Supporting breastfeeding research
Below are the latest studies on interventions to protect, promote and support breastfeeding.
Development and pretesting of “Becoming Breastfeeding Friendly”: Empowering governments for global scaling up of breastfeeding programmes
The Becoming Breastfeeding Friendly research project is a Yale University initiative, designed in conjunction with global breastfeeding experts, including the World Health Organization (WHO), Unicef and the Gates Foundation. It aims to help countries assess their readiness to scale up breastfeeding support, and thus create a country-specific programme to boost and sustain their breastfeeding rates. This article explores how the project is being developed, including the creation of a BBF toolbox to enable countries to assess their breastfeeding scaling up environment, identify gaps, propose policy recommendations, develop a scaling up plan, and track progress.
Hromi-Fiedler, A, dos Santos Buccini, G, Bauermann Gubert, M, et al (2018). Development and pretesting of “Becoming Breastfeeding Friendly”: Empowering governments for global scaling up of breastfeeding programmes. Maternal & Child Nutrition, doi/10.1111/mcn.12659
Breastfeeding practices in the United Kingdom: Is the neighbourhood context important?
This study aimed to explore whether breastfeeding rates were associated with neighbourhood deprivation and maternal neighbourhood perceptions in a nationally representative UK sample. Researchers found that the likelihood of initiating breastfeeding was 40% lower in the most deprived neighbourhoods, and that breastfeeding initiation, exclusivity for 3 months, and any breastfeeding for 6 months were each reduced by about 20% among mothers who perceived their neighbourhoods to be lacking safe play areas for children. The authors conclude that policies to improve breastfeeding rates should consider area‐based approaches and the broader determinants of social inequalities.
Using 24-hour weight as reference for weight loss calculation reduces supplementation and promotes exclusive breastfeeding in infants born by cesarean section
Researchers in this study proposed that using newborns’ weight at 24 hours, rather than an earlier weight, could be a more accurate reference for weight loss and in turn could support breastfeeding by reducing supplementation rates in the absence of clinical need. They argued that whilst loss of >10% of birth weight often triggers supplementation, this measure could be inflated by transplacental passage of maternal intrapartum intravenous fluids for anesthesia. The researchers found that when 24-hour weight was used as a reference amongst healthy full-term newborns delivered by C-section, overall supplementation rate decreased from 43.6% pre- to 27.4% postintervention and in first-time mothers from 51.9% to 31.0%. Among infants losing >10% of birth weight, the supplementation rate decreased from 63.9% to 26.2%. There was no significant increase in maximum weight loss, peak transcutaneous bilirubin level, or length of hospital stay overall or in those with >10% weight loss from birth.
Deng, X, & McLaren, M, (2018). Using 24-hour weight as reference for weight loss calculation reduces supplementation and promotes exclusive breastfeeding in infants born by cesarean section. Breastfeeding Medicine, doi: 10.1089/bfm.2017.0124
Capture the moment
Unicef and WHO’s Capture the Moment report estimates that 78 million babies – or three in five – are not breastfed within the first hour, putting them at higher risk of disease and making them less likely to continue breastfeeding. The report calls for a range of measures to better support breastfeeding, including funding, fuller implementation of the International Code of Marketing of Breastmilk Substitutes and stronger links between health services and communities.
Unicef and WHO, (2018). Capture the Moment, https://www.unicef.org/publications/index_102949.html
Breastfeeding: A mother’s gift for every child
This report from Unicef shares new analysis on breastfeeding practices around the world and sets out key recommendations for governments, the private sector, civil society and communities in low-, middle- and high-income countries to increase breastfeeding rates. The report highlights breastfeeding as one of the most effective ways to protect maternal and child health and promote healthy growth and optimal development in early childhood. Despite this, breastfeeding rates worldwide remain low, particularly in high-income countries – more than 1 in 5 babies in high-income countries are never breastfed, compared to 1 in 25 in low- and middle-income countries. The report’s recommendations to improve breastfeeding rates include implementing the Baby Friendly Initiative in hospitals, strengthening links between health services and communities to ensure continued breastfeeding support, and developing supportive parental leave policies in the private sector.
