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Welma Lubbe,1 Hannakaisa Niela-Vilén,2 Gill Thomson,3 Elina Botha4 1School of Nursing Science/NuMIQ Research Focus Area, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa; 2University of Turku, Department of Nursing Science, Turku, Finland; 3School of Community Health and Midwifery, University of Central Lancashire, Preston, UK; 4School of Social Services and Health Care, Tampere University of Applied Sciences, Tampere, FinlandCorrespondence: Welma Lubbe, Email welma.lubbe@nwu.ac.zaObjective: The aim of this systematic review was to explore the impact of the COVID-19 pandemic on breastfeeding support services and continuation rates.Methods: Electronic searches were undertaken in seven databases: Academic Search Complete, Springer Nature Journals, CINAHL Medline, Health Source: Nursing/Academic Edition, Masterfile premier, and SocINDEX. Publications following the COVID-19 pandemic between January 2020 and March 2022 were searched for using the following keywords: impact or effect or influence and breastfeeding support and breastfeeding continuation and COVID-19 or coronavirus. Fifteen studies were included for investigation and extracted to identify seven themes related to breastfeeding support during COVID-19.Results: Factors which impacted breastfeeding support during the COVID-19 pandemic included separation, lack of skin-to-skin contact, insufficient support, online breastfeeding support, the impact of the pandemic on breastfeeding rates and experiences, fears of the pandemic, and the need for additional support. The pandemic mostly influenced breastfeeding support negatively, with a small exception occurring where some mothers experienced lockdown as positive since it protected the mother-infant dyad from unwanted visitors. Virtual breastfeeding support was introduced in many contexts; however, practitioners and mothers reported that this could not replace the need for face-to-face support.Conclusion: Breastfeeding is a lifesaving intervention, especially in the face of a disruption such as a pandemic. This work highlights the need for clear, consistent, and evidence-based information about risks, and for key practices to be maintained including not separating mothers and infants, promoting skin-to-skin contact, and ensuring availability of high-quality breastfeeding support.Keywords: breastfeeding support, COVID-19, coronavirus, pandemic, effect

