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Background: Breastfeeding competencies are not standardized in healthcare education for any of the health professions. A few continuing education/professional development programs have been implemented, but research regarding the efficacy of these programs is scarce. Research aim: After a 45-hour lactation course, (a) Does breastfeeding knowledge increase? (b) Do beliefs and attitudes about infant feeding improve? (c) Does perceived behavioral control over performance of evidence-based lactation support practices increase? and (d) Do intentions to carry out evidence-based lactation support practices increase?, Methods: A nonexperimental pretest-posttest self-report survey design was conducted with a nonprobability sample of participants ( N = 71) in a lactation course. Theory of Planned Behavior variables were measured and a before-after course analysis was completed., Results: Significantly higher scores were found on the posttests for knowledge, beliefs about breastfeeding scale, and the perceived behavioral control scale. Participants' self-efficacy increased after the course; their beliefs about social norms and their ability to effect change in their workplaces did not change significantly. Participants' intention to perform actions that are consistent with the evidence-based breastfeeding supportive behaviors increased significantly. Positive beliefs about formula feeding significantly increased; this was unexpected., Conclusion: The Theory of Planned Behavior provided a useful approach for examining more meaningful learning outcomes than the traditional knowledge and/or satisfaction outcomes. This study was the first to suggest that more meaningful learning outcomes are needed to evaluate lactation programs. However, it is not enough to educate healthcare providers in evidence-based practice; the places they practice must have the infrastructure to support evidence-based practice.

Background: The American Academy of Pediatrics recommends that pediatricians promote and help manage breastfeeding. However, research has shown that they are not adequately prepared. To address this gap, a 2-week mandatory lactation rotation program was developed for first-year pediatric residents. Research aim: The aim of the study was to provide a lactation education program and to measure the residents' knowledge and perceived confidence regarding breastfeeding., Methods: This longitudinal self-report pretest/posttest study was conducted with a convenience sample of 45 first-year pediatric residents. Each resident spent a minimum of 50 hours with an International Board Certified Lactation Consultant. To measure breastfeeding knowledge and clinical confidence, the American Academy of Pediatrics' Breastfeeding Residency Curriculum pretest was used 4 times: first and last day of the rotation and at 6 and 12 months postrotation., Results: Test and confidence scores were evaluated. Statistically significant differences in knowledge were found between test 1 when compared with tests 2, 3, and 4 ( p < .001). No significant differences were found between tests 2, 3, and 4 ( p > .05). The abilities to "adequately address parents' questions" and to "completely manage common problems" were significant, with confidence increasing in tests 2, 3, and 4 ( p < .001)., Conclusion: As a result of an innovative, comprehensive educational lactation program, the pediatric residents' knowledge and perceived confidence related to breastfeeding significantly increased.

Background: Under-nutrition is a public health problem in Myanmar. Despite current efforts, the exclusive breastfeeding rate (EBF) for children under six months is only 24%. Intention to breastfeed is a strong predictor for long-term breastfeeding, however, little is known about pregnant women's breastfeeding intentions in Myanmar. We, therefore, aimed to identify the factors associated with women's intention to EBF., Method: Data in this article was collected in a baseline survey for a randomized controlled trial, which aimed to assess the impact of mobile text messages on the breastfeeding practices of women in Yangon, Myanmar. A total of 353 pregnant women at 28-34 weeks of gestation, recruited into the trial from the antenatal clinics of the Central Women's Hospital, Yangon, Myanmar, responded to the baseline survey questions, which included background information and breastfeeding related characteristics. To determine factors associated with women's intention to EBF logistic regression was used to analyse individual demographic, household economic and breastfeeding characteristics. In-depth interviews were performed with a sub-sample of 24 women who participated in the survey, to gain a further understanding of these associated factors., Results: After adjusting for potential confounders, working women were less likely to intend to EBF (adjusted odds ratio (AOR) = 0.30, CI 0.17-0.53). Women from rich households (AOR = 2.43, CI 1.08-5.47) and middle income households (AOR = 1.79, CI 1.01-3.16); those who had high (AOR = 10.19, CI 3.43-30.23) and medium (AOR = 5.46, CI 1.79-16.72) breastfeeding knowledge levels, and received information from health professionals (AOR = 2.29, CI 1.29-4.03) and mobile internet (AOR 3.62, CI 2.04-6.41) had a higher intention to EBF. These findings were supported by qualitative analysis, which revealed that returning to work was the main barrier; health staff and printed media are reliable sources and; women with higher knowledge had high intentions to EBF., Conclusions: EBF intention was influenced by many factors. Breastfeeding promotion programs should target the poor, working women and women with lower breastfeeding knowledge. Breastfeeding education via health staff and the Internet, breastfeeding facilities at the work place and longer maternity leave in the private sector should all be encouraged., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000063516.

