A study to promote breast feeding in the Helsinki Metropolitan area in Finland

Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

Contents lists available at ScienceDirect

Midwifery journal homepage: www.elsevier.com/midw

A study to promote breast feeding in the Helsinki Metropolitan area in Finland Leena S. Hannula, PhD (Principal Lecturer, Midwife)a,n, Marja E. Kaunonen, PhD, RN (Professor, Vice Dean)b, Pauli J. Puukka, Master of Social Sciences (Chief Planner)c a

Helsinki Metropolia University of Applied Sciences, Faculty of Health Care and Nursing, P.O. Box 4030, 00079 Metropolia, Finland University of Tampere, School of Health Sciences, 33014 Tampere, Finland c National Institute for Health and Welfare, Population Research Unit, THL, Peltolantie 3, 20720 Turku, Finland b

art ic l e i nf o

a b s t r a c t

Article history: Received 22 January 2013 Received in revised form 19 July 2013 Accepted 8 October 2013

Objective: the aim of this study was to assess the impact of providing intensified support for breast feeding during the perinatal period. Design: a quasi-experimental design with non-equivalent control group. Setting: three public maternity hospitals (two study, one control) in the Helsinki Metropolitan area in Finland. Participants: a convenience sample of 705 mothers (431 in the intervention group, 274 in the control group). Methods and intervention: in this study, families in the intervention group had access to intensified breast feeding support from midpregnancy, whereas those in the control group had access to normal care. Intensified support included lectures and workshops to health professionals, and families in the intervention group had access to more intensive support and counselling for breast feeding and a breast feeding outpatient clinic. Additionally, an internet-based intervention was only used in the intervention group, but not in the control group. Mothers in the control group received normal care from the midwifery and nursing professionals who were to continue their work normally. The data were analysed statistically. Findings: altogether 705 women participated in the study. In the intervention group (n¼ 431), 76% of the women breast fed exclusively throughout the hospital stay, compared to 66% of the mothers in the control group (n¼274). In multivariate analysis, the likelihood of exclusive breast feeding at the time of responding (at hospital discharge or after that at home) was increased by the mother not being treated for an underlying illness or medical problem during pregnancy, being in the intervention group, having normal vaginal childbirth, high breast feeding confidence, positive attitude towards breast feeding, good coping with breast feeding, and 24-hour presence of the infant's father in the ward. Key conclusions and implications for practice: the low exclusive breast feeding rates of newborns could be increased by using intensified breast feeding support. Mothers' health problems during pregnancy can decrease exclusive breast feeding. Mothers with health problems or other than normal childbirth should receive extra breast feeding support, and the presence of fathers in the ward should be encouraged. Intensified breast feeding counselling and support helps mothers to breast feed exclusively. This support should be available in a variety of forms, so that mothers can choose the type of support they need. As breast feeding counselling and support is intensified, more mothers succeed with exclusive breast feeding. & 2013 Elsevier Ltd. All rights reserved.

Keywords: Breast feeding Exclusive breast feeding Hospital Quantitative study

Introduction Exclusive breast feeding for six months and continued breast feeding after introduction of solids until the infant is 12 months or older is recommended in Finland (Finnish Ministry of Social Affairs n

Corresponding author. E-mail addresses: leena.hannula@metropolia.fi (L.S. Hannula), marja. kaunonen@uta.fi (M.E. Kaunonen), pauli.puukka@thl.fi (P.J. Puukka).

and Health, 2004) due to the established health benefits of exclusive breast feeding (Ip et al., 2007). Breast milk is the predominant milk in the maternity ward given to 99% of the infants. However, 80% of the women recall their child being fed supplementary milk (donated breast milk or infant formula) in the maternity ward (Erkkola et al., 2010). The median duration of exclusive breast feeding is 1.4 months and that of total breast feeding 7.0 months (Erkkola et al., 2010). Exclusive breast feeding of children under one month has decreased from 60% in the year

0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.10.005

Please cite this article as: Hannula, L.S., et al., A study to promote breast feeding in the Helsinki Metropolitan area in Finland. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.005i

L.S. Hannula et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

2

2005 to 47% in 2010 (Hasunen and Ryynänen, 2006; Uusitalo et al., 2012). In Finland, only 1% of infants aged six months are exclusively breast fed (Kyttälä et al., 2008), and this low rate gives cause for concern (National Expert Group for Breastfeeding Promotion, 2009). Mothers' breast feeding attitudes and intentions during pregnancy are linked to whether they initiate breast feeding and how long they continue with it (Sittlington et al., 2007; Mossman et al., 2008). Good knowledge on breast feeding is associated with success and continuation of breast feeding (Tarkka et al., 1999) and high breast feeding self-efficacy with exclusive breast feeding (Dennis et al., 2011). Providing the infant access to skin-to-skin contact to begin his/her hand movements and sucking behaviour soon and often after childbirth empowers the infant to begin promptly meeting his/her immediate calorie needs and stimulating maternal prolactin levels, both leading to greater likelihood of successful exclusive breast feeding (Noel et al., 1974; Riordan and Auerbach, 1998; Hill et al., 1999; Matthiesen et al., 2001). Many Finnish mothers are unsure about their ability to assess the sufficiency of the infant's food intake (Tiili et al., 2011). Mothers with good health and a healthy lifestyle are more likely to breast feed than mothers who have health problems (Mezzacappa, 2004; Amir and Donath, 2007; Ip et al., 2007; Erkkola et al., 2010) or are overweight or obese (Oddy et al., 2006). Caesarean childbirth increases the risks for maternal complications (Pallasmaa et al., 2010), supplementation in the hospital and shorter duration of breast feeding (Erkkola et al., 2010). Caesarean childbirth and assisted vaginal childbirth increase the likelihood of supplementation in the hospital whereas initiation of breast feeding in the delivery room increases exclusive breast feeding (Parry et al., 2013). Boosted breast feeding support provided by health care professionals increases exclusive breast feeding (Sikorski et al., 2003; Britton et al., 2007) and coping with breast feeding (Castrucci et al., 2006). After giving birth, mothers need support, whereby positive outcomes on individuals' well-being are achieved with certain measures and behaviours (Tarkka, 1996; Ekström et al., 2003a). In addition to support given by health care professionals, mothers also need peer support given by people close to them (Ekström et al., 2003a, 2003b; Wolfberg et al., 2004; Pisacane et al., 2005; Swanson and Power, 2005). Spouse's knowledge should be increased already during pregnancy, as mothers' breast feeding rates have been shown to increase by education aimed at fathers during pregnancy (Wolfberg et al., 2004; Pisacane et al., 2005; Kaunonen et al., 2012). Family members benefit from instructions telling them how they can support the breast-feeding mother in a practical manner (Lavender et al., 2005; Grassley and Eschiti 2007). According to a Swedish study, fathers' longer presence with their families after childbirth also increased exclusive breast feeding and the duration of breast feeding among first-time mothers (Ekström et al., 2003a) and in Finland individual counselling in family rooms increased exclusive breast feeding (Hannula et al., 2006).