Background: Half of women with overweight gain excessive weight during pregnancy. Perceived self-efficacy plays a significant role in adherence to healthy behaviours, especially in turning points of life, such as a pregnancy., Objectives: To assess the effectiveness of the Supporting lifestyle change in pregnant mothers with obesity through the wearable internet-of-things (SLIM)-intervention in terms of improving self-efficacy in eating and physical activity and preventing excessive weight gain of pregnant women with overweight. The second aim was to evaluate the fidelity of the intervention implementation., Methods: Pregnant women with overweight (N = 54) attending maternity clinics in Southwest Finland between 2021 and 2023, were recruited using convenience sampling. The SLIM-intervention included: health technology, motivational interviewing, feedback, and goal setting. The intervention was implemented in prenatal visits in maternity clinics continuing to 12 weeks postpartum. The change in self-efficacy was measured with Weight Efficacy Life-Style Questionnaire (score 0-180) and Self-Efficacy for Physical Activity Scale (score 5-25) with repeated measures in three timepoints. Data on weight were collected from patient records., Results: The levels of self-efficacy were high throughout the study period and there were no significant changes in self-efficacy in eating (p= 0.650) or physical activity (p= 0.936). Most of the women (N = 9/10), whose gestational weight gain was within recommendations or less, managed to lose weight during the postpartum period (p < 0.001)., Conclusions: Although the intervention was not effective in improving self-efficacy, the importance of recommended gestational weight gain on better postpartum weight management was highlighted. A long follow-up time was valuable for examination of changes over time and understanding trends, patterns, and outcomes of the study., Registration: The trial was registered at the Clinicaltrials.gov register platform (ID NCT04826861) on March 17th, 2021., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Aim: To explore what Internet-based breastfeeding peer support offers to breastfeeding parents., Design: Integrative review., Data Sources and Review Methods: A systematic literature search was conducted in March 2024 using the following electronic databases: CINAHL, The Cochrane Library, PubMed/MEDLINE and PsycINFO. Database searches yielded 717 results. Two researchers removed the duplicates (n = 256) and screened the remaining titles (n = 461), abstracts (n = 197) and full texts (n = 60) independently. Eventually, 19 studies were included in the review. The chosen studies had qualitative (n = 11), quantitative (n = 6), or mixed methods designs (n = 2) and were published between 2015 and 2024. Qualitative content analysis was conducted., Results: The main categories were supplying support that is responsive to the needs of parents and belonging to a breastfeeding community. The parents looked for and received breastfeeding support, advice, information, emotional support, reassurance and access to shared experiences from various online breastfeeding peer support groups. The support groups helped them in their breastfeeding decisions, thus making a difference in their breastfeeding experience. The support groups created breastfeeding communities for these parents and they were able to bond with others, feel like they belonged and share experiences. Additionally, these breastfeeding communities helped to normalize various breastfeeding practices., Conclusion: Breastfeeding peer support groups can offer parents the support and guidance they seek and a sense that they are part of a breastfeeding community. However, it is vital these groups are efficiently moderated to ensure the advice parents receive is evidence-based and the support is encouraging., Impact: These findings show that well-moderated online breastfeeding peer support can offer parents high-quality support. It is essential for health care professionals to be aware of the various options available in order to recommend high-quality support groups for breastfeeding parents., Reporting Method: PRISMA., Patient or Public Contribution: This was an integrative review therefore no patient or public contribution was necessary., (© 2024 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Problem: The Baby-Friendly Hospital Initiative has yet to achieve widespread global implementation., Background: The implementation of the Baby-Friendly Hospital Initiative has been recognised as complex. The challenge has been to maintain accreditation., Aim: To explore and gain a deeper understanding of the healthcare professionals' perceptions of the implementation process and the maintenance of the Baby-Friendly Hospital Initiative., Methods: A qualitative descriptive study with focus groups (n = 10) of the nurses, midwives and unit leaders (n = 43) perceptions of the implementation process were analysed using inductive thematic analysis., Findings: Analysis of the data revealed five main themes: groundwork for the baby-focused breastfeeding context, management support throughout the process, promoting baby-friendly practices, effective communication ensuring the right track, and supporting the maintenance of BFHI designation. The main themes describe the implementation as a journey of climbing a hill and after reaching the top trying to maintain their position., Discussion: The starting point for implementation was an optimal environment supporting baby-friendly breastfeeding practices. The support of the management of the organisation was an important way of moving the implementation forward. Commitment to the common goal strengthened the baby-friendly approach and with concrete and immediate feedback the right pathway on a journey was ensured., Conclusion: Practical ways to support the implementation journey include regular update education on breastfeeding and continuous monitoring, as well as providing statistics to health professionals. Global guidelines on how to sustain change are needed. This will ensure that the work done is not wasted., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Objective: Global breastfeeding rates are not optimal, and the early postpartum period represents a critical time for breastfeeding initiation. The Baby-Friendly Hospital Initiative endeavours to provide mothers with evidence-based breastfeeding support in birth hospitals. This study examined factors associated with breastfeeding exclusivity and breastfeeding difficulties in the first days after being discharged from Baby-Friendly designated hospital. The adequacy of breastfeeding support and maternal preferences for optimal support were also reported., Study Design: A non-experimental correlational study was conducted between May 2021 and October 2022. A total of n = 80 breastfeeding mothers completed a semi-structured questionnaire within two weeks of discharge from Baby-Friendly hospital in Finland. The questionnaire included demographic and obstetric background information and six questions on breastfeeding exclusivity, breastfeeding difficulties, and breastfeeding support. Descriptive statistical analysis and multivariate binary logistic regression analysis were performed., Results: The mean age of the mothers was 30.6 years (SD 5.4), and half of the mothers were primiparas (49 %). Most mothers gave birth vaginally (85 %) to a full-term infant (84 %). Most (85 %) had made some prenatal plans for breastfeeding, and the median planned duration of breastfeeding was 12 months. Half of the infants (53 %) received supplemental milk while in the hospital. Most mothers (81 %) were exclusively breastfeeding after hospital discharge. Mothers whose infants received supplemental milk in the hospital had an increased odds of non-exclusive breastfeeding (aOR 16.5 [CI 95 % 1.7-156.7], p 0.015). Approximately one-third of the mothers (39 %) experienced breastfeeding difficulties. Primiparous mothers had increased odds of experiencing breastfeeding difficulties (aOR 3.41 [CI 95 % 1.2-9.8], p 0.023). Mothers who received adequate postnatal breastfeeding support in birth hospital had decreased odds of experiencing breastfeeding difficulties (aOR 0.16 [CI 95 % 0.03-0.8], p 0.026). Mothers were mainly satisfied with breastfeeding support, although timelier access to support was preferred after hospital discharge., Conclusion: Adequate in-hospital postnatal breastfeeding support, including avoidance of non-medical supplementation, contributes to successful breastfeeding after hospital discharge in terms of more exclusive breastfeeding and fewer breastfeeding difficulties. Primiparous mothers need emphasized support to mitigate breastfeeding difficulties. Timelier access to breastfeeding support after discharge is needed., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Aim: We compared milk volumes, skin-to-skin contact and breastfeeding by the mothers of very preterm twins and singleton infants born at 28-32 weeks of gestation., Methods: This Norwegian longitudinal prospective comparative study was carried out in two neonatal intensive care units: one with single family rooms and one open bay unit. It comprised 49 singleton infants, 28 twins and their mothers. The mothers' milk volume and direct breastfeeding were recorded from birth until 4 months' of corrected age. They also answered the breastfeeding self-efficacy scale and skin-to-skin contact was recorded., Results: The mothers of preterm twins produced doubled the volume of expressed milk at day 14, compared to the mothers of singletons (mean 816 ± 430 mL vs. 482 ± 372 mL, p < 0.05) and this difference was still sustained at 34 + 0 weeks/days (p < 0.02). Mothers of twins had their first breastfeeding attempt later than mothers of singletons (median of 133 h compared to 56 (p < 0.002). Preterm twins received less daily skin-to-skin contact (mean 157 ± 66 min each vs. 244 ± 109) (p < 0.001). There were no differences in receiving mother's own milk, exclusively direct breastfeeding or perceived breastfeeding self-efficacy., Conclusion: Breastfeeding was initiated as successfully in preterm twins as singletons as the mothers' milk production doubled., (© 2023 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background: Breastfeeding practices remain globally suboptimal despite many known maternal and neonatal health benefits and the Baby-Friendly Hospital Initiative as a global effort to support breastfeeding., Objective: We aimed to evaluate the effects of the implementation of the Baby-Friendly Hospital Initiative for a proportion of mothers who exclusively breastfed during a 6-month period, including breastfeeding problems, and maternal breastfeeding attitudes., Methods: Using a quasi-experimental non-equivalent two-group design, we recruited two independent samples of postpartum mothers in a maternity hospital to compare the situation before (N = 162) and after (N = 163) the implementation. We measured breastfeeding status and possible breastfeeding problems via text-message questions at 2 weeks, 1, 4 and 6 months after birth. We measured Mothers' attitudes toward breastfeeding at the maternity hospital and 4 months after birth using the Iowa Infant Feeding Attitude Scale., Results: The implementation of the Baby-Friendly Hospital Initiative had no effect on the proportion of mothers who exclusively breastfed, and we found no significant differences in exclusive breastfeeding at 6 months (41.3 % vs 52.9 %, p =.435). The intervention did not influence the reported number of breastfeeding problems (p =.260) or maternal breastfeeding attitudes (p =.354). More favourable breastfeeding attitudes (p <.001) and less problematic breastfeeding (p <.001) were associated positively with exclusive breastfeeding., Conclusion: Exclusive breastfeeding rates did not increase after the intervention; however, the rates at baseline were already high. Ensuring the Baby-Friendly Hospital Initiative practices through pre- and postnatal periods and preparing mothers to manage common breastfeeding problems might improve breastfeeding rates. This trial was registered (0307-0041) with ClinicalTrials.gov on 03/03/2017., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objectives: To assess, in terms of self-efficacy in weight management, the effectiveness of the SLIM lifestyle intervention among overweight or obese women during pregnancy and after delivery, and further to exploit machine learning and event mining approaches to build personalized models. Additionally, the aim is to evaluate the implementation of the SLIM intervention., Methods: This prospective trial, which is a non-randomized, quasi-experimental, pre-post intervention, includes an embedded mixed-method process evaluation. The SLIM Intervention is delivered by public health nurses (n = 9) working in maternity clinics. The public health nurses recruited overweight women (n = 54) at their first antenatal visit using convenience sampling. The core components of the intervention i.e. health technology, motivational interviewing, feedback, and goal setting, are utilized in antenatal visits in maternity clinics starting from gestational week 15 or less and continuing to 12 weeks after delivery. Mixed effect models are used to evaluate change over time in self-efficacy, weight management and weight change. Simple mediation models are used to assess calories consumed and moderate to vigorous physical activity (MVPA) as mediators between self-efficacy and weight change. Signal processing and machine learning techniques are exploited to extract events from the data collected via the Oura ring and smartphone-based questionnaires., Discussion: The SLIM intervention was developed in collaboration with overweight women and public health nurses working in maternity clinics. This study evaluates the effectiveness of the intervention among overweight women in increasing self-efficacy and achieving a healthy weight; thus, impacting the healthy lifestyle and long-term health of the whole family. The long-term objective is to contribute to women's health by supporting weight-management through behavior change via interventions conducted in maternity clinics., Trial Registration: The trial was registered at the Clinicaltrials.gov register platform (ID NCT04826861) on 17 March 2021., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Saarikko et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Photoplethysmography (PPG) is a low-cost and easy-to-implement method to measure vital signs, including heart rate (HR) and pulse rate variability (PRV) which widely used as a substitute of heart rate variability (HRV). The method is used in various wearable devices. For example, Samsung smartwatches are PPG-based open-source wristbands used in remote well-being monitoring and fitness applications. However, PPG is highly susceptible to motion artifacts and environmental noise. A validation study is required to investigate the accuracy of PPG-based wearable devices in free-living conditions., Objective: We evaluate the accuracy of PPG signals-collected by the Samsung Gear Sport smartwatch in free-living conditions-in terms of HR and time-domain and frequency-domain HRV parameters against a medical-grade chest electrocardiogram (ECG) monitor., Methods: We conducted 24-hours monitoring using a Samsung Gear Sport smartwatch and a Shimmer3 ECG device. The monitoring included 28 participants (14 male and 14 female), where they engaged in their daily routines. We evaluated HR and HRV parameters during the sleep and awake time. The parameters extracted from the smartwatch were compared against the ECG reference. For the comparison, we employed the Pearson correlation coefficient, Bland-Altman plot, and linear regression methods., Results: We found a significantly high positive correlation between the smartwatch's and Shimmer ECG's HR, time-domain HRV, LF, and HF and a significant moderate positive correlation between the smartwatch's and shimmer ECG's LF/HF during sleep time. The mean biases of HR, time-domain HRV, and LF/HF were low, while the biases of LF and HF were moderate during sleep. The regression analysis showed low error variances of HR, AVNN, and pNN50, moderate error variances of SDNN, RMSSD, LF, and HF, and high error variances of LF/HF during sleep. During the awake time, there was a significantly high positive correlation of AVNN and a moderate positive correlation of HR, while the other parameters indicated significantly low positive correlations. RMSSD and SDNN showed low mean biases, and the other parameters had moderate mean biases. In addition, AVNN had moderate error variance while the other parameters indicated high error variances., Conclusion: The Samsung smartwatch provides acceptable HR, time-domain HRV, LF, and HF parameters during sleep time. In contrast, during the awake time, AVNN and HR show satisfactory accuracy, and the other HRV parameters have high errors., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Sarhaddi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The Baby-Friendly Hospital Initiative aims to improve breastfeeding by implementing the Ten Steps to Successful Breastfeeding (Ten Steps) into routine breastfeeding support in birth hospitals. Maternal perspective to breastfeeding support is important to consider as mothers and their infants are in the center of that support., Objectives: To review and synthesize the existing literature on maternal perceptions and experiences of breastfeeding support in Baby-Friendly hospitals. A sub-aim was to describe differences in breastfeeding support between Baby-Friendly hospitals and non-Baby-Friendly hospitals from maternal perspective., Data Sources and Review Methods: An integrative literature review. A systematic literature search was conducted in October 2021 in five databases: PubMed, CINAHL, Cochrane, Scopus, Web of Science. Original peer-reviewed studies published in English exploring maternal viewpoints on breastfeeding support in Baby-Friendly hospitals were included. Two reviewers independently screened the titles (n=914), abstracts (n=226), and full texts (n=47). The review comprised of seventeen studies and includes both quantitative studies (n=14) and qualitative studies (n=3). Inductive content analysis and descriptive synthesis were conducted., Results: Most studies (n=14) measured hospitals' compliance with the Ten Steps practices from maternal perspective. Mothers were provided with breastfeeding information and encouragement, however, a qualitative finding indicated that information focused on positive aspects of breastfeeding. Early skin-to-skin contact between the mother and infant was well facilitated although often not lasting more than 30 min. Breastfeeding was facilitated by practical support but according to findings of two qualitative studies, support was not always adequate to address mothers' problems with breastfeeding. Most mothers were exclusively breastfeeding during the hospital stay and no supplemental milk was offered to infant. Mothers were roomed-in together with their infant and were mostly encouraged to breastfeed on demand. Differences between Baby-Friendly hospitals and non-Baby-Friendly hospitals were observed particularly for steps 6 and 9: supplementary feeding and pacifier use were less common in Baby-Friendly hospitals., Conclusions: From the maternal perspective, breastfeeding support in the Baby-Friendly hospitals was mainly but not completely in adherence with the Ten Steps practices. Low compliance with some of the Ten Steps indicates a need for a more frequent assessment of the breastfeeding support practices and consideration of strategies facilitating a more sustainable implementation of the initiative. Regardless of some shortcomings with the breastfeeding support, mothers were mainly satisfied with the support in the hospital. Mothers in the Baby-Friendly hospitals perceived that breastfeeding support was more adherent to the Ten Steps compared to mothers in non-Baby-Friendly hospitals., Competing Interests: The authors declare no conflicts of interest., (© 2022 The Authors. Published by Elsevier Ltd.)

