A balancing act-midwives' and public health nurses' experiences with breastfeeding counselling.

AIMS AND OBJECTIVES: To explore midwives' and public-health nurses' experiences of breastfeeding counselling in order to provide a deeper insight into breastfeeding counselling. METHODOLOGICAL DESIGN AND JUSTIFICATION: A qualitative design was used, and qualitative content analysis was conducted to analyse the data in accordance with the phenomenological hermeneutic tradition. ETHICAL ISSUES AND APPROVAL: The Norwegian Centre for Research Data approved this study. All participants provided written consent. RESEARCH METHODS: Four focus-group interviews were conducted on a sample of eight midwives and 13 public-health nurses in Norway. RESULTS: Three interrelated themes describing the meaning of midwives' and public-health nurses' experiences with breastfeeding counselling emerged from the analysis: Breastfeeding Counselling Means Responsibility for Collaboration and Facilitation, Being Confident as a Breastfeeding Counsellor Means Striving for Professional Competence and Supporting the Individual Breastfeeding Family Means Being Sensitive and Adapting to Novel Situations. STUDY LIMITATIONS: The focus groups comprised a mix of midwives and public-health nurses, which may have inhibited honest declaration of these professionals' opinions of each other. CONCLUSION: Midwives and public-health nurses regard structural factors and prioritising breastfeeding support in society as important for providing good breastfeeding counselling. Midwives and public-health nurses strive to find a balance between relying on their own competence, promoting breastfeeding in accordance with guidelines and respecting mothers' choices. Healthcare professionals require knowledge about breastfeeding, good clinical judgement, a listening attitude and openness to how breastfeeding affects mother's everyday life to provide good breastfeeding care.

The contribution of breastfeeding to a healthy, secure and sustainable food system for infants and young children: monitoring mothers' milk production in the food surveillance system of Norway.

OBJECTIVE: The mother-child breastfeeding dyad is a powerful force for achieving healthy, secure and sustainable food systems. However, food system reports exclude breastfeeding and mother's milk. To help correct this omission and give breastfeeding women greater visibility in food systems dialogue and action, we illustrate how to estimate mother's milk production and incorporate this into food surveillance systems, drawing on the pioneering experience of Norway to show the potential value of such analysis. DESIGN: The estimates use data on the proportion of children who are breastfed at each month of age (0-24 months), annual number of live births and assumptions on daily human milk intake at each month. New indicators for temporal and cross-country comparisons are considered. SETTING: It is assumed that a breastfeeding mother on average produces 306 l of milk during 24 months of lactation. PARTICIPANTS: The annual number of live births is from Statistics Norway. Data for any breastfeeding at each month of age, between 0 and 24 months, are from official surveys in 1993, 1998-1999, 2006-2007, 2013 and 2018-2019. RESULTS: Estimated total milk production by Norwegian mothers increased from 8·2 to 10·1 million l per year between 1993 and 2018-2019. Annual per capita production increased from 69 to 91 l per child aged 0-24 months. CONCLUSIONS: This study shows it is feasible and useful to include human milk production in food surveillance systems as an indicator of infant and young child food security and dietary quality. It also demonstrates significant potential for greater milk production.

Breastfeeding Rates and Programs in Europe: A Survey of 11 National Breastfeeding Committees and Representatives.

INTRODUCTION: Among the world's regions, the WHO European Region has the lowest rates of exclusive breastfeeding at the age of 6 months with approximately 25%. Low rates and early cessation of breastfeeding have important adverse health consequences for women, infants, and young children. Protecting, promoting, and supporting breastfeeding are a public health priority. OBJECTIVES: National breastfeeding data and monitoring systems among selected European countries and the WHO European Region are compared. Mechanisms for the support, protection, and promotion of breastfeeding are reviewed and successes and challenges in implementation of national programs are presented. METHODS: National representatives of national breastfeeding committees and initiatives in 11 European countries, including Belgium, Croatia, Denmark, Germany, Ireland, Italy, The Netherlands, Norway, Spain, Sweden, and Switzerland, participated in a standardized survey. Results are evaluated and compared in a narrative review. RESULTS: Variation exists in Europe on breastfeeding rates; methodology for data collection; and mechanisms for support, protection, and promotion of breastfeeding. Directly after birth, between 56% and 98% of infants in all countries were reported to receive any human milk, and at 6 months 38% to 71% and 13% to 39% of infants to be breastfed or exclusively breastfed, respectively. National plans addressing breastfeeding promotion, protection, and support exist in 6 of the 11 countries. CONCLUSIONS: National governments should commit to evidence-based breastfeeding monitoring and promotion activities, including financial and political support, to improve breastfeeding rates in the Europe. Renewed efforts for collaboration between countries in Europe, including a sustainable platform for information exchange, are needed.

