Views and experiences of women, peer supporters and healthcare professionals on breastfeeding peer support: A systematic review of qualitative studies.

OBJECTIVE: To examine and synthesise qualitative evidence of women's, peer supporters' and healthcare professionals' views and experiences of breastfeeding peer support. DESIGN: The Joanna Briggs Institute (JBI) approach to systematic reviews of qualitative studies was followed. Seven databases: CINAHL, MEDLINE, EMBASE, PsycINFO, Scopus, Maternal & Infant Care, and Web of Science were searched. Included papers were critically appraised using the JBI Critical Appraisal Checklist for Qualitative Research. JBI's meta-aggregation approach was used to synthesise findings. JBI's ConQual process was followed to assess confidence of evidence. PARTICIPANTS AND SETTING: Primiparous and multiparous women, lay breastfeeding peer supporters, and healthcare professionals based in high, middle, and low income countries. FINDINGS: Twenty-three papers presenting findings from 22 studies were included. The synthesised findings included: (1) Positive characteristics, approaches and benefits of peer support(ers); (2) Relationships between healthcare professionals and peer supporters; (3) Improving women's access to peer support services; (4) Barriers and enablers to provide peer support. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Breastfeeding peer support increased women's self-esteem and confidence in breastfeeding while reducing social isolation. Peer supporters valued the experience, which gave them a sense of purpose and confidence, and felt good about helping the women they supported. Women appreciated peer supporters who were caring, spent time with them, shared experiences, provided realistic information, practical and emotional support. Although there were tensions between some healthcare professionals and peer supporters, many valued the mutual support offered. Embedding peer supporters in healthcare systems for them to work alongside healthcare professionals, combined with good communications and building trusty relationships could be a useful strategy to reduce tensions between them.

Women's and Employers' Experiences and Views of Combining Breastfeeding with a Return to Paid Employment: A Systematic Review of Qualitative Studies.

INTRODUCTION: Returning to paid employment is one of the reasons women stop breastfeeding earlier than they planned to. This systematic review aimed to provide insight into the experiences and views of women and employers on breastfeeding and returning to paid employment, with findings used to inform practice and policy. METHODS: The review was guided by the Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence. Medline, CINAHL, PsycINFO, and Web of Science databases were searched for studies published in English. JBI's meta-aggregative approach informed data analysis. The studies in this analysis included women who stopped breastfeeding before, and those who continued breastfeeding after, returning to paid employment and the employers, work managers, or supervisors of women who continued breastfeeding after returning to paid employment. RESULTS: Twenty-six articles presenting findings from 25 studies were included and critically appraised. Synthesized findings showed that women experienced physical and emotional difficulties and described gender and employment inequalities in accessing and receiving the support they needed. Women reported that the importance of their own motivation and having workplace legislation in place facilitated breastfeeding during employment. Support from employers, colleagues, and family members, as well as access to convenient child care, helped women continue breastfeeding on return to paid employment. Employers' personal experiences influenced their views on breastfeeding and working, and the need for more education and communication between employers and employers on breastfeeding in the workplace was recognized. DISCUSSION: Support from family, work colleagues, and employers was important to reduce the physical and emotional challenges women experienced when combing breastfeeding with return to paid employment. Gender inequalities, especially in low- and middle-income countries, in accessing support exacerbated the difficulties women experienced. Limited data were identified regarding employers' experiences and views, suggesting an urgent need for further research to explore employers' and work colleagues' experiences and views.

Relatively speaking? Partners' and family members' views and experiences of supporting breastfeeding: a systematic review of qualitative evidence.

This review aimed to synthesize qualitative evidence of views and experiences of partners and other family members who provided breastfeeding support for a relative. The Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence was followed. Seven databases: CINAHL, MEDLINE, EMBASE, PsycINFO, Scopus, Maternal and Infant Care, and Web of Science were searched. Partners and other family members (e.g. grandmothers, siblings) of women in any countries were included. Included papers were critically appraised. The JBI meta-aggregative approach was used to analyze data and form synthesized findings. Seventy-six papers from 74 studies were included. Five synthesized findings were: (i) spectrum of family members' breastfeeding knowledge, experiences and roles; (ii) the complexity of infant feeding decision making; (iii) the controversy of breastfeeding in front of others; (iv) impact of breastfeeding on family; and (v) it takes more than just family members: support for family members. Partners' and family members' views and experiences of breastfeeding support reflected multi-faceted personal, social, financial, cultural, religious, emotional, psychological, and societal factors of the support they provided (or not). Healthcare professionals should engage them in breastfeeding discussions with the woman, and offer tailored and practical guidance relevant to help them to appropriately support the woman. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Breastfeeding experiences and support for women who are overweight or obese: A mixed-methods systematic review.