Background: The Baby-Friendly Hospital Initiative represents a global effort to support breastfeeding. Commitment to this program has been associated with the longer duration and exclusivity of breastfeeding and improvements in hospital practices. Further, healthcare professionals' breastfeeding attitudes have been associated with the ability to provide professional support for breastfeeding., Research Aims: To determine healthcare professionals' breastfeeding attitudes and hospital practices before and after the implementation of the Baby-Friendly Hospital Initiative., Methods: Using a quasi-experimental pretest-posttest study design, healthcare professionals ( N = 131) from the single hospital labor and delivery, maternity care, and neonatal intensive care were recruited before and after the Baby-Friendly Hospital Initiative intervention during 2017 and 2019. Breastfeeding attitudes with the validated Breastfeeding Attitude Questionnaire , breastfeeding-related hospital practices, and background characteristics were collected., Results: The healthcare professionals' breastfeeding attitude scores increased significantly after the implementation of the Baby-Friendly Hospital Initiative, difference = 0.16, (95% CI [0.13, 0.19]) and became breastfeeding favorable among all professional groups in each study unit. Positive changes in breastfeeding-supportive hospital practices were achieved. The infants had significantly more frequent immediate and uninterrupted skin-to-skin contact with their mothers. The rate of early breastfeeding, as well as the number of exclusively breastfed infants, increased., Conclusions: After the Baby-Friendly Hospital Initiative and Baby-Friendly Hospital Initiative for neonatal wards (Neo-BFHI) interventions were concluded, we found significant improvements in the breastfeeding attitudes of healthcare professionals and in breastfeeding-related care practices.This RCT was registered (0307-0041) with ClinicalTrials.gov on 03/03/2017.