Recent gestational diabetes was associated with mothers stopping predominant breastfeeding earlier in a multi-ethnic population.

AIM: It has previously been shown that breastfeeding may reduce the risk of type 2 diabetes in mothers with recent gestational diabetes mellitus (GDM). This study compared the cessation of predominant breastfeeding in mothers with and without recent GDM in a multi-ethnic population. METHODS: From May 2008 to May 2010, healthy pregnant women attending antenatal care provided by community health services in Eastern Oslo, Norway were recruited. We included 616 women-58% non-Western-and interviewed and examined them at a mean of 15 and 28 weeks of gestation and 14 weeks' postpartum. Cox regression models examined the association between GDM, as assessed by the 2013 World Health Organization criteria, and breastfeeding cessation. RESULTS: Overall, 190 of the 616 (31%) mothers had GDM and they ended predominant breastfeeding earlier than mothers without GDM, with an adjusted hazard ratio (aHR) of 1.33 and 95% confidence interval (95% CI) of 1.01-1.77. Mothers of South Asian origin ended predominant breastfeeding earlier than Western European mothers in the adjusted analysis (aHR 1.53, 95% CI: 1.04-2.25), but Middle Eastern mothers did not. CONCLUSION: Recent gestational diabetes was associated with earlier cessation of predominant breastfeeding in Western European and non-Western women.

Effectiveness of Baby-friendly community health services on exclusive breastfeeding and maternal satisfaction: a pragmatic trial.

The WHO/UNICEF Baby-friendly Hospital Initiative has been shown to increase breastfeeding rates, but uncertainty remains about effective methods to improve breastfeeding in community health services. The aim of this pragmatic cluster quasi-randomised controlled trial was to assess the effectiveness of implementing the Baby-friendly Initiative (BFI) in community health services. The primary outcome was exclusive breastfeeding until 6 months in healthy babies. Secondary outcomes were other breastfeeding indicators, mothers' satisfaction with the breastfeeding experience, and perceived pressure to breastfeed. A total of 54 Norwegian municipalities were allocated by alternation to the BFI in community health service intervention or routine care. All mothers with infants of five completed months were invited to participate (n = 3948), and 1051 mothers in the intervention arm and 981 in the comparison arm returned the questionnaire. Analyses were by intention to treat. Women in the intervention group were more likely to breastfeed exclusively compared with those who received routine care: 17.9% vs. 14.1% until 6 months [cluster adjusted odds ratio (OR) = 1.33; 95% confidence interval (CI): 1.03, 1.72; P = 0.03], 41.4% vs. 35.8% until 5 months [cluster adjusted OR = 1.39; 95% CI: 1.09, 1.77; P = 0.01], and 72.1% vs. 68.2% for any breastfeeding until 6 months [cluster adjusted OR = 1.24; 95% CI: 0.99, 1.54; P = 0.06]. The intervention had no effect on breastfeeding until 12 months. Maternal breastfeeding experience in the two groups did not differ, neither did perceived breastfeeding pressure from staff in the community health services. In conclusion, the BFI in community health services increased rates of exclusive breastfeeding until 6 months. © 2015 Blackwell Publishing Ltd.

Successive 1-Month Weight Increments in Infancy Can Be Used to Screen for Faltering Linear Growth.

