Baby Friendly Health Initiative Research Articles

Mother-infant contact after birth can reduce postpartum post-traumatic stress symptoms through a reduction in birth-related fear and guilt

ObjectivesDespite the well-documented negative effects of posttraumatic stress symptoms following childbirth (PTSS-FC), research on protective factors for PTSS-FC is still missing. Aiming to fill this gap, we proposed and examined a process model through which maternal-infant skin-to-skin contact after birth reduces PTSS-FC by decreasing negative emotions, especially for women who had operative births. MethodIn this longitudinal study, pregnant women (N = 1833) were recruited at community and hospital medical centres in the center of Israel and through internet forums. At Time 1, during pregnancy, they rated their prenatal depressive symptoms which served as an indicator for prenatal vulnerabilities. At Time 2, two-months postpartum (N = 1371, 75% of the sample), they reported their mode of birth, whether they had skin-to-skin contact with their newborn after birth, their emotions during birth, and rated their current PTSS-FC. A moderated mediation analysis was used to examine the proposed model. ResultsGuilt and fear during birth mediated the association between mode of birth (instrumental or cesarean versus vaginal) and PTSS-FC. Skin-to-skin contact was related to reduced feelings of guilt and fear during birth, especially for women who had a cesarean section. ConclusionsOur results recognize the specific emotions that contribute to the development of PTSS-FC following operative births and show how skin-to-skin contact can possibly reduce them. As such they emphasize the importance of the implementation of skin-to-skin contact following childbirth, and especially following a cesarean section as recommended by the Baby Friendly Health Initiative (World Health Organization & UNICEF, 2009).

Breastfeeding practices in an Australian tertiary care hospital: A retrospective study

BackgroundThe World Health Organization recommend that infants be exclusively breastfed until six months of age. The Baby Friendly Health Initiative (BFHI) was developed for protecting, promoting, and supporting breastfeeding. The BFHI global criteria guides hospital practice for supporting infant feeding and reducing disparities in breastfeeding outcomes. AimThe aim of this study was to analyse 2019 data to identify factors that predict exclusive breastfeeding vs non-exclusive breastfeeding on discharge to determine areas for intervention in relation to BFHI guidelines. Material and MethodsA retrospective chart review of 5836 neonates born at an Australian tertiary hospital in 2019 was conducted. Descriptive statistics were used to report exclusive breastfeeding rates. Univariate and logistic regression analyses were conducted to determine factors associated with exclusive breastfeeding and non-exclusive breastfeeding on discharge. ResultsA total of 69% of neonates were exclusively breastfed on discharge in 2019. When excluding admissions to Newborn Services, 75% of neonates were exclusively breastfed on discharge, achieving the BFHI benchmark. Predictors which significantly reduced the odds of exclusive breastfeeding on discharge were maternal country of birth (Vietnam, p < 0.001, Sudan p < 0.001, Samoa p < 0.01, Philippines p < 0.05), main language (Other, p < 0.05), birth type (caesarean or assisted vaginal birth p < 0.001), first-feed type (mixed feeding or formula p < 0.001), and Newborn Services admission (p < 0.001). ConclusionsExamining breastfeeding outcomes is an important quality assurance process for health services. Understanding groups of mothers who commence breastfeeding but do not exclusively breastfeed upon discharge enables identification of areas for intervention to achieve BFHI targets and reduce breastfeeding disparities.

Knowledge and Attitude of Nursing Staff on Baby-friendly Hospital Initiative Practices in a Tertiary Hospital

Background: Within a hospital setting, health professionals play a key role in providing the right information on breastfeeding and often this source are the nurses who have the primary opportunity to counsel, support and educate mothers on breastfeeding. The Baby Friendly Health Initiative (BFHI) has helped to motivate facilities providing maternity and newborn services worldwide to better support breastfeeding.&#x0D; Objective: The aim of this study is to help identify the knowledge gaps on the BFHI practices among nursing staff in a tertiary care center in Kathmandu.&#x0D; Methodology: A total of 27 nursing staff who encounter pregnant women admitted in the hospital up until post-delivery discharge were selected for the study. Data on knowledge of baby-friendly hospital initiative and attitude towards breastfeeding practices was collected using a structured interview between October and December 2019. Statistical analysis was done using SPSS version 20.&#x0D; Results: Only 41% were acquainted with the ten steps to successful breastfeeding of BFHI, out of whom more than half (55%) had a good level of knowledge. Majority of the participants showed a fairly correct attitude towards BFHI practices, except for the belief that there is no harm in introducing pre-lacteal feeds to babies. The opinion on demand feeding and the time of introduction of complementary feeding seemed to vary. &#x0D; Conclusion: There is an urgent need to re-evaluate the present knowledge of our nursing staff and to ensure they impart the right information. The only way to achieve this is through advocacy and training to promote, support and protect breastfeeding.