Unicef, (2018). Breastfeeding: A mother’s gift for every child, https://www.unicef.org/publications/index_102824.html
Cost-effectiveness and Return on Investment (ROI) of interventions associated with the Best Start in Life
This ROI tool examined the cost-effectiveness of public health interventions aimed at the 0-5 years population and/or pregnant women. It looks at two interventions to support breastfeeding (targeted help for women from disadvantaged backgrounds after discharge, and enhanced staff contact for mothers with low birthweight infants), finding a strong case to be made for investment in breastfeeding support, both in terms of cost saving and positive health outcomes.
Intrapartum Administration of Synthetic Oxytocin and Downstream Effects on Breastfeeding: Elucidating Physiologic Pathways
This review of studies explored the impact of the commonly administered intrapartum drug, synthetic oxytocin, on physiologic mechanisms affecting breastfeeding. The authors found negative effects related to breastfeeding including decreased maternal endogenous oxytocin, increased risk of negative neonatal outcomes, decreased neonatal rest during the first hour with the potential of decreasing the consolidation of memory, decreased neonatal pre-feeding cues, decreased neonatal reflexes associated with breastfeeding, maternal depression, somatic symptoms and anxiety disorders. No positive relationships between the administration of synthetic oxytocin and breastfeeding were found. The researchers argue that practices that could diminish the nearly ubiquitous practice of inducing and accelerating labor with the use synthetic oxytocin should be considered when evaluating interventions that affect breastfeeding outcomes.
Cadwell, K, & Brimdyr, K, (2017). Intrapartum Administration of Synthetic Oxytocin and Downstream Effects on Breastfeeding: Elucidating Physiologic Pathways, Annals of Nursing Research and Practice, Vol. 2, Iss. 3.
Return on investment of public health interventions: A systematic review
This systematic review exploring the impact of public health interventions suggests that local and national public health interventions are highly cost-saving. The authors argue that cuts to public health budgets in high income countries therefore represent a false economy, and are likely to generate billions of pounds of additional costs to health services and the wider economy. Find out more about these issues in our report, “Preventing Disease and Saving Resources” exploring how raising breastfeeding rates could save the NHS money through improving health outcomes.
A realist review of one‐to‐one breastfeeding peer support experiments conducted in developed country settings
This review sought to identify the key factors that underpin successful one-to-one breastfeeding peer support. It found the following were particularly important: a) congruence with local infant feeding norms, (b) integration with the existing system of health care, (c) overcoming practical and emotional barriers to access, (d) ensuring friendly, competent, and proactive peers, (e) facilitating authentic peer–mother interactions, (f) motivating peers to ensure positive within‐intervention amplification, and (g) ensuring positive legacy and maintenance of gains.
Trickey, H, et al (2017) A realist review of one‐to‐one breastfeeding peer support experiments conducted in developed country settings. Maternal and Child Nutrition, https://doi.org/10.1111/mcn.12559 Read Heather Trickey’s blog considering the key lessons from the review.
New research finds that financial incentives may increase breastfeeding rates
Offering new mothers financial incentives may significantly increase low breastfeeding rates, new research from the University of Sheffield and the University of Dundee has found. More than 10,000 new mothers across South Yorkshire, Derbyshire and North Nottinghamshire were involved in the ground-breaking study, which offered vouchers worth up to £120 over six weeks if their babies received breastmilk (breastfeeding or expressed milk) at two days, ten days and six weeks old. A further £80 of vouchers were available if their babies continued to receive breastmilk up to six months. The trial (funded by the National Prevention Research Initiative and Public Health England) saw an increase of six percentage points in breastfeeding rates at 6-8 weeks in the areas where the scheme was offered, compared with those areas where the scheme was not available. Principal investigator Dr Clare Relton, from the University of Sheffield’s School of Health and Related Research (ScHARR), said: “Our scheme offered vouchers to mothers as a way of acknowledging the value of breastfeeding to babies and mothers and the work involved in breastfeeding”.
The study demonstrates the importance of increasing the perceived value of breastfeeding in order to improve rates. Financial incentives appear to act as a mechanism for valuing breastfeeding and demonstrating to mothers that their efforts are appreciated and that breastfeeding makes a difference to the health of their children and themselves. These findings should be considered in the context of the evidence for the need to provide consistent, ongoing and predictable support to enable mothers to breastfeed for as long as they wish.
