The rates of breastfeeding initiation and maintenance in the UK are some of the lowest in the world, despite extensive evidence in support of the notion that ‘breast is best’ (Earle, 2002). Exclusive breastfeeding, defined by the World Health Organization (WHO) as ‘only breastmilk without any additional food or drink’ (Ingram et al, 2011), is recommended for the first 6 months of life followed by breastfeeding in combination with complementary solid foods up to 2 years of age (Ingram et al, 2011). Breastfeeding is the recommended feeding method due to the presence of bioactive agents in breast milk that aid infant development (Martin et al, 2016). Furthermore, it has significant health benefits for the mother, such as protection against breast cancer (Collaborative Group on Hormonal Factors in Breast Cancer, 2002).
In spite of recommendations, just 34% of mothers in the UK are still breastfeeding at 6 months, according to the 2010 Infant Feeding Survey (McAndrew et al, 2012). Prevalence varies greatly in the UK between groups of women and geographical regions. Broadly speaking, mothers from more affluent areas, in professional and managerial occupations, who have previously given birth are more likely to breastfeed than women of other demographics (McAndrew et al, 2012).
Many barriers hinder breastfeeding rates in the UK. Mothers with high levels of familial breastfeeding support, particularly from the father and maternal grandmother, are most likely to initiate breastfeeding (Odom et al, 2014). Additionally, a larger percentage of women with normal pre-pregnancy BMI (between 18.5-24.9 kg/m2) exclusively breastfeed at discharge and 3 months after birth, compared with overweight or obese mothers (BMI >25kg/m2) (Amir, 2007).
Work also affects breastfeeding rates, with women ranking ‘could not breastfeed because had to return to work’ (Arora et al, 2000) in the top three reasons why they did not breastfeed. The physical act of breastfeeding can also be challenging, particularly if the infant rejects the breast, and many women experience discomfort, which can result in early cessation (Arora et al, 2000).
Many interventions have been implemented to address these barriers and raise UK breastfeeding rates. As stated in a systematic review (Fairbank, 2000), breastfeeding interventions can be divided into five broad categories:
Interventions from the past 10 years featuring many of these categories will be discussed in this article. Many of them encompass UNICEF Baby Friendly standards and practices, and the Baby Friendly Initiative (BFI) is often used as a framework (Fairbank et al, 2000).
Aims
The objectives of this article are to:
This question will add to the literature, which has produced varied results on the best approaches to raise breastfeeding prevalence. If some or all of the interventions included here have been effective, then more work can be done to assess their feasibility and to implement them on a larger scale. However, if these interventions have proved to be ineffective, other strategies must be explored.
Methods
Literature search
Literature searches were performed using the following databases below. Table 1 highlights the previously published systematic reviews that have evaluated breastfeeding interventions and the reasons why they differ from this review.
| Systematic | Review Reason why different to this review |
|---|---|
| Fairbank et al (2000) | Outdated; evaluates different interventions to those in this review |
| Renfrew et al (2007) | Outdated; evaluates different interventions to those in this review; focuses specifically on disadvantaged groups; not just UK-based interventions |
| Hannula et al (2008) | Not just UK-based interventions |
| Haroon et al (2013) | Not just UK-based interventions |
| Beake et al (2012) | Not just UK-based interventions; solely support-based interventions |
| Balogun et al (2016) | Not just UK-based interventions |
| Renfrew et al (2012) | Not just UK-based interventions |
Search terms
In order to obtain all relevant articles, specific search terms were developed (Table 2), with which complex database searches were performed.
