Gearing to success with national breastfeeding programmes: The Becoming Breastfeeding Friendly (BBF) initiative experience.

Evidence-based policy toolboxes are essential for decision makers to effectively invest in and scale up maternal-child health and nutrition programs, and breastfeeding is no exception. This special issue focuses on the experiences implementing the Becoming Breastfeeding Friendly (BBF) toolbox in England, Scotland, and Wales. BBF is an initiative that includes a toolbox for decision making based on the Complex Adaptive System-based Breastfeeding Gear Model. The BBF initiative experience in Great Britain presented in this special issue illustrates how versatile BBF is as it can be readily adapted to the specific application context. In this instance one country, England was trained by the Yale School of Public Health team that developed BBF. England, in turn, trained and assisted Scotland and Wales with the implementation and oversight of BBF in those countries. The positive experience implementing BBF in Great Britain is fully consistent with findings related to this initiative in other countries with contrasting economic, social, political and health care systems; including Germany, Ghana, Mexico, Myanmar, and Samoa. In all instances BBF has led to breastfeeding policy improvements with strong implications for enabling breastfeeding environments including maternity benefits, workforce development, the Baby Friendly Hospital Initiative and behavior change communication campaigns. In conclusion, BBF is a powerful tool to help guide the effective scaling up of evidence-based programmes to advance breastfeeding protection, promotion and support globally.

Scaling up breastfeeding in England through the Becoming Breastfeeding Friendly initiative (BBF).

Breastfeeding is the most accessible and cost-effective activity available to public health and has been shown to be one of the most effective preventive measures mothers can take to protect their children's health. Despite the well-documented benefits, the UK has one of the lowest breastfeeding rates in the world. The Becoming Breastfeeding Friendly (BBF) toolkit was developed through highly structured technical and academic collaboration, led by Yale University. It provides an evidence-based process to help countries assess their breastfeeding status and readiness to scale up, and identifies concrete measures countries can take to sustainably increase breastfeeding rates, based on data-driven recommendations. BBF is grounded in the Breastfeeding Gear Model complex adaptive systems framework which is made up of eight simultaneous conditions that sustain breastfeeding. In 2018, a committee of multi-agency stakeholders implemented the BBF process in England, collecting evidence to score the 'gear' components of England's breastfeeding environment against 54 benchmarks. The Training and Programme Delivery gear received the highest score, attributable to existing learning outcomes for health professionals and practitioners, peer supporters and specialist services, although there is a need for greater coordination and integration. The lowest scores were given for Promotion and Coordination, Goals and Monitoring due to the lack of a dedicated national strategy for breastfeeding and poor sharing of localised strategies and programmes. The process generated clear recommendations highlighting the need for more robust routine infant feeding data collection and reporting, and the necessity for strengthening leadership, monitoring and oversight to scale up and sustain breastfeeding.

Non-profit breastfeeding organisations' peer support provision in areas of socio-economic deprivation in the UK: A meta-ethnography.

In many high-income countries such as the United Kingdom, inequalities in breastfeeding initiation and continuation rates exist, whereby socio-economically advantaged mothers are most likely to breastfeed. Breastfeeding peer support interventions are recommended to address this inequality, with non-profit breastfeeding organisations providing such support in areas of deprivation. As these organisations' roots and membership are often formed of relatively highly resourced women who have different backgrounds and experiences to those living in areas of deprivation, it is important to understand their practices in this context. In order to explore how UK non-profit organisations practice breastfeeding peer support in areas of socio-economic deprivation, a systematic review and meta-ethnography of published and grey literature was undertaken. Sixteen texts were included, and three core themes constructed: (1) 'changing communities' reveals practices designed to generate community level change, and (2) 'enabling one to one support', explains how proactive working practices enabled individual mothers' access to supportive environments. (3) 'forging partnerships with health professionals', describes how embedding peer support within local health services facilitated peer supporters' access to mothers. While few breastfeeding peer support practices were directly linked to the context of socio-economic deprivation, those described sought to influence community and individual level change. They illuminate the importance of interprofessional working. Further work to consolidate the peer-professional interface to ensure needs-led care is required.

