Home breastfeeding support by health professionals: findings of a randomized controlled trial in a population of Italian women. Randomised controlled trial of support from volunteer counsellors for mothers considering breast feeding. Efficacy of breastfeeding support provided by trained clinicians during an early, routine, preventive visit: a prospective, randomized, open trial of 226 mother-infant pairs. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Breastfeeding peer support: maternal and volunteer perceptions from a randomized controlled trial. [Controlled study of a regular telephone support program given by volunteers on the establishment of breastfeeding]. The effect of a programme of organised and supervised peer support on the initiation and duration of breastfeeding: a randomised trial. The effect of peer support on breast-feeding duration among primiparous women: a randomized controlled trial. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial [see commments].
We conducted a randomized controlled trial to assess the effectiveness of a support intervention delivered by health professionals to increase the rate and duration of breastfeeding.
                A randomized controlled intervention study was conducted in the period 2000-2001 among 605 mothers who had given birth in a public maternity ward located in the city of Rome, Italy. The intervention consisted of a home visit by a midwife from the maternity ward of the hospital. The outcome of the study was the infant's feeding habits, assessed by a 24-h recall. The effect of the intervention on the duration of breastfeeding was estimated by the Kaplan-Meier method and by the Cox multivariate regression model.
                According to intention-to-treat analysis, there was no significant difference between the intervention and the control group, after controlling for confounding factors (hazard ratio (HR) 1.04; 95% confidence interval (95% CI): 0.85-1.26). The duration of breastfeeding was shorter (HR 1.61; 95% CI: 1.13-2.31) for women in the intervention group who refused the obstetric visit.
                Our study shows that an early home support programme delivered by health professionals was not effective in increasing breastfeeding initiation and duration. To investigate whether offering volunteer support from counsellors in breast feeding would result in more women breast feeding.
                Randomised controlled trial.
                32 general practices in London and south Essex.
                720 women considering breast feeding.
                Primary outcome was prevalence of any breast feeding at six weeks. Secondary outcomes were the proportion of women giving any breast feeds, or bottle feeds at four months, duration of any breast feeding, time to introduction of bottle feeds, and satisfaction with breast feeding.
                Offering support in breast feeding did not significantly increase the prevalence of any breast feeding to six weeks (65% (218/336) in the intervention group and 63% (213/336) in the control group; relative risk 1.02, 95% confidence interval 0.84 to 1.24). Survival analysis up to four months confirmed that neither duration of breast feeding nor time to introduction of formula feeds differed significantly between control and intervention groups. Not all women in the intervention group contacted counsellors postnatally, but 73% (123/179) of those who did rated them as very helpful. More women in the intervention group than in the control group said that their most helpful advice came from counsellors rather than from other sources.
                Women valued the support of a counsellor in breast feeding, but the intervention did not significantly increase breastfeeding rates, perhaps because some women did not ask for help. Despite growing evidence of the benefits of prolonged breastfeeding for mother and infant health, the rate of breastfeeding at infant age of 6 months remains below the Healthy People 2010 goal. The greatest decrease in the breastfeeding rate occurs during the first 4 postpartum weeks. Mothers who discontinue breastfeeding early are more likely to report lack of confidence in their ability to breastfeed, problems with the infant latching or suckling, and lack of individualized encouragement from their clinicians in the early postdischarge period. Observational studies suggest that primary care physicians can increase breastfeeding rates through specific advice and practices during routine preventive visits. However, robust scientific evidence based on randomized, controlled trials is currently lacking.
                The purpose of this study was to determine whether attending an early, routine, preventive, outpatient visit delivered in a primary care physician's office would improve breastfeeding outcomes.
                The study was a prospective, randomized, parallel-group, open trial.
                Participants were recruited at a level 3 maternity facility, with an average of 2000 births per year, in France.
