Interventions to support women who are overweight or obese to start and continue breastfeeding

What is the issue?

Breastfeeding is important for the health of mothers and their infants. Current advice is for exclusive breastfeeding to continue until babies are six months of age. Infants fed with formula milk are at greater risk of infections, asthma and sudden infant death syndrome. Mothers who do not breastfeed are at greater risk of female cancers and type 2 diabetes. Women who are overweight or obese are less likely to start breastfeeding than other women and tend to breastfeed for a shorter length of time. Suggested reasons include physical factors such as larger breasts, which make traditional breastfeeding positions more difficult, and a delay in their milk coming in (normally around 72 hours). This can decrease mothers’ confidence in their milk supply and ability to breastfeed. Cultural factors may also influence women's decision making about starting and continuing breastfeeding, for example, how the woman’s family and friends fed their babies, how confident the mother is in reaching her breastfeeding goals and how the woman views her own body.

Why is this important?

Women who are overweight or obese can experience challenges with breastfeeding that could be overcome with additional encouragement and support. We wanted to find out what types of support are provided and what works best, both before and after birth. Interventions included education, social support and physical methods such as milk expression.

What evidence did we find?

We searched for evidence (January 2019) and identified seven randomised controlled trials (RCTs), involving 831 women (range 36 to 226 women), conducted in high-income countries (USA, Denmark, Australia) between 2006 and 2015. Three trials only included women who were obese prior to pregnancy and four trials included women who were overweight and women who were obese.

The trials compared different types of breastfeeding support to usual care. There were a limited number of trials for each type of support, and differences in how much support the women received in the support and usual care groups.

One trial (39 women) used a physical support intervention through the loan of an electric or manual breast pump versus usual care (no pump). Very low-certainty evidence means it is unclear whether physical support improves exclusive breastfeeding at four to six weeks; or any breastfeeding at four to six weeks. The trial did not report other important outcomes of interest: non-initiation of breastfeeding, and exclusive or any breastfeeding at six months after birth.

Six trials (792 women) used multiple methods of support (including education and social support through telephone or face-to-face contact) versus usual care. One trial (174 women) did not report on any of our main outcomes of interest. One of the trials also provided physical support through providing a breast pump and a baby sling, and another provided a small gift to the women at each trial visit. Support in these trials was provided by a professional (four trials) or a peer (two trials), either in a group (one trial) or individually (five trials).

For women receiving an intervention that incorporated multiple methods of support (including social, educational or physical support) versus usual care, we are unclear about the effects of the intervention because we identified very low-certainty evidence for all of the important outcomes in this review: rate of non-initiation of breastfeeding; exclusive breastfeeding at four to six weeks; any breastfeeding at four to six weeks; rate of exclusive breastfeeding at six months after birth; and any breastfeeding at six months after birth.

What does this mean?

The effectiveness of interventions for supporting women who are overweight or obese to start and continue breastfeeding remains unclear. The methods used by the available trials varied in quality, with small numbers of participants. No trials compared one type of support to another.

We need high-quality trials to evaluate whether social, educational, physical support, or any combination of these interventions can give mothers who are overweight or obese the best chance of starting and continuing to breastfeed. The interventions need to be designed specifically for this group of women and delivered by people who understand the challenges these women face when establishing and maintaining breastfeeding.

Authors' conclusions: 

There is insufficient evidence to assess the effectiveness of physical interventions, or multiple methods of support (social, educational or physical) for supporting the initiation or continuation of breastfeeding in women who are overweight or obese. We found no RCTs comparing one type of support to another type of support. All of our GRADE assessments resulted in very low-certainty evidence, with downgrading decisions based on limitations in trial design (e.g. risk of attrition bias), imprecision, inconsistency. The available trials were mostly of variable quality with small numbers of participants, confounded by poor adherence within both the intervention and control groups.