Researchers Dr Clare Relton and Professor Mary Renfrew shared details of the study at our Annual Conference – view the slides from their talk.
Development and Evaluation of a Lactation Rotation for a Pediatric Residency Program
This study provided a 2 week lactation education program for first-year paediatric residents, and measured their knowledge and perceived confidence regarding breastfeeding, via self-reported tests before and after training. As a result of this program, the paediatric residents’ knowledge and perceived confidence related to breastfeeding significantly increased.
Albert, JB, Heinrichs-Breen, J. & Belmonte, F.W. (2017). Development and Evaluation of a Lactation Rotation for a Pediatric Residency Program. Journal of Human Lactation, doi/abs/10.1177/0890334416679381
An Online Calculator to Estimate the Impact of Changes in Breastfeeding Rates on Population Health and Costs
This American study developed a calculator to estimate population-level changes in disease burden associated with changes in breastfeeding rates. Researchers found that a 5% point increase in breastfeeding rates was associated with statistically significant differences in child infectious morbidity for the U.S. population, including otitis media and gastrointestinal infection. Associated medical cost differences were $31,784,763 for otitis media and $12,588,848 for gastrointestinal infection. They concluded that modest increases in breastfeeding rates could substantially impact healthcare costs in the first year of life.
Breastfeeding as a public health responsibility: a review of the evidence
This narrative review found that many barriers to breastfeeding exist at the societal rather than the individual level, and that although individual support is important, breastfeeding must be considered as a public health issue requiring investment at a societal level. Five core themes were identified; the need for investment in (i) health services; (ii) population level health promotion; (iii) supporting maternal legal rights; (iv) protection of maternal wellbeing; and (v) reducing the reach of the breast milk substitute industry. Find out more about these issues in our Call to Action campaign, urging UK governments to take steps to protect, promote and support breastfeeding.
A Comparison of Factors Associated with Cessation of Exclusive Breastfeeding at 3 and 6 Months
This study in a Spanish hospital accredited as Baby Friendly explored the factors associated with cessation of exclusive breastfeeding. At 3 months, 64.4% of mothers were exclusively breastfeeding. Reasons for cessation included pacifier use, caesarean delivery, and not attending breastfeeding support groups. At 6 months, 31.4% of mothers were continuing to exclusively breastfeed, and the factors associated with cessation were the mother’s reintegration into the workplace, pacifier use and primiparity. The findings have important implications for supporting mothers to continue breastfeeding for as long as they wish.
Availability of breastfeeding peer support in the United Kingdom: A cross-sectional study
This survey of Infant Feeding Co-ordinators in the UK found large inconsistencies in the availability and quality of breastfeeding peer support in the UK, with worrying implications for the UK’s breastfeeding rates. Only 56% of areas surveyed had any breastfeeding peer support provision, and within these areas the roles and training available varied greatly.
‘People try and police your behaviour’: the impact of surveillance on mothers and grandmothers’ perceptions and experiences of infant feeding
This research explored mothers’ and grandmothers’ experiences of infant feeding in relation to external pressures from family, friends and strangers. They argue that as pregnancy and motherhood become increasingly subject to surveillance (and judgement) infant feeding becomes more challenging for women. This study highlights the need to change the conversation around infant feeding in the UK.
Grant, A, et al (2017), ‘People try and police your behaviour’: the impact of surveillance on mothers and grandmothers’ perceptions and experiences of infant feeding, Policy Press, doi.org/10.1332/204674317X14888886530223
Prevalence and determinants of cessation of exclusive breastfeeding in the early postnatal period in Sydney, Australia
This Australian study of 17,564 live births in 2014 explored the factors behind cessation of exclusive breastfeeding. Researchers found that whilst most mothers (90%) exclusively breastfed upon delivery, this declined to 62% in the early postnatal period. Key factors influencing this drop were age (with mothers younger than 20 being less likely to continue to breastfeed), intimate partner violence, assisted delivery, low socio-economic status, pre-existing maternal health problems and a lack of partner support. The findings highlight the importance of identifying those at risk of early cessation of exclusive breastfeeding and the provision of targeted support for these groups.
