Patient navigation for perinatal substance use disorder treatment: A systematic review.

BACKGROUND: Substance use during the perinatal period (i.e., pregnancy through the first year postpartum) can pose significant maternal and infant health risks. However, access to lifesaving medications and standard care remains low for perinatal persons who use substances. This lack of substance use disorder treatment access stems from fragmented services, stigma, and social determinants of health-related barriers that could be addressed using patient navigators. This systematic review describes patient navigation models of care for perinatal people who use substances and associated outcomes. METHODS: We conducted a structured search of peer-reviewed, US-focused, English- or Spanish-language articles from 2000 to 2023 focused on 1) patient navigation, 2) prenatal and postpartum care, and 3) substance use treatment programs using PubMed, Scopus, PsycINFO, and CINAHL databases. RESULTS: After meeting eligibility criteria, 17 studies were included in this review. The majority (n=8) described outpatient patient navigation programs, with notable hospital (n=4) and residential (n=3) programs. Patient navigation was associated with reduced maternal substance use, increased receipt of services, and improved maternal and neonatal health. Findings were mixed for engagement in substance use disorder treatment and child custody outcomes. Programs that co-located care, engaged patients across the perinatal period, and worked to build trust and communication with family members and service providers were particularly successful. CONCLUSION: Patient navigation may be a promising strategy for improving maternal and infant health outcomes among perinatal persons who use substances. More experimental research is needed to test the effect of patient navigation programs for perinatal persons who use substances compared to other models of care.

Forming the Perception of WIC Infant Feeding Recommendations: A Qualitative Study.

Nearly half of newborns in the United States are enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Promoting breastfeeding is a programmatic priority, although formula vouchers are provided for those who do not exclusively breastfeed. Previous literature suggests that participant perception of WIC's breastfeeding recommendations is a significant factor predicting breastfeeding initiation, duration, and exclusivity outcomes. However, little is known about how participants' perceptions of WIC's breastfeeding recommendations are formed. To address this knowledge gap, we conducted a qualitative pilot study in Nevada, interviewing 10 postpartum WIC mothers and 12 WIC staff who had interacted with participants regarding infant feeding. Results showed participants and staff reported various perceptions of what WIC recommends, the factors that contribute to these perceptions, and how these perceptions affect breastfeeding practices. Respondents also described that WIC has a negative legacy as the "free formula program," and that environmental factors, such as the recent formula recall, have had an impact on participants' infant feeding practices. More effective public campaigns and programmatic strategies are needed to target participants' prenatal self-efficacy and to communicate the availability of skilled lactation support in the early postpartum period to improve participants' perceptions of WIC's position on breastfeeding.

Evaluation of an Evidence-Based Prenatal Breastfeeding Education Curriculum Adapted for the COVID-19 Pandemic: Ready, Set, Baby Live COVID-19 Edition.

In response to the cessation of in-person prenatal education services during the COVID-19 pandemic, we adapted an evidence-based curriculum to a live virtual format entitled Ready, Set, Baby Live COVID-19 Edition (RSB Live). In a sample of 146 pregnant people, participation in RSB Live was associated with high levels of knowledge about the benefits of breastfeeding, early infant hunger cues, and recommended maternity care practices, as well as high levels of satisfaction with adaptations to the session's content and virtual delivery. Participation was also associated with a significant increase in prenatal breastfeeding intention, a known predictor of breastfeeding outcomes. This study supports live, virtual education with a standardized curriculum as an effective and acceptable means of providing prenatal education.

Prenatal Perception of WIC Breastfeeding Recommendations Predicts Breastfeeding Exclusivity and Duration in the Infants' First Year.