Background: Knowledge on infant feeding among pregnant women is essential when promoting optimal breastfeeding practices. This study aimed to assess the knowledge of women on optimal breastfeeding during pregnancy and associated factors as well as performance of the health system in reaching women with information on breastfeeding and infant feeding issues., Methods: A cross-sectional study was conducted from October 2013 to April 2014 among pregnant women, in their third trimester, attending for routine care at two primary health care facilities in Moshi urban, northern Tanzania., Results: A total of 536 women were enrolled, with mean age of 25.9 (SD 5.7) years. Only 51% ( n  = 274) reported to have received counselling on breastfeeding from their healthcare providers during the current pregnancy. More than seven out of ten pregnant women were knowledgeable about key issues regarding appropriate breastfeeding practices: importance of colostrum (95%), time of breastfeeding initiation (71%), exclusive breastfeeding (EBF) (81%), and time of introducing complementary feeding (83%). Receiving counselling on breastfeeding during the current pregnancy (Adjusted Odds Ratio [AOR] 3.7; 95% Confidence Interval [CI]: 2.4, 5.7), having two children (AOR 2.6; 95% CI: 1.5, 4.4), having three or more children (AOR 3.5; 95% CI: 1.8, 6.9) and intention to breastfeed the child exclusively (AOR 3.6; 95% CI: 2.0, 6.5) were significantly associated with appropriate breastfeeding knowledge., Conclusions: The health system failed to reach the 49% of women who did not receive counselling on infant feeding. Pregnant women who had received counselling on optimal breastfeeding and women with more than one child were more likely to have knowledge of optimal breastfeeding practices.

Background: Men's attitudes toward public breastfeeding may influence a woman's decisions about breastfeeding and her perceived comfort with public breastfeeding. Research aim: This study aimed to evaluate factors associated with men's visual perception of images of public breastfeeding., Methods: A 95-item online survey was administered to 502 U.S. men ages 21 to 44. Respondents were presented with four images of women breastfeeding and asked to evaluate agreement with 15 adjectives describing each image. Based on factor analysis, 13 of these adjectives were combined to create the Breastfeeding Images Scale for each image. An 8-item Situational Statements Scale and the 17-item Iowa Infant Feeding Attitude Scale (IIFAS) were used to assess breastfeeding knowledge and attitudes. Multiple regression was used to evaluate the association between breastfeeding attitudes and knowledge and the Breastfeeding Images Scale., Results: The image depicting a woman breastfeeding privately at home had the highest mean score of 71.95, 95% confidence interval (CI) [70.69, 73.22], on the Breastfeeding Images Scale, compared with 61.93, 95% CI [60.51, 63.36], for the image of a woman breastfeeding in a public setting. The overall mean scale score for the IIFAS was 56.99, 95% CI [56.27, 57.70], and for the Situational Statements Scale was 28.80, 95% CI [27.92, 29.69]. For all images, increasing breastfeeding knowledge and attitudes measured by the IIFAS and the Situational Statements Scale were associated with a more positive perception of the image., Conclusion: Images of public breastfeeding are viewed less favorably by men in the sample than are images of private breastfeeding. Knowledge and attitudes toward breastfeeding are positively associated with perception of breastfeeding images.