Objective: The purpose of this study was to examine maternal perceptions of postnatal breastfeeding support in the hospital before and after designation to the Baby-Friendly Hospital Initiative (BFHI). Further maternal and infant characteristics associated with the maternal perception of breastfeeding support were investigated. Our hypothesis was that mothers would perceive breastfeeding support more adherent to the standards of the BFHI after the hospital was designated to the BFHI compared with before., Design: The study had a quasi-experimental non-equivalent two-group design., Setting: The study was conducted in one postnatal ward and one neonatal intensive care unit in a public birth hospital in Finland., Participants: Postpartum mothers giving birth in the hospital before (pre-test group, n = 162) and after (post-test group, n = 163) designation to the BFHI participated., Intervention: The aim of the BFHI is to support and promote breastfeeding by implementing the Ten Steps to Successful Breastfeeding into routine care. Implementation in the study hospital required staff training and revision of current hospital practices, which took place during 2017-2018. The postnatal ward and neonatal intensive care unit were designated to the Baby-Friendly Hospital in February 2019., Measurements: Maternal perceptions of postnatal breastfeeding support were measured with a 20-item questionnaire developed for this study. Items were based on maternal self-report of the breastfeeding support in the hospital. A sum variable was created to measure the maternal perception of the support (scale 1-7), and higher scores indicated perception of breastfeeding support that is more adherent to the standards of the BFHI. Descriptive statics, nonparametric statistical tests, and multiple linear regression analysis were used to analyse data., Findings: Mothers in the post-test group (median 6.1, IQR 5.4-6.4) perceived breastfeeding support more adherent to the standards the BFHI compared with mothers in the pre-test group (median 5.0, IQR 4.2-5.8) (p < 0.001). Fifteen of 20 of the measured breastfeeding support practices improved after the hospital's designation to the BFHI. The largest difference between groups was observed for multipara mothers (median 4.6 vs 6.0, p < 0.001), older mothers (> 35 years) (median 4.4 vs 5.8, p < 0.001), and mothers with a longer history of breastfeeding (6-12 months) (median 4.4 vs 6.2, p < 0.001). Before the BFHI designation, multipara mothers and mothers who gave birth to an infant with low Apgar scores (< 7) perceived breastfeeding support less adherent to the BFHI standards than did primiparas or mothers of an infant with high Apgar scores (≥ 7). After the BFHI designation, mothers who experienced preterm birth (GA < 37 weeks) perceived breastfeeding support less adherent to the BFHI standards compared with mothers who experienced a full-term birth., Key Conclusions: Designation to the BFHI had a positive impact on breastfeeding support from the maternal perspective. Designation improved particularly multiparas' perceptions of receiving breastfeeding support that is in adherence with the standards of the BFHI. However, more emphasis should be placed, and further research should be conducted to ensure that mothers giving birth to a preterm infant receive breastfeeding support that is adherent to the BFHI standards., Implications for Practice: Birth hospitals are recommended to implement the BFHI as it improves breastfeeding support in the hospital and provides mothers with a good basis and continuation for breastfeeding, even after hospital discharge. Maternal perceptions about the impact of BFHI designation are important to consider because mother - infant dyads are at the centre of that support, and their viewpoint may help to assess whether the designation to the BFHI in the unit is successful. Results of this study indicate that designation to BFHI improves breastfeeding support from the maternal perspective., Competing Interests: Conflict of Interest None., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Most qualitative research on breastfeeding the preterm or low-birthweight (LBW) infant has focused on negative insights; there are no comprehensive insights into how, when and why mothers experience positive breastfeeding experiences. We aimed to address this knowledge gap by exploring what characterizes and facilitates a positive breastfeeding experience in mothers of preterm and/or LBW infants., Methods: A systematic review using meta-ethnographic methods was conducted. Search strategies involved a comprehensive search strategy on six bibliographic databases, citation tracking and reference checking. The analysis involved a reciprocal level of translation and a line of argument synthesis., Results: Searches identified 1774 hits and 17 articles from 14 studies were included, representing the views of 697 mothers. A positive breastfeeding experience was identified as being 'attuned'. Three themes and eight sub-themes were developed to describe what characterizes attuned breastfeeding. 'Trusting the body and what it can do', concerned how attuned breastfeeding was facilitated through understanding the bodily responses and capacity and feeling comfortable with holding the infant and to breastfeed. 'Being emotionally present - in the here and now' described the importance of feeling relaxed and reassured. 'Experiencing mutual positive responses', illuminated how attunement was related to feelings of mutuality - when the mother recognises the infant's cues, responds to these signals and receives a positive response from the infant. The key factors to facilitate attuned breastfeeding were opportunities for prolonged close physical contact with the infant, positive relationships with and support from staff and peers, and being facilitated to breastfeed when the infant showed feeding cues., Conclusions: This study provides new insights into what characterizes a positive breastfeeding experience and how staff can facilitate and enable mothers to achieve attuned breastfeeding. Improvements in units' design, such as for rooming-in and having prolonged skin-to-skin contact, and care provided by knowledgeable, supportive and encouraging staff and peers, are crucial. The mother's physical and emotional states and the infant's behavioural responses and physiological signals should guide the process towards positive breastfeeding practices., (© 2021. The Author(s).)