                A total of 231 mothers who had delivered a healthy singleton infant (gestational age: > or =37 completed weeks) and were breastfeeding on the day of discharge were recruited and randomized (116 were assigned to the intervention group and 115 to the control group) between October 1, 2001, and May 31, 2002; 226 mother-infant pairs (112 in the intervention group and 114 in the control group) contributed data on outcomes.
                Support for breastfeeding in the control group included the usual verbal encouragement provided by the maternity ward staff members, a general health assessment and an evaluation for evidence of successful breastfeeding behavior by the pediatrician working in the obstetrics department on the day of discharge, provision of the telephone number of a peer support group, mandatory routine, preventive, outpatient visits at 1, 2, 3, 4, 5, and 6 months of infant age, and 10 weeks of paid maternity leave (extended to 18 weeks after the birth of the third child). In addition to the usual predischarge and postdischarge support, the mothers in the intervention group were invited to attend an individual, routine, preventive, outpatient visit in the office of 1 of the 17 participating primary care physicians (pediatricians or family physicians) within 2 weeks after the birth. The participating physicians received a 5-hour training program on breastfeeding, delivered in 2 parts in 1 month, before the beginning of the study.
                The primary outcome was the prevalence of exclusive breastfeeding reported at 4 weeks (defined as giving maternal milk as the only food source, with no other foods or liquids, other than vitamins or medications, being given). The secondary outcomes included any breastfeeding reported at 4 weeks, breastfeeding duration, breastfeeding difficulties, and satisfaction with breastfeeding experiences. Classification into breastfeeding categories reported at 4 weeks was based on 24-hour dietary recall.
                Ninety-two mothers (79.3%) assigned to the intervention group and 8 mothers (7.0%) assigned to the control group reported that they had attended the routine, preventive, outpatient visit in the office of 1 of the 17 primary care physicians participating in the study. Mothers in the intervention group were more likely to report exclusive breastfeeding at 4 weeks (83.9% vs 71.9%; hazard ratio: 1.17; 95% confidence interval [CI]: 1.01-1.34) and longer breastfeeding duration (median: 18 weeks vs 13 weeks; hazard ratio: 1.40; 95% CI: 1.03-1.92). They were less likely to report any breastfeeding difficulties (55.3% vs 72.8%; hazard ratio: 0.76; 95% CI: 0.62-0.93). There was no significant difference between the 2 groups with respect to the rate of any breastfeeding at 4 weeks (89.3% vs 81.6%; hazard ratio: 1.09; 95% CI: 0.98-1.22) and the rate of mothers fairly or very satisfied with their breastfeeding experiences (91.1% vs 87.7%; hazard ratio: 1.04; 95% CI: 0.95-1.14).
                Although we cannot exclude the possibility that findings might differ in other health care systems, this study provides preliminary evidence of the efficacy of breastfeeding support through an early, routine, preventive visit in the offices of trained primary care physicians. Our findings also suggest that a short training program for practicing physicians might contribute to improving breastfeeding outcomes. Multifaceted interventions aiming to support breastfeeding should involve primary care physicians. Exclusive breastfeeding is recommended worldwide but not commonly practised. We undertook a randomised controlled study of the efficacy of home-based peer counselling to increase the proportion of exclusive breastfeeding among mothers and infants residing in periurban Mexico City.
                Two intervention groups with different counselling frequencies, six visits (44) and three visits (52), were compared with a control group (34) that had no intervention. From March, 1995, to September, 1996, 170 pregnant women were identified by census and invited to participate in the study. Home visits were made during pregnancy and early post partum by peer counsellors recruited from the same community and trained by La Leche League. Data were collected by independent interview. Exclusive breastfeeding was defined by WHO criteria.
                130 women participated in the study. Only 12 women refused participation. Study groups did not differ in baseline factors. At 3 months post partum, exclusive breastfeeding was practised by 67% of six-visit, 50% of three-visit, and 12% of control mothers (intervention groups vs controls, p<0.001; six-visit vs three-visit, p=0.02). Duration of breastfeeding was significantly (p=0.02) longer in intervention groups than in controls, and fewer intervention than control infants had an episode of diarrhoea (12% vs 26%, p=0.03).