Adapting breastfeeding support in areas of socio-economic deprivation: a case study approach.

BACKGROUND: There are inequalities in breastfeeding initiation and continuation rates, whereby socio-economically disadvantaged mothers are least likely to breastfeed. Breastfeeding peer support (BPS) interventions are recommended as a solution, and in the UK non-profit organisations are commissioned to deliver BPS services in areas of socio-economic deprivation. BPS interventions have a mixed evidence base, offering limited knowledge about the interaction between context and intervention and how this affects women's experiences. METHODS: This interpretive study used a case study methodology to explore how and why two BPS services developed their services in socio-economically deprived contexts. Methods aimed to generate holistic understanding of BPS service development. Data collected across both cases comprised; observation (n = 1), and semi-structured interviews with: mothers who had (n = 10) and had not (n = 9) engaged with the BPS services, peer supporters (PSs) (n = 9), community health professionals (n = 5), infant feeding co-ordinators (n = 2), non-profit organisation managers (n = 3), and public health commissioners (n = 2). Inductive grounded theory analytic techniques of open coding and constant comparisons, followed by cross case comparisons, were used to analyse the data. RESULTS: The over-arching theme - 'the transcending influence of society' - offers insights into the underlying context and drivers impacting service development. It reflects how funding and data sharing arrangements determined service operation and the peer's access to women. Four underpinning themes explain how: peer supporters were resourceful in adapting their services ('adapting and modifying the support'); BPS organisations worked to enable women's access to supportive breastfeeding environments, but did not necessarily focus service development on the needs of women living in areas of deprivation ('supporting women's journeys to access'); the BPS-professional connections for supporting access and how BPS could result in more supportive community environments ('embedding within healthcare practice'); and how management practices precluded meaningful use of data to provide context led service development ('ways of using knowledge'). CONCLUSIONS: Findings suggest that while PSs are commissioned to focus on those most in need, there is limited discussion, collection, or use of knowledge about women's lives to develop needs-led service delivery. The key recommendation is the development of a social ecological tool to facilitate the use and application of contextual knowledge.

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

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

The ABA intervention for improving breastfeeding initiation and continuation: Feasibility study results.

The UK has low breastfeeding rates, with socioeconomic disparities. The Assets-based feeding help Before and After birth (ABA) intervention was designed to be inclusive and improve infant feeding behaviours. ABA is underpinned by the behaviour change wheel and offers an assets-based approach focusing on positive capabilities of individuals and communities, including use of a Genogram. This study aimed to investigate feasibility of intervention delivery within a randomised controlled trial (RCT). Nulliparous women ≥16 years, (n = 103) from two English sites were recruited and randomised to either intervention or usual care. The intervention - delivered through face-to-face, telephone and text message by trained Infant Feeding Helpers (IFHs) - ran from 30-weeks' gestation until 5-months postnatal. Outcomes included recruitment rates and follow-up at 3-days, 8-weeks and 6-months postnatal, with collection of future full trial outcomes via questionnaires. A mixed-methods process evaluation included qualitative interviews with 30 women, 13 IFHs and 17 maternity providers; IFH contact logs; and fidelity checking of antenatal contact recordings. This study successfully recruited women, including teenagers, from socioeconomically disadvantaged areas; postnatal follow-up rates were 68.0%, 85.4% and 80.6% at 3-days, 8-weeks and 6-months respectively. Breastfeeding at 8-weeks was obtained for 95.1% using routine data for non-responders. It was possible to recruit and train peer supporters to deliver the intervention with adequate fidelity. The ABA intervention was acceptable to women, IFHs and maternity services. There was minimal contamination and no evidence of intervention-related harm. In conclusion, the intervention is feasible to deliver within an RCT, and a definitive trial required.