Methods This study is part of the ‘Urban parenthood’ project. ‘Urban Parenthood’ is a large collaborative longitudinal research project examining the welfare of families during the first year after childbirth (Salonen et al., 2008; Hannula et al., 2010; Tiili et al., 2011; Oommen et al., 2011; Salonen et al., 2011; Koskimäki et al., 2012; Koskinen et al., in press). The aim of this paper was to assess the impact of providing intensified support for parenthood, childcare and breast feeding during the perinatal period. The

intervention group had access to long-term intensified counselling, breast feeding and parenthood support before childbirth (through webpages), in maternity hospital, and after childbirth. The control group received normal counselling and support at maternity health care. Outcome measures were breast feeding initiation and exclusive breast feeding from birth and at the time of responding (at discharge or after that at home).

Design A quasi-experimental design with non-equivalent control group was used. The study was conducted as part of the larger ‘Urban parenthood’ project that offers additional support for infants' parents through interventions. Mothers were recruited to the intervention or control group depending on where they were to give birth. Randomisation of the mothers was not possible because the interventions were developed through multiprofessional collaboration in the study hospitals and the hospital personnel and all parents at the study hospitals were exposed to the interventions. Mothers who were to give birth in the two study hospitals were recruited to the intervention group during pregnancy and it was impossible to know in advance in which wards in these hospitals they were to be treated after childbirth (Salonen et al., 2011). Control group mothers were recruited at the control hospital. The free and non-commercial web-based service www.vauvan kaa.fi was developed as part of the project, aimed at providing the target group intensified support for parenthood, childcare and breast feeding from the 20th gestation week until the child was a year old (Hannula et al., 2008; Salonen et al., 2008; Salonen et al., 2011). The website was created by an editorial team of health care students, their teachers and a multidisciplinary group of health care professionals, and its final structure was organised around six themes: (1) for mothers; (2) for fathers; (3) your infant; (4) life as a couple and family; (5) what to do when you're in trouble and (6) support for the family. The page consists of articles, pictures, videos and an educational game. The final modifications were made on the basis of comments and suggestions from the content evaluation team. The articles were edited by a specialist in online communication. The development (Salonen et al., 2008), pilot testing (Hannula et al., 2010) and effectiveness (Salonen et al., 2011) of the website have been described previously.

Settings In Finland, maternity and child health care is organised by a network of public maternity and child health clinics and public hospitals specialising in obstetric and neonatal care. Antenatal childbirth and parenting education groups are available to all expectant families at maternity clinics. All normal vaginal childbirths are attended by midwives in the maternity hospitals, with obstetricians and anesthesiologists present in the case of more complicated childbirths. In 2008, the mean age for all women giving birth was 30.1 and the average length of hospital stay after childbirth was 3.2 days. According to national statistics 33% of pregnant women were overweight and 11% obese and the most common diagnoses for mothers during pregnancy causing visits to hospital or outpatient clinic in the year 2008 were gestational diabetes (19,259 visits), risk pregnancy (15,991 visits), premature contractions (9993 visits) or underlying maternal diseases that complicate pregnancy, childbirth or postnatal period (8201 visits) (National Institute of Health and Welfare, 2008, 2013). The study was conducted in three public maternity hospitals in the Helsinki Metropolitan area of Finland. All three hospitals (two

Please cite this article as: Hannula, L.S., et al., A study to promote breast feeding in the Helsinki Metropolitan area in Finland. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.005i

L.S. Hannula et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

study hospitals and one control hospital) recommended to the parents the practice of rooming in, and aimed to offer continuity of care and family-centred care. Partners' presence and overnight stays, if possible, were encouraged in all hospitals. In the study hospitals several interventions were used to support breast feeding. These included lectures and workshops to health professionals, families' access to more intensive support and counselling for breast feeding and a breast feeding outpatient clinic. The strategy for intensive support and counselling was based on research evidence showing that breast feeding support is effective if it is continuous and provided using multiple methods (Fairbank et al., 2000; Hannula et al., 2008) and is in line with the BFHI strategy (WHO and UNICEF, 2003; WHO, 2004). The intervention package included the use of website and training of the midwifery and nursing staff working in the two intervention hospitals. The staff were given lectures and workshops on approaches aimed at empowering and promoting parents' own resources. The topics of lectures included partners' presence and role, the importance of first breast feeding and skin-to-skin contact as well as how to assess breast feeding situations and evaluate the need of more individualised support with the aid of the LATCH method (Jensen et al., 1994). All families in the intervention group were cared for by the staff with this additional training. They also had the availability of more individualised support if they needed it, especially if the LATCH scores were low. At six weeks post partum 5% of the mothers reported visiting the breast feeding outpatient clinic after discharge. Additionally, an internet-based intervention was used in the study hospitals but not in the control hospital. In the control hospital nursing and support practices of mothers in the control group followed normal procedures. This included personal advice from midwives and nurses according to mother's wishes and a possibility to watch a breast feeding video at the ward. No assessment tools were used in assessing breast feeding situations and there was no systematic recording of breast feeding, no additional staff training and the families did not have access to more individualised breast feeding support.