Background: Breastfeeding rates among urban, low-income populations are lower than the national average, and social support can affect breastfeeding initiation and duration both positively and negatively. Research aim: This study aimed to determine the effect of the presence of a support person and breastfeeding knowledge and attitudes of that person on a mother's feeding choice and perceived level of support for her choice., Methods: Questionnaires were administered to 192 mothers receiving care for their infants in the Pediatric Practice at University Hospitals Rainbow Babies and Children's Hospital in Cleveland, Ohio, along with 74 adults accompanying these mothers. Data on demographics, feeding characteristics, and breastfeeding knowledge and attitudes were collected., Results: Analysis of the entire group of mothers found that breastfeeding-supportive knowledge and attitudes were an independent predictor of exclusive breastfeeding (odds ratio [ OR] = 1.89, 95% confidence interval [CI] [1.38, 2.60]) and any breastfeeding ( OR = 2.28, 95% CI [1.62, 3.21]). The presence of an accompanying adult was not related to feeding choice. Analysis of the subgroup of mothers with surveyed accompanying adults found independent predictors of any breastfeeding include maternal intention to breastfeed ( OR = 23.68, 95% CI [1.48, 377.6]) and breastfeeding-supportive knowledge and attitudes of the mother ( OR = 2.71, 95% CI [1.36, 5.40]) and the accompanying adult ( OR = 2.78, 95% CI [1.17, 6.60]). The only independent predictor of exclusive breastfeeding was maternal intention to breastfeed ( OR = 7.64, 95% CI [2.22, 26.3]). The majority of mothers (91%) felt supported, regardless of presence or absence of an accompanying adult., Conclusion: These findings emphasize the importance of breastfeeding education for mothers and their support persons.

Background: Prior research in high-income countries finds that young mothers tend to breastfeed their infants for shorter durations than older mothers; however, there are gaps in our understanding of the processes by which age influences breastfeeding. Research aim: The primary objective of this study was to test the mediating effects of parity and education attainment on the association between maternal age and two breastfeeding outcomes: total duration and duration of exclusive breastfeeding., Methods: This study was a secondary data analysis of the IFPS II, a prospective, longitudinal study of ~ 4,900 American mothers. Robust and bias-corrected regression analyses tested the direct effect of age and the indirect effects of age through parity and education for each outcome of interest., Results: Parity and education attainment together explain nearly all of the association between maternal age and both measures of breastfeeding duration. The mediating role of education is significantly larger than parity for both outcomes., Conclusion: These findings indicate that maternal age primarily indexes parity and education but contributes minimally to breastfeeding duration via a direct effect. The findings have implications for intervention development and targeting strategies.

Background: Valid instruments that can reliably assess maternal breastfeeding knowledge in Arabic-speaking populations are nonexistent. The availability of such an instrument is essential for investigators working in this field., Objective: This study aimed to describe the adaptation and validation of the Arabic Breastfeeding Knowledge Questionnaire (BFK-A) from the original 20-item English version., Methods: A translated version of the 20-item BFK was validated among 417 Lebanese women after pilot testing for clarity, comprehension, length, and cultural appropriateness. Exploratory factor analysis was run to examine dimensionality of the instrument and Kuder-Richardson-20 (KR-20) was used to assess its internal consistency., Results: The BFK-A is a unidimensional scale with acceptable internal consistency reliability (KR-20 = 0.652) after the exclusion of 4 items. Higher breastfeeding knowledge levels were strongly and statistically significantly associated with higher mean scores for the validated Arabic Iowa Infant Feeding Attitude Scale ( P < .001), thus confirming its construct validity., Conclusion: The Arabic 16-item BFK-A has an acceptable reliability, similar to the original instrument. Further studies are encouraged to confirm the validity of the 16-item BFK-A among other Arab populations. There is also a need to develop more reliable instruments to use in lactation research in this context.

Background: It is prudent that health care professionals remain cognizant of breastfeeding-related issues to support nursing mothers. In 1995, Freed and colleagues noted deficits in breastfeeding knowledge among family medicine, pediatric, and obstetrics/gynecology residents and practitioners. Others reported similar findings despite calls to action and reports of successful breastfeeding interventions., Objective: This retrospective study compared baseline breastfeeding knowledge and attitude scores from Nevada health care professionals from 2004 through 2013., Methods: In-training and practicing professionals (pediatric/family practice/obstetric residents and attending physicians; hospital nursing staff; nursing and medical students) attended a 90-minute workshop at their sites. Following each session, attendees voluntarily completed a survey consisting of 2 knowledge and 2 attitudinal questions, using the post:pre-evaluation method, which diminishes overinflation of pretest scores as respondents can more accurately reflect their baseline levels. A Kruskal-Wallis test evaluated differences in baseline knowledge and attitude scores among 3 professional groups and for physicians over the 10-year period using Bonferroni post-hoc analyses., Results: A total of 889 professionals participated, with only physicians represented yearly. Except for knowledge of milk production, physician median baseline scores did not differ significantly over time. Overall, hospital nurses had significantly higher median baseline knowledge scores about initiation and frequent feeding than physicians and students. Nurses also had higher median attitude scores (likelihood of and confidence in talking with parents about breastfeeding) than physicians who had higher scores than students., Conclusion: Despite growing societal enthusiasm and support, the baseline knowledge of and attitudes toward breastfeeding showed minimal change over 10 years., (© The Author(s) 2015.)

