Clinical Question: In post-partum first-time mothers, what interventions are successful for helping women sustain exclusive breast feeding for one month or more?

Summary of the Issues

The human practice of breast feeding has existed since time immemorial. Other feeding methods have evolved throughout history. Certain feeding options have become more popular at certain times in history than others including wet nursing, alternative milk, bottle feeding, and formula feeding. According to Stevens et al., 2009, the use of animal milk has been reported back to 2000 BCE. Also, evidence of the advent of feeding bottles in ancient times has been discovered. Breastfeeding has been recommended as the food of choice for infants in past and present times. However, depending on society’s views, social support, education, and many other factors, the choice to breastfeed has been significantly altered. Infant formula was not regulated by the FDA until the Infant Formula Act of 1980. Historically, there have been many infant deaths in association with artificial feedings and/or alternative milk. The growth of scientific knowledge over the centuries has led to improvements in food preservation and the development of infant formulas. Infant formulas have been marketed heavily in the United States as a healthy alternative to breastfeeding; this has likely contributed to declines in breastfeeding¹. Breastfeeding is a practice widely encouraged by healthcare professionals for infants’ health. It is tied to a lesser likelihood of developing obesity, diabetes and asthma. It also confers benefits to mothers, such as partial birth control, more rapid weight loss and a decreased risk of developing endometrial cancer.

The majority of North American women do not breastfeed for the period of 6–12 months recommended by the American Academy of Pediatrics. The rates of breastfeeding decrease quickly through the first 4–8 weeks postpartum. Many women in the United States report the desire to breastfeed². There are many factors that are associated with the duration of breastfeeding. One main reason for the early and drastic cessation within the first six months is difficulty breastfeeding and insufficient early support and education regarding breastfeeding. The top five reasons given for formula supplementation were insufficient milk supply, convenience, infant behavioral problems, feeding problems, and returning to work³.

Other issues associated with early cessation of breastfeeding include inadequate assistance provided to women who wish to breastfeed⁴. Early hospital discharges have also led to decreased support and lack of education regarding breastfeeding. This has often led to increased difficulties breastfeeding⁵. Paternal support for and their knowledge regarding breastfeeding is another factor in successful breastfeeding. The mother’s perception of the father’s attitude regarding breastfeeding was the most important factor in the decision to initiate bottle feeds, according to one study⁶.

However, steps have been taken to reverse this trend. The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) both created the Baby-Friendly Hospital Initiative (BFHI) to encourage hospitals to promote breastfeeding². Undoubtedly, hospital professionals have the responsibility to promote breastfeeding. However, there are other factors that affect mothers’ decision to breastfeed. While there are much data detailing how mothers are encouraged or discouraged from breastfeeding, much of this article will focus on primiparous mothers and factors promote breastfeeding. These factors are the following: paternal support, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), skin-to-skin contact, written educational material, and health professionals. Through the analysis of such articles, it is our hope that this information can be used to help develop programs to promote breastfeeding.

The choice to breastfeed is personal and is ultimately the mother’s decision. It is important that the mother is able to make an informed decision. There are multiple health benefits for breastfed infants and mothers. The health benefits for breastfed infants include decreases in respiratory and gastrointestinal illnesses, sudden infant death syndrome, rates of hospitalizations, and obesity². Breastfeeding is also beneficial from an economic standpoint. It has been reported that if 90% of women in the United States breastfed for 6 months exclusively, it could save the United States about $13 billion each year due to preventable health expenses². These include decreased risks of pediatric diseases due to the protective nature of exclusive breastfeeding². Medical communities in the United States and across the world are promoting the return of exclusive breastfeeding, and many national and international programs have been developed to help achieve this goal. Many factors showing improvement in the chances of continued and successful breastfeeding have been studied and are components of these programs.

Through history, many factors have guided mothers in their personal decision to exclusively breastfeed. In this review, our goal was to determine in postpartum first-time mothers what interventions are successful for helping women sustain exclusive breastfeeding for one month or more.

Summary of the Evidence

In our literature review, we found nine articles including three randomized controlled trials, one longitudinal cohort study, one retrospective cross-sectional study, three survey/questionnaire reviews, and one literature review that explore the multiple factors that lead to more successful breastfeeding.

The first study, Dennis et al., 2002, followed North American women for 12 weeks postpartum. They were divided into control and peer support groups where participants had access to breastfeeding support and feedback from volunteers. These volunteers were similar to the participants based on age, socioeconomic status, culture, and location. As a result, the study suggests that an additional 21% of mothers will continue to breast-feed at 12 weeks postpartum if they are provided with peer support in addition to conventional support. More women were exclusively breast feeding in the peer support versus control group at the end of the interval³.

