Home Visitation and Breastfeeding Rates
by Anne Eglash MD, IBCLC, FABM
The dropoff in breastfeeding rates postpartum is a global health issue, not limited to the USA and other high resource countries. According to the World Health Organization, only 38% of infants aged 0 to 6 months are exclusively breastfed. One of the 6 WHO global nutrition targets for 2025 is to increase exclusive breastfeeding in the first 6 months up to at least 50%.
The authors of this week’s CQW sought to explore the effect of home visitation by professionals in increasing breastfeeding rates postpartum. Even if mothers receive optimal support of breastfeeding in the hospital or birthing center, they leave just as breastfeeding dynamics rapidly change and the infant’s nutritional needs are rapidly increasing. We just learned from the Flaherman study discussed in CQW 150 that any formula use at 2 weeks was associated with a 31.4% rate of any breastfeeding at 6 months, and a 5.7% at 12 months.
This article is a systematic review of 26 studies that researched the effect of home visitation by professionals on breastfeeding rates and that used a randomized controlled trial or quasi-experimental trial design. Professionals included physicians, nurses, midwives, IBCLCs, or trained workers who completed the 18-h or 40-h WHO/UNICEF counseling/lactation management courses. The studies were from a variety of countries, with only 5 from the USA. Other countries included Brazil, Australia, Canada, Bangladesh, Switzerland, Denmark, Syria, Italy, Turkey, Holland, and countries in Africa. The studies varied in their criteria of participant selection based on intention to breastfeed. They also varied on the breastfeeding rates measured, i.e. exclusive vs any.
- The majority of studies measuring exclusive breastfeeding rates found that home visitation increased exclusive breastfeeding rates at 0-6 mo postpartum.
- Home visitation programs that only occur postpartum and not during pregnancy had no effect on breastfeeding rates.
- A longer duration of home visit intervention is more likely to have a positive impact on breastfeeding duration rates.
- Home-based interventions with professional support in general did not increase breastfeeding initiation rates.
- Home-based interventions that taught positioning and latch were more likely to increase breastfeeding rates than interventions that had no specific teaching agenda.
See the Answer
Abstract
Objectives
Low breastfeeding rate and high early cessation of breastfeeding are observed worldwide. There is a need to review the effects of home visits with professional support on promoting breastfeeding. The present study evaluated the efficacy of home visits on promoting breastfeeding outcomes (i.e., breastfeeding initiation rate, exclusive breastfeeding rate/duration, and breastfeeding rate/duration) using a systematic review.
Methods
Search of EMBASE, MEDLINE, CENTRAL—Cochrane central register of controlled trials, PsycInfo, and ClinicalTrials.gov was conducted by February 28, 2019, to identify relevant studies.
Results
A total of 26 studies were included. Fourteen of the included studies investigated rate/duration of exclusive breastfeeding; ten of them demonstrated a significant increase on the rate/duration of exclusive breastfeeding. Sixteen of the included studies investigated rate/duration of breastfeeding; four of them demonstrated a significant increase on the rate/duration of breastfeeding. Four studies evaluated initiation of breastfeeding and three of them did not show a significant effect.
Conclusions
Findings suggest that breastfeeding can be increased by home-based interventions with professional support. Support-based intervention is likely an effective way to promote breastfeeding.
The studies in this systematic review varied greatly in terms of who provided the breastfeeding support, what type of breastfeeding support was offered (structured agenda of topics vs answering questions), the number of visits provided, and the duration of time that home visitations were provided. In addition, the studies varied as to whether they included participants who had a strong intention to breastfeed. This systematic review did not measure whether focusing on participants with strong intention was more likely to show a positive effect of home visitation. This study left me with more questions than answers. Should home visitation programs focus on women with a strong intention to breastfeed? What % of the population has access to professional home visitors for breastfeeding support? How can we ensure that all public health professionals providing home visitation are knowledgeable about breastfeeding, and do they have specific breastfeeding teaching points to discuss on their home visits? Which insurances/national health care programs cover home visitation for breastfeeding support?
I hope some of our readers will share their home-visitation experiences in our comments section!
Rebecca W.
I am a county Public Health nurse and provide prenatal and postpartum home visiting to all of the residents of my county who would like home visits, regardless of income level. Medical assistance generally covers the cost of home visits, private insurance does not, but grant money picks up the tab. Breastfeeding is a major subject covered for those who voice a desire to BF prenatally, or who have started to BF their babies. We offer information prenatally, encourage early utilization of lactation services through the delivering hospital, and fill in the gaps after the mother and baby have discharged home. We have handouts, BF resource lists, videos, and other teaching materials; we also make ourselves available to the mothers who need additional BF cheerleaders in their corner, have occasional questions, or would simply like their babies weighed periodically to make sure they are gaining well. Not knowing what our county BF rate is and how home visitation has affected it over the years, it is difficult to say whether or not our efforts have made a difference.
Anne-Marie Desjardins
I have been a private lactation consultant providing breastfeeding support for over 25 years. The population that I service are usually well educated, middle-class, motivated and seek out my services. I am an RN, so many parents get reimbursed for my services through their private health insurance.
When I initially started this service, I was providing home consultations and would encourage the parents to page me if they had any questions or difficulty afterwards. Very little would call. Once cellphones, texting, emails, and video calls came into fashion, I had to expand my services to offer more support to new parents. I would say that 90% opt for the additional support that I offer as part of my services after the 1st home consultation. The support allows them to call, text, and email me with their questions for as long as they breastfeed. If anything changes with the breastfeeding, I do a video call.
As we all know, breastfeeding does change as the milk gets established and the baby grows. This article didn’t surprise me. Home visits are helpful, but one is not enough. So many parents do not anticipate problems and difficulties can occur.
I use a massage therapist to provide lymphatic drainage to the mothers with general postpartum edema to facilitate latching in the early breastfeeding days. I also use the expertise of a holistic nutritionist to assist with insufficient milk production, hypothyroidism, newborn reflux and colic.
If anyone wants to discuss my experience further, I welcome any email.
Anne-Marie ([email protected])