Review questions
∙ What are the effects of breastfeeding support in healthy mothers with healthy term babies?
∙ What types of breastfeeding support are offered and in which settings?
∙ What are the effects of different modes of offering support?
∙ Are antenatal and postnatal interventions together more effective than postnatal alone?
∙ Are there differences in effectiveness of support interventions between different care providers?
Relevance to primary care and nursing
Nurses and midwives play a vital role in educating and supporting women to initiate and continue breastfeeding (National Institute for Health and Clinical Excellence, Reference McFadden, Gavine, Renfrew, Wade, Buchanan, Taylor, Veitch, Rennie, Crowther, Neiman and MacGillivray2006; Swerts et al., 2016).
Characteristics of the evidence
This Cochrane review analysed data from 73 studies of which 58 were individually randomised-controlled trials and 15 cluster-randomised involving 74 656 mother–infant pairs (McFadden et al., Reference Swerts, Westhof, Bogaerts and Lemiengre2017).
Included studies targeted healthy pregnant women who were intending to breastfeed or currently breastfeeding healthy term babies. Support was offered postnatally, with or without an antenatal component and support interventions were additional to standard postnatal care in any setting. Interventions varied between and within countries. Studies of the antenatal period only, education only interventions, and women and babies who required additional medical or surgical care (eg, for diabetes, HIV/AIDS, overweight or obesity, surgical/Caesarean section) were excluded. Studies were from 29 countries (62.1% high income; 30.1% upper-middle income; 3.4% low-middle income; 4.4% low income).
Summary of key evidence
The overall risk of bias of included trials was mixed. The overall quality of evidence was judged to be of moderate quality (using GRADE: The Grading of Recommendations Assessment, Development and Evaluation) due to high heterogeneity. Significant effect sizes for main outcomes are reported as relative risk (RR) with 95% confidence intervals (CI). Data were pooled in a meta-analysis where appropriate. No secondary outcomes were specified.
All forms of extra support versus usual care
Support interventions were extra organised support in addition to standard care, and included information, such as education, reassurance, addressing mothers’ concerns and training to improve supportive care. They were delivered by trained or untrained medical, nursing and allied professionals or community health workers and volunteers. The format, mode and intensity varied and included individuals (57/73 studies) or groups, and face-to-face and/or telephone support (30/73 studies) or telephone only (47/73 studies). They included proactive direct or indirect support and staff training with individual one-to-one contact in 57/73 studies. Intensity of interventions varied and involved one or more contacts, regular and ongoing for several months.
Interventions were offered by professionals (49 studies), lay and professional (nine studies) and lay only (15 studies), with most being peer supporters. Additional training was provided in 50/73 studies. Two-thirds of studies included postnatal women at or after initiation of breastfeeding.
Primary outcomes
Stopping breastfeeding up to six months or before four to six weeks postpartum.
Breastfeeding support has a beneficial effect with fewer women receiving support stopping breastfeeding by six months (RR 0.91, 95% CI 0.88–0.95; 51 studies, n=21 418) and before four to six weeks (RR 0.87, 95% CI 0.80–0.95; 33 studies, n=11 264).
There was a decrease in cessation of exclusive breastfeeding at six months (RR 0.88, 95% CI 0.85–0.92; 46 studies, n=18 591) and at four to six weeks (RR 0.79, 95% CI 0.71–0.89; 32 studies, n=10 960).
Subgroup analysis
Both lay and professionals providing extra support had a positive impact on breastfeeding outcomes.
Face-to-face interventions, high background initiation rates of breastfeeding, lay support, and four to eight contacts may be important for improving outcomes for women practising exclusive breastfeeding. These results need to be interpreted with caution due to high heterogeneity within these groups. There were no overall subgroup differences for any breastfeeding outcomes.
Implications for practice
Key characteristics of effective support include support delivered by trained health professionals and/or lay supporters or both; ongoing scheduled visits tailored to individual needs and settings with high initiation rates; and face-to-face support in exclusive breastfeeding.
Implications for research
Research should include theoretical basis of support programmes; test the effectiveness of training programmes and their impact on any breastfeeding, analyse timing and intensity of interventions, and impact on different population subgroups; establish the cost-effectiveness of support interventions; and examine strategies for supporting women breastfeeding for longer periods.
Conflicts of Interest
None.
Financial Support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Acknowledgements
The author is a member of the Cochrane Nursing Care Field (CNCF)