Pregnancy is a unique time when many mothers gain awareness of their lifestyle and its impacts on the fetus. High-quality care during pregnancy is needed to identify possible complications early and ensure the mother's and her unborn baby's health and well-being. Different studies have thus far proposed maternal health monitoring systems. However, they are designed for a specific health problem or are limited to questionnaires and short-term data collection methods. Moreover, the requirements and challenges have not been evaluated in long-term studies. Maternal health necessitates a comprehensive framework enabling continuous monitoring of pregnant women. In this paper, we present an Internet-of-Things (IoT)-based system to provide ubiquitous maternal health monitoring during pregnancy and postpartum. The system consists of various data collectors to track the mother's condition, including stress, sleep, and physical activity. We carried out the full system implementation and conducted a real human subject study on pregnant women in Southwestern Finland. We then evaluated the system's feasibility, energy efficiency, and data reliability. Our results show that the implemented system is feasible in terms of system usage during nine months. We also indicate the smartwatch, used in our study, has acceptable energy efficiency in long-term monitoring and is able to collect reliable photoplethysmography data. Finally, we discuss the integration of the presented system with the current healthcare system.

Background: Maternal overweight is increasing, and it is associated with several risk factors for both the mother and child. Healthy lifestyle behaviors adopted during pregnancy are likely to impact women's health positively after pregnancy. The study's aim was to identify and describe weight management behaviors in terms of the Capability, Opportunity and Motivation Behaviour (COM-B) -model to target weight management interventions from both the perspectives of women who are overweight and maternity care professionals., Methods: This qualitative, descriptive study was conducted between 2019 and 2020. Individual interviews with pregnant and postpartum women who were overweight (n = 11) and focus group interviews with public health nurses (n = 5) were undertaken in two public maternity clinics in Southwest Finland. The data were analyzed using deductive content analysis consistent with the COM-B model., Results: In the capability category, the women and the public health nurses thought that there was a need to find consistent ways to approach overweight, as it had often become a feature of the women's identities. The use of health technology was considered to be an element of antenatal care that could be used to approach the subject of weight and weight management. Smart wearables could also support an evaluation of the women's lifestyles. The opportunity category highlighted the lack of resources for support during perinatal care, especially after birth. Both groups felt that support from the family was the most important facilitating factor besides motivation. The women also expressed a conflict between pregnancy as an excuse to engage in unhealthy habits and pregnancy as a motivational period for a change of lifestyle. Furthermore, the women wanted to be offered a more robust stance on weight management and discreet counseling., Conclusions: Our findings offer a theoretical basis on which future research can define intervention and implementation strategies. Such interventions may offer clear advice and non-judgmental support during pregnancy and after delivery by targeting women's capabilities, opportunities, and motivation. Health technology could be a valuable component of intervention, as well as an implementation strategy, as they provide ways during maternity care to approach this topic and support women.

Background: Technology enables the continuous monitoring of personal health parameter data during pregnancy regardless of the disruption of normal daily life patterns. Our research group has established a project investigating the usefulness of an Internet of Things-based system and smartwatch technology for monitoring women during pregnancy to explore variations in stress, physical activity and sleep. The aim of this study was to examine daily patterns of well-being in pregnant women before and during the national stay-at-home restrictions related to the COVID-19 pandemic in Finland., Methods: A longitudinal cohort study design was used to monitor pregnant women in their everyday settings. Two cohorts of pregnant women were recruited. In the first wave in January-December 2019, pregnant women with histories of preterm births (gestational weeks 22-36) or late miscarriages (gestational weeks 12-21); and in the second wave between October 2019 and March 2020, pregnant women with histories of full-term births (gestational weeks 37-42) and no pregnancy losses were recruited. The final sample size for this study was 38 pregnant women. The participants continuously used the Samsung Gear Sport smartwatch and their heart rate variability, and physical activity and sleep data were collected. Subjective stress, activity and sleep reports were collected using a smartphone application developed for this study. Data between February 12 to April 8, 2020 were included to cover four-week periods before and during the national stay-at-home restrictions. Hierarchical linear mixed models were exploited to analyze the trends in the outcome variables., Results: The pandemic-related restrictions were associated with changes in heart rate variability: the standard deviation of all normal inter-beat intervals (p = 0.034), low-frequency power (p = 0.040) and the low-frequency/high-frequency ratio (p = 0.013) increased compared with the weeks before the restrictions. Women's subjectively evaluated stress levels also increased significantly. Physical activity decreased when the restrictions were set and as pregnancy proceeded. The total sleep time also decreased as pregnancy proceeded, but pandemic-related restrictions were not associated with sleep. Daily rhythms changed in that the participants overall started to sleep later and woke up later., Conclusions: The findings showed that Finnish pregnant women coped well with the pandemic-related restrictions and lockdown environment in terms of stress, physical activity and sleep., Competing Interests: The authors have declared that no competing interests exist.