                This is the first reported community-based randomised trial of breastfeeding promotion. Early and repeated contact with peer counsellors was associated with a significant increase in breastfeeding exclusivity and duration. The two-fold decrease in diarrhoea demonstrates the importance of breastfeeding promotion to infant health. Several studies have demonstrated the positive effects of peer support on various breastfeeding outcomes, but no study has assessed women's and peer volunteers' views on, or the nature and intensity of, the supportive intervention. The objective of this study was to describe maternal and peer volunteer perceptions of their experience while participating in a breastfeeding peer support trial.
                A randomized controlled trial was conducted to evaluate the effect of telephone-based peer (mother-to-mother) support on breastfeeding duration. Two hundred and fifty-six primiparous breastfeeding women were randomly allocated to receive either conventional care or conventional care plus peer support. Three primary outcome measures were peer volunteer activity logs, maternal perceptions of peer support, and evaluations of the peer volunteer experience.
                Questionnaires were completed by 98.5 percent (n=130) of the mothers in the peer support group. Mothers reported their peer volunteers were available when difficulties were experienced, increased their confidence, decreased their concerns, and assisted them in reaching their breastfeeding goals. These supportive interactions resulted in 81.5 percent of mothers (n=106) being satisfied with their peer support experience and suggesting that every new mother should be offered this intervention. Similarly, all the peer volunteers interviewed (n=30) viewed their experience positively. They suggested some intervention modifications as follows: ensure that mothers enrolled in the program want peer support; provide peer volunteers with ongoing educational sessions and opportunities to "socialize" with other volunteers; and disseminate the results of peer support efforts.
                Both mothers and peer volunteers perceived their intervention experiences positively. Whereas maternal satisfaction was related to the number and duration of peer volunteer contacts, peer volunteers enjoyed their training session and the opportunity to assist mothers for a variety of reasons. Specific intervention modifications should be implemented to enhance peer volunteer satisfaction and retention. The goal of this controlled trial was to evaluate the impact of a volunteer telephone support program on the ability of the mothers to reach their breastfeeding objectives and to reduce the number of difficulties while nursing. Two hundred expectant women were randomly assigned to two groups. The first group received the usual services from the professionals and the second had the extra service from a trained volunteer. By comparing the proportions of women still breastfeeding at each month, the present study showed that this type of support was ineffective in meeting the objectives. The gap between the intended length of breastfeeding and the duration achieved was equally large in both groups. Only 30% breastfed for the length of time envisaged during pregnancy. Strategies to increase the effectiveness of this type of service are suggested. Peer support may improve breastfeeding rates but the evidence is inconclusive. Previous studies and reviews recommend trials in different healthcare settings.
                To test if a specified programme of peer support affects the initiation and/or the duration of breastfeeding.
                A two-group randomised controlled trial of peer support for breastfeeding with evaluation of breastfeeding initiation and duration on an intention-to-treat basis.
                General practice in Ayrshire, Scotland.
                Following informed consent, 225 women at 28 weeks gestation were allocated to control or peer support group by post-recruitment concealed allocation. All peer support and control group mothers received normal professional breastfeeding support. Additionally, those in the peer support group still breastfeeding on return home from hospital had peer support until 16 weeks.
                Thirty-five of the 112 (31%) women in the peer support group were breastfeeding at 6 weeks compared to 33/113 (29%) in the control group, a difference of 2% (95% confidence interval = -10% to 14%). The median breastfeeding duration for all women in the peer support group was 2 days compared to 1 day for the control group and the Kaplan-Meier survival plot shows the peer support group overall breastfeeding slightly longer than the control group, with no statistically significant difference by logrank test (P = 0.5). The median breastfeeding duration among primagravidae in the peer support group was 7 days, compared to 3 days for the control group. Among women who started to breastfeed the medians were 72 days in the peer support group and 56 days in the control group. These differences were not statistically significant.