The second study (Jones et al., 1985) looked at the effects of lactation nurses on breastfeeding and had similar results. Mothers who received assistance from lactation nurses both in the hospital and at home had higher rates of breastfeeding at 4 weeks (84 vs 72%) and 6 months (38 vs 28%) postpartum compared to the control group. The main beneficial factor noted was ‘consistent advice and encouragement’ which helped mothers cope better with difficulties⁴.

The third article (Hunter et al., 2014) showed that the prevalence of exclusive breastfeeding at 6 months was significantly higher among mothers who had involvement and support from the infants’ father during the early post-partum period⁶.

The fourth study reviewed factors predicting the duration of breastfeeding in a random selection of 617 first-time mothers from the Leeds Area Health Authority. Multiple characteristics including age, socioeconomic class, educational level, smoking status, and mother’s own infant feeding history were significantly associated (p < 0.05) with increased duration of breastfeeding. Other factors listed included lactation education, maternal attitude towards breastfeeding, attendance in mothership classes, and the perceived attitude medical professionals in hospitals have towards breastfeeding. It was found that at six weeks postpartum, mothers older than 25 years who were educated to at least the age of 17 were four times more likely to be breastfeeding⁵.

Breastfeeding practices among first-time mothers and across multiple pregnancies were studied in the fifth article (Sutherland et al., 2013) that included a longitudinal cohort study initiated in 2008 that is still ongoing. A total of 858 women were enrolled with 351 delivering vaginally and 507 via cesarean delivery. Breast feeding practices 5–10 years after initial delivery were reported. The women in this study were categorized as successful breastfeeding initiators, unsuccessful initiators, or non-initiators. Of the 812 women with complete information regarding breastfeeding, 91% reported attempted breastfeeding. It was found that less educated mothers were less likely to initiate breastfeeding. Mothers with college education were reported to be two times more likely to initiate breastfeeding. It was also found that breastfeeding was less likely with subsequent pregnancies after initial unsuccessful breastfeeding with their first child. This study also reported that the mode of delivery, maternal age, or ethnicity does not affect breastfeeding success or initiation⁷. The importance of lactation consultants and community breastfeeding support groups post hospital stay has been demonstrated in other research articles⁸. The importance of identifying the groups of women that would benefit significantly from such programs is crucial.

The sixth article (Grummer-Strawn et al., 2013) included a report released by the Centers for Disease Control (CDC) that reviewed the multiple health benefits of breastfeeding initiatives and the programs it has initiated to help promote breastfeeding through hospital quality improvement efforts. The WHO and UNICEF have determined “Ten Steps to Successful Breastfeeding,” highlighting the important components of maternity support for breastfeeding. Together they have launched the Baby-Friendly Hospital Initiative (BFHI), an international program that distinguishes hospitals based upon their adherence to the ten steps. The ten steps include: having a written breastfeeding policy that is routinely communicated to all healthcare staff, training all healthcare staff in skills necessary to implement this policy, informing all pregnant women about the benefits and management of breastfeeding, helping mothers initiate breastfeeding within an hour of birth, showing mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants, giving breastfed newborn infants no food or drink other than breast milk unless medically indicated, practicing rooming-in and allowing mothers and infants to be together 24 hours per day, encouraging breastfeeding on demand, giving no artificial teats or pacifiers to breastfeeding infants, and fostering the establishment of breastfeeding support groups and referring mothers to them on discharge from the hospital or clinic. The CDC has been promoting the adoption of these steps since 2003².

The CDC works in conjunction with state health departments by supporting funding for multiple programs. “Under the Nutrition, Physical Activity, and Obesity Cooperative Agreement, states are expected to build and implement a state plan of action that includes activities to increase the initiation, duration, or exclusivity of breastfeeding².” Many programs have been developed to encourage changing practices in hospitals settings to promote breastfeeding. There have been notable improvements across multiple dimensions of care including feeding of breastfed infants, labor and delivery care, breastfeeding assistance, mother-infant contact, discharge care, staff training, and structural and organization of care since the development of the BFHI in 1996 with more hospitals across the United States meeting criteria for being Baby-Friendly². The continued efforts of national and international programs promoting breastfeeding continue to have a positive impact of the duration and initiation of breastfeeding. There are currently 251 Baby-Friendly facilities in the United States. Oklahoma has two: Integris Baptist Medical Center and the Claremore Indian Hospital.