BACKGROUND: Linear growth faltering in the first 2 y contributes greatly to a high stunting burden, and prevention is hampered by the limited capacity in primary health care for timely screening and intervention. OBJECTIVE: This study aimed to determine an approach to predicting long-term stunting from consecutive 1-mo weight increments in the first year of life. METHODS: By using the reference sample of the WHO velocity standards, the analysis explored patterns of consecutive monthly weight increments among healthy infants. Four candidate screening thresholds of successive increments that could predict stunting were considered, and one was selected for further testing. The selected threshold was applied in a cohort of Bangladeshi infants to assess its predictive value for stunting at ages 12 and 24 mo. RESULTS: Between birth and age 12 mo, 72.6% of infants in the WHO sample tracked within 1 SD of their weight and length. The selected screening criterion ("event") was 2 consecutive monthly increments below the 15th percentile. Bangladeshi infants were born relatively small and, on average, tracked downward from approximately age 6 to <24 mo (51% stunted). The population-attributable risk of stunting associated with the event was 14% at 12 mo and 9% at 24 mo. Assuming the screening strategy is effective, the estimated preventable proportion in the group who experienced the event would be 34% at 12 mo and 24% at 24 mo. CONCLUSIONS: This analysis offers an approach for frontline workers to identify children at risk of stunting, allowing for timely initiation of preventive measures. It opens avenues for further investigation into evidence-informed application of the WHO growth velocity standards.

Urine NMR metabolomics analysis of breastfeeding biomarkers during and after pregnancy in a large prospective cohort study.

BACKGROUND: Modern metabolomic profiling has not yet been applied to human breastfeeding research. A common reason for breastfeeding cessation is perceived insufficient milk production. We investigated broad biochemical profiles in maternal urine collected during and after pregnancy to identify biomarkers related to reduced reported breastfeeding. METHODS: Fasting urine was collected at three consultations (visit V1: gestational week 8-20; V2: week 28 ± 2; V3: 10-16 weeks postpartum) in the STORK Groruddalen program, a prospective, multiethnic cohort study of gestational diabetes involving healthy, pregnant women in Oslo, Norway, and analyzed using NMR spectroscopy. Breastfeeding at V3 was recorded in three categories: Exclusively breastfeeding (n = 326), partially breastfeeding (n = 156) and formula feeding (n = 67). RESULTS: Five metabolites were relevant to breastfeeding. Lactose was detected at V1 and increased to 0.1 mM/mM creatinine at V2. Postpartum excretion at V3 was significantly higher in exclusively breastfeeding women than partially or non-breastfeeding (median = 0.29, 0.23 and 0.04 mM/mM creatine, respectively; ANOVA p-value = 2e-70). Glycine excretion at V3 (0.12, 0.10 and 0.06, respectively; p = 2e-5) and at V2 were associated with breastfeeding (0.34, 0.33 and 0.26, respectively; p = 4e-5). Creatine and two unidentified substances also correlated with breastfeeding. NMR metabolomics found no other metabolites differing between categories during pregnancy (V1, V2), and did not predict individual breastfeeding postpartum (V3). CONCLUSION: Decreased glycine excretion at V2 may indicate difficulties meeting the metabolic demands of the growing fetus, but urine profiles contained otherwise little indication of early adaptations during pregnancy towards reduced biological potential to breastfeed.

Breastfeeding mother's experiences with breastfeeding counselling: a qualitative study.