| Entry | Term | Number of results | |||
|---|---|---|---|---|---|
| PubMed | MEDLINE | Embase | MIDRS | ||
| 1 | Breastfeeding | 42 300 | 33 803 | 45 574 | 18 718 |
| 2 | UK | 964 165 | 214 023 | 388 386 | 7897 |
| 3 | Promotion |
7 662 285 | 2 005 512 | 2 834 643 | 37 816 |
| 4 | 1 AND 2 AND | 3 1342 | 185 | 306 | 526 |
Refining articles
Following the literature search the total number of articles obtained was 2359. Duplicates were removed, leaving 1936 articles to be refined, in a process delineated by the PRISMA diagram shown in Figure 1. Many articles were initially excluded on the basis of being irrelevant to the topic, non-UK based, or not addressing the question at hand. The remaining articles were further refined by reading their abstracts, narrowing down the number of articles to 24. Of these 24 articles, 3 were inaccessible and therefore had to be excluded. The remaining 21 articles were then read and 11 were removed based on inclusion and exclusion criteria (Table 3). The reference sections of each of these 10 articles were then scanned to obtain any relevant articles not yet identified, and two additional studies were subsequently found. The final number of articles for review was 12.
| Inclusion criteria | Exclusion criteria | |
|---|---|---|
| Population | UK | Non-UK |
| Studies involving mothers/fathers/staff from all backgrounds, ages, ethnicities | No restriction | |
| Interventions | Articles relating to breastfeeding interventions | Non-breastfeeding related interventions |
| All types of interventions | No restriction | |
| Outcomes | Studies must primarily focus on effects of interventions on breastfeeding outcomes | Studies that did not focus on breastfeeding outcomes of interventions |
| Time frame | Published from January 2008–March 2018 | Published pre-2008 |
| Study design | Quantitative and qualitative studies | Systematic reviews, critical reviews, meta-analyses |
| Language of articles | English language | Foreign language |
| Scientific research papers | Articles, books | |
| Primary research | Secondary or other research |
Methods of critical appraisal
Once the refining process was complete, the key findings from each article were extracted and entered into Table 4. Two articles (MacArthur et al, 2009; Jolly et al, 2012) included in this review were based on the same peer-support worker intervention in Birmingham. However, they assessed different outcome measures, and MacArthur et al (2009) only included the antenatal peer support delivered rather than both the antenatal and postnatal support. As such, for the purpose of this article they will be appraised and discussed separately. Critical appraisal of each of the 12 articles was then performed, with the aid of critical appraisal tools, in order to evaluate the literature and formulate a discussion.
| Intervention group | Sources | Explanation |
|---|---|---|
| Support-based interventions |
Hoddinott et al (2009)
|
Interventions that aim to provide support and assistance to breastfeeding mothers, often through the use of peer support workers or support groups |
| Incentives | Relton et al (2018) | Interventions that encourage mothers to continue breastfeeding by giving them gifts or monetary payments at points throughout their breastfeeding ‘journey’ |
| Health sector interventions |
Ball et al (2011)
|
Interventions that involve changes to some aspect of the health sector, such as training for staff, a change to policy or changes on the maternal ward |
| Combined interventions |
Hoddinott et al (2009)
|
Multiple interventions implemented together, within the same setting, to the same target group |
Results
The interventions included were categorised into four broad types, defined in Table 4, aided by a previous review (Fairbank et al, 2000).
Study summaries
Support-based interventions
Hoddinott et al (2009) carried out a cluster randomised controlled trial to assess the effectiveness of new breastfeeding groups for women at Scottish GP practices. No new GP practices were set up during the trial period in the control clusters, and women received usual care. Data were collected for 2 years before the trial and the 2 years after its implementation. The new breastfeeding groups were not associated with increases in breastfeeding rates at 6-8 weeks postpartum.
Jolly et al (2012) assessed the effectiveness of a low-intensity peer-support worker service in Birmingham in a cluster randomised controlled trial over a 6-month period. The support was provided antenatally for women intending to breastfeed and postnatally, while women in control clusters received usual care. The intervention had no effect on breastfeeding rates.
MacArthur et al (2009) implemented an antenatal low-intensity peer-support worker service in Birmingham and assessed its effect on breastfeeding initiation rates using a cluster randomised controlled trial. Outcomes were assessed over a 6-month period. Women in control clusters received usual care. The service was not associated with increases in breastfeeding initiation rates.