A realist qualitative study to explore how low-income pregnant women use Healthy Start food vouchers.

Healthy Start is the UK government's food voucher programme for low-income pregnant women and young children. It was introduced in 2006, but the impact of the programme on nutritional outcomes remains understudied. This study sought to explore potential outcomes of the Healthy Start programme (including intended and unintended outcomes) and develop explanations for how and why these outcomes might occur. A realist review preceded this study, in which programme theories were developed and tested using existing evidence. This qualitative study aimed to further refine and consolidate the programme theories from the realist review while remaining open to new and emerging theories (or hypotheses) about how low-income pregnant women use Healthy Start vouchers. Semistructured interviews were conducted with 11 low-income women from North West England, who received Healthy Start vouchers during pregnancy. A realist logic of analysis was applied to generate clear and transparent linkages between outcomes and explanations. The findings suggested that some women used the vouchers to improve their diets during pregnancy (intended outcome), whereas some women were diverted towards alternative or unintended outcomes. Women's circumstances, values, beliefs, and motivations influenced how they perceived and responded to the vouchers. This paper presents four evidence-based programme theories to explain four contrasting (and potentially overlapping) outcomes: dietary improvements (theory refined from review), shared benefits (new theory), financial assistance (theory refined from review), and stockpiling formula (new theory). It considers how the Healthy Start programme could be improved, to increase the possibilities for low-income women to experience the intended outcome of dietary improvements.

Global implications of the new WHO and UNICEF implementation guidance on the revised Baby-Friendly Hospital Initiative.

Although breastfeeding confers both short- and long-term benefits for children and their mothers, breastfeeding practice remains suboptimal, globally. In addition to barriers including misperceptions and inappropriate marketing of breast milk substitutes, inadequate support for breastfeeding remains a challenge in many settings. To improve access to appropriate health system support, the World Health Organization (WHO) has reviewed the Baby-Friendly Hospital Initiative (BFHI), which ensures provision of optimal clinical care and support to mothers and their infants. This review has resulted in revision of the Ten Steps to Successful Breastfeeding, which form the core standards of (BFHI). These now consist of critical management procedures to support breastfeeding (Steps 1 and 2) and key clinical practices to support breastfeeding (Steps 3-10). In Step 1, there is now specific emphasis on compliance with the WHO Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions as well as on internal monitoring. There are also significant position shifts like the recommendation to "Counsel mothers on the use and risks of feeding bottles, teats, and pacifiers," which is a departure from the earlier position of avoiding reference to these technologies. These revisions require countries and states to revise activities and tools for their local situation but without compromising the standards.

Perceptions and experiences of using a nipple shield among parents and staff - an ethnographic study in neonatal units.

BACKGROUND: Preterm infants have an immature sucking behavior and the capacity to be exclusively breastfed may be reduced for a period of weeks or months, depending on gestational age. Nipple shields have been used, not only as a device to help mothers with sore nipples, but also to facilitate the infant's latch on to the breast. However, the benefits of using nipple shields have been debated. The aim of this study was to explore perceptions and experiences of using a nipple shield among parents and staff in neonatal units in Sweden and England. METHODS: An ethnographic study was undertaken where observations and interviews were conducted in four neonatal units in Sweden and England. The data were analyzed using a thematic networks analysis. RESULT: The global theme was developed and named, 'Nipple shield in a liminal time'. This comprised of two organizing themes: 'Relational breastfeeding' and 'Progression'. 'Relational breastfeeding' was underpinned by the basic themes, 'good enough breast', 'something in between' and 'tranquil moment'. 'Progression' was underpinned by the basic themes, 'learning quicker', 'short-term solution' and 'rescue remedy'. Although breastfeeding was seen primarily as a nutritive transaction, the relational aspects of breastfeeding were of crucial importance. These two organizing themes show the tension between acknowledging the relational aspects of breastfeeding and yet facilitating or supporting the progression of breastfeeding in the period from tube feeding or cup feeding to breastfeeding. It is a liminal time as mothers and their infants are "in between" phases and the outcome, in terms of breastfeeding, is yet to be realized. CONCLUSION: This study demonstrates parents' and staffs' perceptions of the nipple shield as a short term solution to help initiation of breastfeeding but also as a barrier between the mother and infant. It is important that the mother and baby's own particular needs are taken into account, in a person-centred way and on an ongoing basis. Furthermore, we need to emphasise the importance of the 'relational' whilst understanding the need for 'progression'. Holding these in balance may be the key to appropriate use of the nipple shield.

