Breastfeeding education for increased breastfeeding duration
Biological, behavioural and contextual rationale
The importance of appropriate infant feeding and the vital role played by breastfeeding in child survival, growth and development are well known. Breastfeeding helps to protect the infant against some of the major causes of childhood morbidity and mortality.1,2 It is currently recommended that starting within one hour of birth, infants should be exclusively breastfed for the first six months of life3, and that breastfeeding should continue up to 2 years of age or beyond.2 Unfortunately, infant feeding practices are still far from optimal; in many parts of the world rates of exclusive breastfeeding are low4 and many women stop breastfeeding earlier than they intended to.5-7 It is estimated that 1.5 million lives could be saved each year if infants were fed according to recommended breastfeeding practices.1 Research has also shown an association between duration of breastfeeding and reduction in risk of childhood obesity and cardiovascular diseases in later life.8-10
Formal breastfeeding education is that which is provided over and above the breastfeeding information given as part of standard antenatal care, and which may include individual or group education sessions led by peer counsellors or health professionals, homes visits, lactation consultation, distribution of printed/written materials, video demonstrations and inclusion of prospective fathers in learning activities. The antenatal period affords an opportunity for providing pregnant women and their partners and families with information about the benefits of breastfeeding at a time when many decisions about infant feeding are being contemplated.
Systematic review of the available evidence suggests that breastfeeding education is effective in increasing both the rate of breastfeeding initiation and breastfeeding duration.11-15 Though these reviews focus largely on studies in developed countries, a number of highly successful interventions implemented in low- and middle-income countries have been described in the literature.16-21 Some studies have further demonstrated the feasibility of scaling up interventions in settings as diverse as Bolivia, India, Ghana and Madagascar by taking advantage of existing health and nutrition activities.19,22-24 Limited evidence suggests that it may be possible to scale up even with relatively “low-intensity interventions” as demonstrated by studies in Mexico city, where improvement in exclusive breastfeeding was observed with as little as three home visits by peer counsellors17 and in Sub-Saharan Africa, where a recent multicentre randomized controlled trial demonstrated that five or more home visits by peer counsellors resulted in a significant increase in exclusive breastfeeding at 12 and 24 weeks postpartum.21
Implementation of breastfeeding education interventions in low- and middle-income countries may present challenges and contextual factors that might affect breastfeeding duration must often be considered such as differences in income, as studies in Uganda and South Africa have shown that women with their own source of income are more likely to stop breastfeeding early than those without.25,26 The availability and use of infant formula may also present a significant challenge, particularly in settings where rates of HIV-infection are high and fears of transmitting the virus through breast milk are widespread.25 The problem may be compounded in settings where the International Code of Marketing Breast-milk Substitutes or similar legislation regulating the promotion of formula has not been adopted and infant formula is widely available as part of existing public health or nutrition programmes.27
There is a need for further well-designed clinical trials, including in low and middle-income countries, to investigate the benefits of antenatal breastfeeding education on breastfeeding initiation, exclusive breastfeeding rate and duration of breastfeeding. For breastfeeding education to be implemented at scale, different modes of delivery should be considered, including one-on-one, group and peer-led sessions in both home and healthcare facility-based settings. In addition, health professionals should receive pre- and in-service training in how to help mothers with the prevention and treatment of common breastfeeding problems28, which often lead to stopping breastfeeding.
- Black R, Morris S, Bryce J. Child Survival I: where and why are 10 million children dying every year? Lancet. 2003, 361:2226-34.
- WHO Collaborative Study Team on the Role of Breastfeeding in the Prevention of Infant Mortality. Effect of breastfeeding on infant and childhood mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet. 2000, 355:451-5.
- WHO. Global strategy for infant and young child feeding. The optimal duration of exclusive breastfeeding. Geneva: World Health Organization, 2001.
- WHO. Infant and young child feeding. 2011.www.who.int/nutrition/databases/infantfeeding/countries/en/index.html
- Bolling K, et al. Infant feeding survey 2005. London: The Information Centre for Health and Social Care, UK Health Department, 2007.
- Adams C. Breastfeeding trends at a community breastfeeding center: an evaluative study. Journal of Obstetric, Gynecologic and Neonatal Nursing. 2001, 30:392-400.
- Wagner C. Breastfeeding rates at an urban medical university after initiation of an education program. Southern Medical Journal. 2002, 95:909-13.
- Harder T, et al. Duration of breastfeeding and risk of overweight: A meta-analysis. American Journal of Epidemiology. 2005, 162:397-403.
- Owen C, et al. Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published literature. Pediatrics. 2005, 115:1367-70.
- Horta BL, Victora CG. Long-term effects of breastfeeding: a systematic review. Geneva, Switzerland: World Health Organization, 2013.
- Dyson L, McCormick F, Renfrew M. Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews. 2005, 2:CD001688.
- Lumbiganon P, et al. Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane Database of Systematic Reviews. 2012, 9:CD006425.
- Chapman DJ, et al. Breastfeeding peer counseling: from efficacy through scale-up. Journal of Human Lactation. 2010, 26:314-26.
- Bhutta ZA et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013, S0140-6736(13)60996-4.
- Imdad A, Yakoob MY, Bhutta ZA. Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries. BMC Public Health. 2011, 11 Suppl 3:S24.
- Davies-Adetugbo AA, et al. Breast-feeding promotion in a diarrhoea programme in rural communities. Journal of Diarrhoeal Disease Research. 1997,15:161-6.
- Morrow AL, et al. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet. 1999, 353:1226-31.
- Haider R, et al. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. Lancet. 2000,356:1643-7.
- Bhandari N, et al. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomised controlled trial. Lancet. 2003,361:1418-23.
- Aidam BA, Pérez-Escamilla R, Lartey A. Lactation counseling increases exclusive breast-feeding rates in Ghana. Journal of Nutrition. 2005,135:1691-5.
- Tylleskär T, et al. Exclusive breastfeeding promotion by peer counsellors in sub-Saharan Africa (PROMISE-EBF): a cluster-randomised trial. Lancet. 2011,378:420-7.
- Quinn VJ, et al. Improving breastfeeding practices on a broad scale at the community level: success stories from Africa and Latin America. Journal of Human Lactation. 2005,21:345-54.
- Baker EJ, Sanei LC, Franklin N. Early initiation of and exclusive breastfeeding in large-scale community-based programmes in Bolivia and Madagascar. Journal of Health and Population Nutrition. 2006, 24:530-9.
- Guyon AB, et al. Implementing an integrated nutrition package at large scale in Madagascar: the Essential Nutrition Actions framework. Food and Nutrition Bulletin. 2009,30:233-44.
- Fadnes LT, et al. Need to optimise infant feeding counselling: a cross-sectional survey among HIV-positive mothers in Eastern Uganda. BMC Pediatrics. 2009,9:2.
- Doherty T, et al. Early cessation of breastfeeding amongst women in South Africa: an area needing urgent attention to improve child health. BMC Pediatrics. 2012,12:105.
- Doherty T, Sanders D, Goga A, Jackson D. Implications of the new WHO guidelines on HIV and infant feeding for child survival in South Africa. Bulletin of the World Health Organization. 2011,89:62-7.
- Renfrew M, et al. Addressing a learning deficit in breastfeeding: strategies for change. Maternal and Child Nutrition. 2006,2:239-44.
The named authors alone are responsible for the views expressed in this document.
Declarations of interests
Conflict of interest statements were collected from all named authors and no conflicts were identified.