Factors associated with abandoning exclusive breastfeeding in Mexican mothers at two private hospitals.

BACKGROUND: Exclusive breastfeeding (EBF) has multiple benefits for both the child and the mother; however, there is little data regarding the reason why Mexican mothers with a high socio-economic level abandon EBF before 6 months, and there is limited information about the practice of breastfeeding in private hospitals. The objective was to identify the factors associated with the cessation of exclusive breastfeeding in Mexican mothers at two private hospitals. METHODS: A cross-sectional study was conducted with 218 upper-class mothers selected according to their place of residence by geographic location, socio-economic level, and pediatric consultations cost. They were over 18 years old and with children aged 6 to 24 months. Data were collected between July and November 2016 by face to face interview using a structured questionnaire while the mothers waited for the pediatric postnatal care consultation in two private hospitals in northeastern Mexico. Exclusive breastfeeding was measured according to World Health Organization (WHO) recommendations, which consist of providing only breast milk for the first 6 months of life. Chi-squared tests and multivariate logistic regression were performed. RESULTS: Mean maternal age was 31.4 years (SD of 4.4) and most of the participants had an undergraduate education, were married, and worked outside the home. The prevalence of exclusive breastfeeding at 6 months was 28%. Upper-class working mothers are less likely to continue breastfeeding. There was a negative association with employment (AOR 13.69; 95% CI 1.59, 111.11), bottle use in the first 6 months (AOR 7.93; 95% CI 3.07, 20.48), and a low level of knowledge (AOR 2.18; 95% CI 1.04, 4.56). After 6 months, only 61 mothers (28%) maintained exclusive breastfeeding. CONCLUSIONS: Knowledge level, bottle use, and employment are associated with premature cessation of EBF in Mexican upper-class mothers, attending two private hospitals. There was a high percentage of breastfeeding cessation in the sample. It is necessary to reinforce a strategy that coordinates the action of the different laws, regulations and programs affecting the exclusive breastfeeding practice, in order to adequately promote breastfeeding and support mothers in both public and private sectors.

The Economic Impact of Donor Milk in the Neonatal Intensive Care Unit.

OBJECTIVE: To assess the cost-effectiveness of mother's own milk supplemented with donor milk vs mother's own milk supplemented with formula for infants of very low birth weight in the neonatal intensive care unit (NICU). STUDY DESIGN: A retrospective analysis of 319 infants with very low birth weight born before (January 2011-December 2012, mother's own milk + formula, n = 150) and after (April 2013-March 2015, mother's own milk + donor milk, n = 169) a donor milk program was implemented in the NICU. Data were retrieved from a prospectively collected research database, the hospital's electronic medical record, and the hospital's cost accounting system. Costs included feedings and other NICU costs incurred by the hospital. A generalized linear regression model was constructed to evaluate the impact of feeding era on NICU total costs, controlling for neonatal and sociodemographic risk factors and morbidities. An incremental cost-effectiveness ratio was calculated for each morbidity that differed significantly between feeding eras. RESULTS: Infants receiving mother's own milk + donor milk had a lower incidence of necrotizing enterocolitis (NEC) than infants receiving mother's own milk + formula (1.8% vs 6.0%, P = .048). Total (hospital + feeding) median costs (2016 USD) were $169 555 for mother's own milk + donor milk and $185 740 for mother's own milk + formula (P = .331), with median feeding costs of $1317 and $936, respectively (P < .001). Mother's own milk + donor milk was associated with $15 555 lower costs per infant (P = .045) and saved $1812 per percentage point decrease in NEC incidence. CONCLUSIONS: The additional cost of a donor milk program was small compared with the cost of a NICU hospitalization. After its introduction, the NEC incidence was significantly lower with small cost savings per case. We speculate that NICUs with greater NEC rates may have greater cost savings.

Costs of maternity leave to support breastfeeding; Brazil, Ghana and Mexico.