Women who are overweight or obese have increased health risks during and beyond pregnancy, with consequences for their infants' shorter and longer term health. Exclusive breastfeeding to 6 months has many benefits for women and their infants. However, women who are overweight or obese have lower rates of breastfeeding intention, initiation, and duration compared with women with normal weight. This systematic review aimed to examine evidence of (a) breastfeeding barriers and support experienced and perceived by women who are overweight or obese, (b) support shown to be effective in increasing breastfeeding initiation and duration among these women, and (c) perceptions of health care professionals, peer supporters, partners, and family members regarding providing breastfeeding support to these women. Sixteen quantitative and qualitative papers were included and critically appraised. Thematic synthesis was undertaken to obtain findings. Maternal physical barriers such as larger breasts, difficulties of positioning to breastfeed, delayed onset of lactation, perceived insufficient supply of breast milk, and impact of caesarean birth were evident. Maternal psychological barriers including low confidence in ability to breastfeed, negative body image, embarrassment at breastfeeding in public, and experiencing stigma of obesity were also described. Support from health care professionals and family members influenced breastfeeding outcomes. Education for maternity care professionals is needed to enable them to provide tailored, evidence-based support to women who are overweight or obese who want to breastfeed. Research on health care professionals, partners, and family members' experiences and views on supporting this group of women to breastfeed is needed to support development of appropriate interventions.

Initial protocol for a national evaluation of an area-based intervention programme (A Better Start) on early-life outcomes: a longitudinal cohort study with comparison (control) cohort samples.

INTRODUCTION: Pregnancy and the first few years of a child's life are important windows of opportunity in which to equalise life chances. A Better Start (ABS) is an area-based intervention being delivered in five areas of socioeconomic disadvantage across England. This protocol describes an evaluation of the impact and cost-effectiveness of ABS. METHODS AND ANALYSIS: The evaluation of ABS comprises a mixed-methods design including impact, cost-effectiveness and process components. It involves a cohort study in the 5 ABS areas and 15 matched comparison sites (n=2885), beginning in pregnancy in 2017 and ending in 2024 when the child is age 7, with a separate cross-sectional baseline survey in 2016/2017. Process data will include a profiling of the structure and services being provided in the five ABS sites at baseline and yearly thereafter, and data regarding the participating families and the services that they receive. Eligible participants will include pregnant women living within the designated sites, with recruitment beginning at 16 weeks of pregnancy. Data collection will involve interviewer-administered and self-completion surveys at eight time points. Primary outcomes include nutrition, socioemotional development, speech, language and learning. Data analysis will include the use of propensity score techniques to construct matched programme and comparison groups, and a range of statistical techniques to calculate the difference in differences between the intervention and comparison groups. The economic evaluation will involve a within-cohort study economic evaluation to compare individual-level costs and outcomes, and a decision analytic cost-effectiveness model to estimate the expected incremental cost per unit change in primary outcomes for ABS in comparison to usual care. ETHICS AND DISSEMINATION: Ethical approval to conduct the study has been obtained. The learning and dissemination workstream involves working within and across the sites to generate learning via communities of practice and a range of learning and dissemination events.

Interventions for women who have a caesarean birth to increase uptake and duration of breastfeeding: A systematic review.

Rates of breastfeeding uptake are lower after a caesarean birth than vaginal birth, despite caesarean rates increasing globally over the past 30 years, and many high-income countries reporting overall caesarean rates of above 25%. A number of factors are likely to be associated with women's infant feeding decisions following a caesarean birth such as limited postoperative mobility, postoperative pain, and ongoing management of medical complications that may have triggered the need for a caesarean birth. The aim of this systematic review was to evaluate evidence of interventions on the initiation and duration of any and exclusive breastfeeding among women who had a planned or unplanned caesarean birth. Seven studies, presenting quantitative and qualitative evidence, published in the English language from January 1994 to February 2016 were included. A limited number of interventions were identified relevant to women who had had a caesarean birth. These included immediate or early skin-to-skin contact, parent education, the provision of sidecar bassinets when rooming-in, and use of breast pumps. Only one study, an intervention that included parent education and targeted breastfeeding support, increased initiation and continuation of breastfeeding, but due to methodological limitations, findings should be considered with caution. There is a need to better understand the impact of caesarean birth on maternal physiological, psychological, and physical recovery, the physiology of lactation and breastfeeding and infant feeding behaviors if effective interventions are to be implemented.

