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Support for breastfeeding mothers

RHL Commentary by Martis R

1. EVIDENCE SUMMARY

This Cochrane review (1) was updated from an earlier version that had been withdrawn. A total of 34 trials – including 14 new trials – involving 29 385 breastfeeding mother–baby pairs were included in this update.

The review sought to analyse the impact of extra breastfeeding support with a view to facilitating continued breastfeeding. The main outcome measure was the effect of extra breastfeeding support on the duration of breastfeeding at specific points in time: before 4–6 weeks and at two, three, four, six, nine and 12 months.

Randomized and quasi-randomized controlled trials comparing extra support for breastfeeding mothers with usual maternity care were assessed for quality and inclusion. The 34 assessed trials were conducted in 14 countries – seven low- and middle-income (11 trials) and seven high-income (23 trials).

The authors concluded that all forms of extra support analysed together increased the duration of any breastfeeding (including partial and exclusive breastfeeding) and reduced the risk of stopping any breastfeeding before six months [relative risk (RR) 0.91; 95% confidence interval (CI): 0.86–0.96]. Furthermore, subgroup analysis showed that additional professional support was effective in prolonging any breastfeeding, but its effect on exclusive breastfeeding was not definite. In contrast, lay support was effective in prolonging exclusive breastfeeding, while its effect on the duration of any breastfeeding was uncertain.

The authors also concluded that lay and professional support together extended the duration of any breastfeeding significantly as follows:

• before 4–6 weeks (one trial, 900 mother–baby pairs): RR 0.65; 95% CI: 0.51–0.82;
• before two months (three trials, 1088 mother–baby pairs): RR 0.74; 95% CI: 0.66 to 0.83.

The duration of exclusive breastfeeding was significantly prolonged with the use of WHO/UNICEF training course (six trials) (2) for health-care professionals (RR 0.69; 95% CI: 0.52–0.91). Maternal satisfaction was reported inconsistently in all included trials.

The following interventions were made in support of breastfeeding in the included trials:

• pre- and antenatal visits by a lactation consultant, National Childbirth Trust-trained breastfeeding counsellor, or La Leche League-trained peer counsellor;
• postpartum visits at home and in hospital by social assistants, nutritionists, community health or nutrition workers trained in breastfeeding counselling using the WHO/UNICEF training course or by woman peer-counsellors with personal breastfeeding experience trained using WHO/UNICEF training course or by the La Leche League;
• postpartum home and hospital visits by a midwife, community nurse, public health nurse, certified nurse–midwife, physician or paediatrician; and
• telephone support after hospital discharge by a health-care professional or lay/volunteer supporter.

In the previous edition of this review, support was categorized as either ‘professional’ or ‘lay’. This review added a new category of ‘lay and professional’, as six studies used a combination of both professional and lay people (3–8). Overall, the combined category showed a significant reduction in the cessation of any breastfeeding, with two studies (4, 7) demonstrating a significant reduction in the cessation of exclusive breastfeeding. However, the numbers analysed were relatively small (1156 participants) (4). Face-to-face support showed statistically significant benefit, while telephone support demonstrated no significant effect.

2. RELEVANCE TO UNDER-RESOURCED SETTINGS

2.1. Magnitude of the problem

Breastfeeding is widely acknowledged to be the best way to feed a baby. Breastfeeding provides a range of health benefits for the mother and the baby, protecting babies against common childhood diseases, including repeated gastrointestinal infections and pneumonia, and hence against some of the major causes of childhood mortality. To optimize the benefits of breastfeeding, the World Health Organization has recommended that babies should be breastfed exclusively for six months, with continued breastfeeding up to two years of age or beyond, regardless of settings (9).

Unfortunately, rates of exclusive breastfeeding or any breastfeeding are not optimal. Global monitoring indicates that only 39% of all babies worldwide are exclusively breastfed, even when the assessment is made in children less than four months of age (10). Breastfeeding is a life and death issue in under-resourced countries. A recent meta-analysis reported marked reductions in mortality (especially due to infectious disease) with breastfeeding even into the second year of life (11).

The low incidence of exclusive breastfeeding is partially due to the lack of knowledge about breastfeeding among health-care professionals and traditional birth attendants, as well as the lack of availability of peer or lay breastfeeding support.

2.2. Applicability of the results

Although the majority of the 34 trials were conducted in seven high-income countries (23 trials), 11 trials were conducted in seven low- and middle-income countries. There is no biological or social reason to expect that support for breastfeeding mothers will not be equally effective in prolonging exclusive breastfeeding rates in different populations.

