An extended midwifery support programme did not increase breast feeding at 6 months, compared with standard postnatal midwifery support
- Correspondence to Louise M Wallace
Applied Research Centre Health & Lifestyles Interventions, Coventry University, Coventry CV1 5FB, UK;
Breastfeeding for health gain
It is well known that resorting to infant-feeding methods other than breastfeeding has negative implications for both mother and infant. Exclusive breastfeeding is currently promoted for at least the first 6 months of life; however, even in countries where recent efforts have been made to improve initiation of breastfeeding, the trend shows that few babies are exclusively breastfed over this period. The fragility of breastfeeding is underscored by numerous studies that show breastfeeding duration is seldom achieved for as long as intended.
A pragmatic RCT
The study compares a standard midwifery support (SMS) to an extended midwifery programme (EMS) in a randomised controlled trial (RCT) design which recruited 849 mothers and singleton babies who wished to breastfeed. The intervention consists of a brief post-delivery educational session and twice-weekly phone calls and the offer of weekly home visits until the baby is 6 weeks old. This is delivered by one of four midwives who have had (unspecified) breastfeeding training but are not certified lactation consultants.
Measurements were taken by survey and feeding diaries, with surveys applied at 2 and 6 months postpartum, and telephone completion for those unwilling to return surveys. Completion of some follow-up was more than 96% in both arms. The sample was stratified for parity and education level. The study used intention-to-treat analyses, with relative risks (RRs) and confidence intervals (CI) adjusted for stratification.
There were no differences on any breastfeeding outcomes at 6 months, and no differences emerged when data were adjusted for variables associated with breastfeeding cessation before 6 months. Data were combined to analyse predictors of breastfeeding cessation, and the occurrence of self-reported breastfeeding problems. The authors conclude that the EMS programme did not improve breastfeeding duration in a setting of high initiation. In both groups the commonest reason for cessation was perceived milk insufficiency.
The trial was well conducted, with adequate power, and randomisation concealment and high response rates maintained to 6-month follow-up.
It is unclear whether the evaluators were blind to assignment; therefore, it is possible there is an ascertainment bias. The authors refer to the higher-than-expected breastfeeding rates in the control arm, which also suggests a possible bias in recruitment. The authors do not explain why only 22.8% of those eligible were approached. Also, 32.2% refused to participate, raising questions about the generalisability of the study and the acceptability of the intervention for the target population.
The study has a pragmatic advantage: it tests an intervention that can also be provided by non-specialists. However, no data are presented on the fidelity of the intervention, that is, how much of the intervention was received and to what standard or quality was this delivered, or whether there were differences in delivery by the four midwives. The cluster effect of midwife is not adjusted for.1 2 That is, some practitioners may be more effective with particular mothers than others, which has important implications for future interventions.
Mother-centred design of interventions
The authors suggest research is needed into why mothers cease early and why they attribute cessation to insufficient milk supply and unsettled babies and that they may not be (sufficiently) anxious about switching to formula. The absence of the mothers' ‘voice’ in this study is striking. Views of mothers receiving a postnatal intervention, also in Western Australia, show the wide range of views about what facilitated and what hindered their attempts to breastfeed, with many reporting adverse effects of aspects of the intervention and the services in which these are situated on the mothers' self-confidence.3
There is good evidence that professionally delivered educational interventions are ineffective on breastfeeding duration. Breastfeeding is a skill conducted in a social and emotional context. Future interventions should target support to build and maintain self-efficacy to maintain the preferred feeding choice. A good place to start is by asking mothers what they need, and designing and delivering mother-centred services. Within these services, studies should pay as much attention to measuring the process of delivery as the outcome, in order to understand how to enhance the self-efficacy of women to make decisions and follow through on their intention to feed their baby in the healthiest way.
Competing interests LW is a director and shareholder of Health Behaviour Research Ltd, a company that uses the results of research to provide evidence-based interventions, including training healthcare staff in breastfeeding support skills.