Background: Human milk is uniquely superior as a source of nutrition for infants, and breastfeeding has many benefits. This study determined the breastfeeding knowledge and practices of women who have children aged 0-2 years living in a Naval Barracks., Methods: This descriptive cross sectional study was carried out among 220 women in a Naval Barracks selected using systematic random sampling method. Pre tested questionnaires were administered by trained interviewers, and data was analyzed using Epi info 2000 and Statistical Package for Social Sciences version 19., Results: There was generally fair knowledge about breastfeeding among the women. Most of the respondents (97.3%) had ever breastfed their babies, 56.5% of them initiated breastfeeding within an hour of delivery, 24.1% admitted that they gave pre lacteal feeds, 74.1% practiced exclusive breastfeeding for a mean period of 4.98 months and 30.7% engaged in bottle-feeding. Several factors were significantly associated with breastfeeding practices., Conclusions: Breastfeeding practices varied among the respondents despite the fair knowledge., Global Health Implications: This study reveals the need to educate women and communities worldwide particularly in low-income countries about good breastfeeding practices. Targeting these women will help to improve maternal and child health., Competing Interests: The authors declare no conflicts of interests relevant to this study.

Background: A link between postpartum mood and breastfeeding has been established in the literature, but little is known about the relationship of breastfeeding self-efficacy (BSE) to breastfeeding and mood outcomes, particularly in primiparous women., Objectives: The purpose of this study was to prospectively evaluate the relationship among BSE, mood, and breastfeeding outcomes in primiparous women. A secondary purpose was to explore self-reported reasons for difficult emotional adjustment during the transition to motherhood., Methods: Primiparous women who initiated breastfeeding were surveyed at 2 days, 6 weeks, and 6 months postpartum. Breastfeeding self-efficacy, depressive symptoms, work status, breastfeeding difficulties, partner support, and use of lactation services were included in a hierarchical multiple regression analysis. Women who identified as emotionally distressed provided open-ended responses identifying the main cause of their stress., Results: High BSE at 2 days postpartum predicted positive emotional adjustment and fewer depressive symptoms at 6 weeks postpartum, as well as more exclusive breastfeeding at 6 months postpartum. Among distressed mothers, breastfeeding concerns were among the most commonly named reasons for stress, along with lack of sleep, lack of social support, and overwhelming learning demands involved with being a new parent., Conclusion: Breastfeeding perceptions are associated with emotional health and breastfeeding outcomes. Bolstering women's early BSE may be an important goal for multiple dimensions of postpartum health., (© The Author(s) 2015.)