Management of pregnant and postnatal women with pre-existing diabetes or cardiac disease using multi-disciplinary team models of care: a systematic review.

BACKGROUND: More women with an increased risk of poor pregnancy outcome due to pre-existing medical conditions are becoming pregnant. Although clinical care provided through multi-disciplinary team (MDT) working is recommended, little is known about the structure or working practices of different MDT models, their impact on maternal and infant outcomes or healthcare resources. The objectives of this review were to consider relevant international evidence to determine the most appropriate MDT models of care to manage complex medical conditions during and after pregnancy, with a specific focus on pre-existing diabetes or cardiac disease in high income country settings. METHODS: Quantitative and qualitative evidence of MDT models of care for the management of pregnant/postnatal women with pre-existing diabetes and cardiac disease was considered. A search of the literature published between January 2002 - January 2014 was undertaken. Methodological quality was assessed using checklists developed by the Joanna Briggs Institute. Given limited primary and secondary research evidence, guidelines and opinion papers were included. Two independent reviewers conducted critical appraisal of included papers. RESULTS: Nineteen papers were included from UK, Canada, USA, the Netherlands and Singapore. No studies were found which had compared MDT models for pregnant/postnatal women with pre-existing diabetes or cardiac disease. Two small retrospective studies reported better outcomes for women with cardiac disease if an MDT approach was used, although evidence to support this was limited. Due to study heterogeneity it was not possible to meta-analyse data. No evidence was identified of MDT management in the postnatal period or impacts of MDT working on healthcare resources. CONCLUSIONS: Despite widespread promotion of MDT models of care for pregnant and postnatal women with pre-existing diabetes or cardiac disease, there is a dearth of primary evidence to inform structure or working practices or beneficial impact on maternal and infant outcomes or healthcare resources. Primary research into if or how MDT models of care improve outcomes for women with complex pregnancies is urgently needed.

A national cross sectional survey of heads of midwifery services of uptake, benefits and barriers to use of obstetric early warning systems (EWS) by midwives.

OBJECTIVE: to identify the extent to which Early Warning Systems (EWS) are used by midwives in the United Kingdom (UK), the maternity settings they are used in, physiological parameters used to 'trigger' referral, training provision, barriers to implementation and role in preventing maternal morbidity. DESIGN: cross-sectional survey of heads of midwifery services. An email questionnaire was sent in September 2012. SETTING: UK NHS secondary care organisations providing maternity care. FINDINGS: heads of midwifery from 107 (68%) of 157 NHS organisations responded, with 108 questionnaires returned as two organisations had recently merged. All organisations, apart from one which only had a free-standing midwifery unit, had introduced EWS. Nearly all respondents (99%) reported EWS were used by midwives antenatally, 76% in labour and 100% on the postnatal ward. All EWS charts included body temperature, heart rate, respiratory rate, systolic blood pressure and oxygen saturation although parameters for escalation varied widely. Barriers to use of EWS by midwives included overlap with the partogram in labour, and staff shortages and delays obtaining clinical review when referral was triggered. Two-thirds considered EWS prevented maternal morbidity although few could provide supporting evidence, for example, audit findings. Training for midwives in use of EWS was available in 83% of organisations. CONCLUSION: most UK midwives are using EWS, with the highest use in obstetric units. The heterogeneity of EWS currently used potentially limits collation of evidence to inform appropriate system level responses. Research is needed to evaluate the role of EWS to prevent maternal morbidity during and after pregnancy in different maternity settings.

Caseload midwifery in a multi-ethnic community: the women's experiences.

OBJECTIVE: to evaluate caseload midwifery in a relatively deprived and ethnically diverse inner-city area. DESIGN AND SETTING: semi-structured interviews were undertaken with 24 women from diverse ethnic backgrounds, 12 of whom had received caseload care and 12 women from an adjacent area who had received conventional maternity care in a large inner-city maternity unit. Framework analysis was adopted drawing on links with the authors' previous work on women's views of caseload midwifery. FINDINGS: key themes from previous work fitted well with the themes that emerged from this study. Themes included 'knowing and being known', 'person-centred care', 'social support', 'gaining trust and confidence', 'quality and sensitivity of care' and 'communication'. KEY CONCLUSIONS AND IMPLICATIONS: women from this socially and ethnically diverse group of women had similar views and wanted similar care to those in previous studies of caseload midwifery. Many of the women receiving caseload care highlighted the close relationship they had with the midwives and as a result of this felt more able to discuss their concerns with them. This has the potential not only for improved quality of care but also improved safety.