Data collection The data for this study were collected using a convenience sample of mothers. The inclusion criteria for mothers were willingness to participate, ability to speak Finnish, infant treated at the maternity or neonatal unit and singleton pregnancy. Both primiparous and multiparous women were included in the study; multiple pregnancy was used as exclusion criterion. The data were collected between November 2007 and September 2008 in the three hospitals. A registered midwife recruited intervention group parents when they visited the hospital for routine ultrasound examination available for all mothers and conducted at 18–21 weeks of gestation. Mothers in the intervention group received passwords giving them access to the web-based service. The participants in the control group were recruited postnatally by midwifery and nursing professionals before discharge from the postnatal ward. Altogether 1400 questionnaires were distributed to mothers on postnatal wards (700 in the study hospitals and 700 in the control hospital). Mothers were asked to complete a structured baseline questionnaire at the hospital before discharge or at home after discharge during the first week post partum. Reasons for refusal were not asked. Mothers returned the questionnaires on discharge or from home with a prepaid postal envelope. All completed questionnaires were included in the analysis. In the intervention group 431 (62%) of the 700 mothers returned the questionnaire

3

after childbirth. In the control group 274 (39%) mothers returned a completed questionnaire. Instruments Sociodemographics, internet skills and use, participation in the antenatal childbirth and parenting education groups and medical treatment during pregnancy were examined (Table 1). In addition, mother's physical status, infant's weight, spouse's attitudes towards breast feeding, spouse's presence during childbirth and in the ward and rooming in were asked about. Mothers were asked if they had a designated or primary nurse in the ward. Factors related to childbirth, breast feeding after childbirth, earlier breast feeding experience, dummy use and care in maternity hospital were also examined as background variables (Table 2). The LATCH assessment tool (Jensen et al. 1994), a breast feeding charting system developed for use by health professionals on breast feeding efficacy, was used to evaluate the breast feeding dyads in the intervention group in the delivery room and before discharge from the hospital. In the study, exclusive breast feeding during the entire hospital stay was enquired by asking about the amount of supplemental food given to the infant in hospital (Table 2). Breast feeding at the time of responding (at discharge or after discharge at home) was enquired by asking about the current manner of feeding the infant (exclusive breast feeding, partial breast feeding or infant formula). Breast feeding confidence was measured using the Breastfeeding Self Efficacy Scale – Short Form (BFSE-SF) (Dennis, 2003). Breast feeding attitudes were measured with the Iowa Infant Feeding Attitude Scale (IIFAS) (de la Mora et al., 1999). Both instruments (BFSE-SF, IIFAS) have been shown to be reliable in previous studies, however, they have not been used previously in Finland. The Cronbach alpha coefficients of the instruments were 0.93 and 0.73. An instrument measuring coping with breast feeding (eight statements) was drawn up for this study based on earlier dissertation studies (Tarkka, 1996; Hannula, 2003; Tiili et al., 2011; Koskimäki et al., 2012). The validity and reliability of the instrument was confirmed by an expert panel (n¼7) and with pretesting (n¼ 13 mothers). The Cronbach alpha of this instrument was 0.82 in this study and 0.85 in an earlier study (Tiili et al., 2011). All sum variables have a five-point (1–5) Likert scale, with a high value indicating high confidence, good coping or positive attitudes toward breast feeding. In addition, the use of the web-based service was enquired of the intervention group mothers.

Data analysis The data were analysed with SAS for Windows 9.1 statistical software. Mother's age and infant's weight and the formed sum variables between the intervention and control groups were compared with t-test. Categorical background variables between the groups were compared with χ2 test. Classes with frequencies that were too small for the test (under 10) were combined with other appropriate classes (see Tables 1 and 2). The associations of categorical background variables and sum variables with breast feeding were first tested with logistic analyses, with exclusive breast feeding at the time of responding (at discharge or after discharge at home) as response and the intervention group and the variables studied, one at a time, as explanatory factors. Finally, logistic multivariate analysis was performed, first using the intervention group and all categorical background variables (mother's age, parity, civil status, previous breast feeding experience, treatment during pregnancy, participation in family coaching, route of childbirth, father's presence at childbirth, immediate skin contact, time of first breast feeding, first breast feeding as an experience, physical status and presence of the infant's father in the ward),

Please cite this article as: Hannula, L.S., et al., A study to promote breast feeding in the Helsinki Metropolitan area in Finland. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.005i

L.S. Hannula et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

4

Table 1 Description of study material. Intervention group (n¼ 431) Mean (SD)

Control group (n¼ 274) Mean (SD)

p

30.7 (4.1) 3527 (485)

30.9 (4.6) 3559 (473)

0.41 0.39

Mother's age, years Infant's weight, g n

(%)

n

(%)

Educationn Basic education (9years) Matriculation examination Vocational qualification University of applied science University degree Other

4 32 57 128 204 4

(1) (7) (13) (30) (48) (1)

10 11 39 89 124 1

(4) (4) (14) (32) (45) (0.4)

Civil statusn Married Registered cohabitation Cohabitation Single

295 2 125 7

(69) (0.5) (29) (2)

197 1 66 8

(72) (0.4) (24) (3)

Parity Primipara Multipara

265 165

(62) (38)

130 144

(47) (53)

Treatment during pregnancy for underlying disease or pregnancy-related medical problem Not treated Treated

330 96

(77) (23)

208 65

(76) (24)

Participation in parenting education No Yes

174 255

(41) (59)

154 119

(56) (44)

Current physical status Poor or moderate Good

168 263

(39) (61)

90 182

(33) (67)

Infant's father/spouse present at childbirth Yes No

416 12

(97) (3)

258 14

(95) (5)

Infant's father/spouse present in the ward 24 hours per day Only during days/evenings Not at all

204 210 10

(48) (50) (2)

98 163 12

(36) (60) (4)

Father's/spouse's attitudes towards breast feeding Neutral or negative Positive Very positive

17 67 340

(4) (16) (80)

6 53 214

(2) (19) (78)

Infant roomed in with mothern 24 hours per day Only some of the time Not at all

382 36 8

(90) (8) (2)

248 24 0

(91) (9) (0)

Primary nurse in the ward Yes No Cannot say

272 40 116

(64) (9) (27)

138 32 104

(50) (12) (38)

n

p 0.80

0.21

0.0002

0.70

o 0.0001

0.11

0.11

0.0039

0.23

0.51

0.0023

Classes with frequencies below 10 have been combined with others in statistical tests.

one at a time, as explanatory factors, with significance p o0.05, and three sum variables of breast feeding attitudes, confidence and coping with breast feeding. In the logistic model, one explanatory factor at a time was eliminated in a stepwise manner, until all factors in the model were statistically significant. The limit for statistical significance was set at p o0.05 (Burns and Grove, 2009).