OBJECTIVE: To develop a method to assess the cost of extending the duration of maternity leave for formally-employed women at the national level and apply it in Brazil, Ghana and Mexico. METHODS: We adapted a World Bank costing method into a five-step method to estimate the costs of extending the length of maternity leave mandates. Our method used the unit cost of maternity leave based on working women's weekly wages; the number of additional weeks of maternity leave to be analysed for a given year; and the weighted population of women of reproductive and legal working age in a given country in that year. We weighted the population by the probability of having a baby that year among women in formal employment, according to individual characteristics. We applied nationally representative cross-sectional data from fertility, employment and population surveys to estimate the costs of maternity leave for mothers employed in the formal sector in Brazil, Ghana and Mexico for periods from 12 weeks up to 26 weeks, the WHO target for exclusive breastfeeding. FINDINGS: We estimated that 640 742 women in Brazil, 33 869 in Ghana and 288 655 in Mexico would require formal maternity leave annually. The median weekly cost of extending maternity leave for formally working women was purchasing power parity international dollars (PPP$) 195.07 per woman in Brazil, PPP$ 109.68 in Ghana and PPP$ 168.83 in Mexico. CONCLUSION: Our costing method could facilitate evidence-based policy decisions across countries to improve maternity protection benefits and support breastfeeding.

Economic determinants of breastfeeding in Haiti: The effects of poverty, food insecurity, and employment on exclusive breastfeeding in an urban population.

There is limited and inconsistent empirical evidence regarding the role of economic factors in breastfeeding practices, globally. Studies have found both negative and positive associations between low income and exclusive breastfeeding (EBF). Employment, which should improve household income, may reduce EBF due to separation of mother and infant. In the context of a randomized controlled study of lipid-based complementary feeding in an urban slum in Cap Haitien, Haiti, we examined the economic factors influencing breastfeeding practices using mixed methods. Findings demonstrate relationships between urban context, economic factors, and breastfeeding practices. Poverty, food insecurity, time constraints, and limited social support create challenges for EBF. Maternal employment is associated with lower rates of EBF and less frequent breastfeeding. Extreme food insecurity sometimes leads to increased exclusive breastfeeding among Haitian mothers, what we call "last resort EBF." In this case, women practice EBF because they have no alternative food source for the infant. Suggested policies and programs to address economic constraints and promote EBF in this population include maternal and child allowances, quality child care options, and small-scale household urban food production.

Incentive-based Intervention to Maintain Breastfeeding Among Low-income Puerto Rican Mothers.

BACKGROUND AND OBJECTIVE: Despite maternal and child health benefits, breastfeeding rates are relatively low among low-income Puerto Rican mothers. This study examined the hypothesis that monthly financial incentives would significantly increase the proportion of breastfeeding mothers at 6 months postpartum compared with Supplemental Nutrition Program for Women, Infants, and Children (WIC) services only among Puerto Rican mothers. METHODS: A randomized, 2-arm parallel-group design, from February 2015 through February 2016. Half of the randomized participants received monthly financial incentives contingent on observed breastfeeding for 6 months (Incentive), and the other half received usual WIC services only (Control). Thirty-six self-identified Puerto Rican women who initiated breastfeeding were enrolled. Monthly cash incentives were contingent on observed breastfeeding increasing the amount given at each month from $20 to $70 for a total possible of $270. RESULTS: The intent-to-treat analysis showed significantly higher percentages of breastfeeding mothers in the incentive group at each time point compared with those in the control group (89% vs 44%, P = .01 at 1 month; 89% vs 17%, P < .001 at 3 months; 72% vs 0%, P < .001 at 6 months). No significant differences were detected at any time point between study groups for self-reported exclusive breastfeeding rate and infant outcomes (ie, weight, emergency department visits). CONCLUSIONS: Contingent cash incentives significantly increased breastfeeding through 6-month postpartum among WIC-enrolled Puerto Rican mothers; however, no significant differences between the study groups were observed on exclusive breastfeeding rate and infant outcomes. Larger-scale studies are warranted to examine efficacy, implementation potential, and cost-effectiveness.