BACKGROUND: Mothers are recommended to breastfeed their children but can find it challenging and experience breastfeeding problems. Qualified breastfeeding counselling from healthcare professionals can help mothers master breastfeeding, but there is a need to explore mothers' lived experiences with receiving breastfeeding counselling. We aimed to reveal breastfeeding mothers' experiences with receiving breastfeeding counselling from midwives and public health nurses (PHNs) to provide a deeper insight into the phenomenon of breastfeeding counselling, which may improve breastfeeding counselling in practice. METHODS: A qualitative design with a hermeneutic phenomenological approach was used. Individual interviews of 11 breastfeeding mothers from Norway were conducted from September 2021 to 2022. Van Manen's guided existential inquiry guided the reflective process to provide deeper insights into the phenomenon of breastfeeding counselling. RESULTS: The study captured the meaning of breastfeeding mothers' lived experiences with breastfeeding counselling. Three themes and eight sub-themes were found. Breastfeeding was at stake for the mothers because breastfeeding could be reduced or stopped, and qualified breastfeeding counselling from midwives and PHNs was essential for them to establish and continue breastfeeding. They needed to be perceived as both breastfeeding mothers and as women with their own needs to master everyday life during the breastfeeding period. CONCLUSIONS: This study offers insights to midwives, PHNs and others offering breastfeeding counselling by facilitating an understanding of being a breastfeeding mother receiving breastfeeding counselling. Qualified breastfeeding counselling and a trusting relationship with midwives and PHNs are essential for mothers to establish and continue breastfeeding, while deficient counselling may cause breastfeeding difficulties. Mothers need to be treated as whole and competent persons to avoid objectification and fathers/partners need to be included in breastfeeding counselling. The 'Baby-Friendly Hospital Initiative' should be continued, and guidelines should align with the mothers' need to incorporate breastfeeding into their daily lives during the breastfeeding period.

Post-partum weight change patterns in the WHO Multicentre Growth Reference Study.

The interplay of factors that affect post-partum loss or retention of weight gained during pregnancy is not fully understood. The objective of this paper is to describe patterns of weight change in the six sites of the World Health Organization (WHO) Multicentre Growth Reference Study (MGRS) and explore variables that explain variation in weight change within and between sites. Mothers of 1743 breastfed children enrolled in the MGRS had weights measured at days 7, 14, 28 and 42 post-partum, monthly from 2 to 12 months and bimonthly thereafter until 24 months post-partum. Height, maternal age, parity and employment status were recorded and breastfeeding was monitored throughout the follow-up. Weight change patterns varied significantly among sites. Ghanaian and Omani mothers lost little or gained weight post-partum. In Brazil, India, Norway and USA, mothers on average lost weight during the first year followed by stabilization in the second year. Lactation intensity and duration explained little of the variation in weight change patterns. In most sites, obese mothers tended to lose less weight than normal-weight mothers. In Brazil and Oman, primiparous mothers lost about 1 kg more than multiparous mothers in the first 6 months. In India and Ghana, multiparous mothers lost about 0.6 kg more than primiparas in the second 6 months. Culturally defined mother-care practices probably play a role in weight change patterns among lactating women. This hypothesis should stimulate investigation into gestational weight gain and post-partum losses in different ethnocultural contexts.

[Human milk, immune responses and health effects]. / Morsmelk, immunrespons og helseeffekter.

BACKGROUND: Besides providing optimal nutrition to infants, human milk contains a multitude of immunological components. These components are important for protection against infections and also support the development and maturation of the infant's own immune system. This review focuses on the function of some classical immunocomponents of human milk. Relevant studies are presented that describe health benefits of human milk for the child and of lactation for the mother. MATERIAL AND METHODS: Relevant articles were found mainly by searching PubMed. RESULTS AND INTERPRETATION: Humoral and cellular components of human milk confer protection against infections in the respiratory--, gastrointestinal--and urinary tract. Human milk also protects premature children from neonatal sepsis and necrotizing enterocolitis. There is evidence that human milk may confer long-term benefits such as lower risk of certain autoimmune diseases, inflammatory bowel disease and probably some malignancies. Human milk possibly affects components of the metabolic syndrome. Recent studies demonstrate long-term health benefits of lactation also for the mother. A reduced incidence of breast cancer is best documented. An increasing number of studies indicate protection against ovarian cancer, rheumatoid arthritis and type II diabetes.

[The WHO Child Growth Standards for children under 5 years]. / Verdens helseorganisasjons nye vekststandard for barn under fem år.

