Evaluating the ‘Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme’: A mixed method study in England

Background Caesarean section plays an important role in ensuring safety of mother and infant but rising rates are not accompanied by measurable improvements in maternal or neonatal mortality or morbidity. The ‘Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme’ was a facilitative initiative developed to promote opportunities for normal birth and reduce Caesarean section rates in England. Objective To evaluate the ‘Focus on Normal Birth and Reducing Caesarean section Rates’ programme, by assessment of: impact on Caesarean section rates, use of service improvements tools and participants’ perceptions of factors that sustain or hinder work within participating maternity units. Design A mixed methods approach included analysis of mode of birth data, web-based questionnaires and in-depth semi-structured telephone interviews. Participants Twenty Hospital Trusts in England (selected from 68 who applied) took part in the ‘Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme’ initiative. In each hospital Trust, the head of midwifery, an obstetrician, the relevant lead for organisational development, a supervisor of midwives, or a clinical midwife and a service user representative were invited to participate in the independent evaluation. Methods Collection and analysis of mode of birth data from twenty participating hospital Trusts, web-based questionnaires administered to key individuals in all twenty Trusts and in-depth semi-structured telephone interviews conducted with key individuals in a sample of six Trusts. Results There was a marginal decline of 0.5% (25.9% from 26.4%) in mean total Caesarean section rate in the period 1 January 2009 to 31 January 2010 compared to the baseline period (1 July to 31 December 2008). Reduced total Caesarean section rates were achieved in eight trusts, all with higher rates at the beginning of the initiative. Features associated with lower Caesarean section rates included a shared philosophy prioritising normal birth, clear communication across disciplines and strong leadership at a range of levels, including executive support and clinical leaders within each discipline. Conclusions It is important that the philosophy and organisational context of care are examined to identify potential barriers and facilitative factors

Interventions for promoting the initiation of breastfeeding

BACKGROUND: Despite the widely documented health advantages of breastfeeding over formula feeding, initiation rates remain relatively low in many high-income countries, particularly among women in lower income groups. OBJECTIVE : To evaluate the effectiveness of interventions which aim to encourage women to breastfeed in terms of changes in the number of women who start to breastfeed. METHODS : Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2007), handsearched the Journal of Human Lactation, Health Promotion International and Health Education Quarterly from inception to 15 August 2007, and scanned reference lists of all articles obtained. Selection criteria: Randomized controlled trials, with or without blinding, of any breastfeeding promotion intervention in any population group except women and infants with a specific health problem. Data collection and analysis: One review author independently extracted data and assessed trial quality, checked by a second author. We contacted investigators to obtain missing information. MAIN RESULTS: Main results: Eleven trials were included. Statistical analyses were conducted on data from eight trials (1553 women). Five studies (582 women) on low incomes in the USA with typically low breastfeeding rates showed breastfeeding education had a significant effect on increasing initiation rates compared to standard care (risk ratio (RR) 1.57, 95% confidence interval (CI) 1.15 to 2.15, P = 0.005). Subgroup analyses showed that one-to-one, needs-based, informal repeat education sessions and generic, formal antenatal education sessions are effective in terms of an increase in breastfeeding rates among women on low incomes regardless of ethnicity and feeding intention. Needs-based, informal peer support in the antenatal and postnatal periods was also shown to be effective in one study conducted among Latina women who were considering breastfeeding in the USA (RR 4.02, 95% CI 2.63 to 6.14, P < 0.00001). AUTHORS' CONCLUSIONS: This review showed that health education and peer support interventions can result in some improvements in the number of women beginning to breastfeed. Findings from these studies suggest that larger increases are likely to result from needs-based, informal repeat education sessions than more generic, formal antenatal sessions. These findings are based only on studies conducted in the USA, among women on low incomes with varied ethnicity and feeding intention, and this raises some questions regarding generalisability to other settings

Preventing disease and saving resources:the potential contribution of increasing breastfeeding rates in the UK

Two challenges stand out as we contemplate the future of health services in the United Kingdom. The first is the state of the public finances and therefore the pressure in real terms on health services funding. The second is the recurring and vexing problem of health inequalities. The state of health inequalities in Britain has been commented on by many, but we have seen precious little real change in the disproportionate burden of early death and illness among the most disadvantaged and indeed across the whole health gradient in recent years.This work was funded by UNICEF UK

A systematic review of education and evidence-based practice interventions with health professionals and breast feeding counsellors on duration of breast feeding

Objective: to examine the effects of training, education and practice change interventions with health professionals and lay breast feeding educator/counsellors on duration of breast feeding. Review methods: this was part of a series of reviews of interventions that affect duration of breast feeding. Full details of methods used, including search strategy, are reported separately. Selection criteria for included studies: randomised controlled trials, non randomised controlled trials with concurrent controls and before after studies (cohort or cross-sectional), undertaken in a developed country, published between 1980 and 2003 in any language. The primary outcome was duration of breast feeding. Secondary and process outcomes, including attitude, knowledge and behaviour change of participants, were included from papers that also reported breast feeding duration outcomes. Study-quality assessment: inclusion and exclusion criteria were applied, data extracted and study quality assessments made by one reviewer and independently checked by another, with a third reviewer to resolve differences, as recommended by the NHS Centre for Reviews and Dissemination's guidance for reviews. Findings: the search identified nine papers. All were before after studies that included the education of health professionals; no studies were identified that related to breast feeding counsellors. In six of the studies, the participants were working with mothers and babies in hospitals (three in the UK, two in Italy and one in France); in three studies, the participants were working in community settings (Canada, Spain and the USA). Two UK studies and two non-UK studies (Spain and USA) involved mothers living in disadvantaged areas. Most interventions aimed to increase knowledge and change professional practice in support of breast feeding. Key conclusions: many of the studies reviewed have methodological limitations. Study settings and contexts vary and lack comparability. Evidence from these studies was insufficient to draw conclusions about overall benefit or harm associated with the interventions. From the studies identified, there seems to be no single way that consistently achieves changes in breast feeding duration. From one of the methodologically more robust studies, it seems that UNICEF/WHO Baby Friendly Hospital Initiative (BFI) training might have the potential to influence breast feeding duration. Recommendations for further research: further testing of the BFI initiative within a controlled design. Future research into the education of health-care professionals that relates to the support of breast feeding women should have appropriate theoretical underpinning, describe educational programmes and the context of care delivery comprehensively and use standardised time points in the assessment of the effect of interventions. Intermediate outcomes should also be reported, including those related to the effect on education and practice