BACKGROUND: Pregnant participants who perceived that the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) recommends breastfeeding only were more likely to have better early breastfeeding outcomes. OBJECTIVES: Our objective was to examine the association between prenatal perception of WIC's breastfeeding recommendations and breastfeeding duration through the first year of infant life. METHODS: This observational study used a national longitudinal sample of 1594 pregnant participants in the WIC Infant and Toddler Feeding Practices Study-2 in 2013. Four measures of breastfeeding duration were used: 1) a discrete measure of exclusive breastfeeding through 5 mo; 2) a continuous measure of exclusive breastfeeding (in days up to 7 mo); 3) a discrete measure of any breastfeeding through 11 mo; and 4) a continuous measure of any breastfeeding (in days up to 13 mo). The primary explanatory variable was the participant's prenatal perception of whether WIC recommended breastfeeding only. The univariate analyses of time to breastfeeding cessation were performed using Kaplan-Meier curves. The Cox regression model was adopted to estimate the likelihood of breastfeeding outcomes over time. All analyses accounted for complex survey design effects. RESULTS: Compared with their peers who perceived WIC to recommend formula only or both breastfeeding and formula equally, participants who perceived WIC as recommending breastfeeding only were less likely to stop exclusive breastfeeding through 5 mo (HR = 0.83; 95% CI: 0.69, 0.99) or to stop any breastfeeding through 11 mo (HR = 0.80; 95% CI: 0.69, 0.92), without controlling for prenatal infant feeding intentions. Similar patterns were observed in the 2 continuous measures, as they were also less likely to stop exclusive breastfeeding by 7 mo (HR = 0.78; 95% CI: 0.69, 0.90) or to stop any breastfeeding by 13 mo (HR = 0.82; 95% CI: 0.71, 0.95). CONCLUSIONS: Prenatal perception of WIC's breastfeeding recommendation can be a useful predictor of breastfeeding duration in WIC participants.

Lactation Support for People Who Are Incarcerated: A Systematic Review.

Background: Lactation support, defined here as the access to educational resources, supplies, mental health and psychosocial support, skilled lactation counseling, and peer support, has been identified as critical to optimal health outcomes for birthing parents and infants. People who give birth while incarcerated are likely to receive suboptimal lactation support. The purpose of this review is to explore the literature on lactation support for incarcerated people to identify existing programs and policies, gaps in lactation support and ways to address the gaps, and incarcerated people's perspectives on breastfeeding and lactation support. Methods: We conducted a systematic review of the peer-reviewed literature to identify studies that addressed two main concepts: (1) breastfeeding and (2) incarcerated populations in the United States. Results: After meeting the eligibility criteria, 29 studies were included in the qualitative synthesis of the findings. Studies highlight the importance of supporting birthing people who want to provide milk to their infants in a way that is desired, psychologically safe, and structurally supported. Programs are needed to delay or prevent parent-infant separation after birth, provide education around breastfeeding misconceptions, and link to resources and ongoing support for both breastfeeding and milk expression. Implementation of breastfeeding programs may be most effectively undertaken with clear policies and dedicated leadership either internally or through community or health care partnerships. Discussion: This review highlights the policies and practices that hinder adequate lactation support for birthing parent-infant dyads who are incarcerated and describes feasible policies, education, and clinical support that can be used to improve care.

Correlates of Receiving Guideline-Concordant Postpartum Health Services in the Community Health Center Setting.

Introduction: New clinical guidelines recommend comprehensive and timely postpartum services across 3 months after birth. Research is needed to characterize correlates of receiving guideline-concordant, quality postpartum care in federally qualified health centers serving marginalized populations. Methods: We abstracted electronic health record data from patients who received prenatal health care at three health centers in North Carolina to characterize quality postpartum care practices and to identify correlates of receiving quality care. We used multivariable log-binomial regression to estimate associations between patient, provider, and health center characteristics and two quality postpartum care outcomes: (1) timely care, defined as an initial assessment within the first 3 weeks and at least one additional visit within the first 3 months postpartum; and (2) comprehensive care, defined as receipt of services addressing family planning, infant feeding, chronic health, mood, and physical recovery across the first 3 months. Results: In a cohort of 253 patients, 60.5% received comprehensive postpartum care and 30.8% received timely care. Several prenatal factors (adequate care use, an engaged patient-provider relationship) and postpartum factors (early appointment scheduling, exclusive breastfeeding, and use of enabling services) were associated with timely postpartum care. The most important correlate of comprehensive services was having more than one postpartum visit during the first 3 months postpartum. Discussion: Identifying best practices for quality postpartum care in the health center setting can inform strategies to reduce health inequities. Future research should engage community stakeholders to define patient-centered measures of quality postpartum care and to identify community-centered ways of delivering this care.

Impact of Mentoring on Academic Career Success for Women in Medicine: A Systematic Review.