Latin American Clinical Epidemiology Network Series - Paper 4: Economic evaluation of Kangaroo Mother Care: cost utility analysis of results from a randomized controlled trial conducted in Bogotá.

BACKGROUND AND OBJECTIVE: Although kangaroo mother care (KMC) has been shown to be safe and effective in randomized controlled trials (RCTs), there are no published complete economic evaluations including the three components of the full intervention. METHODS: A cost utility analysis performed on the results of an RCT conducted in Bogotá, Colombia between 1993 and 1996. Hospital and ambulatory costs were estimated by microcosting in a sample of preterm infants from a University Hospital in Bogotá in 2011 and at a KMC clinic in the same period. Utility scores were assigned by experts by means of (1) direct ordering and scoring discrete health states and (2) constructing a multi-attribute utility function. Ninety-five percent confidence intervals (CIs) for the incremental cost-utility ratios (ICURs) were computed by the Fiellers theorem method. One-way sensitivity analysis on price estimates for valuing costs was performed. RESULTS: ICUR at 1 year of corrected age was $ -1,546 per extra quality-adjusted life year gained using the KMC method (95% CI $ -7,963 to $ 4,910). CONCLUSION: In Bogotá, the use of KMC is dominant: more effective and cost-saving. Although results from an economic analysis should not be extrapolated to different systems and communities, this dominant result suggests that KMC could be cost-effective in similar low and middle income countries settings.

Disparities in Breastfeeding: Impact on Maternal and Child Health Outcomes and Costs.

OBJECTIVE: To estimate the disease burden and associated costs attributable to suboptimal breastfeeding rates among non-Hispanic blacks (NHBs), Hispanics, and non-Hispanic whites (NHWs). STUDY DESIGN: Using current literature on associations between breastfeeding and health outcomes for 8 pediatric and 5 maternal diseases, we used Monte Carlo simulations to evaluate 2 hypothetical cohorts of US women followed from age 15 to 70 years and their infants followed from birth to age 20 years. Accounting for differences in parity, maternal age, and birth weights by race/ethnicity, we examined disease outcomes and costs using 2012 breastfeeding rates by race/ethnicity and outcomes that would be expected if 90% of infants were breastfed according to recommendations for exclusive and continued breastfeeding duration. RESULTS: Suboptimal breastfeeding is associated with a greater burden of disease among NHB and Hispanic populations. Compared with a NHW population, a NHB population had 1.7 times the number of excess cases of acute otitis media attributable to suboptimal breastfeeding (95% CI 1.7-1.7), 3.3 times the number of excess cases of necrotizing enterocolitis (95% CI 2.9-3.7), and 2.2 times the number of excess child deaths (95% CI 1.6-2.8). Compared with a NHW population, a Hispanic population had 1.4 times the number of excess cases of gastrointestinal infection (95% CI 1.4-1.4) and 1.5 times the number of excess child deaths (95% CI 1.2-1.9). CONCLUSIONS: Racial/ethnic disparities in breastfeeding have important social, economic, and health implications, assuming a causal relationship between breastfeeding and health outcomes.

A influência da amamentação na economia de famílias da Região Leste de São Paulo / The influence of breastfeeding on the economy of families in the region east of Sao Paulo

Objetivo identificar o impacto que a amamentação pode causar na economia familiar. Pesquisa de campo, de natureza quanti-qualitativa, com mães de crianças entre quatro e seis meses de idade, a respeito da forma de amamentação. A pesquisa foi realizada em Unidades Básicas de Saúde da Região Leste de São Paulo, Dos resultados, 48,9% das 45 participantes amamentavam exclusivamente por seio materno, e 51,1 % já haviam introduzido o leite artificial. Destas, 15,6% relataram que o motivo para a introdução do leite artificial foi o retorno ao trabalho, Considera-se que o pré-natal e o puerpério são momentos adequados para orientá-las sobre a importância da amamentação e a diferença que ela pode fazer também na renda familiar.