Perspectives about the baby friendly hospital/health initiative in Australia: an online survey

BackgroundEvidence supports the health and economic benefits of breastfeeding, and the positive impact of the Baby Friendly Health Initiative (BFHI) on increasing breastfeeding rates and improving breastfeeding outcomes. The BFHI is a World Health Organization and United Nations International Children’s Emergency Fund initiative to promote, support and maintain breastfeeding. The BFHI was updated in 2018 and includes the Ten Steps to Successful Breastfeeding (the Ten Steps 2018) and the International Code of Marketing of Breast-milk Substitutes (the WHO Code). Despite policy and guideline support for breastfeeding and the BFHI, there are currently only 70 accredited hospitals, healthcare centres and regional clusters in Australia, accounting for 23% of maternity facilities. This research aimed to explore health professionals and other stakeholders’ perspectives on the uptake and implementation of the BFHI in Australia from an organisational change perspective.MethodsAn online survey administered via relevant Australian-based professional associations was fully or partially completed by 332 participants who support mothers and newborns in their roles. Descriptive statistics and content analysis were used to analyse quantitative and qualitative data.ResultsThe majority of participants supported legislating the WHO Code, closely monitoring BFHI compliance, ensuring sufficient knowledge about breastfeeding and the BFHI among staff, improving care within maternity facilities, continuous support of mothers’ post-discharge, and improving social media support of breastfeeding. It was also perceived that an interdisciplinary team approach and multidisciplinary involvement were important requirements for successfully implementing the BFHI. There was no consensus among participants that Australian health policies support breastfeeding and the implementation of the BFHI.ConclusionsThis study emphasised the significance of legislation around the Code, executive and leadership support and culture, and providing adequate resources concerning uptake and implementation of the BFHI. Considering that uptake of the BFHI has been limited and no formal government support has been provided to further develop the BFHI and support the Code in Australia, findings of this research may help with potential future actions to facilitate the BFHI uptake and Code implementation.

The uptake and implementation of the Baby Friendly Health Initiative in Australia

ProblemDespite evidence that implementation of the Initiative has been effective in increasing breastfeeding rates and duration of breastfeeding worldwide; the uptake is low with only 70 Baby Friendly accredited maternity facilities across Australia (approximately 23% of facilities). BackgroundThe Ten Steps to Successful Breastfeeding and International Code of Marketing of Breastmilk Substitutes shaped the foundation for the Initiative to implement practices that protect, promote and support breastfeeding. There is evidence that implementation of the Initiative is impacted by individual and organisational culture, organisational support, and education. Organisational change is also identified as playing an important role in the successful implementation of the Initiative. Despite policy and guideline support for the Initiative at national and state levels in Australia the uptake of the Initiative is low. AimThe aim of this research was to explore health practitioners’ perspectives about the uptake and implementation of the Initiative in Australia. MethodsSemi-structured, face-to-face, telephone and Skype interviews were conducted with 12 health practitioners. Thematic analysis was used to analyse data. ResultsParticipants identified that the uptake and implementation of the Initiative in Australia is complex. This complexity was related to six themes: (1) policy and guideline support for the Initiative, (2) leadership support to implement the Initiative, (3) improving breastfeeding and Initiative-related knowledge, (4) improving communication between stakeholders regarding the Initiative, (5) accreditation and reaccreditation processes, and (6) implementation complexity. ConclusionUsing organisational change theories as a guide to implementation of the Initiative may be useful for facilities intending to become accredited.

An instrumental case study examining the introduction and dissemination of the Baby Friendly Health Initiative in Australia: Participants' perspectives.