Ogbo, F.A. et al (2017) Prevalence and determinants of cessation of exclusive breastfeeding in the early postnatal period in Sydney, Australia. International Breastfeeding Journal, doi: 10.1186/s13006-017-0110-4
Breastfeeding in South Gloucestershire: Mothers’ early experiences of infant feeding
This study exploring mothers’ early experiences of infant feeding identified three ‘critical stages’ in supporting a woman to breastfeed: before the birth, around the time of the birth and once at home, with consistent messages throughout being particularly important. Family and friends were found to be especially influential, highlighting the need to involve a mother’s whole support network in infant feeding education.
Cochrane Library Special Collection: Enabling breastfeeding for mothers and babies
This Cochrane Special Collection of systematic reviews on Breastfeeding explores the kind of support that enables women to breastfeed. It found that women need sensitive, reliable and face-to-face guidance from pregnancy through to the first weeks and months of their babies’ lives, helping them to get breastfeeding off to a good start and continue to breastfeed in the long-term. Support is needed to prevent and treat physical problems, and to build confidence, particularly in communities where breastfeeding is no longer seen as the norm. With eight out of 10 women in the UK stopping breastfeeding before they want to, it is crucial that this evidence is used to protect and increase breastfeeding support. Read our blog on translating this evidence into action.
NIHR themed review: Better Beginnings – improving health for pregnancy
The National Institute for Health Research’s Better Beginnings report explores ways to improve health before, during and after pregnancy. It highlights the importance of tailored breastfeeding support, as well as skin-to-skin contact, in enabling women to breastfeed for as long as they wish.
Breastfeeding knowledge and duration
This American study of 2,935 women explored the relationship between mothers’ knowledge of breastfeeding recommendations and breastfeeding duration. Researchers found that one in five did not know current breastfeeding recommendations; they had a lower probability of breastfeeding and a higher risk of ceasing breastfeeding at any point.
Wallenborn, J, et al (2017), Knowledge of Breastfeeding Recommendations and Breastfeeding Duration: A Survival Analysis on Infant Feeding Practices II, Breastfeeding Medicine, doi:10.1089/bfm.2016.0170
World Breastfeeding Trends Initiative (WBTi) UK Report 2016
November 2016 saw the launch of the first WBTi report for the UK. The report uses 10 key measures to identify how well breastfeeding is protected and supported in a particular country – it highlights the UK’s worryingly low breastfeeding rates and the importance of providing consistent support at every level – from hospital to home and community.
The World Breastfeeding Trends Initiative (WBTi) is a collaborative national assessment of the implementation of key policies and programmes from the WHO’s Global Strategy for Infant and Young Child Feeding. Unlike other assessments, the WBTi brings together the main agencies and organisations involved in aspects of IYCF in a particular country to work together to collect information, identify gaps and generate recommendations for action. This is the first WBTi assessment for the UK; the process is repeated every 3–5 years in order to track trends.
Determinants of breastfeeding initiation and cessation among employed mothers
This prospective cohort study of 817 women in Minnesota found that the odds of breastfeeding initiation were higher for women who: held professional jobs, were primiparae, had a graduate degree and did not smoke prenatally. Women were also more likely to start and continue breastfeeding if they had family or friends who breastfed. Breastfeeding cessation was more common amongst women who returned to work within 6 months of giving birth. The authors conclude that future research should examine women’s awareness of employer policies regarding paid and unpaid leave.
Factors associated with infant feeding choices in the adolescent population
This study of 457 adolescent maternity patients at the University of Louisville Hospital found that involvement of the adolescents’ mothers or caregivers in feeding decisions was associated with a higher likelihood of deciding to bottle feed, whilst participation in early skin-to-skin contact was linked to a decision to breastfeed.
What do women really want? Lessons for breastfeeding promotion and education
This study explored new mothers’ attitudes towards breastfeeding promotion and education to consider where improvements could be made. Mothers identified a need to move away from the perception that breastfeeding is best (rather than normal), an emphasis on wider values other than the health benefits of breastfeeding, and a message that every feed, rather than just 6 months exclusive breastfeeding, matters. Mothers also highlighted the need for promotion and education to target family members and wider society rather than simply mothers themselves, all of whom influenced both directly or indirectly the maternal decision and ability to breastfeed.