BACKGROUND: In 2006, the World Health Organization (WHO) launched the new global WHO Child Growth Standards for children under five years. The rationale for developing this new growth standard was that a review of the NCHS/WHO-reference, which had been recommended for international use since 1978, showed that the growth of breast-fed infants deviated negatively from this reference. Most children included in the NCHS/WHO-reference from 1978 were fed mainly with infant formula. MATERIAL AND METHOD: A growth reference describes HOW: children without a diagnosed disease grow. The WHO Child Growth Standards document how children SHOULD: grow when they are raised in healthy environments, are breastfed and not exposed to tobacco through their mother. The standard was developed on the basis of a multi-ethnic sample with participants from Norway, USA, Brazil, Oman, Ghana and India. RESULTS AND INTERPRETATION: The WHO Child Growth Standards describe how healthy children grow when key health and environmental needs are met. The new growth standards documents that children with different ethnic backgrounds grow very similarly under equal conditions. The WHO Child Growth Standards are an important tool for prevention and early recognition of overweight, as well as growth faltering and wasting.

Explaining socioeconomic inequalities in exclusive breast feeding in Norway.

BACKGROUND AND OBJECTIVE: In high-income countries, lower socioeconomic position is associated with lower rates of breast feeding, but it is unclear what factors explain this inequality. Our objective was to examine the association between socioeconomic position and exclusive breast feeding, and to explore whether socioeconomic inequality in exclusive breast feeding could be explained by other sociodemographic characteristics, for example, maternal age and parity, smoking habits, birth characteristics, quality of counselling and breastfeeding difficulties. METHODS: We used data from a questionnaire sent to mothers when their infants were five completed months as part of a trial of a breastfeeding intervention in Norway. We used maternal education as an indicator of socioeconomic position. Analyses of 1598 mother-infant pairs were conducted using logistic regression to assess explanatory factors of educational inequalities in breast feeding. RESULTS: Socioeconomic inequalities in exclusive breast feeding were present from the beginning and persisted for five completed months, when 22% of the most educated mothers exclusively breast fed compared with 7% of the least educated mothers: OR 3.39 (95% CI 1.74 to 6.61). After adjustment for all potentially explanatory factors, the OR was reduced to 1.49 (95% CI 0.70 to 3.14). This decrease in educational inequality seemed to be mainly driven by sociodemographic factors, smoking habits and breastfeeding difficulties, in particular perceived milk insufficiency. CONCLUSIONS: Socioeconomic inequalities in exclusive breast feeding at 5 months were largely explained by sociodemographic factors, but also by modifiable factors, such as smoking habits and breastfeeding difficulties, which can be amenable to public health interventions. TRIAL REGISTRATION NUMBER: NCT01025362.

Implementation of the WHO Multicentre Growth Reference Study in Norway.

The World Health Organization (WHO) Multicentre Growth Reference Study (MRGS) European site was Oslo, Norway. Oslo has a high breastfeeding rate. Ninety-nine percent of mothers initiate breastfeeding soon after delivery, and 80% continue for at least six months. There is no evidence that socioeconomic conditions constrain growth. As in other sites, the study had two components, longitudinal and cross-sectional. Recruitment for the longitudinal component was conducted in three hospitals that account for most births in Oslo. Approximately 850 subjects were screened in one year by using a systematic allocation scheme to recruit a sample of about 300. Recruitment for the cross-sectional component was based on a systematic interval sampling scheme prepared by the National Registry. More than 4,000 subjects were screened to achieve the required sample size. One of the major challenges of the study was to achieve an acceptable participation rate; great efforts were made to motivate pregnant women via the health care system and the media.

Adiposity and hyperglycaemia in pregnancy and related health outcomes in European ethnic minorities of Asian and African origin: a review.