Australia experiences high breastfeeding initiation but low duration rates. UNICEF introduced the global breastfeeding strategy, the Baby-Friendly Hospital Initiative, to Australia in 1992, transferring governance to the Australian College of Midwives (ACM) in 1995. In 2017 23% of facilities were registered as 'baby-friendly' accredited. To examine the introduction and dissemination of the Baby-friendly Hospital Initiative into the Australian national setting. An instrumental case study was conducted containing two components: analysis of historical documents pertaining to the Initiative and participant's interviews, reported here. A purposive sampling strategy identified 14 participants from UNICEF, ACM, maternity and community health services, the Australian government and volunteer organisations who took part in in-depth interviews. Thematic analysis explored participants' perceptions of factors influencing the uptake and future of the since renamed Baby Friendly Health Initiative (BFHI) and accreditation programme, BFHI Australia. Two broad categories, enablers and barriers, guided the interviews and analysis. Participants revealed a positive perception of the BFHI whilst identifying that its interpretation and expansion in Australia had been negatively influenced by intangible government support and suboptimal capacity building. BFHI's advocacy agenda competed with BFHI Australia's need for financial viability. Widespread stakeholder collaboration and tangible political endorsement was seen as a way to move the strategy forward. Dissemination of BFHI Australia is hampered by multi-level systems issues. Prioritisation, stakeholder collaboration and adequate resourcing of the BFHI is required to create a supportive and enabling environment for Australian women to determine and practice their preferred infant feeding method.

Legislation, policies and guidelines related to breastfeeding and the Baby Friendly Health Initiative in Australia: a document analysis.

Objectives The aim of the present study was to assess the extent to which publicly available legislation, policy and guidelines related to breastfeeding and the Baby Friendly Health Initiative (BFHI) underpin and support the uptake and implementation of the BFHI in Australia. Methods Altheide's document analysis model (sample, data collection, data organisation, data analysis and report) was used to source and analyse publicly available legislation, policies and guidelines in Australia that were related to breastfeeding and the BFHI at national, state and professional organisational levels. Results Legislation documents contained no direct references to the BFHI or Code of Marketing of Breast-milk Substitutes, despite the documents being supportive of breastfeeding. There is little reference to the Code of Marketing of Breast-milk Substitutes or to monitoring of the Marketing in Australia of Infant Formulae (MAIF) Agreement at national and state levels. A gap exists in documents that provide up-to-date records regarding monitoring of breastfeeding rates at the national level. Conclusions National and state guidelines are supportive of breastfeeding and the BFHI. However, the BFHI and Code of Marketing of Breast-milk Substitutes are not legislated in Australia and information related to breastfeeding rates is not up to date. A legislative establishment supporting the Code and establishing plans to monitor the MAIF Agreement and breastfeeding outcomes may influence uptake and implementation of the BFHI. What is known about the topic? Extensive evidence supports the health and economic benefits of breastfeeding. Despite a high initiation rate of breastfeeding in Australia (96%) most recently reported in 2010, the rate of breastfed infants dropped considerably over time: approximately 15% of infants were breastfed for the recommended 6 months. Research supports the positive effect of the BFHI on increasing breastfeeding rates and improving breastfeeding outcomes. In 2016, there are 69 Baby-friendly-accredited maternity facilities across Australia, compared with 77 accredited facilities in 2011 (~23% of all maternity facilities). What does this paper add? This is the first document analysis of publicly available legislation, policy and guidelines related to breastfeeding and the BFHI at Australian national, state and professional organisational levels to assess the extent to which these documents support breastfeeding, as well as the uptake and implementation of the BFHI. This study identifies strengths and weaknesses at legislative, policy and guideline levels that could potentially influence the uptake and implementation of the BFHI. What are the implications for practitioners? The uptake and implementation of the BFHI is potentially influenced by legislation, policy and guidelines at national and state levels. Given the low uptake of the BFHI in Australia, this analysis outlines the extent to which these documents support breastfeeding and the BFHI, and indicates what these documents lack with regard to supporting the uptake and implementation of the BFHI.

