e-Library of Evidence for Nutrition Actions (eLENA)

Breastfeeding education for increased breastfeeding duration

Biological, behavioural and contextual rationale

Juana Willumsen
Consultant to WHO Department of Nutrition for Health and Development
July 2013

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.



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.