The objective was to identify the impact that breastfeeding can cause in the family econorny. This is a field research, of quantitative and qualitative nature, with mothers of children between four and six months old, about the way of breastfeeding, The survey was conducted in the Basic Health Units of São Paulo Eastern Region, From the results, 48,9% of the 45 participants exclusively breastfed their children, and 51,1 % had introduced artificial rnilk. Of these, 15,6% reported that the reason for the introduction of artificial milk was the return to work. It was concluded that prenatal and postpartum period are appropriate times to educate them about the importance of breastfeeding and the difference it can make in the family incorne.

Lo objetivo de este estudio es identificar el impacto que la lactancia materna puede causar en la economía familiar. Fue realizada una busca de campo de naturaleza cuantitativa y cualitativa, con las madres de nines de entre cuatro y seis meses de edad, sobre el uso de la lactancia materna, La encuesta fue realizada en las Unidades Básicas de Salud de Ia región oriental de Sao Paulo, A partir de los resultados, el 48,9% de las 45 participantes utilizan exclusivamente en Ia leche de Ia madre, y el 51,1% habían introducido Ia leche artificial. De estos, 15,6% informaran que la razón de Ia introducción de la leche artificial fue el retorno ai trabajo, Se concluyó que el período prenatal y posparto son momentos apropiados para educar sobre Ia importancia de la lactancia materna y la diferencia que esta puede hacer en los ingresos familiares

Impact of Optimized Breastfeeding on the Costs of Necrotizing Enterocolitis in Extremely Low Birthweight Infants.

OBJECTIVE: To estimate risk of necrotizing enterocolitis (NEC) for extremely low birth weight (ELBW) infants as a function of preterm formula (PF) and maternal milk intake and calculate the impact of suboptimal feeding on the incidence and costs of NEC. STUDY DESIGN: We used aORs derived from the Glutamine Trial to perform Monte Carlo simulation of a cohort of ELBW infants under current suboptimal feeding practices, compared with a theoretical cohort in which 90% of infants received at least 98% human milk. RESULTS: NEC incidence among infants receiving ≥98% human milk was 1.3%; 11.1% among infants fed only PF; and 8.2% among infants fed a mixed diet (P = .002). In adjusted models, compared with infants fed predominantly human milk, we found an increased risk of NEC associated with exclusive PF (aOR = 12.1, 95% CI 1.5, 94.2), or a mixed diet (aOR 8.7, 95% CI 1.2-65.2). In Monte Carlo simulation, current feeding of ELBW infants was associated with 928 excess NEC cases and 121 excess deaths annually, compared with a model in which 90% of infants received ≥98% human milk. These models estimated an annual cost of suboptimal feeding of ELBW infants of $27.1 million (CI $24 million, $30.4 million) in direct medical costs, $563 655 (CI $476 191, $599 069) in indirect nonmedical costs, and $1.5 billion (CI $1.3 billion, $1.6 billion) in cost attributable to premature death. CONCLUSIONS: Among ELBW infants, not being fed predominantly human milk is associated with an increased risk of NEC. Efforts to support milk production by mothers of ELBW infants may prevent infant deaths and reduce costs.

The costs of inadequate breastfeeding of infants in Mexico.