                Peer support did not increase breastfeeding in this population by a statistically significant amount. Most mothers stop breast-feeding before the recommended 6 months post partum. A systematic review showed that breast-feeding support programs by health care professionals did not substantially improve breast-feeding outcomes beyond 2 months post partum. We conducted a randomized controlled trial to evaluate the effect of peer (mother-to-mother) support on breast-feeding duration among first-time breast-feeding mothers.
                We recruited 256 breast-feeding mothers from 2 semi-urban community hospitals near Toronto and randomly assigned them to a control group (conventional care) or a peer support group (conventional care plus telephone-based support, initiated within 48 hours after hospital discharge, from a woman experienced with breast-feeding who attended a 2.5-hour orientation session). Follow-up of breast-feeding duration, maternal satisfaction with infant feeding method and perceptions of peer support received was conducted at 4, 8 and 12 weeks post partum.
                Significantly more mothers in the peer support group than in the control group continued to breast-feed at 3 months post partum (81.1% v. 66.9%, p = 0.01) and did so exclusively (56.8% v. 40.3%, p = 0.01). Breast-feeding rates at 4, 8 and 12 weeks post partum were 92.4%, 84.8% and 81.1% respectively among the mothers in the peer support group, as compared with 83.9%, 75.0% and 66.9% among those in the control group (p < or = 0.05 for all time periods). The corresponding relative risks were 1.10 (95% confidence interval [CI] 1.01-2.72) at 4 weeks, 1.13 (95% CI 1.00-1.28) at 8 weeks and 1.21 (95% CI 1.04-1.41) at 12 weeks post partum. In addition, when asked for an overall rating of their feeding experience, significantly fewer mothers in the peer support group than in the control group were dissatisfied (1.5% v. 10.5%) (p = 0.02). Of the 130 mothers who evaluated the peer support intervention, 81.6% were satisfied with their peer volunteer experience and 100% felt that all new breast-feeding mothers should be offered this peer support intervention.
                The telephone-based peer support intervention was effective in maintaining breast-feeding to 3 months post partum and improving satisfaction with the infant feeding experience. The high satisfaction with and acceptance of the intervention indicates that breast-feeding peer support programs, in conjunction with professional health services, are effective. Most mothers breastfeed in Bangladesh, but they rarely practise exclusive breastfeeding. Hospital-based strategies for breastfeeding promotion cannot reach them because about 95% have home deliveries. We postulated that with the intervention of trained peer counsellors, mothers could be enabled to breastfeed exclusively for the recommended duration of 5 months.
                40 adjacent zones in Dhaka were randomised to intervention or control groups. Women were enrolled during the last trimester of pregnancy between February and December, 1996. In the intervention group, 15 home-based counselling visits were scheduled, with two visits in the last trimester, three early postpartum (within 48 h, on day 5, between days 10 and 14), and fortnightly thereafter until the infant was 5 months old. Peer counsellors were local mothers who received 10 days' training.
                363 women were enrolled in each group. Peer counselling significantly improved breastfeeding practices. For the primary outcome, the prevalence of exclusive breastfeeding at 5 months was 202/228 (70%) for the intervention group and 17/285 (6%) for the control group (difference=64%; 95% CI 57%-71%, p>0.0001). For the secondary outcomes, mothers in the intervention group initiated breastfeeding earlier than control mothers and were less likely to give prelacteal and postlacteal foods. At day 4, significantly more mothers in the intervention group breastfed exclusively than controls.
                Peer counsellors can effectively increase the initiation and duration of exclusive breastfeeding. We recommend incorporation of peer counsellors in mother and child health programmes in developing countries.
All women should be offered support to breastfeed their babies to increase the duration and exclusivity of breastfeeding. Support is likely to be more effective in settings with high initiation rates, so efforts to increase the uptake of breastfeeding should be in place. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed. Support that is only offered reactively, in which women are expected to initiate the contact, is unlikely to be effective; women should be offered ongoing visits on a scheduled basis so they can predict that support will be available. Support should be tailored to the needs of the setting and the population group.