Ingram (2013) carried out a mixed-methods evaluation of a combined antenatal and postnatal peer-support worker service in Bristol. This service was set up in 2010, and evaluated for 12 months from the end of 2012. Despite the psychosocial benefits for mothers, the service was not associated with increased breastfeeding rates.
Scott et al (2017) produced a time series analysis of a Nottingham-based, high-intensity, peer–support intervention for mothers under 25 years of age. Support for mothers began antenatally and was carried through to 6 weeks postpartum, with data collected for the 4 years surrounding the intervention. Significant increases in rates at birth and 2 weeks postpartum were observed.
Incentives
Relton et al (2018) developed and implemented a financial incentive intervention in electoral wards across northern England. Breastfeeding women in intervention clusters were eligible for the incentives on top of usual care, while women in control wards received usual care only. The cluster randomised controlled trial ran for 14 months and was associated with an increase in breastfeeding prevalence at 6-8 weeks postpartum.
Health sector interventions
Ingram et al (2011) used a process evaluation to study the effects of BFI training for health visitors across Bristol, using data collected over the 3 years surrounding the training intervention. The training was associated with significant increases in rates at 8 weeks postpartum.
Bick et al (2012) used a longitudinal study to determine the effects of a breastfeeding policy change in a maternity unit in the south of England. Changes were made to the care provided in the maternity unit over a 10-month period and pre- and post-intervention data were collected. The intervention was associated with significant increases in rates at 10 days postpartum and in breastfeeding duration.
Ball et al (2011) carried out a randomised controlled trial to assess the effects of a sidecar crib instead of a standalone cot on the postnatal ward. The study was carried out in one maternity unit in Newcastle-on-Tyne over 28 months and saw no significant changes in breastfeeding rates.
Combined interventions
Hoddinott et al (2012) compared a reactive and a proactive telephone support service for breastfeeding women, as well as assessing the effectiveness of a feeding support team on a Scottish postnatal ward in 2010. A randomised controlled trial assessed the success of proactive telephone calls, while a before-and-after cohort study was used to assess the success of the feeding team. Both studies reported slight, although non-significant, increases in breastfeeding rates.
Thomson et al (2012) combined an gift incentive intervention with a pre-existing peer-support worker service, used as the control for the incentive intervention, in north-west England. The trial took the form of a prospective qualitative evaluation. Increases in breastfeeding rates were observed after the intervention.
Miller et al (2016) conducted a cross-sectional service evaluation over 9 months to determine the effectiveness of a combined midwifery and chiropractic clinic in southern England for mothers with breastfeeding difficulties, using a multidisciplinary approach. Attendance at the clinic was associated with increases in breastfeeding rates, although no cause and effect could be inferred.
Discussion
The aim of this review was to assess the effectiveness of interventions at increasing UK breastfeeding rates. Overall, there was uncertainty regarding what could be viewed as meaningful increases in breastfeeding rates. Statistically significant results may have a minimal effect on the population, although any improvements are of some value (Relton et al, 2018).
Support-based interventions
The only successful trial found was that by Scott et al (2017), which targeted young mothers. One difference was that the support offered in the study by Scott et al (2017) was high-intensity and offered both antenatally and postnatally, which may help to explain its success. However, the service evaluated by Ingram (2013) was of high-intensity but produced only small increases in rates, meaning intensity cannot be the only contributing factor. Furthermore, the study by Scott et al (2017) was the only study to target a specific demographic. It was also a smaller study, so a longer trial period would have been beneficial to observe if the intervention was still effective when catering for more women, which may put strain on the available resources.