BACKGROUND: Breastfeeding is vital for child survival, health, and development. Mexico has very low rates of breastfeeding and experienced a severe decrease in the prevalence of exclusive breastfeeding from 21% in 2006 to 14% in 2012. OBJECTIVE: The objective of the article was to estimate the pediatric costs of inadequate breastfeeding in Mexico associated with the following acute health conditions: respiratory infections, otitis media, gastroenteritis, necrotizing enterocolitis (NEC), and sudden infant death syndrome (SIDS). DESIGN: The authors estimated the economic costs of inadequate breastfeeding as follows: the sum of direct health care costs for diseases whose risk increases when infants are non-exclusively breastfed <6 mo or are not breastfed from ages 6 to <11 mo, lost future earnings due to premature infant death, and the costs of purchasing infant formula. Incidence cases were retrieved from national surveillance systems, except for NEC and SIDS, which were estimated from the literature. A sensitivity analysis was carried out to provide a range of costs based on different assumptions of the number of incident cases of all infant health outcomes examined. The model applied to the cohort of 1-y-old children born in 2012. RESULTS: The total annual costs of inadequate breastfeeding in Mexico for the studied cohort ranged from $745.6 million to $2416.5 million, where the costs of infant formula accounted for 11-38% of total costs. A range of 1.1-3.8 million reported cases of disease and from 933 to 5796 infant deaths per year for the diseases under study are attributed to inadequate infant breastfeeding practices; altogether these represent nearly 27% of the absolute number of episodes of such diseases. CONCLUSIONS: This study provides costs of inadequate breastfeeding that had not been quantified in Mexico. The costs presented in this article provide the minimum amount that the country should invest to achieve better breastfeeding practices.

[Characterizing breastfeeding and associated factors in Puerto Carreño, Colombia]. / Caracterización de la lactancia materna y factores asociados en Puerto Carreño, Colombia.

OBJECTIVE: Characterizing breastfeeding in Puerto Carreño and identifying factors associated with providing breast-milk for the newborn, exclusive breastfeeding and total breastfeeding. METHODS: This descriptive, cross-sectional study, using structured individual and non-random surveys, involved 609 mothers. The statistical analysis methods included univariate and bivariate analysis, survival curves, binary logistic regression and Cox proportional hazard models. RESULTS: The duration of total and exclusive breastfeeding was higher than reported times at national and regional level in most cases. The main factors associated with breastfeeding were related to occupation, family background, Indigenous status, previous maternal experience and access to healthcare services. CONCLUSIONS: Exclusive breastfeeding was influenced more by the mother'’s occupation, while the total duration of breastfeeding was influenced by home-based family support network. The results are significant regarding planning intervention measures addressed towards improving breastfeeding habits in the target municipality.

The cost-savings of implementing kangaroo mother care in Nicaragua.

OBJECTIVE: To examine the costs of implementing kangaroo mother care (KMC) in a referral hospital in Nicaragua, including training, implementation, and ongoing operating costs, and to estimate the economic impact on the Nicaraguan health system if KMC were implemented in other maternity hospitals in the country. METHODS: After receiving clinical training in KMC, the implementation team trained their colleagues, wrote guidelines for clinicians and education material for parents, and ensured adherence to the new guidelines. The intervention began September 2010 The study compared data on infant weight, medication use, formula consumption, incubator use, and hospitalization for six months before and after implementation. Cost data were collected from accounting records of the implementers and health ministry formularies. RESULTS: A total of 46 randomly selected infants before implementation were compared to 52 after implementation. Controlling for confounders, neonates after implementation had lower lengths of hospitalization by 4.64 days (P = 0.017) and 71% were exclusively breastfed (P < 0.001). The intervention cost US$ 23 113 but the money saved with shorter hospitalization, elimination of incubator use, and lower antibiotic and infant formula costs made up for this expense in 1 - 2 months. Extending KMC to 12 other facilities in Nicaragua is projected to save approximately US$ 166 000 (based on the referral hospital incubator use estimate) or US$ 233 000 after one year (based on the more conservative incubator use estimate). CONCLUSIONS: Treating premature and low-birth-weight infants in Nicaragua with KMC implemented as a quality improvement program saves money within a short period even without considering the beneficial health effects of KMC. Implementation in more facilities is strongly recommended.

