Yan-Shing Chang

Maternal extraversion, emotional stability and conscientiousness are associated with initiation and continuation of breastfeeding

Implications for practice and research: Understanding maternal trait personality could inform targeted interventions for women identified as requiring additional breastfeeding support and help to facilitate discussion of barriers to breastfeeding. Further research is needed to explore the impact of maternal personality on effectiveness of interventions designed to increase coping strategies and influence of social networks among women who wish to start and continue to breastfeed.

Implementação de evidências na prática: complexa, com múltiplas facetas e múltiplas camadas

During the last two decades, academics, healthcare providers and funders, policy makers and those who access our health services have acknowledged the need to ensure healthcare organizations, systems and practices are evidence-based. Drivers for evidence-based practice quite rightly highlight that implementation of care which is clinically and cost effective could reduce variation in healthcare outcomes, make better use of finite healthcare resources, and support healthcare systems in which clinicians and patients reach shareddecisions about management informed by best evidence.As razões para a prática baseada em evidências enfatizam apropriadamente que a implementação de cuidados efetivos do ponto de vista econômico e clínico pode reduzir a variação dos desfechos em saúde, levar a melhor utilização dos recursos limitados da saúde e apoiar sistemas de saúde em que profissionais de saúde e pacientes compartilhem o processo de tomada de decisão relacionada à gestão informados pela melhor evidência.

Implementation of evidence into practice: complex, multi-faceted and multi-layered.

During the last two decades, academics, healthcare providers and funders, policy makers and those who access our health services have acknowledged the need to ensure healthcare organizations, systems and practices are evidence-based. Drivers for evidence-based practice quite rightly highlight that implementation of care which is clinically and cost effective could reduce variation in healthcare outcomes, make better use of finite healthcare resources, and support healthcare systems in which clinicians and patients reach shareddecisions about management informed by best evidence.As razões para a prática baseada em evidências enfatizam apropriadamente que a implementação de cuidados efetivos do ponto de vista econômico e clínico pode reduzir a variação dos desfechos em saúde, levar a melhor utilização dos recursos limitados da saúde e apoiar sistemas de saúde em que profissionais de saúde e pacientes compartilhem o processo de tomada de decisão relacionada à gestão informados pela melhor evidência.