Understanding communication pathways to foster community engagement for health improvement in North West Pakistan.

BACKGROUND: This paper describes the community engagement process undertaken to ascertain the focus, development and implementation of an intervention to improve iodised salt consumption in rural communities in North West Pakistan. The Jirga is a traditional informal structure, which gathers men respected within their community and acts in a governing and decision-making capacity in the Pukhtoon culture. The Jirga system had a dual purpose for the study: to access men from the community to discuss the importance of iodised salt, and as an engagement process for the intervention. METHODS: A number of qualitative data collection activities were undertaken, with Jirga members and their wives, male and female outreach workers and two groups of women, under and over 40 years old. The aim of these was to highlight the communication channels and levers of influence on health behaviour, which were multiple and complex and all needed to be taken into consideration in order to ensure successful and locally sensitive community engagement. RESULTS: Communication channels are described within local families and the communities around them. The key influential role of the Jirga is highlighted as linked both to the standing of its members and the community cohesion ethos that it embodies. Engaging Jirga members in discussions about iodised salt was key in designing an intervention that would activate the most influential levers to decision making in the community. Gendered decision-making processes within the household have been highlighted as restricting women's autonomy. Whilst in one respect our data confirm this, a more complex hierarchy of decisional power has been highlighted, whereby the concept of 'wisdom'- an amalgamation of age, experience and education- presents important possibilities. Community members with the least autonomy are the youngest uneducated females, who rely on a web of socially and culturally determined ways to influence decision-making. CONCLUSIONS: The major lines of communication and influence in the local community described are placed within the wider literature on community engagement in health improvement. The process of maximisation of local cultural knowledge as part of a community engagement effort is one that has application well beyond the particular setting of this study.

Breast pumps as an incentive for breastfeeding: a mixed methods study of acceptability.

Increasing breastfeeding rates would improve maternal and child health, but multiple barriers to breastfeeding persist. Breast pump provision has been used as an incentive for breastfeeding, although effectiveness is unclear. Women's use of breast pumps is increasing and a high proportion of mothers express breastmilk. No research has yet reported women's and health professionals' perspectives on breast pumps as an incentive for breastfeeding. In the Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS) study, mixed methods research explored women's and professionals' views of breast pumps as an incentive for breastfeeding. A survey of health professionals across Scotland and North West England measured agreement with 'a breast pump costing around £40 provided for free on the NHS' as an incentive strategy. Qualitative interviews and focus groups were conducted in two UK regions with a total of 68 participants (pregnant women, new mothers, and their significant others and health professionals) and thematic analysis undertaken. The survey of 497 health professionals found net agreement of 67.8% (337/497) with the breast pump incentive strategy, with no predictors of agreement shown by a multiple ordered logistic regression model. Qualitative research found interrelated themes of the 'appeal and value of breast pumps', 'sharing the load', 'perceived benefits', 'perceived risks' and issues related to 'timing'. Qualitative participants expressed mixed views on the acceptability of breast pumps as an incentive for breastfeeding. Understanding the mechanisms of action for pump type, timing and additional support required for effectiveness is required to underpin trials of breast pump provision as an incentive for improving breastfeeding outcomes. © 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.

Effective suckling in relation to naked maternal-infant body contact in the first hour of life: an observation study.