Well designed, adequately powered research is needed to answer questions about the social, educational, physical support, or any combination of these interventions that could potentially help mothers who are overweight or obese to achieve optimal breastfeeding outcomes. We need trials that examine interventions designed specifically for women who are overweight or obese, delivered by people with training about how to overcome some of the challenges these women face when establishing and maintaining breastfeeding. Particular attention could be given to the assessment of antenatal interventions aimed at improving breastfeeding initiation in women with a raised BMI, and not just focusing on recruiting women who have an intention to breastfeed. Given that the majority of current trials were undertaken in the USA, further trials in a diverse range of countries and settings are required. Future trials need to give consideration to the theoretical basis of the intervention using established frameworks to enable replicability by others and to better determine the components of effective interventions.

Read the full abstract...
Background: 

Exclusive breastfeeding is recommended for all infants until six months of age due to the many health benefits for both the mother and infant.

Evidence suggests that mothers who are overweight (body mass index (BMI) 25.0 to 29.9 kg/m²) or obese (BMI ≥ 30.0 kg/m²) are less likely to initiate breastfeeding and to breastfeed for a shorter duration. Considering the rising prevalence of overweight and obesity globally and the known benefits of breastfeeding particularly in reducing the long-term risks of obesity and diabetes for infants, establishing effective ways to support and promote breastfeeding in women who are overweight or obese is paramount in achieving the goal of healthier communities.

Objectives: 

To assess the effectiveness of interventions to support the initiation or continuation of breastfeeding in women who are overweight or obese.

Search strategy: 

On 23 January 2019 we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) and reference lists of retrieved trials.

Selection criteria: 

Randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to support the initiation and continuation of breastfeeding in women who are overweight or obese. Interventions included social support, education, physical support, or any combination of these. Interventions were compared either with each other or against a control group.

Data collection and analysis: 

We assessed all potential trials identified from the search strategy. Two review authors extracted data from each included trial and assessed risk of bias. We resolved discrepancies through discussion with the third review author. We assessed the quality of the evidence using the GRADE approach.

Main results: 

We found no trials comparing one type of support versus another. We included seven RCTs (including one cluster-RCT) involving 831 women. The number of women in each trial ranged from 36 to 226. The trials were conducted in high-income countries: USA (5 trials); Denmark (1 trial) and Australia (1 trial), between 2006 and 2015. Three trials only included women who were obese prior to pregnancy and four trials included both women who were overweight and women who were obese. We judged risk of bias in the included trials to be mixed; only one trial was judged to be low risk of bias for random sequence generation, allocation concealment and attrition bias.

Physical breastfeeding support (manual or electric breast pump) versus usual care (no breast pump)

Very low-certainty evidence from one small trial (39 women) looking at a physical support intervention (manual or electric breast pump) versus usual care (no pump) means it is unclear whether physical support improves exclusive breastfeeding at four to six weeks (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.20 to 1.51) or any breastfeeding at four to six weeks (RR 0.65, 95% CI 0.41 to 1.03). The trial did not report other important outcomes of interest in this review: non-initiation of breastfeeding, exclusive or any breastfeeding at six months postpartum.

Multiple methods of breastfeeding support versus usual care

Six trials (involving 792 women) used multiple methods of support including education and social support through telephone or face-to-face contact. One of these trials also provided physical support through providing a breast pump and a baby sling and one trial provided a small gift to the women at each trial visit. Support in the trials was provided by a professional (four trials) or a peer (two trials). One trial provided group support, with the other five trials supporting women individually. One trial (174 women) did not report on any of our main outcomes of interest.

We are unclear about the effects of the intervention because we identified very low-certainty evidence for all of the important outcomes in this review: rate of non-initiation of breastfeeding (average RR 1.03, 95% CI 0.07 to 16.11; 3 trials, 380 women); exclusive breastfeeding at four to six weeks (average RR 1.21, 95% CI 0.83 to 1.77; 4 trials, 445 women); any breastfeeding at four to six weeks (average RR 1.04, 95% CI 0.57 to 1.89; 2 trials, 103 women); rate of exclusive breastfeeding at six months postpartum (RR 7.23, 95% CI 0.38 to 137.08; 1 trial, 120 women); and any breastfeeding at six months postpartum (average RR 1.42, 95% CI 1.08 to 1.87; 2 trials, 223 women).

The included trials under the above comparisons also reported on some of this review's secondary outcomes but very low-certainty evidence means that we are unclear about the effects of the intervention on those outcomes.

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