The influence of grandmothers on breastfeeding rates: a systematic review
Researchers reviewed studies into the influence that grandmothers could have on breastfeeding rates. Although data quality varied, they found some evidence that grandmothers who had had their own breastfeeding experience or were positively inclined towards breastfeeding had a beneficial impact on exclusive breastfeeding. They suggest that breastfeeding promotion programmes should include grandmothers to maximise impact.
Evaluation of the effectiveness of school-based breastfeeding education
A systematic review of relevant literature was conducted to identify scientifically rigorous studies on school-based interventions and promotion activities that focus on breastfeeding. The authors contend that school-based breastfeeding promotion programs hold promise for increasing knowledge of breastfeeding and support for breastfeeding, promoting positive attitudes, creating a culture where breastfeeding is the norm, and increasing future intentions to breastfeed.
The impact of a prenatal education video on rates of breastfeeding
This study aimed to determine whether a low-cost prenatal education video improves hospital rates of breastfeeding initiation and exclusivity in a low-income population. The results suggested that an educational breastfeeding video alone is ineffective in improving the hospital breastfeeding practices of low-income women. The authors conclude that increasing breastfeeding rates in this at-risk population likely requires a multi-pronged effort begun early in pregnancy or preconception.
Kellams, A.L. et al (2016) The Impact of a Prenatal Education Video on Rates of Breastfeeding Initiation and Exclusivity during the Newborn Hospital Stay in a Low-income Population. Journal of Human Lactation, doi: 10.1177/0890334415599402.
Breastfeeding among adolescent mothers: a systematic review of interventions from high-income countries
This study reviewed interventions designed to improve breastfeeding rates among adolescents. The authors recommend that more interventions should be developed and evaluated, and that interventions should include mothers and partners of adolescents to successfully promote breastfeeding among adolescent mothers.
Interventions to improve breastfeeding outcomes
This study provided comprehensive evidence of the effect of interventions on early initiation, exclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health systems and services (ii) Home and family environment (iii) Community environment (iv) Work environment (v) Policy environment or a combination of any of above.
Results indicated that intervention delivery in combination of settings seemed to have higher improvements in breastfeeding rates. Greatest improvements in early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding rates, were seen when counselling or education were provided concurrently in home and community, health systems and community, health systems and home settings, respectively. Baby Friendly Hospital support at health system was the most effective intervention to improve rates of any breastfeeding.
Sinha, B. et al (2015). Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis. Acta Paediatrica, Special Issue: Impact of Breastfeeding on Maternal and Child Health. Volume 104, Issue Supplement S467, pages 114-134.
Fathers’ involvement in childcare and perceived skill as a parent
A study in the USA explored 152 first-time fathers’ perceived childcare skill during the transition to parenthood. Face-to-face interviews were carried out with fathers at one month and one year following the birth. Analyses examined the associations among fathers’ perceived skill and child care involvement related to a number of factors including breastfeeding, maternal gate-keeping, mothers’ work hours, fathers’ depressive symptoms, and fathers’ beliefs about responding to a crying child. The researchers found that breastfeeding at one month was not related to involvement or perceived skill. Maternal gate-keeping, however, was negatively associated with father involvement. Greater involvement at one month strongly predicted greater involvement at one year. The authors suggest that invoking breastfeeding as an impediment to father involvement could in fact be more of a pretext than a significant reason for decreased involvement.
Co-parenting breastfeeding support and exclusive breastfeeding: a randomised controlled trial
This randomized controlled trial evaluated the effectiveness of a co-parenting intervention on exclusive breastfeeding among primiparous mothers and fathers. Couples were randomized to receive either usual care or a co-parenting breastfeeding support intervention. Follow-up of exclusive breastfeeding and diverse secondary outcomes was conducted at 6 and 12 weeks postpartum. It was found that this co-parenting intervention involving fathers resulted in significant improvements in breastfeeding duration, paternal breastfeeding self-efficacy, and maternal perceptions of paternal involvement and assistance with breastfeeding.
Structured breastfeeding programmes in maternity services shown to improve breastfeeding rates
A systematic review was carried out to evaluate outcomes of structured versus non-structured breastfeeding programmes in acute maternity care settings in supporting initiation and duration of exclusive breastfeeding. A ‘structured programme’ was deemed to be a programme which included a multifaceted approach to support breastfeeding that targeted change at organisational, service delivery and individual behaviour levels, for example implementation of the Baby Friendly Hospital Initiative.