BACKGROUND: Best practice guidelines to promote breastfeeding suggest that (i) mothers hold their babies in naked body contact immediately after birth, (ii) babies remain undisturbed for at least one hour and (iii) breastfeeding assistance be offered during this period. Few studies have closely observed the implementation of these guidelines in practice. We sought to evaluate these practices on suckling achievement within the first hour after birth. METHODS: Observations of seventy-eight mother-baby dyads recorded newborn feeding behaviours, the help received by mothers and birthing room practices each minute, for sixty minutes. RESULTS: Duration of naked body contact between mothers and their newborn babies varied widely from 1 to 60 minutes, as did commencement of suckling (range = 10 to 60 minutes). Naked maternal-infant body contact immediately after birth, uninterrupted for at least thirty minutes did not predict effective suckling within the first hour of birth. Newborns were four times more likely to sustain deep rhythmical suckling when their chin made contact with their mother's breast as they approached the nipple (OR 3.8; CI 1.03 - 14) and if their mothers had given birth previously (OR 6.7; CI 1.35 - 33). Infants who had any naso-oropharyngeal suctioning administered at birth were six times less likely to suckle effectively (OR .176; CI .04 - .9). CONCLUSION: Effective suckling within the first hour of life was associated with a collection of practices including infants positioned so their chin can instinctively nudge the underside of their mother's breast as they approach to grasp the nipple and attach to suckle. The best type of assistance provided in the birthing room that enables newborns to sustain an effective latch was paying attention to newborn feeding behaviours and not administering naso-oropharyngeal suction routinely.

Creating a positive place and space in NICUs.

There has been an increased focus on place and space within maternity and neonatal care and how configuration of space influences the experiences of parents, babies and staff. Furthermore, although there is increasing emphasis upon family-centred care, research shows wide differences in NICUs' provision of facilities to enable parental presence and involvement. In this article we refer to key findings from a recent ethnographic study on parents' and staff experiences related to feeding preterm babies in four NICUs in England and Sweden. We describe the ways in which design of space in NICUs influences infant feeding experiences and the developing parent-baby relationship.

Building Breastfeeding Research Relations and Beyond: An Interview With Fiona Dykes.

Professor Fiona Dykes is Professor Emerita of Maternal and Infant Health at the University of Central Lancashire in the United Kingdom (UCLAN). Fiona has a particular interest in the global, sociocultural, and political influences upon infant and young child feeding practices; her methodological expertise is in ethnography and other qualitative research methods. She founded the Maternal and Infant Nutrition and Nurture Unit (MAINN) in 2000 which she led until she retired from her full-time professorship in 2020. Fiona established the associated MAINN Conference in 2007. The MAINN conference is a 3 day, international, peer reviewed event held bi-annually in the United Kingdom and, more recently, in alternate years overseas (Sydney, Australia; Falun, Dalarna, Sweden; and Florida, United States). The conference draws together key researchers in the field of infant and young child feeding from around the world. Fiona was a founding member of the journal Maternal and Child Nutrition. She is author of Breastfeeding in Hospital: Mothers, Midwives and the Production Line (Routledge) and co-author, with Dr Tanya Cassidy, of Banking on Milk: An Ethnography of Donor Human Milk Relations (Routledge). She is also joint editor of several books including Infant and Young Child Feeding: Challenges to Implementing a Global Strategy (Wiley-Blackwell) and Ethnographic Research in Maternal and Child Health (Routledge). This interview was conducted on April 20, 2023, by Dr. Tanya Cassidy, and is based on a verbatim transcription and edited for readability.TC = Tanya Cassidy; FD = Fiona Dykes.

EURRECA-Estimating zinc requirements for deriving dietary reference values.