In terms of the breastfeeding groups trial (Hoddinott et al, 2009), few women actually attended the groups during pregnancy and early postpartum, making it difficult to have a significant impact on rates. The Birmingham peer-support worker services (MacArthur et al, 2009; Jolly et al, 2012) failed to combat the breastfeeding difficulties that mothers cited pre-intervention, thus resulting in poor rates. Jolly et al (2012) reported that higher peer-support worker uptake may have increased its success, a theory supported by a Canadian study (Dennis et al, 2002), although high uptake was achieved in the unsuccessful trial by MacArthur et al (2009). Moreover, the Bristol peer-support worker service (Ingram, 2013) reported a high drop-out rate of peer-support workers, thereby reducing the continuity of support mothers that received and negatively affecting breastfeeding rates.
Nonetheless, the qualitative data indicates that mothers valued the interventions (Hoddinott et al, 2009; Ingram et al, 2013; Scott et al, 2017) suggesting that support services eased the breastfeeding process. Creating these more positive breastfeeding experiences may be a step in the right direction in terms of increasing breastfeeding rates in the future.
This mixed picture with regard to the effectiveness of support interventions is supported by previous literature. Low intensity interventions (Hoddinott et al, 2009; Ingram et al, 2013) appear to be broadly ineffective, and so increasing peer support intensity and targeting it at particular populations may improve its success (Scott et al, 2017). Increasing mothers' confidence in their breastfeeding abilities through support may have more long-term effects on breastfeeding outcomes that have not been captured here (Ingram et al, 2013).
Incentives
Significant increases in breastfeeding rates were reported after the implementation of financial incentives in the trial by Relton et al (2018). Such schemes may be an acceptable and effective way of encouraging breastfeeding, particularly as they have successfully promoted other maternal health behaviours (Tappin et al, 2015). The incentives acted as a motivator to encourage women to breastfeed, and assisted mothers experiencing difficulties. They may have instilled a sense that women's efforts were appreciated and encouraged women to reach breastfeeding ‘milestones’. Further trials into cost-effectiveness would be beneficial in order to determine the feasibility of providing incentives nationwide (Relton et al, 2018).
Health sector interventions
The UNICEF BFI training improved the knowledge and confidence of staff with regard to providing breastfeeding support (Ingram et al, 2011). The enhanced support for mothers eased the breastfeeding process and encouraged them to persevere; therefore, breastfeeding rates increased. Additionally, attendance at the training was high and the course was just 3 days long, showing that lengthy training is not necessarily required to produce results (Ingram et al, 2011).
Bick et al (2012) revised the care systems in place in order to increase the support for women around birth. This included promotion of early skin-to-skin contact, which is linked to increases in breastfeeding prevalence (McAndrew et al, 2012). Furthermore, the introduction of new postnatal records resulted in breastfeeding difficulties being addressed at an earlier stage, enabling mothers to continue breastfeeding (Bick et al, 2012).
The sidecar crib trial (Ball et al, 2011) was the only unsuccessful health sector intervention reviewed. The short amount of exposure to the sidecar crib may have contributed to this, as did the fact that many women in the intervention group did not actually receive the crib. The dominant intervention here may have been the weekly reporting of infant feeding, rather than the crib. As both trial arms were reporting this, the effect of this on breastfeeding rates cannot be determined (Ball et al, 2011), something that should also be considered in the other studies. Furthermore, women who initially did not intend to breastfeed were excluded from the trial so the impacts of the crib on initiation rates could not be measured (Ball et al, 2011).
The results of implementing health sector interventions are dependent on the type of intervention being trialled. These findings suggest that breastfeeding training for relevant health professionals should be encouraged nationwide. Increasing the knowledge and skills of staff enhances the quality of breastfeeding support delivered and may increase breastfeeding prevalence over time, a hypothesis supported by the results of a critical review assessing the effects of ongoing education for health professionals (Ward and Byrne, 2011). Changes to hospital policies regarding the delivery of support to mothers may also improve breastfeeding outcomes.