Authors conducted an extensive literature review and included 26 articles in the study. They note that most studies found a statistically significant improvement in breastfeeding initiation following introduction of a structured breastfeeding programme, although effect sizes varied. The impact on the duration of exclusive breastfeeding and duration of any breastfeeding to 6 months was also evident, although not all studies found statistically significant differences.
The authors conclude that despite poor overall study quality, structured programmes compared with standard care positively influence the initiation and duration of both exclusive breastfeeding and any breastfeeding. The researchers recommend further high quality trials, particularly to evaluate the impact of programmes within the community setting.
Beake S, Pellowe C, Dykes F et al (2012). A systematic review of structured compared with non-structured breastfeeding programmes to support the initiation and duration of exclusive and any breastfeeding in acute and primary health care settings. Maternal and Child Nutrition. DOI: 10.1111/j.1740-8709.2011.00381.x
Influence of childcare arrangements on breastfeeding outcomes
This study of 18,050 infants observed the likelihood of breastfeeding for at least 4 months according to informal childcare (care by friends, grandparents, other relatives, etc.) and formal childcare (e.g. nurseries, crèches), compared to being cared for ‘only by a parent’ and also by socio-economic group.
Researchers found that informal childcare was associated with a reduced likelihood of breastfeeding for all groups of mothers. Formal childcare arrangements were only associated with a reduced likelihood of breastfeeding if used full-time by more advantaged families. The researchers suggest that childcare centres offer a potential setting to promote breastfeeding, for example through offering storage of expressed milk and encouraging mothers to continue to breastfeed. The lower likelihood of being breastfed experienced by infants cared for by family, friends and neighbours was evident in all socio-economic groups.
The researchers therefore recommend that breastfeeding campaigns in the UK might be aimed at all members of society. Qualitative research into how childcare acts to facilitate or discourage breastfeeding for mothers from different socioeconomic groups may help to target policy and practice more effectively.
Infant feeding decisions of socioeconomically deprived pregnant teenagers: the moral dimension
This study examined the infant feeding intentions of white pregnant teenagers living in a northern English inner city. The researchers found that breastfeeding was viewed as a morally inappropriate behaviour by most of the teenagers, with formula feeding being perceived as the appropriate behaviour. They conclude that existing breastfeeding promotion activities are likely to continue to fail to reach teenagers experiencing deprivation in England in the absence of effective strategies to change the underlying negative moral norms toward breastfeeding.
Indices of multiple deprivation and breastfeeding support
This study of 216 mothers with a child between six and 24 months old found that breastfeeding duration was associated with socio-economic indicators and levels of multiple deprivation in both English and Welsh samples. The authors suggest that targeting women by their postcode is an effective, non-intrusive way of identifying women most at risk of low breastfeeding rates.
Antenatal confidence about and commitment to breastfeeding linked to breastfeeding success
This study of Caucasian and African American women in three major United States cities found that those mothers who were more likely to breastfeed successfully had confidence in the process of breastfeeding, confidence in their ability to breastfeed, and commitment to making breastfeeding work despite obstacles. The authors conclude that contrary to popular conceptions, breastfeeding appears to be a learned skill. Antenatal preparation appears to be crucial to the process; if mothers achieved a level of “confident commitment” before the birth, they were able to withstand lack of support by significant others and the common challenges that occurred as they initiated breastfeeding. Without the element of “confident commitment,” a decision to breastfeed appeared to fall apart once challenged.
Breastfeeding support: what works?
This literature review of articles published in Finnish, Swedish and English between the year 2000 and March 2006 examined the impact of breastfeeding support interventions. Researchers found that interventions started during pregnancy and continued into the postnatal period were more effective than interventions concentrating on a shorter period. The authors concluded that the Baby Friendly Hospital Initiative, practical hands-off teaching and the use of multiple education methods combined with support and encouragement, were effective approaches. Postnatally, home visits, telephone support and breastfeeding ‘centres’ combined with peer support were found to be effective.
Related research and further reading
The Lancet: Increasing breastfeeding worldwide could prevent over 800,000 child deaths every year