A mixed methods study to develop and pilot a competency assessment tool to support midwifery care of women with intellectual disabilities.

BACKGROUND: Recent reports have highlighted the poor quality of health care received by people with intellectual disabilities (otherwise known as 'learning disabilities') in the United Kingdom (UK). UK Confidential Enquiries into maternal deaths have highlighted adverse pregnancy outcomes for women with intellectual disabilities and need for timely and appropriate clinical care. OBJECTIVES: To develop and test a competency assessment tool to support midwifery care of women with intellectual disabilities. DESIGN: A mixed methods study. SETTING: Large inner city maternity unit. PARTICIPANTS: Midwives and key experts in intellectual disabilities, maternity policy and midwifery education. METHODS: Phase one comprised a systematic narrative review of the literature. Evidence identified informed phase two which included focus groups and interviews. Emergent themes informed the development of a competency assessment tool which was piloted in phase three. RESULTS: Phase one: Four primary research papers and two systematic reviews met the review inclusion criteria. Support to develop parenting skills of women with intellectual disabilities was highlighted as was the need to optimise organisation of maternity services. No studies specifically considered midwifery competencies to support women with intellectual disabilities. Phase two: 23 midwives attended three focus groups and individual interviews were conducted with national leaders in intellectual disability (n=6) and midwifery policy and education (n=7). Themes identified included need for individualised care provided by a known midwife, the importance of effective communication skills and need for clear knowledge and understanding of the legislative framework relevant to intellectual disability. Phase three: A convenience sample of 60 midwives was asked to participate in a pilot study to test the tool, 46 (77%) of whom responded. Thirty midwives (65%) felt competent in their ability to recognise intellectual disability and 37 (80%) competent or expert in understanding women have the right to be offered choice and make informed decisions. A high proportion (n=40, 87%) reported little or no knowledge regarding consent issues. CONCLUSION: Work to inform timely and appropriate care of women with intellectual disability has been neglected in the UK maternity services. Use of a tool could aid assessment of midwifery competencies to support women with intellectual disability and highlight where further midwifery education and development are needed. Evidence of optimal care for women with intellectual disabilities and their families across the continuum of pregnancy and birth is required.

Revising care to meet maternal needs post birth: an overview of the hospital to home postnatal study.

There have been limited improvements in care and support for women post-birth despite publication of National Institute of Health and Clinical Excellence (NICE) guidelines for routine postnatal care (NICE 2006). NICE recommendations included that care should be individualised to women's physical and psychological health needs, the content of care should be relevant to the time of recovery post birth and information should be offered regarding life-threatening conditions and more commonly experienced morbidity. A study was conducted in one maternity unit informed by a quality improvement approach to implement NICE guidance. Revisions were introduced to hospital systems and processes relevant to the continuum of pregnancy, birth and beyond to improve individualised care and women's views of this.

Revising acute care systems and processes to improve breastfeeding and maternal postnatal health: a pre and post intervention study in one English maternity unit.

BACKGROUND: Most women in the UK give birth in a hospital labour ward, following which they are transferred to a postnatal ward and discharged home within 24 to 48 hours of the birth. Despite policy and guideline recommendations to support planned, effective postnatal care, national surveys of women's views of maternity care have consistently found in-patient postnatal care, including support for breastfeeding, is poorly rated. METHODS: Using a Continuous Quality Improvement approach, routine antenatal, intrapartum and postnatal care systems and processes were revised to support implementation of evidence based postnatal practice. To identify if implementation of a multi-faceted QI intervention impacted on outcomes, data on breastfeeding initiation and duration, maternal health and women's views of care, were collected in a pre and post intervention longitudinal survey. Primary outcomes included initiation, overall duration and duration of exclusive breastfeeding. Secondary outcomes included maternal morbidity, experiences and satisfaction with care. As most outcomes of interest were measured on a nominal scale, these were compared pre and post intervention using logistic regression. RESULTS: Data were obtained on 741/1160 (64%) women at 10 days post-birth and 616 (54%) at 3 months post-birth pre-intervention, and 725/1153 (63%) and 575 (50%) respectively post-intervention. Post intervention there were statistically significant differences in the initiation (p = 0.050), duration of any breastfeeding (p = 0.020) and duration of exclusive breastfeeding to 10 days (p = 0.038) and duration of any breastfeeding to three months (p = 0.016). Post intervention, women were less likely to report physical morbidity within the first 10 days of birth, and were more positive about their in-patient care. CONCLUSIONS: It is possible to improve outcomes of routine in-patient care within current resources through continuous quality improvement.

