Interventions for encouraging women to start breastfeeding

The World Health Organization recommends that all infants should be fed exclusively on breast milk from birth to six months of age. Breastfeeding is supported by extensive evidence for short-term and long-term health benefits, for both mother and baby. Babies who are not fully breastfed for the first three to four months are more likely to suffer health problems such as gastroenteritis, respiratory and ear infections, urinary tract infections, allergies and diabetes mellitus. Practical benefits include savings on buying artificial formulas, particularly where they are not subsidised. Yet many women choose to bottle feed their babies. Reasons include personal and social biases against breastfeeding such as attitudes of family and close friends, attitudes to breastfeeding in public and employment practices.

This review showed that health education and peer support interventions can result in some improvements in the number of women beginning to breastfeed. Studies were of low-income women in the USA, where baseline breastfeeding rates are typically low.

Eleven randomised controlled trials were included. Eight trials involving 1553 women contributed to the data. Five studies with 582 women on low incomes in the USA showed breastfeeding education clearly increased breastfeeding rates compared to providing routine care. One trial with 165 women showed peer support for women considering breastfeeding also increased breastfeeding rates. Needs-based, one-to-one, informal education or support sessions, delivered either before or before and after the birth by a trained breastfeeding professional or peer counsellor, was the most effective intervention among women of different ethnicity and feeding intention in three studies. The one evaluation of hospital breastfeeding promotion packs compared to formula-company produced materials about infant feeding showed this intervention to be ineffective. Approximately 40% of women in both groups reported receipt of formula company promotion items from sources other than their obstetric provider.

Authors' conclusions: 

This review showed that health education and peer support interventions can result in some improvements in the number of women beginning to breastfeed. Findings from these studies suggest that larger increases are likely to result from needs-based, informal repeat education sessions than more generic, formal antenatal sessions. These findings are based only on studies conducted in the USA, among women on low incomes with varied ethnicity and feeding intention, and this raises some questions regarding generalisability to other settings.

Read the full abstract...

Despite the widely documented health advantages of breastfeeding over formula feeding, initiation rates remain relatively low in many high-income countries, particularly among women in lower income groups.


To evaluate the effectiveness of interventions which aim to encourage women to breastfeed in terms of changes in the number of women who start to breastfeed.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2007), handsearched the Journal of Human Lactation, Health Promotion International and Health Education Quarterly from inception to 15 August 2007, and scanned reference lists of all articles obtained.

Selection criteria: 

Randomised controlled trials, with or without blinding, of any breastfeeding promotion intervention in any population group except women and infants with a specific health problem.

Data collection and analysis: 

One review author independently extracted data and assessed trial quality, checked by a second author. We contacted investigators to obtain missing information.

Main results: 

Eleven trials were included. Statistical analyses were conducted on data from eight trials (1553 women). Five studies (582 women) on low incomes in the USA with typically low breastfeeding rates showed breastfeeding education had a significant effect on increasing initiation rates compared to standard care (risk ratio (RR) 1.57, 95% confidence interval (CI) 1.15 to 2.15, P = 0.005). Subgroup analyses showed that one-to-one, needs-based, informal repeat education sessions and generic, formal antenatal education sessions are effective in terms of an increase in breastfeeding rates among women on low incomes regardless of ethnicity and feeding intention. Needs-based, informal peer support in the antenatal and postnatal periods was also shown to be effective in one study conducted among Latina women who were considering breastfeeding in the USA (RR 4.02, 95% CI 2.63 to 6.14, P < 0.00001).