2.3. Implementation of the intervention

Consideration should be given to providing additional breastfeeding support as part of routine health service provision. As noted in the 'Evidence summary' above, different studies used a variety of support strategies for breastfeeding mothers.

Implementation of this intervention needs to start first with an assessment of strategies that would work best within the local context. However, the review showed that face-to face interaction was of significant benefit and lay and professional support together extended the duration of any breastfeeding significantly. The duration of exclusive breastfeeding was significantly prolonged with the use of WHO/UNICEF training course for health-care professionals.

Some organizational changes might be needed to incorporate lay support into the existing health service infrastructure. Implementation of a clinical practice guideline for provision of support to breastfeeding mothers will help in making the required organizational changes as well as changes in attitudes of individuals to the provision of such support.

The WHO/UNICEF Baby Friendly Hospital Initiative (BFHI) or other similar training courses should be incorporated into the maternal health-care services offered. While it may seem daunting to set up training courses, the WHO/UNICEF 10–20 hour training programme is relatively easy to set up and follow. Although, the costs of setting up and sustaining the course would need to be determined, the BFHI initiative is a good place to start for financial and training assistance (12).

Successful implementation of this intervention will involve: education of health-care providers regarding the effectiveness and implementation of support for breastfeeding mothers and the benefits of exclusive breastfeeding; introduction of a clinical practice guideline; identification of appropriate lay support people and health-care professionals for training and providing information to pregnant and breastfeeding women and their family and community.

3. RESEARCH

Further research on this issue should include:

• cost-effectiveness analysis of the different support models and comparisons;
• studies of the effect of both lay and professional breastfeeding support in settings with low rates of breastfeeding initiation and for women who wish to breastfeed longer than three months:
• further trials of the combination of professional and lay support for breastfeeding duration, both for any and exclusive breastfeeding;
• studies on ways of training lay and professional providers of support for breastfeeding mothers to increase their knowledge base;
• studies of cultural, biological, institutional and socioeconomic barrier and enabling factors for the implementation of a clinical practice guideline for support of breastfeeding mothers in different geographical and cultural settings in under-resourced countries; and
• studies of maternal satisfaction with support for breastfeeding.

Acknowledgement: The author appreciated the assistance of Philippa Middleton and Prof. Caroline Crowther with the editing of this commentary.

References

• Britton C, McCormick FM, Renfrew MJ, Wade A, King SE. Support for breastfeeding mothers. Cochrane Database of Systematic Reviews 2007. Issue 1. Art. No.;CD001141:10.1002/14651858.CD001141.pub3.
• Integrated management of childhood illness: management of the sick young infant age 1 week up to 2 months. Geneva: World Health Organization; 1997. (Document No.: WHO/CHD/97.3F; www.who.int/entity/child_adolescent_health/documents/imci_in_service_mod05.doc)
• Barros FC, Halpern R, Victora CG, Teixera AM, Beria J. A randomized intervention study to increase breastfeeding prevalence in southern Brazil. Revista de Saude Publica 1994;28(4):277-83.
• Bhandari N, Bahl R, Mazumdar S, Martines J, Black RE, Bhan MK, et al. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomised controlled trial. Lancet 2003;361:1418-23.
• Brent NB, Redd B, Dworetz A, D'Amico FD, Greenberg J. Breastfeeding in a low-income population. Archives of Pediatric and Adolescent Medicine 1995;149(7):798-803.
• Haider R, Islam A, Hamadani J, Amin NJ, Kabir I, Malek MA, et al. Breast-feeding counseling in a diarrhoeal disease hospital. Revista Panamericana De Salud Publica/Pan American Journal of Public Health 1997;1:355-61.
• Pugh L, Milligan R, Frick K, Spatz D, Bronner Y. Breastfeeding duration, costs, and benefits of a support program for low-income breastfeeding women. Birth 2002;29(2):95-100.
• Winterburn S, Moyez J, Thompson J. Maternal grandmothers and support for breastfeeding. Journal of Community Nursing 2003;17 (12):4-9.
• Global strategy on infant and young child feeding. Geneva: World Health Organization; 2003.
• UNICEF Global Database on Breastfeeding Indicators as of March 2006. http://www.childinfo.org/areas/breastfeeding/countrydata.php
• WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet 2001;355:451-5.
• The Baby-Friendly Hospital Initiative. http://www.unicef.org/programme/breastfeeding/baby.htm

This document should be cited as: Martis R. Support for breastfeeding mothers: RHL commentary (last revised:26 September 2007) The WHO Reproductive Health Library; Geneva: World Health Organization.