Findings Altogether 700 mothers signed a consent to participate in the intervention group and 431 (62%) of them completed the questionnaire after childbirth. In the control group 274 (39%) mothers

consented to take part in the study and returned a completed questionnaire. Mothers' background data Majority of the mothers were primiparas. There were more primiparas in the intervention group (62% versus 47%, p ¼0.0002) than in the control group (Table 1). Nearly one in four mothers had visited a hospital or maternity outpatient clinic during pregnancy for examination or treatment of an underlying disease or pregnancy-related medical problem. In all, 59% of the mothers in the intervention group and 44% in the control group had taken part in public childbirth and parenting education groups (p o0.0001).

Please cite this article as: Hannula, L.S., et al., A study to promote breast feeding in the Helsinki Metropolitan area in Finland. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.005i

L.S. Hannula et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

5

Table 2 Breast feeding amongst intervention and control mothers. Intervention group (n¼ 431)

Control group (n¼ 274)

n

(%)

n

(%)

Route of childbirth Normal vaginal Assisted vaginal Caesarean section

308 50 73

(71) (12) (17)

222 17 32

(82) (6) (12)

Skin contact after childbirth Immediately Later

364 66

(85) (15)

245 28

(90) (10)

Time of first breast feedingn Within 1 hour of childbirth More than 1 hour but less than 2 hour after childbirth More than 2 hour but less than 12 hour after childbirth More than 12 hour after childbirth Has not breast fed yet

269 51 80 24 6

(63) (12) (19) (6) (1)

172 34 56 9 0

(63) (13) (21) (3) (0)

Success of first breast feeding The infant suckled the breast The infant did not suckle

375 48

(89) (11)

224 48

(82) (18)

First breast feeding as an experience Neutral or negative Positive Very positive

43 156 224

(10) (37) (53)

36 96 141

(13) (35) (52)

Previous breast feeding experience No Yes

264 166

(61) (39)

130 143

(48) (52)

Quality of previous breast feeding experiences Positive experience Neutral or negative experience

147 18

(89) (11)

122 24

(84) (16)

Supplemental food in hospitaln No supplemental food Sipped from a cup From a bottle In some other way

300 39 82 3

(71) (9) (19) (1)

159 5 106 2

(58) (2) (39) (1)

Dummy use in hospital No Yes

354 66

(84) (16)

167 103

(62) (38)

Feeding method at discharge Exclusive breast feeding Partial breast feeding Infant formula†

322 101 2

(76) (24) (0.5)

179 92 2

(66) (34) (0.7)

Breast feeding attitudes – IIFAS Coping with breast feeding Breast feeding confidence BFSE-SF n

†

p 0.0058

0.053

0.20

0.019

0.47

0.0003

0.15

o 0.0001

o 0.0001

0.0099

Mean (SD)

Mean (SD)

p

3.90 (0.38) 3.79 (0.67) 4.01 (0.62)

3.84 (0.41) 3.86 (0.70) 3.98 (0.70)

0.12 0.037 0.79

Classes with frequencies below 10 have been combined with others in statistical tests. Excluded in statistical test.

There were no differences between the groups in terms of mothers' education, civil status, health and physical status, neither were there any differences between the groups in infants' weight or the timing of first breast feeding, or the frequency of rooming in. Nearly all fathers had been present at the birth of their infants, and majority were also present in the postnatal ward. It was more common in the intervention group for fathers to be in the ward 24 hours per day (p ¼0.0039). More than half of the mothers had a primary nurse in the postnatal ward; this was significantly more common in the intervention group (64% versus 50%) (p ¼0.0023). Implementation of intensified counselling and support in the intervention group All mothers in the intervention group received passwords giving them access to the web-based service on their second

ultrasound examination, but only 49% of them reported that they had used the web-based service during pregnancy. The antenatal use of the web-based service was more common among those with good internet skills (p¼ 0.032). A LATCH assessment form on the implementation of breast feeding (filled in by midwives) in the delivery room was returned on 253 mothers (59% of the intervention group mothers). On delivery room assessment, 57% of the mothers received a good score, 8–10, whereas 43% received 7 or below. A good LATCH score (8–10) in the delivery room increased the likelihood of exclusive breast feeding from birth throughout the hospital stay (p ¼0.0083). In all, 85% of the mothers who received a good LATCH score at birth were breast feeding exclusively from birth throughout their hospital stay. A second LATCH assessment on 280 mothers (65%) was filled in by midwives before discharge from the postnatal ward. 93% of the mothers received a good assessment (8–10). Three out of four (78%) of the mothers who received

Please cite this article as: Hannula, L.S., et al., A study to promote breast feeding in the Helsinki Metropolitan area in Finland. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.005i

L.S. Hannula et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

6

a good LATCH score were breast feeding exclusively at hospital discharge. A good LATCH score (8–10) before discharge increased the likelihood of exclusive breast feeding (p ¼0.0280) at discharge. Childbirth and breast feeding in hospital There were fewer normal vaginal childbirths (p ¼0.0017) in the intervention than in the control group (71% versus 81%) as well as more caesarean sections (17% versus 12%) and assisted vaginal childbirths (12% versus 6%). For 63% of the mothers, first breast feeding took place within one hour of childbirth and was successful in most cases (Table 2); more commonly in the intervention group (89% versus 82%, p ¼0.019). During hospital stay, some of the infants were given either infant formula or donated breast milk as supplemental food. The proportion of infants exclusively breast fed from birth was 71% in the intervention and 58% in the control group (p o0.0001). Majority of the infants (85% in the intervention group versus 90% in the control group) had skin contact immediately after childbirth. Dummy use was rare in the intervention group (16%), however 38% of the infants in the control group used dummies (p o0.0001). On discharge, intervention group mothers breast fed exclusively more often than control group mothers (76% versus 66%, p ¼0.0099). Four of the mothers who took part in the study did not breast feed, and seven did not answer the question on this; they were excluded from the analysis on exclusive breast feeding. Mothers' attitudes towards breast feeding were on average equally positive in both groups (mean 3.90 versus 3.84) and their breast feeding confidence equally high (mean 4.01 versus 3.98), whereas coping with breast feeding was poorer in the intervention group compared to the control group (mean 3.79 versus 3.86, p ¼0.037). Factors associated with breast feeding All univariately significant factors associated with exclusive breast feeding at the time of responding (at discharge or after discharge at home) were combined in a stepwise cumulative logistic multivariate model (Table 3). The likelihood of exclusive breast feeding was increased the most by the mother not having any treatment during pregnancy for an underlying disease or pregnancy-related problem (p ¼0.0005). Having a normal vaginal childbirth increased the likelihood of exclusive breast feeding