A systematic review of structured compared with non-structured breastfeeding programmes to support the initiation and duration of exclusive and any breastfeeding in acute and primary health care settings.

Policies and guidelines have recommended that structured programmes to support breastfeeding should be introduced. The objective of this review was to consider the evidence of outcomes of structured compared with non-structured breastfeeding programmes in acute maternity care settings to support initiation and duration of exclusive breastfeeding. Quantitative and qualitative studies were considered. Primary outcomes of interest were initiation of breastfeeding and duration of exclusive breastfeeding. Studies that only considered community-based interventions were excluded. An extensive search of literature published in 1992-2010 was undertaken using identified key words and index terms. Methodological quality was assessed using checklists developed by the Joanna Briggs Institute. Two independent reviewers conducted critical appraisal and data extraction; 26 articles were included. Because of clinical and methodological heterogeneity of study designs, it was not possible to combine studies or individual outcomes in meta-analyses. Most studies found a statistically significant improvement in breastfeeding initiation following introduction of a structured breastfeeding programme, although effect sizes varied. The impact on the duration of exclusive breastfeeding and duration of any breastfeeding to 6 months was also evident, although not all studies found statistically significant differences. Despite poor overall study quality, structured programmes compared with standard care positively influence the initiation and duration of exclusive breastfeeding and any breastfeeding. In health care settings with low breastfeeding initiation and duration rates, structured programmes may have a greater benefit. Few studies controlled for any potential confounding factors, and the impact of bias has to be considered.

Improving inpatient postnatal services: midwives views and perspectives of engagement in a quality improvement initiative.

BACKGROUND: Despite major policy initiatives in the United Kingdom to enhance women's experiences of maternity care, improving in-patient postnatal care remains a low priority, although it is an aspect of care consistently rated as poor by women. As part of a systems and process approach to improving care at one maternity unit in the South of England, the views and perspectives of midwives responsible for implementing change were sought. METHODS: A Continuous Quality Improvement (CQI) approach was adopted to support a systems and process change to in-patient care and care on transfer home in a large district general hospital with around 6000 births a year. The CQI approach included an initial assessment to identify where revisions to routine systems and processes were required, developing, implementing and evaluating revisions to the content and documentation of care in hospital and on transfer home, and training workshops for midwives and other maternity staff responsible for implementing changes. To assess midwifery views of the quality improvement process and their engagement with this, questionnaires were sent to those who had participated at the outset. RESULTS: Questionnaires were received from 68 (46%) of the estimated 149 midwives eligible to complete the questionnaire. All midwives were aware of the revisions introduced, and two-thirds felt these were more appropriate to meet the women's physical and emotional health, information and support needs. Some midwives considered that the introduction of new maternal postnatal records increased their workload, mainly as a consequence of colleagues not completing documentation as required. CONCLUSIONS: This was the first UK study to undertake a review of in-patient postnatal services. Involvement of midwives at the outset was essential to the success of the initiative. Midwives play a lead role in the planning and organisation of in-patient postnatal care and it was important to obtain their feedback on whether revisions were pragmatic and achieved anticipated improvements in care quality. Their initial involvement ensured priority areas for change were identified and implemented. Their subsequent feedback highlighted further important areas to address as part of CQI to ensure best quality care continues to be implemented. Our findings could support other maternity service organisations to optimise in-patient postnatal services.

Vigilance must be a priority: maternal genital tract sepsis.

Although very rare in the UK, sepsis was the leading cause of direct maternal deaths during 2006-2008, with an increase in community acquired Group A streptococcal infection (CMACE 2011). Most deaths occurred in the postnatal period and were often preceded by a sore throat or other upper respiratory infection, with a clear seasonal pattern. An associated factor was women of BME origin (black or minority ethnic origin). More than half of the deaths followed birth by caesarean section. All antenatal and postnatal women should be offered advice on the signs and symptoms of life threatening conditions, including sepsis. Information should include the importance of good hand and perineal hygiene and of the need to seek immediate medical care if feeling unwell. Relevant NICE guidance should be disseminated and implemented as widely as possible. Greater priority should be given to ensuring all women, particularly those in the most vulnerable groups, are aware of how to access timely and appropriate care.