PURPOSE: Research has shown that barriers to career success in academic medicine disproportionately affect women. These barriers include inadequate mentoring, which may perpetuate the underrepresentation of women in senior leadership positions. The purpose of this review was to summarize the qualitative and quantitative evidence of the impact of mentoring on women's career outcomes and to inform future interventions to support the promotion and retention of women in academic medicine. METHOD: The authors conducted a systematic review of original research published in English-language, peer-reviewed journals through March 20, 2020. Search terms related to mentorship, women, and academic medicine. The authors searched MEDLINE, Embase, Scopus, Current Contents Connect via Web of Science, Cochrane Library, and PsycINFO. They excluded studies not specifically addressing women and those without gender-stratified outcomes. They extracted and analyzed the following data: study design, population, sample size, response rate, participant age, percentage of women, mentoring prevalence, and outcomes. RESULTS: Of 2,439 citations identified, 91 studies met the inclusion criteria, including 65 quantitative and 26 qualitative studies. Mentoring was associated with objective and subjective measures of career success. Women perceived mentorship to be more valuable to their career development yet were more likely to report having no mentor. Additionally, women were more likely to report lower levels of research productivity, less career satisfaction, and greater barriers to promotion. Qualitative results indicated that women had less access to informal mentoring and family responsibilities had a greater effect on their career outcomes. Professional networking, female mentors, and relational aspects of mentoring were common themes. CONCLUSIONS: This review examined gender disparities in mentoring and the impact on research productivity, promotion success, and career satisfaction for women in academic medicine. Institution-supported mentoring programs are needed to facilitate identification of appropriate mentors and promotion of a more equitable academic career environment for women.

Prenatal perception of breastfeeding recommendations predicts early breastfeeding outcomes of participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

BACKGROUND: Prenatal psychosocial factors predict breastfeeding practices but are not assessed in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). OBJECTIVES: This study examined how prenatal perceptions of WIC's breastfeeding recommendations were associated with early breastfeeding outcomes. METHODS: This study used longitudinal data from a national sample of 2053 pregnant participants in the WIC Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2) in 2013, the only national data assessing prenatal perceptions of WIC's breastfeeding recommendations. Early breastfeeding outcomes included breastfeeding initiation, breast milk first fed after birth, breastfeeding in the first hour, breast milk first fed after leaving the hospital, and breastfeeding status at the first and third months. The primary predictor was the participant's prenatal perception of whether WIC recommended breastfeeding only or not. Log-binomial regression was used with adjustment for socio-demographics, previous breastfeeding, WIC participation, breastfeeding support, and infant feeding intentions (IFI). RESULTS: Without controlling for IFI, the perception of WIC recommending breastfeeding only predicted breastfeeding outcomes positively. The risk ratio (RR) associated with prenatal perceptions varied from 1.14 (95% CI: 1.03, 1.25; P = 0.008) for breastfeeding in the first hour, to 1.27 (95% CI: 1.12, 1.43; P < 0.001) for breast milk first fed after leaving hospital, to 1.66 (95% CI: 1.35, 2.04; P < 0.001) for 3-mo breastfeeding only. After controlling for IFI, the RRs were 1.13 (95% CI: 1.02, 1.24; P = 0.017) for breastfeeding in the first hour, 1.20 (95% CI: 1.06, 1.35; P = 0.004) for breast milk first fed after leaving hospital, and 1.49 (95% CI: 1.21, 1.84; P < 0.001) for 3-mo breastfeeding only, suggesting that prenatal perception was independently associated with breastfeeding outcomes. CONCLUSIONS: Prenatal perception of WIC's breastfeeding recommendations can be regarded as a new psychosocial predictor of breastfeeding and a possible target for future intervention.

A Systematic Review of Patient-, Provider-, and Health System-Level Predictors of Postpartum Health Care Use by People of Color and Low-Income and/or Uninsured Populations in the United States.

Introduction: People of color and low-income and uninsured populations in the United States have elevated risks of adverse maternal health outcomes alongside low levels of postpartum visit attendance. The postpartum period is a critical window for delivering health care services to reduce health inequities and their transgenerational effects. Evidence is needed to identify predictors of postpartum visit attendance in marginalized populations. Methods: We conducted a systematic review of the peer-reviewed literature to identify studies that quantified patient-, provider-, and health system-level predictors of postpartum health care use by people of color and low-income and uninsured populations. We extracted study design, sample, measures, and outcome data from studies meeting our eligibility criteria, and used a modified Cochrane Risk of Bias tool to evaluate risk of bias. Results: Out of 2,757 studies, 36 met our criteria for inclusion in this review. Patient-level factors consistently associated with postpartum care included higher socioeconomic status, rural residence, fewer children, older age, medical complications, and previous health care use. Perceived discrimination during intrapartum care and trouble understanding the health care provider were associated with lower postpartum visit use, while satisfaction with the provider and having a provider familiar with one's health history were associated with higher use. Health system predictors included public facilities, group prenatal care, and services such as patient navigators and appointment reminders. Discussion: Postpartum health service research in marginalized populations has predominantly focused on patient-level factors; however, the multilevel predictors identified in this review reflect underlying inequities and should be used to inform the design of structural changes.