The seventh article (Campbell et al., 2014) highlights another factor in increasing the compliance of first time mothers for breastfeeding their child: the assistance WIC peer counselors. This study used a survey that included roughly 50 multiple choice questions and 2 open ended questions to first-time mothers and mothers who had not previously breastfed their children. The survey was administered at the child’s first birthday. Only biological mothers with singleton pregnancies were included in the study. The study found that women who discussed the benefits of breast-feeding and the availability of breast pumps with WIC peer counselors were more likely to initiate breast feeding. Sixty four percent (n = 1,969) of the 3070 women in the survey breastfed while 36% did not. Women with peer counseling during pregnancy, at the hospital and after delivery had a higher likelihood of initiating breastfeeding than mothers that did not (OR 1.36, 2.06 and 1.85 respectively). The strength appears to be highest for in-hospital counseling, followed by post-delivery and to a lesser degree during pregnancy. This study also compared race and the presence of high school education. It showed that Hispanic women and women with a high school education were more likely to breastfeed (p <0.001). In general, they concluded that education, appraisal and support of pregnant mothers were important in increasing their compliance with breast feeding, but more studies were needed to assess these three factors. One limitation to this study is that the authors could not find proof that WIC peer counseling was the most likely factor in more women breastfeeding⁹.

The eighth article (Aghdas et al., 2014) discusses skin-to-skin contact (SCC), which is defined as a naked baby pressed closely to the mother’s breast. This helps to facilitate breastfeeding, as summarized by Aghdas et al., that followed 114 primiparous, 18–35 y.o. mothers from Mashhad, Iran who had their babies by vaginal delivery. It compared the self- efficacy between mothers who initiated skin to skin contact to mothers who did not. Self-efficacy is defined as the level of confidence mothers had in breast feeding their child. A survey called the Infant Breast Feeding Assessment Tool had moms at 28 weeks postpartum assess their babies’ suckling, readiness to feed, rooting, reflex, and latch-on. Mothers with medical problems or high risk OB complications such as caesarean section, use of drugs and multiple pregnancies were excluded. Ninety two mother-baby dyads made up the final study, and from the surveys, it was found that 68.05% of moms who did SCC were confident whereas only 15.55% of routine care moms felt confident. Successful breastfeeding initiation rate was 56.6% in the mother-baby pairs who did skin-to-skin versus 35.65% in the routine-care group with p<0.02. This study also suggested that time for the first feed was also shorter in the SCC group. The authors conclude that SCC is inexpensive, easy and should be encouraged to increase breastfeeding compliance¹⁰.

The final article (Gage et al., 2012) compares 17 different influences (breast feeding advice from antenatal midwife, books, partner, hospital staff, leaflets, magazines, friends, parents, private antenatal class, other health professionals, internet, other relatives, doctor, advertising, TV, video/DVD, radio) on primiparous mothers in 5 different countries: England, Finland, Germany, Hungary and Spain. Mothers ranked how these influences affected their decision to breastfeed at age 0 and 8 months on a scale of 0 to 4 (0 being “not at all” and 4 being “extremely”). A total of 2071 mothers filled out the initial questionnaire at birth and 1617 (78.2%) filled the questionnaire 8 months postpartum. Spanish mothers were less likely to do the 8 month questionnaire, and had less education, lower income, and higher rates of smoking during their pregnancies. Mothers who were retained at 8 months were more educated, had a higher social economic status, and were less likely to have smoked during their pregnancy. Across all 5 countries, books, significant others, and health professionals were rated most important in educating mothers about breastfeeding with the least important being audio-visual media. Mothers in all countries were likely to learn from multiple sources. Primary written sources were more accessible to more educated mothers, whereas lesser educated mothers relied on information from health professionals. Spanish mothers were more reliant on family and friends, and English and Finnish mothers reported more influence from doctors at 8 months than the other countries’ mothers. Given the importance of family, friends and significant others, the authors suggest educating these groups is important. One limitation is that this study is not truly representative of each of populations with the lack of follow-up found with Spanish mothers. Spanish and Hungarian moms were also less precise about reporting information sources¹¹.

Conclusion

Three main categories assist primiparous mothers in initiating and sustaining breastfeeding practices: internal support, health care support, and media sources. Internal support is defined as support from significant others, family and friends. Health care support includes doctors, lactation nurses, WIC peer counselors, and skin-to-skin care encouragement by nurses. Media sources include written sources of different types. Most of these results are based on surveys (self-report by mothers), which can be imprecise.

The common theme from these articles is more education and support.

Father and family support, lactation consultant advice, and peer support before, during and after delivery all demonstrated significant increases in breastfeeding. A higher educational level was also associated with more breastfeeding. Also, it is critical to emphasize the education of women and support from health professionals. While it is challenging to change mothers’ perspectives on breastfeeding, it is our hope that with more research and education, we will be able to increase our rates.