The Baby Friendly Health Initiative: strengths and weaknesses in Australia…

The Baby Friendly Health Initiative: strengths and weaknesses in Australia…

Trying to translate research into practice: The Baby Friendly Health Initiative in Australia – Twenty years on

Introduction: Australia’s health care policy in relation to breastfeeding includes in-principle support for the Baby Friendly Health Initiative (BFHI). The BFHI is an evidence based quality assurance program that has shown a positive effect on breastfeeding practices, more so on initiation than duration. Currently seventy-four maternity facilities (19%) are accredited as ‘baby friendly’; there is ongoing interest in initial accreditation andmany facilities have achievedmultiple reaccreditations; however there is an unknowndegree of implementation by individual hospitals. The numbers of currently accredited facilities across states/territories also varies. Several Australian studies have revealed the existence of multi-level barriers. Competition for health funding, selective prioritisation by managers, plus skill deficits and negative attitudes of individual health professionals appears to hamper widespread knowledge translation into practice. Aim: To examine the factors influencing the operationalising of an evidence-based, global, health-promotion strategy, in a national setting, twenty years post-implementation. Methods: A case study research (CSR) approach was used to examine the influences on BFHI operationalisation twenty years post-implementation. CSR requires a range of data to be collected to confirm findings. In this study relevant literature, archival data and in depth individual interviews with key stakeholders have been analysed. Findings: Stakeholders shared their unique perspective and assessment of the challenges that have influenced the sustainability of the Initiative in Australia. There was consensus on the lack of commitment to and understanding of the Initiative by policy makers, health professionals, health administrators and clinicians. Opinion differed however on the currency and usefulness of the BFHI to the Australian context, in its current form. Implications: The BFHI is a well evidenced strategy which continues to be hampered by a lack of comprehensive support. Implementing strategies to improve BFHI’s ‘fit’ in the Australian context may better facilitate the translation of research into practice.

Support needs of breast-feeding women: Views of Australian midwives and health nurses

Objectiveto explore the views of midwives and maternal–child health nurses regarding factors that influence breast feeding initiation and continuation, focusing on how support for women could be improved to increase breast feeding duration. Designa focus group study. Settinghospital or domiciliary (home-visiting) midwives and community-based maternal and child health (MCH) nurses in one region of Victoria, Australia. Methodstwelve MCH nurses and five midwives who provided supportive services to women in the immediate postnatal period attended one of three audio-recorded focus groups. Thematic findings were identified. Findingsfour key themes were: ‘Guiding women over breast-feeding hurdles’, ‘Timing, and time to care’; ‘Continuity of women’s care’ and ‘Imparting professional knowledge’. Given the a pattern of hospital discharge of mother and infant on day one or day two after birth, participants thought the timing of immediate postnatal breast-feeding support was critical to enable women to initiate and continue breast feeding. Community-based MCH nurses reported time gaps in uptake of new mother referrals and time-pressured face-to-face consultations. Both groups perceived barriers to continuity of women’s care. Conclusionshealth services subscribe to the Baby Friendly Health Initiative and government policies which support breast feeding, however providers described time pressures and a lack of continuity of women’s care, including during transition from hospital to community services. Implications for practicethere is a need to examine administration of service delivery and how domiciliary and community nurses can collaborate to establish and maintain supportive relationships with breast feeding women.

A meta-ethnographic study of health care staff perceptions of the WHO/UNICEF Baby Friendly Health Initiative

BackgroundImplementation of the Baby Friendly Health Initiative (BFHI) is associated with increases in breastfeeding initiation and duration of exclusive breastfeeding and ‘any’ breastfeeding. However, implementation of the BFHI is challenging. AimTo identify and synthesise health care staff perceptions of the WHO/UNICEF BFHI and identify facilitators and barriers for implementation. MethodSeven qualitative studies, published between 2003 and 2013 were analysed using meta-ethnographic synthesis. FindingsThree overarching themes were identified. First the BFHI was viewed variously as a ‘desirable innovation or an unfriendly imposition’. Participants were passionate about supporting breastfeeding and improving consistency in the information provided. This view was juxtaposed against the belief that BFHI represents an imposition on women's choices, and is a costly exercise for little gain in breastfeeding rates. The second theme highlighted cultural and organisational constraints and obstacles to BFHI implementation including resource issues, entrenched staff practices and staff rationalisation of non-compliance. Theme three captured a level of optimism and enthusiasm amongst participants who could identify a dedicated and credible leader to lead the BFHI change process. Collaborative engagement with all key stakeholders was crucial. ConclusionsHealth care staff hold variant beliefs and attitudes towards BFHI, which can help or hinder the implementation process. The introduction of the BFHI at a local level requires detailed planning, extensive collaboration, and an enthusiastic and committed leader to drive the change process. This synthesis has highlighted the importance of thinking more creatively about the translation of this global policy into effective change at the local level.

