Successful promotion of the benefits of breastfeeding requires balanced co-ordination of education and peer support for mothers, as well as training for healthcare staff, write Lisa Fairbank and Sue O'Meara

Breastfeeding is a key public health issue and offers benefits to both the mother and her baby. These include protection against gastroenteritis, respiratory infection and otitis media for the baby and against premenopausal breast, ovarian and endometrial cancers for the mother. Breastfeeding also protects against the hazards associated with bottle-feeding such as contamination and inaccurate preparation of feeds.

Despite the benefits, the numbers of women initiating and maintaining breastfeeding have remained static since 1980.

Across the UK, initiation rates range from approximately 40 per cent to 60 per cent depending on region, with 50 per cent of women from social class 5 starting to breastfeed, compared with 90 per cent from social class 1.

1 The health departments in England, Northern Ireland, Scotland and Wales are taking steps to increase these rates - for example, by appointing national infant feeding advisers, who are responsible for assisting with the development and implementation of breastfeeding strategies.

Increasing initiation rates Strategies to increase the uptake of breastfeeding should be informed by good-quality research evidence about what works. The latest edition of Effective Health Care summarises the research evidence on the effectiveness of interventions to promote breastfeeding and makes recommendations for policy and practice.

2 It is based on a systematic review commissioned by the NHS health technology assessment programme.

3 A variety of interventions have been evaluated, including health education, changes to the organisation and/or delivery of healthcare, peer support programmes and media campaigns. Many of the studies were carried out in the US, which may limit the applicability to UK settings as sociocultural factors are an important influence, particularly in relation to acceptability.

Health education interventions The interventions covered in the bulletin ranged from providing single leaflets or pamphlets to group educational sessions.

Irrespective of the way the information was delivered, most interventions focused on the benefits of breastfeeding.

Some also included information about how to breastfeed.

Overall, the results suggest that small, informal discussion classes, emphasising the benefits of breastfeeding, can increase initiation rates and may be particularly effective among women of certain ethnic groups.

In contrast, breastfeeding literature used on its own was found to have limited impact on initiation rates.

Health sector initiatives The organisation of health services is likely to influence the choice and ability of mothers to breastfeed. Even when a policy supporting breastfeeding is in place, mothers may still experience poor practice, such as separation from their babies on the first night after birth.

Health sector initiatives range from professional training for healthcare workers to international programmes such as the baby-friendly hospital initiative and the US Department of Agriculture special supplemental nutrition programme for women, infants and children.

The UK BFHI was launched in 1994 with the aim of helping all parents to make informed decisions about feeding their babies and then supporting them in their chosen method. Currently in the UK there are 29 fully accredited baby-friendly hospitals.

Although no good-quality evaluations of the effectiveness of the BFHI were found, one randomised controlled trial evaluated the implementation of the '10 steps to successful breastfeeding'.

The hospitals which received training on the 10 steps were more likely to have implemented the recommendations, and health professionals were more positive towards making changes to their routines and practices. The UK BFHI offers breastfeeding training courses for health professionals but their effectiveness has yet to be established.

Evaluations of the women, infants and children programme targeting pregnant women on low income throughout the US suggested such programmes were generally effective, particularly when peer support was included.

Peer support programmes There is also some evidence for the effectiveness of peer support programmes when evaluated as stand-alone interventions. When experienced and trained peers offered support to low-income, socially disadvantaged women, breastfeeding initiation rates were found to increase.

In a separate study using qualitative methods to collect data from first-time mothers living in a deprived inner city in the UK, regular exposure to women breastfeeding was found to be an important factor in encouraging others to follow suit.

Media campaigns Evidence for the impact of media campaigns was very limited and only two studies using 'before and after' designs were found. Breastfeeding rates and attitudes towards breastfeeding were reported to improve after the intervention. However, it is difficult to attribute any change directly to the campaigns as there were no control groups.

National media campaigns such as breastfeeding awareness week, together with local media activities, can raise public awareness. Their impact in shaping cultural norms and influencing breastfeeding rates needs to be monitored.

Implications Trusts have an important role to play in promoting breastfeeding and should consider updating their policies so as to reflect what has been shown to be effective. This might include evaluation of existing breastfeeding literature and the audit of education programmes. Where they are currently not available, small discussion classes focusing on the benefits of breastfeeding and practical information about how to breastfeed could be offered. Training for health professionals may be necessary so that consistent information about breastfeeding is given to women.

Although evidence for the effectiveness of providing training for health professionals is limited, this should not be taken as evidence of no effect. Where courses are provided their impact needs to be assessed. In addition to professional advice, pregnant women are likely to benefit from access to peer support, offered by organisations such as the National Childbirth Trust, the Association of Breastfeeding Mothers, the Breastfeeding Network and La Leche League. Again, the impact of peer support programmes needs to be monitored.

Trusts may also consider working towards achieving 'baby-friendly' status. They are then required to develop a written breastfeeding policy, provide training for staff, offer information to women about the benefits of breastfeeding and practical advice about how to breastfeed, as well as providing an environment which is supportive of breastfeeding.

The introduction of current good practice needs to be monitored and, as a minimum, breastfeeding rates should be routinely recorded. The 1997 review of maternity services by The Audit Commission found that only eight out of the 13 trusts visited could provide information about breastfeeding rates at hospital discharge. Guidance on the use of standard definitions for measuring initiation rates would help to monitor breastfeeding. The definition of 'ever breastfed' as used in national surveys of infant feeding could be adopted


1 Foster K, Lader D, Cheesbrough S. Infant feeding 1995. Office for National Statistics: The Stationery Office, 1997.

2 Promoting the initiation of breastfeeding. Effective Health Care 2000; 6 (2).

3 Fairbank L, O'Meara S, Woolridge M, Sowden A, Renfrew M, ListerSharp D. A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding. Health Technol Assess (forthcoming).

Effective Health Care is an independent report based on systematic reviews of the research evidence, produced by the NHS centre for reviews and dissemination at York Un ivers ity. The bullet in aims to provide NHS decision-makers with information on the effectiveness of interventions and the delivery and organisation of health care. For more information phone 01904-433648 or email Effective Health Care is at