Women's perceptions and experiences of breastfeeding support: a metasynthesis.

BACKGROUND: Both peer and professional support have been identified as important to the success of breastfeeding. The aim of this metasynthesis was to examine women's perceptions and experiences of breastfeeding support, either professional or peer, to illuminate the components of support that they deemed "supportive." METHODS: The metasynthesis included studies of both formal or "created" peer and professional support for breastfeeding women but excluded studies of family or informal support. Qualitative studies were included as well as large-scale surveys if they reported the analysis of qualitative data gathered through open-ended responses. Primiparas and multiparas who initiated breastfeeding were included. Studies published in English, in peer-reviewed journals, and undertaken between January 1990 and December 2007 were included. After assessment for relevance and quality, 31 studies were included. Meta-ethnographic methods were used to identify categories and themes. RESULTS: The metasynthesis resulted in four categories comprising 20 themes. The synthesis indicated that support for breastfeeding occurred along a continuum from authentic presence at one end, perceived as effective support, to disconnected encounters at the other, perceived as ineffective or even discouraging and counterproductive. A facilitative approach versus a reductionist approach was identified as contrasting styles of support that women experienced as helpful or unhelpful. CONCLUSIONS: The findings emphasize the importance of person-centered communication skills and of relationships in supporting a woman to breastfeed. Organizational systems and services that facilitate continuity of caregiver, for example continuity of midwifery care or peer support models, are more likely to facilitate an authentic presence, involving supportive care and a trusting relationship with professionals.

A systematic review of structured versus non-structured breastfeeding programmes to support the initiation and duration of exclusive breastfeeding in acute and primary healthcare settings.

EXECUTIVE SUMMARY: Background: Breastfeeding has many important health benefits for the woman and her baby. Despite evidence of benefit from a large number of well conducted studies, breastfeeding uptake and the duration of exclusive breastfeeding remain low in many countries. In order to improve breastfeeding rates, policy and guidelines at global, individual country level and in local healthcare settings have recommended that structured programmes to support breastfeeding should be introduced. The objective of this review was to consider the evidence of outcomes of structured compared with non-structured breastfeeding programmes in acute maternity care settings to support initiation and duration of exclusive breastfeeding. REVIEW METHODS: The definition of structured programme used included a multi-faceted or single intervention approach to support breastfeeding; definition of non-structured included support offered within standard care. The review considered quantitative and qualitative studies which addressed outcomes following the introduction of a structured programme in acute healthcare settings to support breastfeeding compared with no programme. The primary outcomes of interest were uptake of breastfeeding and duration of exclusive breastfeeding (only breast milk, including milk expressed). Studies which only considered community based interventions were not included. SEARCH STRATEGY: A search of the literature published between 1992 and 2010 was conducted, which followed a four step process. After a limited search of MEDLINE and CINAHL to identify key words contained in the title or abstract and index terms to describe relevant interventions, a second extensive search was undertaken using identified key words and index terms. The third step included a search of reference lists and bibliographies of relevant articles and the fourth step included a search of grey and unpublished literature and national databasesMethodological quality: Methodological quality was assessed using checklists developed by the Joanna Briggs Institute. Two independent reviewers conducted critical appraisal and data extraction. RESULTS: Twenty-six articles were included; one randomised controlled trial, two non randomised trials, one cross-sectional study, five systematic reviews, 15 cohort studies and two descriptive studies. Due to the poor quality of evidence presented and clinical and methodological heterogeneity of study designs, including definitions of breastfeeding and duration of follow-up, it was not possible to combine studies or individual outcomes in meta-analyses, therefore findings are presented in a narrative form.In most studies the structured programme of interest reflected some or all of the Baby Friendly Hospital Initiative 'Ten Steps'. Most studies found a statistically significant improvement in initiation of breastfeeding following introduction of a structured breastfeeding programme, although effect sizes varied widely.The impact of introducing a structured programme on the duration of exclusive breastfeeding and duration of any breastfeeding was also evident, although not all studies found statistically significant differences. At hospital discharge or within the first week post-birth, implementation of a structured programme appeared to increase duration of exclusive breastfeeding and the duration of any breastfeeding compared with usual care. After hospital discharge and up to six months post-birth, use of structured programmes also appeared to support continued duration of exclusive and any breastfeeding although differences in outcomes were not reported across all included studies. At six months, three of five studies which included data on longer-term outcomes showed women were statistically significantly more likely to be exclusively breastfeeding. Only one of these studies compared outcomes following implementation of BFHI. CONCLUSIONS: Despite the poor overall quality of studies, structured programmes, regardless of content, compared with standard care appear to influence the uptake and duration of exclusive breastfeeding and any breastfeeding. In healthcare settings with low breastfeeding uptake and duration rates, structured programmes may have a greater benefit. In countries where breastfeeding uptake is already high, the benefit is less apparent. The extent to which structured programmes in different maternity acute care settings have a significant effect on the duration of exclusive breastfeeding at six months is less clear. Most of the recommendations of this review were based on observational studies and retrospective data collection. Few studies controlled for any potential confounding factors and the impact of bias has to be considered. IMPLICATIONS FOR PRACTICE: Acute maternity care settings should implement structured programmes to support breastfeeding as part of routine maternity care. Programmes can replicate an existing programme, such as the BFHI, in full or in part, or be specifically developed to support implementation of evidence to reflect the needs and demands of the local healthcare organisation. In healthcare settings which have a high uptake of breastfeeding, resources may be better directed at improving support for duration of exclusive breastfeeding in the community. IMPLICATIONS FOR RESEARCH: Further high quality RCTs are needed which address the impact of introduction of structured programmes on women's experiences of infant feeding, on the role of the relevant healthcare professionals and on short and longer-term health outcomes. Prospective data capture to inform economic analyses should also be undertaken. Trial interventions need to be well defined and implementation processes described to inform reproducibility across different locations and different country settings. Research is also needed to address the issue of which elements of a structured programme are likely to lead to the most clinical and cost effective use of healthcare resources and to address how sustainable these interventions are in health systems facing increased economic pressures.