Combined interventions
Hoddinott et al (2012) implemented a feeding support team intervention to assist mothers on the postnatal ward and combined this with a telephone call intervention. Several factors may have contributed to the ineffectiveness of the feeding team intervention, including the prioritisation of care to trial participants. Moreover, the team had limited time so were unable to observe a breastfeed of all women on the ward or affect the 30% of women who stopped breastfeeding before discharge. Women may also have had breastfeeding difficulties that were not addressed, resulting in cessation. The positive, although statistically insignificant, findings of the telephone call may be explained by the increased levels of support provided to women in the intervention group, along with reluctance of women in the control group to contact the team (Hoddinott et al, 2012).
Thomson et al (2012) targeted disadvantaged breastfeeding women with a combined peer support and incentives intervention. The incentives, which included café vouchers, provided encouragement to mothers to breastfeed outside the home and gave women access to a wider support network, which is a promising finding, even if the increases in rates were non-significant. The gift-giving process increased contact between mothers and peer–support workers, enabling meaningful relationships to be formed. Increasing the time that mothers had with peer–support workers encouraged discussions of more sensitive breastfeeding issues, and enabled peer–support workers to provide personalised support (Thomson et al, 2012).
The study by Miller et al (2016), which provided a combined midwifery and a chiropractic clinic, showed some success, which may in part be due to high maternal satisfaction and positive attitudes of mothers towards breastfeeding following clinic attendance. Longer appointment times than those available elsewhere allowed more breastfeeding difficulties to be addressed, with provision of more personalised care (Miller et al, 2016).
Combined interventions can be effective, a theory supported by the results of a systematic review (Fairbank et al, 2000), although more work regarding their feasibility and cost-effectiveness is required to determine their future place in maternal care. It is also important to consider that chiropractic treatment is not widely used in the UK (Harris et al, 2012) so this intervention may have limited scope for implementation in the NHS.
Other points and areas for future research
In the case of all the interventions discussed, it may have been beneficial to perform longer-term follow-up in order to determine the full extent of their effect on breastfeeding rates, as changes in infant feeding behaviours take time to achieve (Ingram et al, 2013). Many of the interventions may have had additional benefits, such as normalising breastfeeding, but this is difficult to evaluate and may only reveal itself further down the line when national breastfeeding rates are reassessed. It is important to note that although there is uncertainty regarding the generalisability of many interventions, this is not of great concern, given that effective interventions were those targeted at specific demographics.
The literature suggests that women make their infant feeding decisions at an earlier stage, with breastfeeding duration positively associated with an early breastfeeding decision (Dennis, 2002). Therefore, targeting women during their first trimester may be more effective than targeting postpartum women. Additionally, educating young people about breastfeeding, thus normalising it, is likely to increase many people's motivation to breastfeed or support a partner to do so, and so positively affecting future breastfeeding rates (Giles et al, 2014).
Limitations
In scanning the references of the articles, two additional articles were picked up. This suggests that perhaps the search strategy was not extensive enough, due to the time constraints and the use of only one researcher. This may also have resulted in citation bias (Jannot et al, 2013).
Conclusion
This review has demonstrated that a wide range of interventions have been implemented in attempts to increase UK breastfeeding rates, with varying levels of effectiveness. Interventions showed that a team of midwives and ‘lower grade’ staff were capable of delivering effective support (Hoddinott et al, 2012). The interventions included here were widely accepted and supported by mothers and clinicians.
The key to an effective intervention appears to lie in the provision of personalised care for mothers that helps them overcome breastfeeding difficulties and rewards them for their efforts. Future interventions should aim to provide more tailored support for mothers with a focus on early identification and management of breastfeeding difficulties and positive reinforcement of breastfeeding behaviours. Further research into the cost-effectiveness and long-term success of interventions is required. Interventions implemented in communities may have the added benefit of communicating the value of breastfeeding to the wider population. By supporting breastfeeding mothers and moving towards a culture where it is seen as normal to breastfeed (Johnson et al, 2018) over and above ‘breast is best’ (Earle, 2002), the future of breastfeeding in the UK may begin to look more positive.