Applying a knowledge translation model to the uptake of the Baby Friendly Health Initiative in the Australian health care system

The Baby Friendly Hospital Initiative is a global, evidence-based, public health initiative. The evidence underpinning the Initiative supports practices promoting the initiation and maintenance of breastfeeding and encourages women's informed infant feeding decisions. In Australia, where the Initiative is known as the Baby Friendly Health Initiative (BFHI) the translation of evidence into practice has not been uniform, as demonstrated by a varying number of maternity facilities in each State and Territory currently accredited as 'baby friendly'. This variance has persisted regardless of BFHI implementation in Australia gaining 'in principle' support at a national and governmental level as well as inclusion in health policy in several states. There are many stakeholders that exert an influence on policy development and health care practices. Identify a theory and model to examine where and how barriers occur in the gap between evidence and practice in the uptake of the BFHI in Australia. Knowledge translation theory and the research to practice pipeline model are used to examine the identified barriers to BFHI implementation and accreditation in Australia. Australian and international studies have identified similar issues that have either enabled implementation of the BFHI or acted as a barrier. Knowledge translation theory and the research to practice pipeline model is of practical value to examine barriers. Recommendations in the form of specific targeted strategies to facilitate knowledge transfer and supportive practices into the Australian health care system and current midwifery practice are included.

Exploring pregnant women's current level of nutrition knowledge, attitudes, and readiness for dietary change during pregnancy

International impact studies have identified a positive association between the initiative and breastfeeding trends however in Australia BFHI struggles to gain momentum with 19% of facilities currently accredited. Australian studies have identified several impediments: a misunderstanding of the initiative’s aims, a discord with practice and organisational attitudinal issues. Critics have recommended redirecting any proposed funding as the initiative has not proven its applicability to the Australian context. This poster discusses the social context in which feeding practices occur and explores the state of evidence on which the Baby Friendly Health Initiative is founded. The weight of evidence supportingbreastfeeding is reconsidered tocritique thecurrent stateof knowledge onwhich breastfeeding promotion activities are based. The challenge of successfully developing and reporting breastfeeding indicators is also examined. The impact of breastfeeding is then explored in order to examine the relationship between breastfeeding and BFHI practices.

The Baby Friendly Health Initiative in Australia: Desirable strategy or lame duck?

The Baby Friendly Health Initiative in Australia: Desirable strategy or lame duck?

The Use of Oral Sucrose for Procedural Pain Relief in Infants Up to Six Months of Age: A Randomized Controlled Trial

The aim of this study was to evaluate the effectiveness of oral sucrose in decreasing pain during minor procedures in infants of 1-6 months corrected age. A blinded randomized controlled trial with infants aged 4-26 weeks who underwent venipuncture, heel lance or intravenous cannulation were stratified by corrected age into >4-12 weeks and >12-26 weeks. They received 2 mL of either 25% sucrose or sterile water orally 2 minutes before the painful procedure. Nonnutritional sucking and parental comfort, provided in adherence to hospital guidelines, were recorded. Pain behavior was recorded using a validated 10 point scale at baseline, during and following the procedure. Data collectors were blinded to the intervention. A total of 21 and 20 infants received sucrose and water, respectively, in the >4–12-week age group, and 21 and 22, respectively, in the >12–26-week age group. No statistical differences were found in pain scores between treatment and control groups at any data collection points in either age group. Infants aged >4-12 weeks who did nonnutritional sucking showed statistically significantly lower median pain scores at 1, 2, and 3 minutes after the procedure than those who did not suck. Infants aged >4-26 weeks exhibited pain behavior scores that indicated moderate to large pain during painful procedures; however, there was insufficient evidence to show that 2 mL 25% sucrose had a statistically significant effect in decreasing pain. Infants should be offered nonnutritional sucking in compliance with the Baby Friendly Health Initiative during painful procedures.