Background: Assessment of sleep quality is essential to address poor sleep quality and understand changes. Owing to the advances in the Internet of Things and wearable technologies, sleep monitoring under free-living conditions has become feasible and practicable. Smart rings and smartwatches can be employed to perform mid- or long-term home-based sleep monitoring. However, the validity of such wearables should be investigated in terms of sleep parameters. Sleep validation studies are mostly limited to short-term laboratory tests; there is a need for a study to assess the sleep attributes of wearables in everyday settings, where users engage in their daily routines., Objective: This study aims to evaluate the sleep parameters of the Oura ring along with the Samsung Gear Sport watch in comparison with a medically approved actigraphy device in a midterm everyday setting, where users engage in their daily routines., Methods: We conducted home-based sleep monitoring in which the sleep parameters of 45 healthy individuals (23 women and 22 men) were tracked for 7 days. Total sleep time (TST), sleep efficiency (SE), and wake after sleep onset (WASO) of the ring and watch were assessed using paired t tests, Bland-Altman plots, and Pearson correlation. The parameters were also investigated considering the gender of the participants as a dependent variable., Results: We found significant correlations between the ring's and actigraphy's TST (r=0.86; P<.001), WASO (r=0.41; P<.001), and SE (r=0.47; P<.001). Comparing the watch with actigraphy showed a significant correlation in TST (r=0.59; P<.001). The mean differences in TST, WASO, and SE of the ring and actigraphy were within satisfactory ranges, although there were significant differences between the parameters (P<.001); TST and SE mean differences were also within satisfactory ranges for the watch, and the WASO was slightly higher than the range (31.27, SD 35.15). However, the mean differences of the parameters between the watch and actigraphy were considerably higher than those of the ring. The watch also showed a significant difference in TST (P<.001) between female and male groups., Conclusions: In a sample population of healthy adults, the sleep parameters of both the Oura ring and Samsung watch have acceptable mean differences and indicate significant correlations with actigraphy, but the ring outperforms the watch in terms of the nonstaging sleep parameters., (©Milad Asgari Mehrabadi, Iman Azimi, Fatemeh Sarhaddi, Anna Axelin, Hannakaisa Niela-Vilén, Saana Myllyntausta, Sari Stenholm, Nikil Dutt, Pasi Liljeberg, Amir M Rahmani. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 02.11.2020.)

Background: Pregnant women who are at risk of preterm birth are often stressed, anxious and depressed because of worries and fears related to the health of the unborn baby, their own health and uncertainty about the future. Only a few studies have assessed the types of psychological support that would relieve these stress symptoms among women with high-risk pregnancies. The aim of this study was to describe 1) how women at risk of preterm birth experienced an interactive 3/4-dimensional (3/4D) ultrasound examination, and 2) their need for psychological support during the antenatal period., Methods: This qualitative study was conducted at one university hospital in Finland in 2017. Women with a singleton pregnancy of 26-32 gestational weeks (gwks) were included in the study. The interactive 3/4D ultrasound included a joint observation of the baby, based on the mother's wishes, with an obstetrician and psychologist. After the examination, the experiences were explored with a semi-structured interview. The data was analyzed using inductive thematic analysis., Results: The women enjoyed the fact that the staff were focused on her fetus and genuinely present during the session and also enabled the women to actively participate. Watching the baby and her/his activities made the baby more concrete and relieved their concerns. The need for additional psychological support varied individually., Conclusions: Interactive ultrasound examination is an interesting way to awaken mental images, increase attachment, and reduce stress. The results imply that an interactive way of jointly looking at the fetus supports pregnant women at risk of preterm birth and may be useful in clinical practice.

Background: Breastfeeding is an important element of motherhood with a preterm infant, but the role of maternal emotions in relation to breastfeeding is vague., Purpose: To describe maternal emotions regarding and insights into breastfeeding during the first year after a preterm birth., Methods: In total, 80 mothers of preterm infants (<35 gestational weeks) participated in this secondary analysis of a larger study. The data were collected with an open question at discharge and 3, 6, and 12 months after the expected birth date and analyzed using thematic analysis., Findings: A typology of breastfeeding mothers of preterm infants was created. The group of survivors wished to be breastfeeding mothers, but after some unexpected difficulties, they had to give up their dream. The disappointment alleviated with time, but some of the mothers still harbored self-accusations after a year. The highfliers were mothers who succeeded in breastfeeding because of their own persistence. They described breastfeeding as enjoyable for both the mother and the infant. The pragmatist mothers breastfed because it was the general norm and a practical way to feed the infant; breastfeeding caused neither passion nor discomfort. The group of bottle-feeding-oriented mothers expressed that breastfeeding did not interest them at any point., Implications for Practice: Being aware of the typology could help nurses and midwives carefully observe mothers' individual counselling needs. Mothers' wishes and decisions regarding breastfeeding need to be respected and supported without any judgment., Implications for Research: The possibilities to tailor breastfeeding interventions based on the typology should be investigated.

Background: Smart wristbands enable the continuous monitoring of health parameters, for example, in maternity care. Understanding the feasibility and acceptability of these devices in an authentic context is essential. The aim of this study was to evaluate the feasibility of using a smart wristband to collect continuous activity, sleep and heart rate data from the beginning of the second trimester until one month postpartum., Methods: The feasibility of a smart wristband was tested prospectively through pregnancy in nulliparous women (n = 20). The outcomes measured were the wear time of the device and the participants' experiences with the smart wristband. The data were collected from the wristbands, phone interviews, questionnaires, and electronic patient records. The quantitative data were analyzed with hierarchical linear mixed models for repeated measures, and qualitative data were analyzed using content analysis., Results: Participants (n = 20) were recruited at a median of 12.9 weeks of gestation. They used the smart wristbands for an average of 182 days during the seven-month study period. The daily use of the devices was similar during the second (17.9 h, 95% CI 15.2 to 20.7) and third trimesters (16.7 h, 95% CI 13.8 to 19.5) but decreased during the postpartum period (14.4 h, 95% CI 11.4 to 17.4, p = 0.0079). Participants who could not wear smart wristbands at work used the device 300 min less per day than did those with no use limitations. Eight of the participants did not wear the devices or wore them only occasionally after giving birth. Nineteen participants reported that the smart wristband did not have any permanent effects on their behavior. Problems with charging and synchronizing the devices, perceiving the devices as uncomfortable, or viewing the data as unreliable, and the fear of scratching their babies with the devices were the main reasons for not using the smart wristbands., Conclusions: A smart wristband is a feasible tool for continuous monitoring during pregnancy. However, the daily use decreased after birth. The results of this study may support the planning of future studies and help with overcoming barriers related to the use of smart wristbands on pregnant women.