Breastfeeding support for women following caesarean birth: An exploratory study

Breastmilk is the optimal source of nutrition for babies although there are a range of situations in which breastfeeding is difficult, including prematurity. Human milk is donated in the UK in both regulated and unregulated ways. A network of human milk banks receive and distribute donor milk, primarily to premature and sick infants, supported by NICE guidance (NICE, 2010) and the UK Association for Milk Banking (UKAMB). Variations in the geographical spread and funding of the banks mean that women who want to donate or receive breastmilk are not always able to do so. Discourse around the ethics of the provision and use of human milk in this way often emphasises issues of risk and safety. There are also ways in which breastmilk is donated informally, often using the terminology of ‘sharing’, usually to full-term infants. Some women feed each other’s babies via friendship groups whilst others contact each other using online (often international) networks specifically set up for the purpose of peer-to-peer human milk sharing. Health bodies in a number of countries (although not in the UK) have issued warnings against obtaining breastmilk in this way, focussing again on ‘danger’ and ‘risk’ and drawing on limited research evidence (Keim et al, 2013; Stuebe et al., 2014, cited in Palmquist and Doehler, 2014). In the UK the issues were raised in a recent BMJ editorial (Steele et al, 2015). Other researchers have compared the risk of sharing breastmilk with the (known) risks of formula feeding (Gribble and Hausman, 2012). These topics have been the subject of a range of academic papers as well as online discussions, raising questions about the ethical issues and obligations in both regulated and unregulated practices of milk donation. These include the nature of donation and whether donors and recipients are viewed differently according to the mode of donation (milk bank vs. milk sharing; donating vs. selling) and the situation of the recipient. Is the ethics of ‘giving’ a body product different when the product is human milk rather than blood or organs? Is this an area which should remain unregulated, as a private practice, or should it be more widely or formally considered? In addition there are a range of Issues relating to the perception of human milk – as both ‘white/liquid gold’ and ‘matter out of place’ (Douglas, 1966) – which draw on ideas of cultural unease about women’s bodily fluids. Milk for use in milk banks is depersonalised but there is unease about sharing intimate bodily fluids with known/unknown others. The focus here is on informal milk sharing – why and how it happens (the lived experience of donors and recipients) and how both donation and risk are framed and accounted for. What is known is mostly from the US and Australia; women who use websites for milk sharing talk about ‘informed choice’. Where they examine all the available evidence, share information about milk collection and storage and gather knowledge about the donor (e.g. is the donor breastfeeding her own baby?). Health professionals and non-professionals working with pregnant and lactating women may be asked for advice and need to consider these issues. My conclusion is that breastmilk donation differs from other forms of donation in important ways; donating and sharing breastmilk has increased in prevalence and possibilities but the scale and scope of informal milk sharing in the UK is unknown. Many opportunities to donate and receive breastmilk have arisen in grassroots woman-to-woman ways (in a similar way to other forms of parenting and breastfeeding support). Ideas of risk frame the ‘official’ reaction to sharing breastmilk via the internet (but not in the UK) and little is known about how individual women understand and make sense of these risks.Whether they live in low, middle or high income countries, many women encounter barriers to breastfeeding. Worldwide, fewer than 40% of infants under six months old are breastfed exclusively and more than half of newborns are not breastfed within the first hour of life (UNICEF Global Databases 2014). Many of the barriers to breastfeeding are socio-cultural, economic or relate to the lack of support from health services (Save the Children 2013). Socio-cultural barriers include societal norms for infant feeding, inappropriate advice from family and friends, lack of acceptability of breastfeeding in public spaces, and cultural beliefs e.g. that breastmilk alone is inadequate to meet the nutritional needs of babies. Economic barriers include the need for women to engage in paid employment soon after birth and the influence of commercial interests e.g. lobbying and advertising by breast-milk substitutes companies. Health service barriers include lack of skilled practitioners and lack of breastfeeding support programmes in hospitals and communities. The evidence for what enables women to breastfeeding highlights the importance of factors such as mother-to-mother support/peer counselling and initiatives such as the UNICEF Baby Friendly Initiative (Renfrew et al 2012), adequate paid maternity leave, legislation to support breastfeeding mothers in the workplace, and implementation and monitoring of the WHO Code of Marketing of Breastmilk Substitutes. Previous studies have highlighted that global and national organisations are key to protecting, promoting breastfeeding, and supporting women to breastfeed but their efforts are not always harmonised or effective (UNICEF 2013). This study aimed to explore the role of global and national organisations in influencing political will to protect, promote and support breastfeeding. The objectives were to: highlight examples of good practice where global and national organisations have successfully influenced national political commitment to breastfeeding; identify barriers that prevent global and national organisations from influencing national governments to prioritise breastfeeding; and make recommendations for how global organisations can more effectively influence political commitment to breastfeeding. . We conducted case studies of six countries: Bangladesh, Brazil, Indonesia, Nigeria, the Philippines and the United Kingdom. The countries were selected to represent different geographical regions, income levels and a range of experiences and achievements in protecting and promoting breastfeeding, and supporting women to breastfeed. Each case study comprised: 1. a desk-based review of published and grey literature; 2. telephone interviews with 23 key informants from 19 global organisations across the six countries (an additional 16 informants from 10 global organisations provided written responses to the interview questions) 3. an online survey of national organisations to which 20 organisations responded. Data were collected during November and December 2014. The research material was analysed and triangulated under key themes. Each case study was written up following a structured template and reviewed by respondents from global organisations who had participated in the study for accuracy and clarification. The findings of the case studies identified that global and national organisations were most effective when they worked collaboratively using strong, unified and consistent breastfeeding messages such as the Common Narrative approach used in Bangladesh. Our study highlighted four components that coalitions of global, national and government partners need to incorporate in their plans to successfully improve breastfeeding practices at scale. These are: creating an enabling environment for breastfeeding through implementing the International Code of Marketing of Breastmilk Substitutes (the Code) and maternity protection legislation; implementing infant and young child feeding programmes that focus on health facilities and community support, and include individual counselling; raising community awareness of the importance of breastfeeding using mass media such as television, radio and social media; and equipping all health workers with the knowledge and skills to support women to breastfeed. According to our study, the most common barrier to governments’ commitment to breastfeeding is inadequate implementation of the Code and the negative influence of representatives of BMS companies. Other barriers include a lack of effective global leadership for breastfeeding, lack of knowledge, capacity and staff turnover at national government level, lack of accurate data and lack of resources for breastfeeding programmes. Our study culminated in four over-arching recommendations: 1. Enhance and strengthen international leadership on breastfeeding 2. Facilitate and support national government ownership of breastfeeding-focussed initiatives, policies, plans and programmes 3. Initiate improved collaboration and coordination among global and national organisations operating at the national level 4. At both international and national levels, enhance breastfeeding advocacy and communications through the identification of breastfeeding champions, including pregnant women, breastfeeding mothers and families, and fathers, as well as the provision of consistent breastfeeding messages. References UNICEF Global Databases (2014). Infant and Young Child Feeding. Available at www.data.unicef.org/nutrition/iycf Save the Children (2013). Superfood for babies: how overcoming barriers to breastfeeding will save babies lives. London: Save the Children Renfrew MJ, McCormick FM, Wade A, Quinn B, Dowswell T. (2012) Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews, 5: DOI: 10.1002/14651858.CD001141.pub4. UNICEF (2014) Breastfeeding on the worldwide agenda: findings from a landscape analysis on political commitment for programmes to protect, promote and support breastfeeding. New York: United Nations Children’s Fund The study was funded by Save the Children UK and supported by a Project Advisory Group with representation from Alive & Thrive, Helen Keller Institute, MAINN, UNICEF IYCF Group and WHO. The full report is available at: http://www.savethechildren.org.uk/resources/online-library/breastfeeding-policy-matters