A qualitative study of the experiences and expectations of women receiving in-patient postnatal care in one English maternity unit.

BACKGROUND: Studies consistently highlight in-patient postnatal care as the area of maternity care women are least satisfied with. As part of a quality improvement study to promote a continuum of care from the birthing room to discharge home from hospital, we explored women's expectations and experiences of current in-patient care. METHODS: For this part of the study, qualitative data from semi-structured interviews were transcribed and analysed using content analyses to identify issues and concepts. Women were recruited from two postnatal wards in one large maternity unit in the South of England, with around 6,000 births a year. RESULTS: Twenty women, who had a vaginal or caesarean birth, were interviewed on the postnatal ward. Identified themes included; the impact of the ward environment; the impact of the attitude of staff; quality and level of support for breastfeeding; unmet information needs; and women's low expectations of hospital based postnatal care. Findings informed revision to the content and planning of in-patient postnatal care, results of which will be reported elsewhere. CONCLUSIONS: Women's responses highlighted several areas where changes could be implemented. Staff should be aware that how they inter-act with women could make a difference to care as a positive or negative experience. The lack of support and inconsistent advice on breastfeeding highlights that units need to consider how individual staff communicate information to women. Units need to address how and when information on practical aspects of infant care is provided if women and their partners are to feel confident on the woman's transfer home from hospital.

Midwives' reflections on their educational programme: a traditional or problem-based learning approach?

OBJECTIVE: to explore the longer-term effect of a problem-based learning (PBL) programme on midwives in practice. DESIGN: qualitative study. Graduates involved in an earlier study of the implementation of a PBL programme were interviewed between 5 and 6 years after graduating to explore the possible longer-term effect of a PBL programme on their practice as midwives. SETTING: Thames Valley University with graduates who had completed an 18-month programme on one of two campuses on a variety of clinical sites. PARTICIPANTS: interviews were held with four graduates who had completed their programme before the implementation of PBL and five who had completed a PBL programme. Key themes were identified and compared cross-sectionally. FINDINGS: midwives who had graduated from a PBL programme found that the approach was valuable in enabling them to access information and to develop a critical questioning approach. Some felt anxious at the beginning of their programme and said that they would have benefited from more direction and feedback from the facilitator early on in the programme. The focus on individual presentations sometimes inhibited the students learning from others in the group. The success of the PBL approach was felt to be dependent on the way in which the group worked together. The quality of the clinical placement, and the support of mentors and link teachers in the clinical setting, was a key factor in learning for students from both programmes. CONCLUSIONS: PBL has been incorporated into some programmes because it is thought to benefit practice disciplines, especially in a world of uncertain and changing evidence. However, no clear picture has emerged about the benefits of a PBL programme for midwifery education. IMPLICATIONS FOR PRACTICE: our findings have implications for curriculum development to ensure the potential benefits of PBL are realised in practice. This may include providing further guidance and feedback to students, particularly at the start of their programme. Further research using innovative methodologies is needed to critically assess the longer-term effect of this approach to education.