Oxytocin during breastfeeding and maternal mood symptoms.

This study aimed to quantify the relationship between postpartum depression and anxiety, oxytocin, and breastfeeding. We conducted a longitudinal prospective study of mother-infant dyads from the third trimester of pregnancy to 12 months postpartum. A sample of 222 women were recruited to complete the Beck Depression Inventory II and Spielberger State-Trait Anxiety Inventory-state subscale, participate in observed infant feeding sessions at 2 and 6 months postpartum, and provide venous blood samples during feeding. Maternal venous oxytocin levels in EDTA-treated plasma and saliva were determined by enzyme immunoassay with extraction and a composite measure of area under the curve (AUC) was used to define oxytocin across a breastfeeding session. Linear regression was used to estimate associations between postpartum depression and anxiety as predictors and oxytocin AUC during breastfeeding as the outcome at both 2 and 6 months postpartum. Mixed models accounting for correlations between repeated oxytocin measures were used to quantify the association between current depression and/or anxiety symptoms and oxytocin profiles during breastfeeding. We found no significant differences in oxytocin AUC across a feed between depressed or anxious women and asymptomatic women at either 2 or 6 months postpartum. Repeated measures analyses demonstrated no differences in oxytocin trajectories during breastfeeding by symptom group but possible differences by antidepressant use. Our study suggests that external factors may influence the relationship between oxytocin, maternal mood symptoms, and infant feeding.

Positive Emotions During Infant Feeding and Breastfeeding Outcomes.

BACKGROUND: Few studies have examined the role of maternal emotions in breastfeeding outcomes. RESEARCH AIM: We aimed to determine the extent to which positive maternal emotions during human milk feeding at 2 months were associated with time to any and exclusive human milk feeding cessation and overall breastfeeding experience. METHODS: A sample of 192 women intending to breastfeed for at least 2 months was followed from the third trimester until 12 months postpartum. Positive emotions during infant feeding at 2 months were measured using the modified Differential Emotions Scale. Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHR) for time to any and exclusive human milk feeding cessation associated with a 1-point increase in positive emotions. Linear regression was used to estimate the association between positive emotions and maternal breastfeeding experience reported at 12 months. RESULTS: Among those human milk feeding at 2 months, positive emotions during feeding were not associated with human milk feeding cessation by 12 months (aHR = 0.94, 95% CI [0.64, 1.31]). However, among women exclusively human milk feeding at 2 months, a 1-point increase in positive emotions was associated with a 35% lower hazard of introducing formula or solid foods by 6 months (aHR = 0.65, 95% CI [0.46, 0.92]). Positive emotions were associated with a significantly more favorable maternal report of breastfeeding experience at 12 months. Results were similar in sensitivity analyses using maternal feelings about breastfeeding in the first week as the exposure. CONCLUSIONS: A positive maternal emotional experience of feeding is associated with breastfeeding outcomes.

The Lactational Effects of Contraceptive Hormones: an Evaluation (LECHE) Study.

OBJECTIVE: To estimate the proportion of women for whom use of hormonal contraception was associated with reporting a decreased breast milk supply. STUDY DESIGN: The Lactational Effects of Contraceptive Hormones: an Evaluation ("LECHE") Study was an anonymous, internet-based, exploratory, cross-sectional survey of postpartum women using approximately 70 questions. Women were eligible to participate in the survey if they were 18 years or older, had a singleton infant between 3 and 9 months of age, had breastfed this infant for any amount of time and could read English. The survey included questions about breastfeeding, reproductive health, demographic characteristics and the timing of postpartum events. RESULTS: A total of 3971 participants clicked on the survey. Our final study population included 2922 participants. Overall, 1201 (41%) reported having had milk supply concerns at some point in the first 12 weeks postpartum. The median time from birth until milk supply concerns was 3 weeks (IQR 1-7). Eight hundred fifty-two women (29%) started hormonal contraception in the first 12 weeks postpartum. Fifteen percent (127/852) of women reported new or additional milk supply concerns after starting hormonal contraception. Reported milk supply concerns were higher for women who used hormonal contraception than those who did not (44% vs. 40%; p=.05) Adjusted hazard ratios (HRs) assessing the association between contraceptive use and time to milk supply concerns were not statistically significant (HR 1.18, 95% confidence interval 0.94-1.47 for any type of hormonal contraception). CONCLUSIONS: This study found a slightly increased proportion of reported milk supply concerns among women who started hormonal contraception. IMPLICATIONS: It is important for caregivers in the postpartum period to recognize the potential for multiple factors, including initiation of hormonal contraception, to affect breastfeeding. Patient-centered counseling can help elicit women's values and preferences regarding breastfeeding and pregnancy prevention.