Health in pregnancy and post-birth: contribution to improved child outcomes

The purpose of this paper is to describe the major factors affecting health during pregnancy, birth and the postnatal period and outline the evidence for interventions to improve outcomes in women and their children.

Interventions to support effective communication between maternity care staff and women in labour: A mixed-methods systematic review

Objectives the objectives of this review were (1) to assess whether interventions to support effective communication between maternity care staff and healthy women in labour with a term pregnancy could improve birth outcomes and experiences of care; and (2) to synthesize information related to the feasibility of implementation and resources required. Design a mixed-methods systematic review. Setting and participants studies which reported on interventions aimed at improving communication between maternity care staff and healthy women during normal labour and birth, with no apparent medical or obstetric complications, and their family members were included. ‘Maternity care staff’ included medical doctors (e.g. obstetricians, anaesthetists, physicians, family doctors, paediatricians), midwives, nurses and other skilled birth attendants providing labour, birth and immediate postnatal care. Studies from all birth settings (any country, any facility including home birth, any resource level) were included. Findings two papers met the inclusion criteria. One was a step wedge randomised controlled trial conducted in Syria, and the other a sub-analysis of a randomised controlled trial from the United Kingdom. Both studies aimed to assess effects of communication training for maternity care staff on womens experiences of labour care. The study from Syria reported that a communication skills training intervention for resident doctors was not associated with higher satisfaction reported by women. In the UK study, patient-actors’ (experienced midwives) perceptions of safety and communication significantly improved for postpartum haemorrhage scenarios after training with patient-actors in local hospitals, compared with training using manikins in simulation centres, but no differences were identified for other scenarios. Both studies had methodological limitations. Key conclusions and implications for practice the review identified a lack of evidence on impact of interventions to support effective communication between maternity care staff and healthy women during labour and birth. Very low quality evidence was found on effectiveness of communication training of maternity care staff. Robust studies which are able to identify characteristics of interventions to support effective communication in maternity care are urgently needed. Consideration also needs to be given to how organisations prepare, monitor and sustain interventions to support effective communication, which reflect outcomes of priority for women, local culture and context of labour and birth care.

Try to see the bigger picture.

MANY OLDER people are healthy and live independently or with some support in their own homes. However, an increasing ageing population with a varied profile of health, functioning and wellbeing means that in later life more people may need some form of health and social care and live in various facilities.

Implantación de la evidencia en la práctica: compleja, polifacética y multicapa

During the last two decades, academics, healthcare providers and funders, policy makers and those who access our health services have acknowledged the need to ensure healthcare organizations, systems and practices are evidence-based. Drivers for evidence-based practice quite rightly highlight that implementation of care which is clinically and cost effective could reduce variation in healthcare outcomes, make better use of finite healthcare resources, and support healthcare systems in which clinicians and patients reach shareddecisions about management informed by best evidence.As razões para a prática baseada em evidências enfatizam apropriadamente que a implementação de cuidados efetivos do ponto de vista econômico e clínico pode reduzir a variação dos desfechos em saúde, levar a melhor utilização dos recursos limitados da saúde e apoiar sistemas de saúde em que profissionais de saúde e pacientes compartilhem o processo de tomada de decisão relacionada à gestão informados pela melhor evidência.

Implementation of evidence into practice

During the last two decades, academics, healthcare providers and funders, policy makers and those who access our health services have acknowledged the need to ensure healthcare organizations, systems and practices are evidence-based. Drivers for evidence-based practice quite rightly highlight that implementation of care which is clinically and cost effective could reduce variation in healthcare outcomes, make better use of finite healthcare resources, and support healthcare systems in which clinicians and patients reach shareddecisions about management informed by best evidence.As razões para a prática baseada em evidências enfatizam apropriadamente que a implementação de cuidados efetivos do ponto de vista econômico e clínico pode reduzir a variação dos desfechos em saúde, levar a melhor utilização dos recursos limitados da saúde e apoiar sistemas de saúde em que profissionais de saúde e pacientes compartilhem o processo de tomada de decisão relacionada à gestão informados pela melhor evidência.