A meta-synthesis of women's perceptions and experiences of breastfeeding support.

BACKGROUND: Breastfeeding conveys significant health benefits to infants and mothers yet in many affluent nations breastfeeding rates continue to decline across the early months following birth. Both peer and professional support have been identified as important to the success of breastfeeding. What is not known are the key components or elements of support that are effective in increasing the duration of breastfeeding? OBJECTIVES: The aim of this meta-synthesis was to examine women's perceptions and experiences of breastfeeding support, either professional or peer, in order to illuminate the components of support that they deem 'supportive'. A secondary aim was to describe any differences between components of Peer and Professional support. SELECTION CRITERIA: Both primiparous and multiparous women who initiated breastfeeding were included in the study. Studies that included a specific demographic sub-group, such as adolescents, were included. Studies focused on a specific clinical sub-group, such as women post-caesarean, were not included. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST: This meta-synthesis focused on maternal experiences of breastfeeding support. The meta-synthesis included both formal or 'created' peer and professional support for breastfeeding women but excluded studies of family or informal support for breastfeeding. TYPES OF STUDIES: Primarily qualitative studies were included in the review. Studies such as large scale surveys were also included if they reported in sufficient detail the analysis of qualitative data gathered through open ended responses or included in depth interviews. Only studies published or available in English, in peer reviewed journals and undertaken between 1990 and December 2007 were included. SEARCH STRATEGY: Key data bases were searched. The following search terms were individually added to the main keyword - breastfeeding: qualitative research, breast feeding support, peer support, professional support, postnatal support, post-natal support, volunteer support, lay support, breastfeeding counsellors, lactation consultants, social support, health education, breastfeeding education and lactation. Delimiters applied were humans, English language and years 1990-2007. METHODOLOGICAL QUALITY: JBI-QARI (Qualitative Assessment and Review Instrument) was used to assess the quality of 38 articles selected for full review. Seven were excluded primarily because they included little qualitative data relevant to the review focus. The studies reviewed were generally of reasonable quality in terms of clarity, appropriate methodology, credibility and evidence cited to support the conclusions drawn. However, most included relatively limited discussion of theoretical or conceptual perspectives, discussion of relevant literature and reflection on the roles of the researchers. DATA COLLECTION AND SYNTHESIS: JBI-QARI was used to manage and appraise textual data, Meta-ethnographic methods were used to develop 'interpretive explanations and understanding of breastfeeding support. Each study was systematically reviewed, reading and re-reading papers to create a list of themes through 'reciprocal translation'. Both first order and second order constructs were used to create the themes and these were then synthesised into four interpretive categories. RESULTS: The meta-synthesis resulted in four categories comprising a total of 20 themes. The synthesis indicates that support for breastfeeding occurs along a continuum from authentic presence at one end, perceived as effective support, to disconnected encounters at the other, perceived as ineffective or even discouraging and counter productive. Second, the synthesis identified a facilitative approach, versus a reductionist approach as contrasting styles of support women experienced as helpful or unhelpful. CONCLUSIONS: The findings of this meta-synthesis emphasise the importance of person-centred communication skills and of relationships in supporting a woman to breastfeed. Authentic presence is best supported by building a trusting relationship, demonstrating empathy, listening and being responsive to a woman's needs. Organisational systems and services that facilitate continuity of care/r and time spent with the woman, for example continuity of midwifery care or peer support models, are more likely to facilitate an authentic presence. The findings suggest the need to increase opportunities to offer women across all social groups access to peer support. IMPLICATIONS FOR PRACTICE: The review indicates several changes in direction for practice to foster provision of support that women consider helpful and enabling, rather than disabling. These include service design that facilitates effective relationships to be established between supporters and the woman, including greater continuity of carer, Midwives need to work in service models that enable them to provide more individualised, rather than standard care and advice, to spend time and provide practical help to those women who need it. Antenatal education needs to be more learner-centred, using pedagogic models based on adult-learning principles, and should provide women with information that is realistic, detailed and positively encouraging. Midwifery education needs to integrate sufficient focus on developing midwives' communication and information giving skills. Schemes to offer peer support should be developed further, using a pro-active approach, including home visits and support groups. IMPLICATIONS FOR RESEARCH: Further research is warranted on schemes to develop peer models of support. Research is also needed to investigate in more depth the service models and conditions that are conducive to midwives' ability to offer effective support for breastfeeding.