Objective: To identify and understand how parents develop a close bond to their infants in the neonatal intensive care unit (NICU)., Design: A qualitative descriptive study; closeness and separation stories recorded in a smartphone application by the parents were analyzed using thematic analysis., Setting and Participants: Twenty-three parents of nineteen infants who were taken care of in a level III NICU in Finland., Findings: Bonding moments and a disrupted dyadic parent-infant relationship continuously alternated as in a rollercoaster ride during the hospital stay. Transitions from closeness to separation and vice versa were the most emotional stages on the journey. Parents had a natural desire to be close and create a bond with their infants; however, they accepted the separation as part of NICU care., Key Conclusions: The findings indicate that closeness with their infant was the power that parents stored and that led them through unavoidable separation to normal parenthood., Implications for Practice: Bonding and attachment will occur naturally if parents are close to their infants and permitted privacy and time with their infants. NICU staff should create a peaceful and calming environment that enables and supports this bonding process., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Despite the evidence of multiple benefits of early skin-to-skin contact, it does not always happen and infants are separated from their parents because of different hospital practices. The aim of this study was to explore parent-infant closeness and separation, and which factors promote closeness or result in separation in the birthing unit in the first 2 hours after birth from the point of view of staff members., Methods: This qualitative descriptive pilot study was conducted in one university hospital in Finland in December 2014. Midwives and auxiliary nurses working in the birthing unit were eligible for the study. The data were collected with a new application downloaded on a smartphone. The participants were asked to record all the closeness and separation events they observed between the infants and parents using the application., Results: The application was used during 20 work shifts by 14 midwives or auxiliary nurses. The participants described more closeness than separation events. Our findings indicated that the staff of the birthing unit aimed for mother-infant closeness, and father-infant closeness was a secondary goal. Closeness was mostly skin-to-skin contact and justified as a normal routine care practice. Infants were separated from their parents for routine measurements and because of infants' compromised health., Conclusion: Routines and normal care practices both promoted parent-infant closeness and caused separation. Parent-infant closeness and separation were controlled by staff members of the birthing unit., (© 2017 Wiley Periodicals, Inc.)

Aims: The aim of this study was to examine whether an Internet-based peer-support intervention has an effect on the duration of breastfeeding or breast milk expression or maternal breastfeeding attitude compared with routine care in the mothers of preterm infants. In addition, the feasibility of the intervention was examined., Background: A few peer-support interventions conducted face-to-face or by telephone have given promising results in promoting breastfeeding in preterm infants., Design: A randomized controlled trial with a 1-year follow-up was conducted in one hospital in Finland in 2011-2015., Methods: Altogether 124 mothers of preterm (<35 weeks) infants were recruited; 60 in an experimental and 64 in a control group. The intervention was a closed peer-support group in social media. Data were collected by structured questionnaires. Neonatal and breastfeeding data were collected from patient records., Results: The duration of overall breastfeeding was on average 3·0 and 4·3 months, in the experimental and control groups respectively. The intervention had no effect on breastfeeding or expressing the breast milk or maternal breastfeeding attitude. A breastfeeding-favourable attitude and at least two previous children predicted longer duration of breastfeeding. Attitude-score decreased during the follow-up. The mothers in the experimental group enjoyed peer support, but only a few reported it as having some impact on breastfeeding., Conclusion: Although the Internet-based peer-support intervention had no effect, the importance of breastfeeding attitude for the duration of breastfeeding in mothers of preterm infants was shown. In future, interventions in social media should be studied more and attitude-focused interventions be developed., (© 2016 John Wiley & Sons Ltd.)

Background: When a newborn requires neonatal intensive care unit (NICU) hospitalization, parent and infant experience an unusual often prolonged separation. This critical care environment poses challenges to parent-infant closeness. Parents desire physical contact and holding and touching are particularly important. Evidence shows that visitation, holding, talking, and skin to skin contact are associated with better outcomes for infants and parents during hospitalization and beyond. Thus, it would be important to understand closeness in this context. The purpose of this study was to explore from nurses' perspective, what do parents and nurses do to promote parent-infant closeness or provoke separation., Methods: Qualitative methods were utilized to attain an understanding of closeness and separation. Following ethics approval, purposive sampling was used to recruit nurses with varying experience working different shifts in NICUs in two countries. Nurses were loaned a smartphone over one work shift to record their thoughts and perceptions of events that occurred or experiences they had that they considered to be closeness or separation between parents and their hospitalized infant. Sample size was determined by saturation (18 Canada, 19 Finland). Audio recordings were subjected to inductive thematic analysis. Team meetings were held to discuss emerging codes, refine categories, and confirm these reflected data from both sites. One overarching theme was elaborated., Results: Balancing closeness and separation was the major theme. Both parents and nurses engaged in actions to optimize closeness. They sought closeness by acting autonomously in infant caregiving, assuming decision-making for their infant, seeking information or skills, and establishing a connection in the face of separation. Parents balanced their desire for closeness with other competing demands, such as their own needs. Nurses balanced infant care needs and ability to handle stimulation with the need for closeness with parents. Nurses undertook varied actions to facilitate closeness. Parent, infant and NICU-related factors influenced closeness. Consequences, both positive and negative, arose for parents, infants, and nurses., Conclusion: Findings point to actions that nurses undertake to promote closeness and help parents cope with separation including: promoting parent decision-making, organizing care to facilitate closeness, and supporting parent caregiving.