Table 3 Logistic model of factors associated with exclusive breast feeding in maternity hospital. Variable

Total data OR (95% confidence interval)

Group Normal counselling, control group (n¼ 248) Intensified counselling, experimental group (n¼ 389) Treatment during pregnancy Treated (n¼ 150) Not treated (n¼ 487) Route of childbirth Normal vaginal (n¼ 530) Assisted vaginal or caesarean section (n ¼172) Infant's father present in the ward Only during days or not at all (n¼352) 24 hours per day (n ¼285) Breast feeding attitudes – sum variable Coping with breast feeding – sum variable Confidence in one's own abilities – sum variable

p

0.005 1 1.73 (1.18–2.53) 0.0005 1 2.08 (1.37–3.14) 0.003 1.88 (1.24–2.84) 1 0.024 1 1.56 (1.06–2.30) 1.75 (1.07–2.88) 0.027 1.49 (1.03–2.15) 0.036 1.93 (1.31–2.85) 0.001

(p ¼0.003). High breast feeding confidence (p ¼ 0.001), positive breast feeding attitudes (p ¼0.043) and good perceived coping with breast feeding (p¼ 0.036) on the part of the mother also increased the likelihood of exclusive breast feeding. Participating in the intervention group increased the likelihood of exclusive breast feeding (p¼ 0.005), as did father's full-time presence in the ward with the mother and the infant (p ¼0.024).

Discussion Ethicality and reliability of the study The research ethical principles of the Helsinki Declaration (The Finnish Medical Association, 2009) were followed in the study. The study was approved by the Ethics Committee of Helsinki and Uusimaa Hospital District. The families in the intervention group received additional support, whereas those in the control group were given normal care. Participation in the study was voluntary, and all signed an informed consent. The reliability of the study was increased by the fact that all of the instruments had been used previously and had been validated and pilot-tested. The Cronbach values of the instruments ranged between 0.73 and 0.93, which means that they can be considered as internally consistent (Burns and Grove, 2009). There were limitations in the validity and reliability of the study. The reliability of the study is weakened by the fairly low response rate to the questionnaires and the LATCH assessment, which may have been influenced by the complex and longitudinal data collection process. The possibility of using a web-based service during pregnancy and to continue using it throughout the first year after birth combined with intensified breast feeding support after birth may have contributed to the greater proportion of primiparas in the intervention group. It is also possible that a greater number of multiparas with positive attitudes towards breast feeding may have been selected to the control group. Comparison between non-responders and participants would have been useful in terms of assessing the generalisability of the results. However, nonresponse analysis could not be performed as the information required for it was not recorded when recruiting mothers. The support and care practices used in the intervention and control group differed from each other. Mothers in the intervention group were offered several simultaneous breast feeding support forms (training for midwives and nurses, LATCH, intensified breast feeding counselling, breast feeding outpatient clinic); in addition, mothers had access to the web-based service vauvankaa. fi. Completed LATCH assessments were returned and recorded for 59% of the mothers in the delivery room and for 65% in the postnatal ward. The association between LATCH score and exclusive breast feeding throughout hospital stay and on discharge was statistically significant, although the results must be interpreted with caution due to the relatively low response rate to the LATCH assessment. Discussion of the results of the study Majority of the mothers breast fed their infants, a significant proportion of them exclusively, during their entire hospital stay and on discharge from hospital. Majority of the fathers were present at childbirth, had a positive attitude towards breast feeding and stayed with their families in the hospital. Fathers in the intervention group stayed full-time in hospital more often than fathers in the control group. There were more multiparas in the control group, which is why the spouses may not have been able to stay in the ward overnight.

Please cite this article as: Hannula, L.S., et al., A study to promote breast feeding in the Helsinki Metropolitan area in Finland. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.005i

L.S. Hannula et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

Exclusive breast feeding throughout the entire hospital stay was more common among intervention group than control group mothers. In the intervention group, 71% of the mothers breast fed exclusively throughout their hospital stay; in the control group the figure was 58%. The results are in line with previous studies indicating that intensified breast feeding support (Sikorski et al., 2003), breast feeding support using multiple methods (Fairbank et al., 2000; Hannula et al., 2008) and operation in accordance with the Baby Friendly Hospital Initiative increase the prevalence of exclusive breast feeding (Merten et al., 2005; Bartington et al., 2006). The mothers in the intervention group were motivated to breast feed, even though their perceived ability to cope with breast feeding was poorer compared to mothers in the control group. There were more primiparas and mothers with caesarean or assisted vaginal childbirths in the intervention group, which partly explains the poorer perceived coping. Breast feeding requires learning and perseverance on the part of new mothers. One explanation for the higher exclusive breast feeding rates in the intervention group may also be an attempt to behave as expected. According to Swanson and Power (2005), mothers have a tendency to behave in the way they think that people close to them expect them to behave. Intensified breast feeding support intervention had a positive effect on the mothers' breast feeding, their first breast feeding was more often successful, and the use of dummies and supplemental bottle feeding was less common. In the multivariate model, the most significant factor affecting exclusive breast feeding was the mother not being treated for an underlying disease or a pregnancy-related medical problem during pregnancy. In previous studies, mother's good health and healthrelated habits have been linked to longer duration of breast feeding (Mezzacappa, 2004; Amir and Donath, 2007; Ip et al., 2007; Erkkola et al., 2010) and overweight and obese mothers have been found to be less likely to breast feed (Oddy et al.,2006). Unfortunately, we do not know the reasons for treatment during pregnancy of the mothers in this study. Among Finnish mothers the most common reason for treatment during pregnancy was gestational diabetes, and it is likely that this was the common reason in our sample too (National Institute of Health and Welfare, 2008). In Finland, newborns of mothers with medical conditions, including diabetes or gestational diabetes are likely to have their blood sugar tested routinely after birth. Supplemental milk is given to them if the blood sugar level is low and does not increase with breast feeding (see South Ostrobothnia Hospital District (2013)). This practice should be studied further because of its potential impact on breast feeding success. A normal vaginal childbirth increased the likelihood of exclusive breast feeding and mothers who had caesarean or assisted vaginal childbirths breast fed more often partially, which confirms the results of previous studies (Erkkola et al., 2010). A good way to improve national exclusive breast feeding rates is to intensify hospital practices around breast feeding for mothers with health problems and more complicated childbirths. The more promptly and frequently after childbirth the infant removes milk from the breast, the sooner his/her latching begins to supply his/her own calorie needs while also stimulating prolactin, and leading to milk composition changes that increase the likelihood of successful exclusive breast feeding (Noel et al., 1974; Riordan and Auerbach, 1998; Hill et al., 1999; Matthiesen et al., 2001). Feeding from the breast should be made easy for all newborns regardless of the route of childbirth. Mother's high breast feeding confidence promoted exclusive breast feeding. The results are in line with previous results obtained with the same instrument: high breast feeding confidence increases exclusive breast feeding rates (Dennis et al., 2011). In Finland mothers are poorly able to assess the sufficiency of their infants' food intake (Tiili et al., 2011) and this is linked with poorer