An Examination of Maternity Staff Attitudes Towards Implementing Baby Friendly Health Initiative (BFHI) Accreditation in Australia

The Baby Friendly Hospital Initiative (BFHI) influences health care practices and increases the initiation and duration of exclusive breastfeeding. Consistent definitions enable the accurate monitoring of breastfeeding rates and behaviour. This information refines policy and helps reach national breastfeeding targets. Only 21% (66/317) of Australian hospitals are BFHI accredited. To examine the factors perceived to promote or hinder BFHI accreditation. Focus group interviews explored opinions of 31 participants, in differing roles and levels of employment, across midwifery, medical, nursing and ancillary staff at six South Australian maternity hospitals. The results suggest that staffs' understanding and personal views are often discordant with BFHI aims. Perceived difficulties include the accreditation process, hospital dynamics, and the Ten Steps implementation plus a bottle feeding culture and maternal employment that impact upon continued breastfeeding. Upper management support, specific funding, a dedicated co-ordinator with "area leaders", development of a specific breastfeeding policy incorporating various disciplines and staff, containing detailed protocols that comply with the International Code of Marketing of Breast Milk Substitutes and subsequent World Health Assembly (WHA) resolutions, are all required. Staff and mothers require multiple modes of education to understand the BFHI, including sponsorship for training of lactation consultants. Full implementation of BFHI across Australia will assist the development of nationally accepted breastfeeding definitions, improve monitoring and evaluation of rates and practices, and improve breastfeeding outcomes.

Passive resistance: Early experiences of midwifery students/graduates and the Baby Friendly Health Initiative 10 steps to successful breastfeeding

PASSIVE RESISTANCE: Early experiences of midwifery students/graduates and the Baby Friendly Health Initiative (BFHI) 10 steps to successful breastfeeding. What factors, in relation to the BFHI 10 steps to successful breastfeeding, influence the development of breastfeeding support practice for beginning practitioner midwives? Newly graduated midwives about to commence a Graduate Midwifery Program (GMP) were recruited from two South Australian universities and one Western Australian hospital to participate in the study. This qualitative longitudinal study used critical incident technique for a series of three semi-structured interviews with each participant. The theoretical framework of the project was Bandura's Social Learning Theory with Boyatzis' Data driven approach used to thematically analyze the data. Participants highlighted experiences such as time pressure and the established clinical practices of experienced midwives that undermined their commitment to the BFHI 10 steps. Outdated practices by senior midwives and passive resistance to the BFHI 10 steps were commonplace even in participating hospitals which are BFHI accredited. The clinical working environment has a major impact on the way newly graduated midwives integrate the BFHI 10 steps into their breastfeeding support practice. Commitment to the BFHI 10 steps should not be taken for granted just because a hospital achieves BFHI accreditation. Many experienced midwives are continuing with outdated practices that confuse breastfeeding mothers and newly graduated midwives alike.

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

Review Objectives: The primary objective of this review is to assess if a structured programme, such as the WHO/UNICEF Baby Friendly Hospital Initiative (BFHI, which may also be referred to in Australia as the Baby Friendly Initiative or the Baby Friendly Health Initiative), implemented in maternity acute care settings is more likely to be associated with higher rates of initiation and duration of exclusive breastfeeding than no structured programme. Secondary objectives include eliciting whether the introduction of a structured programme (compared with no programme): • is more likely to be effective at increasing breastfeeding initiation and duration in particular groups of women and/or particular health care settings • enhances maternal and infant health outcomes • makes more effective use of healthcare resources • influences policy with respect to infant nutrition at local, national and international level Criteria for considering studies for this review: Types of participants: Participants will include pregnant women, mothers of newborn infants and women who may decide in the future to breastfeed in hospital or community settings. Population subgroups of women, such as women from low-income or minority ethnic groups, are also part of this review. Participants will incorporate all women exposed to interventions as part of a structured programme to support increased breastfeeding initiation and duration. When considering data from RCTs, intervention and control group data will be presented. Types of interventions / phenomenon of interest: Any intervention developed as part of a structured programme to promote the initiation and duration of exclusive breastfeeding. For example, programmes may include: the BFHI 10 step initiative; initiatives to support national or local adaptation of protocols or guidelines; training of relevant health care professionals; and implementation of a national or local policy initiative aimed at increasing the initiation and duration of breastfeeding and/or support for breastfeeding. Evaluations of interventions delivered as part of a structured programme taking place after the first breastfeed or whose primary purpose is to affect the duration or exclusivity of breastfeeding (which may have commenced antenatally) will be included in this review. This may include studies which have examined the effectiveness of a package of TRUNCATED AT 350 WORDS