Positive Emotions During Infant Feeding and Postpartum Mental Health.

BACKGROUND: Research shows that individuals can improve mental health by increasing experiences of positive emotions. However, the role of positive emotions in perinatal mental health has not been investigated. This study explored the extent to which positive emotions during infant feeding are associated with maternal depression and anxiety during the first year postpartum. MATERIALS AND METHODS: One hundred and sixty-four women drawn from a longitudinal cohort of mother-infant dyads were followed from the third trimester through 12 months postpartum. We measured positive emotions during infant feeding at 2 months using the mean subscale score of the modified Differential Emotions Scale. Depression and anxiety symptoms were assessed with the Beck Depression Inventory-II and State Trait Anxiety Inventory-State subscale at months 2, 6, and 12. Generalized linear mixed models were used to estimate crude and multivariable associations. RESULTS: Among women with no clinical depression during pregnancy, higher positive emotions during infant feeding at 2 months were associated with significantly fewer depression symptoms at 2, 6, and 12 months and with lower odds of clinically significant depression symptoms at 2 and 6 months. In contrast to depression outcomes, women with clinical anxiety during pregnancy who experienced higher positive emotions had significantly fewer anxiety symptoms at 2, 6, and 12 months and lower odds of clinically significant anxiety at 2 and 6 months. CONCLUSIONS: Positive emotions during infant feeding are associated with depression and anxiety outcomes during the first year postpartum and may be a modifiable protective factor for maternal mental health.

A Geospatial Analysis of the Impact of the Baby-Friendly Hospital Initiative on Breastfeeding Initiation in North Carolina.

BACKGROUND:: Significant disparities in breastfeeding support and practice exist in North Carolina. The Baby-Friendly Hospital Initiative is a worldwide intervention that encourages birth facilities to adopt specific practices in support of breastfeeding. RESEARCH AIM:: This study aimed to evaluate the impact of the Baby-Friendly Hospital Initiative on breastfeeding initiation in North Carolina, with special attention to rural areas. METHODS:: To better understand disparities in breastfeeding initiation across North Carolina, we conducted a secondary analysis of birth certificate data from 2011 to 2014. Univariate and multivariate logistic regression models were used to estimate the association between breastfeeding initiation and (a) birth at a Baby-Friendly hospital and (b) maternal residence in a county with a Baby-Friendly hospital. Model residuals were aggregated by county and analyzed for spatial autocorrelation. RESULTS:: Birth at a Baby-Friendly hospital was associated with increased odds of breastfeeding initiation, adjusted odds ratio = 1.7, 95% confidence interval [1.65, 1.89]. Model residuals showed significant clustering by county, with some rural areas' rates systematically overestimated. Whereas presence of a Baby-Friendly hospital in a mother's community of residence was not associated with increased initiation, birth at a Baby-Friendly hospital was associated with smaller disparities in initiation between rural and urban births. CONCLUSION:: Birth at a Baby-Friendly hospital is associated with improved breastfeeding initiation and reduced disparities in initiation between rural and urban counties in North Carolina.

Contraception and Breastfeeding at 4 Months Postpartum Among Women Intending to Breastfeed.