7

coping with breast feeding. Uncertainty as to whether the amount of breast milk is sufficient may lead to mothers giving their infants supplemental milk, just to be sure that the infant is getting enough milk. In this study good coping with breast feeding was associated with exclusive breast feeding. Mothers with high breast feeding confidence believe in their ability to produce enough milk. Exclusive breast feeding was also predicted by mothers' positive attitudes towards breast feeding, which supports the findings of previous studies (Tarkka et al., 1999; Hannula, 2003). The finding that fathers' presence in the hospital 24 hours a day increased exclusive breast feeding was a new one. A previous study in Sweden found that longer presence of fathers after childbirth increased the duration of breast feeding as well as exclusive breast feeding (Ekström et al., 2003a). In the present study, full-time presence of fathers with their families increased exclusive breast feeding rates among mothers. Families received individually tailored counselling during their stay in family rooms. According to previous Finnish studies, individual counselling in family rooms increases exclusive breast feeding (Hannula et al., 2006), and mothers' breast feeding decisions are influenced by positive attitudes on the part of fathers (Pisacane et al., 2005). According to Kingston et al. (2007), emotional support in the form of praise and encouragement given by spouse and other close people increase mothers' breast feeding confidence. In this study, intervention group fathers also had access to information on breast feeding via the web-based service, and the fathers who stayed in hospital full-time were able to receive more counselling in the postnatal ward as well. Knowledge about the benefits of breast feeding may already have increased fathers' breast feeding support behaviour during the hospital stay. Finally, after taking into account other significant factors associated with exclusive breast feeding, belonging to the intervention group had a significant and independent impact on exclusive breast feeding. In this study, an intensified breast feeding support intervention was developed for families in the intervention group. The support comprised staff training, possibility to use a web-based service, assessment of breast feeding situations with the aid of LATCH as well as intensified counselling based on the assessment. Mothers' use of the support available to them varied, and it cannot be said which of the different support forms had a particularly high impact. None of the hospital-related factors were significant in the multivariate model. As a whole, the intensified breast feeding support intervention was linked to higher exclusive breast feeding rates in the intervention group compared to the control group in a statistically significant manner on discharge from hospital.

Conclusions Intensified breast feeding support was linked to higher exclusive breast feeding rates, and a Baby-Friendly approach aimed at empowering parents was shown to be useful. The prevalence of exclusive breast feeding was increased by mothers' positive attitudes towards breast feeding, high confidence in their own ability to breast feed and strong faith in their ability to cope with breast feeding. Intensified breast feeding counselling and support helps mothers to breast feed exclusively. Breast feeding support should be available in a variety of forms, allowing mothers to choose the type of support they need. As breast feeding counselling and support aimed at mothers is intensified, more mothers succeed with exclusive breast feeding. Mothers' health problems during pregnancy and caesarean or assisted vaginal childbirth increase the risk of partial breast feeding, which should be taken into account in treatment planning and while developing hospital

Please cite this article as: Hannula, L.S., et al., A study to promote breast feeding in the Helsinki Metropolitan area in Finland. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.005i

L.S. Hannula et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

8

practices. Mothers who have health problems during pregnancy should receive intensified breast feeding support starting from pregnancy. Full-time presence of the spouse with the mother and the infant in hospital increases exclusive breast feeding on discharge. This should be taken into account in the ward design. The presence of fathers in the ward should be encouraged and breast feeding support for mothers should be developed in a more family-oriented direction.

