What is the issue?
International rates of breastfeeding initiation are extremely variable both between and within countries. Low- and middle-income countries generally have high rates of women starting breastfeeding, and the challenge is for breastfeeding to begin within one hour of birth. High-income countries have a much greater variation in the number of women who start breastfeeding, with more highly educated and more well-off women likely to start.
The World Health Organization recommends that breastfeeding should start within the first hour after giving birth, that all infants should be exclusively breastfed from birth to six months of age, and that breastfeeding should continue until 2 years or beyond. We know that breastfeeding is good for the health of women and babies. Babies who are not fully breastfed for the first three to four months of life are more likely to suffer from infections of the stomach and intestines, air passages and lungs, or develop ear infections. Babies who are not breastfed are more likely to be overweight or have diabetes later in life, and mothers who do not breastfeed have increased risks of breast and ovarian cancer. Other practical benefits of breastfeeding include saving money on buying breast milk substitutes and, for society, on treating illness. Yet many women feed their babies with infant formula.
Why is this important?
We want to have a better understanding of what works to promote breastfeeding, for women, their families, the health system and society. Women face many barriers to breastfeeding, including lack of public spaces where women can breastfeed without feeling embarrassment; lack of flexible working days for breastfeeding women at work; widespread advertising of breast milk substitutes; and public policy that ignores the needs of breastfeeding women. New ways to promote breastfeeding are needed.
What evidence did we find?
We searched for evidence on 29 February 2016. This updated review now includes 28 randomised controlled studies involving 107,362 women. Twenty studies involving 27,865 women looked at interventions to increase the number of women who started breastfeeding, in three high-income countries (Australia, 1 study; UK, 4 studies; and USA, 14 studies) and one lower middle-income country (Nicaragua, 1 study). Three studies investigated the effect of an intervention to increase the number of women who started breastfeeding early, within one hour after birth. These involved 76,373 women from Malawi, Nigeria and Ghana. The study from Malawi was large, with 55,931 participants.
Health education delivered by doctors and nurses and counselling and peer support by trained volunteers improved the number of women who began breastfeeding their babies. Five studies involving 564 women reported that women who received breastfeeding education and support from doctors or nurses were more likely to start breastfeeding compared to women who received standard care. Four of these studies were conducted in low-income or amongst minority ethnic women in the USA, where baseline breastfeeding rates are typically low. Eight studies involving 5712 women showed improved rates of starting breastfeeding with trained volunteer-delivered interventions and support groups compared to the women who received standard care.
Breastfeeding education provided by trained volunteers could also improve the rates of early initiation of breastfeeding, within one hour of giving birth, in low-income countries.
We assessed all the evidence in this review to be low-quality because of limitations in study design and variations in the interventions, to whom, when, where, and how an intervention was delivered. Standard care also differed and could include some breastfeeding support, for example, in the UK.
We found too little evidence to say whether strategies with multimedia, early mother-infant contact, or community-based breastfeeding groups were able to improve breastfeeding initiation.
What does this mean?
Health professionals with training in breastfeeding including midwives, nurses, and doctors, and trained volunteers can deliver education sessions and provide counselling and peer support to increase the number of women who start breastfeeding their babies. High-quality research is needed to understand which interventions are likely to be effective in different population groups. More studies are needed in low- and middle-income countries to find out which strategies will encourage women to start breastfeeding just after giving birth.
This review found low-quality evidence that healthcare professional-led breastfeeding education and non-healthcare professional-led counselling and peer support interventions can result in some improvements in the number of women beginning to breastfeed. The majority of the trials were conducted in the USA, among women on low incomes and who varied in ethnicity and feeding intention, thus limiting the generalisability of these results to other settings.
Future studies would ideally be conducted in a range of low- and high-income settings, with data on breastfeeding rates over various timeframes, and explore the effectiveness of interventions that are initiated prior to conception or during pregnancy. These might include well-described interventions, including health education, early and continuing mother-infant contact, and initiatives to help mothers overcome societal barriers to breastfeeding, all with clearly defined outcome measures.
Despite the widely documented risks of not breastfeeding, initiation rates remain relatively low in many high-income countries, particularly among women in lower-income groups. In low- and middle-income countries, many women do not follow World Health Organization (WHO) recommendations to initiate breastfeeding within the first hour after birth. This is an update of a Cochrane Review, first published in 2005.
To identify and describe health promotion activities intended to increase the initiation rate of breastfeeding.
To evaluate the effectiveness of different types of breastfeeding promotion activities, in terms of changing the number of women who initiate breastfeeding.
To evaluate the effectiveness of different types of breastfeeding promotion activities, in terms of changing the number of women who initiate breastfeeding early (within one hour after birth).
We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) and scanned reference lists of all articles obtained.
Randomised controlled trials (RCTs), with or without blinding, of any breastfeeding promotion intervention in any population group, except women and infants with a specific health problem.
Two review authors independently assessed trial reports for inclusion, extracted data and assessed trial quality. Discrepancies were resolved through discussion and a third review author was involved when necessary. We contacted investigators to obtain missing information.
Twenty-eight trials involving 107,362 women in seven countries are included in this updated review. Five studies involving 3,124 women did not contribute outcome data and we excluded them from the analyses. The methodological quality of the included trials was mixed, with significant numbers of studies at high or unclear risk of bias due to: inadequate allocation concealment (N = 20); lack of blinding of outcome assessment (N = 20); incomplete outcome data (N = 19); selective reporting (N = 22) and bias from other potential sources (N = 17).
Healthcare professional-led breastfeeding education and support versus standard care
The studies pooled here compare professional health workers delivering breastfeeding education and support during the prenatal and postpartum periods with standard care. Interventions included promotion campaigns and counselling, and all took place in a formal setting. There was evidence from five trials involving 564 women for improved rates of breastfeeding initiation among women who received healthcare professional-led breastfeeding education and support (average risk ratio (RR) 1.43, 95% confidence interval (CI) 1.07 to 1.92; Tau² = 0.07, I² = 62%, low-quality evidence) compared to those women who received standard care. We downgraded evidence due to design limitations and heterogeneity. The outcome of early initiation of breastfeeding was not reported in the studies under this comparison.
Non-healthcare professional-led breastfeeding education and support versus standard care
There was evidence from eight trials of 5712 women for improved rates of breastfeeding initiation among women who received interventions from non-healthcare professional counsellors and support groups (average RR 1.22, 95% CI 1.06 to 1.40; Tau² = 0.02, I² = 86%, low-quality evidence) compared to women who received standard care. In three trials of 76,373 women, there was no clear difference between groups in terms of the number of women practicing early initiation of breastfeeding (average RR 1.70, 95% CI 0.98 to 2.95; Tau² = 0.18, I² = 78%, very low-quality evidence). We downgraded the evidence for a combination of design limitations, heterogeneity and imprecision (wide confidence intervals crossing the line of no effect).
Other comparisons in this review also looked at the rates of initiation of breastfeeding and there were no clear differences between groups for the following comparisons of combined healthcare professional-led education with peer support or community educator versus standard care (2 studies, 1371 women) or attention control (1 study, 237 women), breastfeeding education using multimedia (a self-help manual or a video) versus routine care (2 studies, 497 women); early mother-infant contact versus standard care (2 studies, 309 women); and community-based breastfeeding groups versus no breastfeeding groups (1 study, 18,603 women). None of these comparisons reported data on early initiation of breastfeeding.