Poor breastfeeding practices are widely documented in Kenya, where only a third of children are exclusively breastfed for 6 months and only 2% in urban poor settings. This study aimed to better understand the factors that contribute to poor breastfeeding practices in two urban slums in Nairobi, Kenya. In-depth interviews (IDIs), focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with women of childbearing age, community health workers, village elders and community leaders and other knowledgeable people in the community. A total of 19 IDIs, 10 FGDs and 11 KIIs were conducted, and were recorded and transcribed verbatim. Data were coded in NVIVO and analysed thematically. We found that there was general awareness regarding optimal breastfeeding practices, but the knowledge was not translated into practice, leading to suboptimal breastfeeding practices. A number of social and structural barriers to optimal breastfeeding were identified: (1) poverty, livelihood and living arrangements; (2) early and single motherhood; (3) poor social and professional support; (4) poor knowledge, myths and misconceptions; (5) HIV; and (6) unintended pregnancies. The most salient of the factors emerged as livelihoods, whereby women have to resume work shortly after delivery and work for long hours, leaving them unable to breastfeed optimally. Women in urban poor settings face an extremely complex situation with regard to breastfeeding due to multiple challenges and risk behaviours often dictated to them by their circumstances. Macro-level policies and interventions that consider the ecological setting are needed., (© 2014 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Objective: To evaluate the baseline knowledge and knowledge gained of nurses, nursing students, midwives, and nurse practitioners who completed Breastfeeding Basics, an online educational program., Design: This study reports on an anonymous evaluation of an online breastfeeding education program developed and maintained to promote evidence-based breastfeeding practice., Participants: Included in the study were 3736 nurses, 728 nurse practitioners/midwives, and 3106 nursing students from the United States who completed ≥ one pretest or posttest on the Breastfeeding Basics website between April 1999 and December 31, 2011., Methods: Baseline scores were analyzed to determine if nurses' baseline knowledge varied by selected demographic variables such as age, gender, professional level, personal or partner breastfeeding experience, and whether they were required to complete the website for a job or school requirement and to determine knowledge gaps. Pretest and posttest scores on all modules and in specific questions with low pretest scores were compared as a measure of knowledge gained., Results: Lower median pretest scores were found in student nurses (71%), males (71%), those required to take the course (75%), and those without personal breastfeeding experience (72%). The modules with the lowest median pretest scores were Anatomy/Physiology (67%), Growth and Development of the Breastfed Infant (67%), the Breastfeeding Couple (73%), and the Term Infant with Problems (60%). Posttest scores in all modules increased significantly (p < .001)., Conclusion: Breastfeeding Basics was used by a large number of nurses and nursing students. Gaps exist in nurses' breastfeeding knowledge. Knowledge improved in all areas based on comparison of pretest and posttest scores., (© 2015 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

Background: Despite the high breastfeeding initiation rate in China (> 90%), the low exclusivity rate is of concern. Some traditional behaviors, combined with increasing popularity of infant formula, may negatively affect future breastfeeding rates. As suggested by the theory of planned behavior, understanding breastfeeding beliefs of young adults may help identify and address misperceptions of future parents, supporting maintenance of the current initiation rate while increasing rates of exclusivity and duration. No research has evaluated these factors among young adults in Mainland China., Objective: The objective was to explore any relationships between breastfeeding knowledge, attitudes, previous experiences, and future intention among undergraduate students in Mainland China., Methods: This was a cross-sectional, quantitative study conducted from May to June 2012. A convenience sample of 395 students from a major public university in southwest China participated in the survey., Results: Breastfeeding knowledge was moderate (76.7% of total score), and breastfeeding was considered to be painful (34.2%), to make breasts sag (43.1%), and to restrict the freedom of mothers (52.5%). In addition, 58.2% of students reported that they would feel embarrassed if they or their partners were to breastfeed in public, and acceptability of breastfeeding in public was low (34.7%). Three-fourths of the students (75.1%) expressed future breastfeeding intent, though males were more likely to report this intention (ie, to support a partner in breastfeeding) than were females (81.3% vs 71.7%, P = .04)., Conclusion: To create a more breastfeeding-friendly culture, future research is warranted to explore these negative beliefs about breastfeeding and to counter misunderstandings among future parents in Mainland China., (© The Author(s) 2014.)

Background: Working mothers who place their infants into out-of-home child care face many challenges to sustaining breastfeeding. Child care providers, who are in frequent close contact with young families, may be potential resources for promoting breastfeeding., Objectives: This study focused on identifying child care providers' attitudes toward and knowledge about breastfeeding as well as providers' perceptions about strategies to increase breastfeeding rates among mothers of infants in child care centers., Methods: Seventy-five providers from 11 child care centers in the Baton Rouge, Louisiana, area were surveyed using paper and pencil questionnaires. Self-reported demographics, attitudes, knowledge, and perceptions about breastfeeding were collected., Results: Responses demonstrated a generally positive attitude toward breastfeeding among child care providers but a knowledge deficit in terms of the health impacts and proper handling of breast milk. A minority of providers reported that their center's staff currently receives breastfeeding education, but most providers believed that measures to promote the use of breast milk in their center should target parents rather than the center staff., Conclusion: Child care providers need resources about the benefits of human milk, proper handling of expressed milk, and ways to make centers more breastfeeding friendly. Many providers feel ineffective in supporting breastfeeding and are unaware of the role they may play in mothers' infant feeding decisions. Though child care providers do not appear to believe they can influence parents' decisions about breastfeeding, educating and empowering them could play an important role in increasing breastfeeding rates.