Funding and conflict of interest This study has received funding from the Finnish Ministry of Health and Welfare from Health Promotion Funding. There are no conflicts of interest. References Amir, L.H., Donath, S., 2007. A systematic review of maternal obesity and breastfeeding intention, initiation and duration. BMC Pregnancy Childbirth 7, 9. Bartington, S., Griffiths, L.J., Tate, A.R., Dezateux, C., 2006. The Millenium Cohort Study Child Health Group. Are breastfeeding rates higher among mothers delivering in Baby Friendly accredited maternity units in the UK? Int. J. Epidemiol. 35, 1178–1186. Britton, C., McCormick, F.M., Renfrew, M.J., Wade, A., King, S.E., 2007. Support for breastfeeding mother. Cochrane Database of Systematic Review, CD001141. Burns, N., Grove, S.K., 2009. The Practice of Nursing Research. The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence, 6th edn. Saunders/Elsevier, St. Louis, MO. Castrucci, B.C., Hoover, K.L., Lim, S., Maus, K.C., 2006. A comparison of breastfeeding rates in urban birth cohort among women delivering infants at hospital that employ and do not employ lactation consultants. J. Public Health Manag. Pract. 12, 578–585. de la Mora, A., Russell, D.W., Dungy, C.I., Losch, M., Dusdieker, L., 1999. The Iowa Infant Feeding Attitude Scale: analysis of reliability and validity. J. Appl. Soc. Psychol. 29, 2362–2380. Dennis, C.-L., 2003. The Breastfeeding Self-Efficacy Scale: psychometric assessment of the short form. J. Obstet. Gynecol. Neonatal Nurs. 32, 734–744. Dennis, C., Heaman, M., Mossman, M., 2011. Psychometric testing of the Breastfeeding Self-Efficacy Scale-Short Form among adolescents. J. Adolesc. Health 49, 265–271. Ekström, A., Widstrom, A., Nissen, E., 2003a. Breastfeeding support from partners and grandmothers: perceptions of Swedish women. Birth 30, 261–266. Ekström, A., Widstrom, A., Nissen, E., 2003b. Duration of breastfeeding in Swedish primiparous and multiparous women. J. Hum. Lact. 19, 172–178. Erkkola, M., Salmenhaara, M., Kronberg-Kippilä, C., et al., 2010. Determinants of breast-feeding in a Finnish birth cohort. Public Health Nutr. 13, 504–513. Fairbank, L., O'Meara, S., Renfrew, M.J., Woolridge, M., Sowden, A.J., Lister-Sharp, D., 2000. A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding. Health Technol. Assess. 25, 1–171. Finnish Ministry of Social Affairs and Health, 2004. Lastenneuvola lapsiperheiden Tukena. Opas Työntekijöille. (Child Health Clinics in Support of Families with Children. A Guide for Staff). Handbooks of the Ministry of Social Affairs and Health, vol. 14. Helsinki (in Finnish with English abstract). Grassley, J.S., Eschiti, V.S., 2007. Two generations learning together: facilitating grandmothers' support of breastfeeding. Int. J. Childbirth Educ. 22, 23–26. Hannula, L., 2003. Imetysnäkemykset ja imetyksen toteutuminen. Suomalaisten synnyttäjien seurantatutkimus. (Perceptions of Breastfeeding and the Outcomes of Breastfeeding – A Follow-up Study of Finnish Mothers). Doctoral Dissertation. Annales Universitatis Turkuensis. Series C 195. University Press, Helsinki. (in Finnish with English abstract). Hannula, L., Leino-Kilpi, H., Puukka, P., 2006. Imetyksestä selviytyminen ja lisäruoan käyttö synnytyssairaalassa – äitien näkökulma. (Mothers' selfreported success with breastfeeding and use of supplements in maternity hospitals). Hoitotiede 18, 175–185. (in Finnish with English abstract). Hannula, L., Kaunonen, M., Tarkka, M.-T., 2008. A systematic review of professional support interventions for breastfeeding. J. Clin. Nurs. 17, 1132–1143. Hannula, L., Salonen, A., Rekola, L., Tarkka, M.-T., 2010. Vauvaperheille kehitetyn verkkopalvelun pilottitutkimus – vanhempien näkökulma. (A pilot study of an internet website for families with an infant – parents' view). Tutkiva hoitotyö 2, 22–29. (in Finnish with English abstract). Hasunen, K., Ryynänen, S., 2006. Imeväisikäisten ruokinta Suomessa vuonna 2005. Sosiaali- ja terveysministeriön selvityksiä 2005:19. Sosiaali- ja terveysministeriö, Helsinki. (Infant Feeding in Finland 2005. Reports of the Ministry of Social Affairs and Health 2005:19, Helsinki) (in Finnish with English abstract). Hill, P., Chatterton, R., Aldag, J., 1999. Serum prolactin in breastfeeding: state of the science. Biol. Res. Nurs. 1, 65–75. Ip, S., Chung, M., Raman, G., et al., 2007. Breastfeeding and maternal and infant health outcomes in developed countries. Evid. Rep. Technol. Assess. 153, 1–186.