Zinc was selected as a priority micronutrient for EURRECA, because there is significant heterogeneity in the Dietary Reference Values (DRVs) across Europe. In addition, the prevalence of inadequate zinc intakes was thought to be high among all population groups worldwide, and the public health concern is considerable. In accordance with the EURRECA consortium principles and protocols, a series of literature reviews were undertaken in order to develop best practice guidelines for assessing dietary zinc intake and zinc status. These were incorporated into subsequent literature search strategies and protocols for studies investigating the relationships between zinc intake, status and health, as well as studies relating to the factorial approach (including bioavailability) for setting dietary recommendations. EMBASE (Ovid), Cochrane Library CENTRAL, and MEDLINE (Ovid) databases were searched for studies published up to February 2010 and collated into a series of Endnote databases that are available for the use of future DRV panels. Meta-analyses of data extracted from these publications were performed where possible in order to address specific questions relating to factors affecting dietary recommendations. This review has highlighted the need for more high quality studies to address gaps in current knowledge, in particular the continued search for a reliable biomarker of zinc status and the influence of genetic polymorphisms on individual dietary requirements. In addition, there is a need to further develop models of the effect of dietary inhibitors of zinc absorption and their impact on population dietary zinc requirements.

'Being in a womb' or 'playing musical chairs': the impact of place and space on infant feeding in NICUs.

BACKGROUND: Becoming a parent of a preterm baby requiring neonatal care constitutes an extraordinary life situation in which parenting begins and evolves in a medical and unfamiliar setting. Although there is increasing emphasis within maternity and neonatal care on the influence of place and space upon the experiences of staff and service users, there is a lack of research on how space and place influence relationships and care in the neonatal environment. The aim of this study was to explore, in-depth, the impact of place and space on parents' experiences and practices related to feeding their preterm babies in Neonatal Intensive Care Units (NICUs) in Sweden and England. METHODS: An ethnographic approach was utilised in two NICUs in Sweden and two comparable units in England, UK. Over an eleven month period, a total of 52 mothers, 19 fathers and 102 staff were observed and interviewed. A grounded theory approach was utilised throughout data collection and analysis. RESULTS: The core category of 'the room as a conveyance for an attuned feeding' was underpinned by four categories: the level of 'ownership' of space and place; the feeling of 'at-homeness'; the experience of 'the door or a shield' against people entering, for privacy, for enabling a focus within, and for regulating socialising and the; 'window of opportunity'. Findings showed that the construction and design of space and place was strongly influential on the developing parent-infant relationship and for experiencing a sense of connectedness and a shared awareness with the baby during feeding, an attuned feeding. CONCLUSIONS: If our proposed model is valid, it is vital that these findings are considered when developing or reconfiguring NICUs so that account is taken of the influences of spatiality upon parent's experiences. Even without redesign there are measures that may be taken to make a positive difference for parents and their preterm babies.

Integrating a sense of coherence into the neonatal environment.

BACKGROUND: Family centred care (FCC) is currently a valued philosophy within neonatal care; an approach that places the parents at the heart of all decision-making and engagement in the care of their infant. However, to date, there is a lack of clarity regarding the definition of FCC and limited evidence of FCCs effectiveness in relation to parental, infant or staff outcomes. DISCUSSION: In this paper we present a new perspective to neonatal care based on Aaron Antonovksy's Sense of Coherence (SOC) theory of well-being and positive health. Whilst the SOC was originally conceptualised as a psychological-based construct, the SOCs three underpinning concepts of comprehensibility, manageability and meaningfulness provide a theoretical lens through which to consider and reflect upon meaningful care provision in this particular care environment. By drawing on available FCC research, we consider how the SOC concepts considered from both a parental and professional perspective need to be addressed. The debate offered in this paper is not presented to reduce the importance or significance of FCC within neonatal care, but, rather, how consideration of the SOC offers the basis through which meaningful and effective FCC may be delivered. Practice based implications contextualised within the SOC constructs are also detailed. SUMMARY: Consideration of the SOC constructs from both a parental and professional perspective need to be addressed in FCC provision. Service delivery and care practices need to be comprehensible, meaningful and manageable in order to achieve and promote positive well-being and health for all concerned.