The cost-savings of implementing kangaroo mother care in Nicaragua / Reducción de costos mediante la implantación del método madre canguro en Nicaragua

OBJECTIVE: To examine the costs of implementing kangaroo mother care (KMC) in a referral hospital in Nicaragua, including training, implementation, and ongoing operating costs, and to estimate the economic impact on the Nicaraguan health system if KMC were implemented in other maternity hospitals in the country. METHODS: After receiving clinical training in KMC, the implementation team trained their colleagues, wrote guidelines for clinicians and education material for parents, and ensured adherence to the new guidelines. The intervention began September 2010 The study compared data on infant weight, medication use, formula consumption, incubator use, and hospitalization for six months before and after implementation. Cost data were collected from accounting records of the implementers and health ministry formularies. RESULTS: A total of 46 randomly selected infants before implementation were compared to 52 after implementation. Controlling for confounders, neonates after implementation had lower lengths of hospitalization by 4.64 days (P = 0.017) and 71% were exclusively breastfed (P < 0.001). The intervention cost US$ 23 113 but the money saved with shorter hospitalization, elimination of incubator use, and lower antibiotic and infant formula costs made up for this expense in 1 - 2 months. Extending KMC to 12 other facilities in Nicaragua is projected to save approximately US$ 166 000 (based on the referral hospital incubator use estimate) or US$ 233 000 after one year (based on the more conservative incubator use estimate). CONCLUSIONS: Treating premature and low-birth-weight infants in Nicaragua with KMC implemented as a quality improvement program saves money within a short period even without considering the beneficial health effects of KMC. Implementation in more facilities is strongly recommended.

OBJETIVO: Analizar los costos de la implantación del método madre canguro en un hospital de referencia de Nicaragua, incluidos los costos de capacitación, implantación y funcionamiento, y calcular la repercusión económica en el sistema de salud nicaragüense si se aplicara el método en otras maternidades del país. MÉTODOS: Tras recibir capacitación clínica en el método, los miembros del equipo encargado de su implantación capacitaron a sus colegas, elaboraron directrices para los médicos y material educativo para los padres, y garantizaron la adhesión a las nuevas directrices. La intervención empezó en septiembre del 2010. El estudio comparó los siguientes datos: peso de los lactantes, empleo de medicamentos, consumo de leches maternizadas, uso de incubadoras, y hospitalizaciones durante los seis meses previos y posteriores a la implantación. Los datos relativos a los costos se recopilaron a partir de los registros contables de los ejecutores y los formularios del Ministerio de Salud. RESULTADOS: Los datos de 46 lactantes seleccionados aleatoriamente antes de la implantación se compararon con los de 52 lactantes del período posterior a la intervención. Mediante el control de los factores de confusión, después de la intervención, el tiempo medio de hospitalización de los recién nacidos fue inferior en 4,64 días (P = 0,017), y el 71% (P < 0,001) de los lactantes recibieron lactancia materna exclusiva. La intervención tuvo un costo de US$ 23 113 pero el dinero ahorrado gracias a la menor duración de las hospitalizaciones, la eliminación del uso de incubadoras, y la reducción de los costos en antibióticos y leches maternizadas compensó estos gastos en uno a dos meses. Se proyecta extender el método a otros 12 establecimientos sanitarios de Nicaragua para ahorrar aproximadamente US$ 233 000 (con base en el cálculo del uso de incubadoras en el hospital de referencia) o US$ 166 000 (con base en un cálculo más conservador del uso de incubadoras) al cabo de un año. CONCLUSIONES: El tratamiento de los neonatos prematuros y con bajo peso al nacer mediante el método madre canguro, implantado como un programa de mejora de la calidad en Nicaragua, ahorra dinero en un período corto, incluso sin tener en cuenta los efectos beneficiosos del método sobre la salud. Se recomienda su implantación en otros establecimientos sanitarios.