Jensen, D., Wallace, S., Kelsay, P., 1994. LATCH: a breastfeeding charting system and documentation tool. J. Obstet. Gynecol. Neonatal Nurs. 19, 209–215. Kaunonen, M., Hannula, L., Tarkka, M.-T., 2012. Peer support interventions for breastfeeding: a systematic review. J. Clin. Nurs. 21, 1132–1143. Kingston, D., Dennis, C.L., Sword, W., 2007. Exploring breast-feeding self-efficacy. J. Perinat. Neonatal Nurs. 21, 207–215. Koskimäki, M., Hannula, L., Rantanen, A., Kaunonen, M., Rekola, L., Tarkka, M.-T., 2012. Äitien imetyksestä selviytyminen ja imetysluottamus lapsivuodeosastolla. (Mothers' coping with breastfeeding and breastfeeding confidence on a postnatal ward). Hoitotiede 24, 3–13. (in Finnish with English abstract). Koskinen, K.S, Aho, A.-L., Hannula, L., Kaunonen, M. Maternity hospital practices and breastfeeding self-efficacy in Finnish primiparous and multiparous women during first week after birth. Midwifery, http://dx.doi.org/10.1016/j.midw.2013. 05.003, in press. Kyttälä, P., Ovaskainen, M., Kronberg-Kippilä, C., et al., 2008. Lapsen ruokavalio ennen kouluikää. Kansanterveyslaitos, julkaisuja B32/2008, Helsinki ja Tampere. (The Diet of Finnish Preschoolers. Publications of the National Public Health Institute, B32/2008. In Finnish with English abstract). Lavender, T., Baker, L., Smyth, R., Collins, S., Spofforth, A., Dey, P., 2005. Breastfeeding expectations versus reality: a cluster randomised controlled trial. BJOG: Int. J. Obstet. Gynaecol. 112, 1047–1053. Matthiesen, A.-S., Ransjo-Arvidson, A.-B., Nissen, E., Uvnas-Moberg, K., 2001. Postpartum maternal oxytocin release by newborns: effects of infant hand massage and sucking. Birth 28, 13–19. Merten, S., Dratva, J., Ackermann-Liebrich, U., 2005. Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics 116, e702–e708. Mezzacappa, E.S., 2004. Breastfeeding and maternal stress response and health. Nutr. Rev. 62, 261–268. Mossman, M., Heaman, M., Dennis, C., Morris, M., 2008. The influence of adolescent mothers' breastfeeding confidence and attitudes on breastfeeding initiation and duration. J. Hum. Lact. 24, 268–277. National Expert Group for Breastfeeding Promotion, 2009. Breastfeeding promotion in Finland. Action programme 2009–2012. National Institute for Health and Welfare, reports 32/2009, Helsinki. (Kansallinen imetyksen edistämisen asiantuntijaryhmä. 2009. Imetyksen edistäminen Suomessa. Toimintaohjelma 2009– 2012. Terveyden ja hyvinvoinnin laitos THL. Raportti 32/2009, Helsinki 2009. In Finnish with English abstract). National Institute of Health and Welfare, 2008. Births and newborns 2008. Official statistics of Finland. National Institute of Health and Welfare, Helsinki. 〈http:// www.stakes.fi/tilastot/tilastotiedotteet/2009/Tr22_09.pdf〉. Statistical report (last accessed February 2010). Noel, G., Suh, Han K., Franz, A., 1974. Prolactin release during nursing and breast stimulation in postpartum and nonpostpartum subjects. J. Clin. Endocrinol. Metab. 38, 413–423. Oddy, W., Jianghong, L., Landsborough, L., Kendall, G., Henderson, S., Dowie, J., 2006. The association of maternal overweight and obesity with breastfeeding duration. J. Pediatr. 149, 185–191. Oommen, H., Rantanen, A., Kaunonen, M., Tarkka, M.-T., Salonen, A.H., 2011. Social support provided to Finnish mothers and fathers by nursing professionals in the postnatal ward. Midwifery 27, 754–761. Pallasmaa, N., Ekblad, U., Aitokallio-Tallberg, A., et al., 2010. Caesarean delivery in Finland: maternal complications and obstetric risk factors. Acta Obstet. Gynecol. Scand. 89, 896–902. Parry, J.E., Ip, D.K., Chau, P.Y., Wu, K.M., Tarrant, M., 2013. Predictors and consequences of in-hospital formula supplementation for healthy breastfeeding newborns. J. Hum. Lact 29, 527–536. Pisacane, A., Continisio, G.I., Aldinucci, M., D'Amora, S., Continisio, P., 2005. A controlled trial of the father's role in breastfeeding promotion. Pediatrics 116, e494–e498. Riordan, J., Auerbach, K., 1999. Breastfeeding and Human Lactation, second edn. Jones & Bartlett, Boston. Salonen, A.H., Kaunonen, M., Åstedt-Kurki, P., Järvenpää, A.-L., Tarkka, M.-T., 2008. Development of an internet-based intervention for parents of infants. J. Adv. Nurs. 64, 60–72. Salonen, A.H., Kaunonen, M., Åstedt-Kurki, P., Järvenpää, A.-L., Isoaho, H., Tarkka, M.-T., 2011. Effectiveness of an internet-based intervention enhancing Finnish parents' parenting satisfaction and parenting self-efficacy during the postpartum period. Midwifery 27, 832–841. Sikorski, J., Renfrew, M.J., Pindoria, S., Wade, A., 2003. Support for breastfeeding mothers: a systematic review. Paediatr. Perinat. Epidemiol. 17, 407–417. Sittlington, J., Stewart-Knox, B., Wright, M., Bradbury, I., Scott, J., 2007. Infantfeeding attitudes of expectant mothers in Northern Ireland. Health Educ. Res. 22, 561–570. South Ostrobothnia Hospital District, 2013. In hospital blood sugar level follow-up (Etelä-Pohjanmaan sairaanhoitopiiri. Sairaalassa vauvan verensokeri seuranta). 〈http://www.epshp.org/kotisivut/synn/Virtuaalisynnytys/h01/vauvan_verenso keri_seuranta.asp〉 (last accessed June 2013). Swanson, V., Power, K.G., 2005. Initiation and continuation of breastfeeding: theory of planned behaviour. J. Adv. Nurs. 50, 272–282. The Finnish Medical Association, 2009. The Declaration of Helsinki. 〈http://www. laakariliitto.fi/etiikka/helsinginjulistus.html〉 (last accessed 12 June 2011). Tarkka, M.-T., 1996. Äitiys ja sosiaalinen tuki. Ensisynnyttäjän selviytyminen äitiyden varhaisvaiheessa. (Motherhood and Social support. Coping of First-Time Mothers in Early Motherhood). Department of Nursing Science,

Please cite this article as: Hannula, L.S., et al., A study to promote breast feeding in the Helsinki Metropolitan area in Finland. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.005i

L.S. Hannula et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎ University of Tampere. Doctoral dissertation. Acta Universitatis Tamperensis A:518 (in Finnish with English abstract). Tarkka, M.-T., Paunonen, M., Laippala, P., 1999. Factors related to successful breastfeeding by first-time mothers when the child is 3 months old. J. Adv. Nurs. 29, 113–118. Tiili, N., Kaunonen, M., Hannula, L., Halme, N., Rekola, L., Tarkka, M.-T., 2011. Imetyksestä selvitytyminen ja imetysluottamus lapsivuodeosastolla. (Coping with breastfeeding and marital satisfaction after childbirth). Tutkiva hoitotyö 2, 4–11. (in Finnish with English abstract). Uusitalo, L., Nyberg, H., Pelkonen, M., Sarlio-Lähteenkorva, S., Hakulinen-Viitanen, T., Virtanen, S., 2012. Imeväisikäisten ruokinta Suomessa 2010. Terveyden ja

9

hyvinvoinnin laitos raportteja 8/2012. (Infant feeding in Finland 2010. National Institute for Health and Welfare, reports 8/2012), Helsinki. World Health Organization and UNICEF, 2003. Global Strategy for Infant and Young Child Feeding. Geneva, Switzerland. World Health Organization, 2004. Promoting Proper Feeding for Infants and Young Children. Geneva. 〈http://www.who.int/nutrition/topics/infantfeeding/en/〉. Wolfberg, A., Michels, K., Shields, W., O'Campo, P., Bronner, Y., Bienstock, J., 2004. Dads as breastfeeding advocates: results from a randomized controlled trial of an educational intervention. Am. J. Obstet. Gynecol. 191, 708–712.

Please cite this article as: Hannula, L.S., et al., A study to promote breast feeding in the Helsinki Metropolitan area in Finland. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.005i