OBJECTIVE: To estimate the association between postpartum contraception and breastfeeding among women intending to breastfeed. METHODS: We analyzed data from the Infant Feeding Practices Study II, a prospective cohort study of U.S. mothers (2005-2007). Among 1,349 women with prenatal intention to breastfeed at least 4 months who reported contraception use 3 months postpartum, we used multivariable logistic regression to estimate odds and predicted probabilities of breastfeeding by contraceptive category. We considered prenatal breastfeeding intention, age, race, education, income, marital status, region, depressive symptoms, parity, and timing of return to work as potential confounders, using standard statistical methods to determine model covariates. RESULTS: At 3 months postpartum, contraception was reported as follows: 720 (53%) nonhormonal contraceptives (NHCs), 256 (19%) combined hormonal contraceptives (CHCs), 217 (16%) progestin-only pills (POPs), 92 (7%) intrauterine devices, and 64 (5%) depot medroxyprogesterone acetate. Compared with NHCs, adjusted odds ratio (aOR) for any breastfeeding at 4 months postpartum among women using POPs was 3.15 (95% confidence interval [CI] 1.42-7.02), and for women using CHCs aOR was 0.17 (95% CI 0.10-0.29). For women using NHCs, predicted probability of any breastfeeding at 4 months postpartum was 90% (95% CI 85-94); it was 97% (95% CI 92-99) among those using POPs and 61% (95% CI 46-74) among those using CHCs. CONCLUSION: In a cohort of women intending to breastfeed at least 4 months, women using POPs were most likely, and women using CHCs were least likely, to achieve their breastfeeding intentions.

Systematic Review of Evidence for Baby-Friendly Hospital Initiative Step 3.

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

Improving Access to Medical Lactation Support and Counseling: Building the Case for Medicaid Reimbursement.

Objective While the Affordable Care Act improves access to lactation services for many women across the US, low-income mothers in states without Medicaid expansion lack coverage for lactation support. As these states consider individual Medicaid reimbursement policies, the availability, effectiveness, and cost-benefit of lactation services must be evaluated. We conducted such an analysis for low-income mothers in North Carolina (NC), providing a model for other states. Methods First, we analyzed the distribution of NC International Board Certified Lactation Consultants (IBCLCs) and county-level breastfeeding rates among low-income infants. Logistic regression was used to examine the association between IBCLC density and 6-week breastfeeding duration. Finally, state advocates collaborated on a cost-benefit analysis of Medicaid coverage of IBCLCs. Results Maps of the NC breastfeeding support landscape indicate that IBCLCs are available to provide services to low-income women across the state. Compared to counties with no IBCLCs, those with high IBCLC density were found to have a 6-week breastfeeding prevalence ratio of 1.20 (95 % CI 1.12, 1.28). Medicaid reimbursement of IBCLCs showed an estimated annual cost savings of $2.33 million. Conclusions for Practice In one state without Medicaid expansion, we found that breastfeeding support resources are available across the state, high density IBCLC support is associated with increased breastfeeding by low-income mothers, and services are cost-effective. Our model for Medicaid reimbursement in NC provides a framework for states to improve equity in access to optimal lactation support.

Postpartum Mental Health and Breastfeeding Practices: An Analysis Using the 2010-2011 Pregnancy Risk Assessment Monitoring System.

Objective Evidence suggests that women with postpartum depression (PPD) are at risk for early breastfeeding cessation, but previous studies have been limited by small samples. The objective of this analysis is to estimate the association between PPD symptoms and breastfeeding using a national, stratified, random sample of U.S. mothers. Methods Data from the 2010-2011 Pregnancy Risk Assessment Monitoring System were analyzed for New York City and the 29 states for which data were available. Multivariable logistic regression was used to explore the association between a pre-pregnancy mental health visit and subsequent breastfeeding initiation as well as PPD and 3-month any and exclusive breastfeeding. To identify state-level variation, we created maps of prevalence and adjusted odds of breastfeeding by PPD and pre-pregnancy mental health status. Results Women reporting a pre-pregnancy mental health visit had 0.61 (95 % CI 0.56, 0.67) times the odds of initiating breastfeeding compared with women who reported no pre-pregnancy visit. At 3 months postpartum, women with PPD symptoms since birth had 0.79 (95 % CI 0.70, 0.88) times the odds of any breastfeeding and reduced odds of exclusive breastfeeding modified by race/ethnicity. We found variation in state-level PPD symptoms and pre-pregnancy mental health prevalence and adjusted odds of breastfeeding. Conclusions for Practice Our results highlight the importance of providing targeted breastfeeding support to women with PPD symptoms, because they are at risk of early breastfeeding cessation. Given the cross-sectional nature of these data, women with early breastfeeding cessation may also be at risk for PPD, requiring screening and treatment.