Objective: To determine factors that predict the initiation and frequency of breastfeeding, attitudes about breastfeeding, and the self-efficacy of mothers of preterm infants in a neonatal intensive care unit., Design: A structured survey using two measurement points., Setting: A university hospital in Finland., Participants: Mothers (N = 124) and their infants born at less than 35 weeks gestation., Methods: Structured questionnaires were used during the first week postpartum and at discharge of infants from the hospital. Neonatal and breastfeeding data were collected from patient records., Results: Preterm infants initiated breastfeeding at the median postnatal age of 4 days (range = 0-70 days). The factors that predicted earlier initiation of breastfeeding were greater gestational age, no ventilator treatment, early physical contact, and greater maternal education level. Greater gestational age, early physical contact, and a breastfeeding-favorable attitude also predicted the frequency of breastfeeding. The attitudes of the mothers regarding breastfeeding immediately after birth were generally positive but decreased during their infants' hospital stays., Conclusion: Gestational age and early physical contact seemed to be the strongest predictors of breastfeeding initiation and frequency in the NICU. In addition, the role of the mother's attitude regarding breastfeeding was significant. Current care practices should be critically reviewed with emphasis on early physical contact at the time of birth., (Copyright © 2016 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Preterm infants are usually breastfed less than full-term infants, and successful breastfeeding requires a supportive environment and special efforts from their mothers. A breastfeeding peer-support group, utilising social media, was developed for these mothers in order to support them in this challenge. Mothers were able to discuss breastfeeding and share experiences. The purpose of this study was to describe the perceptions of breastfeeding mothers of preterm infants based on the postings in peer-support group discussions in social media. The actively participating mothers (n = 22) had given birth <35 gestational weeks. They were recruited from one university hospital in Finland. The social media postings (n = 305) were analysed using thematic analysis. A description of the process of breastfeeding a preterm infant from the point of view of a mother was created. The process consisted of three main themes: the breastfeeding paradox in hospital, the 'reality check' of breastfeeding at home and the breastfeeding experience as part of being a mother. The mothers encountered paradoxical elements in the support received in hospital; discharge was promoted at the expense of breastfeeding and pumping breast milk was emphasised over breastfeeding. After the infant's discharge, the over-optimistic expectations of mothers often met with reality - mothers did not have the knowledge or skills to manage breastfeeding at home. Successful breastfeeding was an empowering experience for the mothers, whereas unsuccessful breastfeeding induced feelings of disappointment. Therefore, the mothers of preterm infants need evidence-based breastfeeding counselling and systematic support in a neonatal intensive care unit (NICU) and at home., (© 2014 John Wiley & Sons Ltd.)

Objectives: The Internet and social media provide various possibilities for online peer support. The aim of this review was to explore Internet-based peer-support interventions and their outcomes for parents., Design: A systematic integrative review., Data Sources: The systematic search was carried out in March 2014 in PubMed, Cinahl, PsycINFO and Cochrane databases., Review Methods: Two reviewers independently screened the titles (n=1793), abstracts and full texts to decide which articles should be chosen. The inclusion criteria were: (1) an Internet-based community as an intervention, or at least as a component of an intervention; (2) the participants in the Internet-based community had to be mothers and/or fathers or pregnant women; (3) the parents had to interact and communicate with each other through the Internet-based community. The data was analysed using content analysis. When analysing peer-support interventions only interventions developed by researchers were included and when analysing the outcomes for the parents, studies that focused on mothers, fathers or both parents were separated., Results: In total, 38 publications met the inclusion criteria. Most of the studies focused on Internet-based peer support between mothers (n=16) or both parents (n=15) and seven focused on fathers. In 16 studies, the Internet-based interventions had been developed by researchers and 22 studies used already existing Internet peer-support groups, in which any person using the Internet could participate. For mothers, Internet-based peer support provided emotional support, information and membership in a social community. For fathers, it provided support for the transition to fatherhood, information and humorous communication. Mothers were more active users of Internet-based peer-support groups than fathers. In general, parents were satisfied with Internet-based peer support. The evidence of the effectiveness of Internet-based peer support was inconclusive but no harmful effects were reported in these reviewed studies., Conclusions: Internet-based peer support provided informational support for parents and was accessible despite geographical distance or time constraints. Internet-based peer support is a unique form of parental support, not replacing but supplementing support offered by professionals. Experimental studies in this area are needed., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: the first aim of this two-phase study was to describe and compare, between two university hospitals, the early physical contact of mothers and their preterm or sick newborn infants in the delivery room. Secondly, the staff's perceptions of factors facilitating and promoting or impeding this contact were evaluated. Thirdly, the association between early physical contact and the initiation of breast feeding was examined., Design and Setting: a structured survey was conducted between November 2008 and March 2009 in two university hospitals in Finland., Participants: in phase I, the sample consisted of all preterm or sick infants who needed NICU care and whose questionnaires were completed by labour ward staff (hospital A, n=178/185, hospital B, n=203/235). In phase II, a subsample of these infants (A, n=76, B, n=94) and their mothers who completed their questionnaires participated in the study., Measurements: structured questionnaires developed for this study were used., Findings: the implementation of early physical contact differed between the study hospitals. The infants had physical contact with their mothers more often in hospital A than in hospital B whether they were sick full-term (83% versus 58%, p<0.001) or late preterm (49% versus 34%, p=0.051). None of the very preterm infants (<32 weeks) had early physical contact in the delivery room in either hospital. An infant's unstable condition and delivery by caesarean section were the most common obstacles against early contact. There was a moderate association between early contact and the initiation of breast feeding., Key Conclusion and Implications for Practice: caring practices concerning early physical contact seemed to be different in the study hospitals. The obstacles impeding early contact should be re-evaluated. Guidelines might enhance early physical contact between preterm or sick infants and their mothers., (Copyright © 2013 Elsevier Ltd. All rights reserved.)