BACKGROUND: Ethnic minorities in Europe have high susceptibility to type 2 diabetes (T2DM) and, in some groups, also cardiovascular disease (CVD). Pregnancy can be considered a stress test that predicts future morbidity patterns in women and that affects future health of the child. OBJECTIVE: TO REVIEW ETHNIC DIFFERENCES IN: 1) adiposity, hyperglycaemia, and pre-eclampsia during pregnancy; 2) future risk in the mother of obesity, T2DM and CVD; and 3) prenatal development and possible influences of maternal obesity, hyperglycaemia, and pre-eclampsia on offspring's future disease risk, as relevant for ethnic minorities in Europe of Asian and African origin. DESIGN: Literature review. RESULTS: Maternal health among ethnic minorities is still sparsely documented. Higher pre-pregnant body mass index (BMI) is found in women of African and Middle Eastern descent, and lower BMI in women from East and South Asia compared with women from the majority population. Within study populations, risk of gestational diabetes mellitus (GDM) is considerably higher in many minority groups, particularly South Asians, than in the majority population. This increased risk is apparent at lower BMI and younger ages. Women of African origin have higher risk of pre-eclampsia. A GDM pregnancy implies approximately seven-fold higher risk of T2DM than normal pregnancies, and both GDM and pre-eclampsia increase later risk of CVD. Asian neonates have lower birth weights, and mostly also African neonates. This may translate into increased risks of later obesity, T2DM, and CVD. Foetal overgrowth can promote the same conditions. Breastfeeding represents a possible strategy to reduce risk of T2DM in both the mother and the child. CONCLUSIONS: Ethnic minority women in Europe with Asian and African origin and their offspring seem to be at increased risk of T2DM and CVD, both currently and in the future. Pregnancy is an important window of opportunity for short and long-term disease prevention.

[Rooming-in in the maternity ward--are mothers satisfied?]. / Barna inne natt og dager barselkvinnene fornøyde?

BACKGROUND: 24-hour rooming-in in Norwegian maternity wards has been introduced as one of the "10 steps to successful breastfeeding", the basis for WHO/UNICEF Baby-Friendly Hospital Initiative. This step, optimal in order to get lactation off to a flying start, has lead to some worry about maternal fatigue. MATERIALS AND METHODS: Self-administrated questionnaires to health care personnel as well as to mothers in all Norwegian maternity wards were used to evaluate the impact of the Baby-Friendly Hospital Initiative. The same mothers were interviewed again 15 months later. RESULTS: Many (52%) felt tired after giving birth, but most (85%) were content with the care received. There was no difference in tiredness between mothers who chose to keep their babies with them and those who did not. Only 3.3% cited this at a main reason for tiredness. INTERPRETATION: Most mothers felt positive about keeping their infants with them at night. This demonstrates that Norwegian maternity wards generally have been able to implement 24 hour rooming-in in a caring way. Staff should offer to look after fussy babies without mothers demanding it and give the new mothers care and support in all possible ways.

Breast-feeding at 12 months of age and dietary habits among breast-fed and non-breast-fed infants.

OBJECTIVE: To analyse factors associated with breast-feeding and use of sweetened drinks at 12 months, and to compare dietary habits among breast-fed and non-breast-fed infants. DESIGN: Data were collected by a semi-quantitative food-frequency questionnaire filled in by the parents. SETTING: National dietary survey in Norway. SUBJECTS: In total, 1932 12-month-old infants were included. RESULTS: At 12 months, 36% of the infants were breast-fed. The odds of breast-feeding at this age were more than doubled both for mothers > or =35 years compared with mothers <25 years and for mothers in the highest educational group compared with mothers in the lowest. A negative association was found for maternal smoking, and the odds of breast-feeding were 40% lower for mothers who smoked than for non-smokers. Some dietary differences were observed between breast-fed and non-breast-fed infants apart from intake of milk. In particular, breast-fed infants had a significantly lower daily intake of sweetened drinks than non-breast-fed infants and a 16% lower mean daily intake of added sugars (P<0.001). Furthermore, breast-fed infants had 30% higher odds of not receiving sweetened drinks daily, compared with non-breast-fed infants. CONCLUSIONS: Maternal age, education and smoking status were important factors for breast-feeding at 12 months. Breast-fed infants had lower intakes of sweetened drinks and added sugars than non-breast-fed infants. From a public health perspective, continued promotion of breast-feeding is needed to reduce inequalities in breast-feeding. Moreover, prevention of high intakes of sweetened drinks and added sugars should start in infancy.