breast-feeding at 3 or 6 months for participants v. non-participants of three non-randomised controlled studies was 3·21 (95 % CI 1·70, 6·06, I2 = 22 %). Despite high heterogeneity, other pooled outcomes were consistently in a positive direction with acceptable CI. Pooled mean duration of breast-feeding for five single-arm studies was 9·16 months (95 % CI 8·25, 10·07). Pooled proportion of breast-feeding at 6 months for six single-arm studies was 0·76 (95 % CI 0·66, 0·84) and breast-feeding at 12 months for three single-arm studies was 0·41 (95 % CI 0·22, 0·62). Most programmes were targeted at mothers; two were targeted at expectant fathers. Conclusions:
 Workplace programmes may be effective in promoting breast-feeding among employed mothers and partners of employed fathers. However, no randomised controlled trials were identified, and better-quality research on workplace interventions to improve breast-feeding is needed.

Workplace programmes for supporting breast-feeding: a systematic review and meta-analysis.

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Workplace programmes for supporting breast-feeding: a systematic review and meta-analysis.