A Literature Review of Breastfeeding Interventions

Megan Hensley
Health 634 DO2
November 12, 2015

Introduction
This literature review seeks to analyze the effectiveness of
breastfeeding interventions within low-socioeconomic populations. The
benefits of breastfeeding are well recognized and difficult to argue.
Breastfeeding has physical, psychological, economical, and environmental
benefits for both mother and baby.1 Breast milk is the perfect formula that
changes to meet the babys specific needs and provide the perfect nutrition. 1
The World Health Organization (WHO) estimates that millions of infants
contract infectious diseases and malnutrition as a result of formula feeding
as opposed to breastfeeding.2 Even with several prominent health
organizations recommending breastfeeding, many women still choose to use
infant formula.2 This could be a result of misconceptions regarding
breastfeeding, lack of support from family and friends, limitations in work
environments, or pain and difficulties associated with breastfeeding.
This Health Communication Program Plan strives to provide women
with the resources and support they need to make the choice to successfully
breastfeed their child. The program intervention described in this literature
review seeks to increase the proportion of infants who are breastfed through
public health education and encouraging worksite lactation rooms. Health
communication interventions are aimed at breaking the barriers to
successful breastfeeding. The program will provide support and guidance to
mothers to increase initiation and duration of breastfeeding.

The demographic of the target audience is low-income women with a

low educational attainment. Low income women are more likely to return to
work earlier and be in a job setting that makes it more challenging to
breastfeed than those with a higher income.3 The program will serve women
of multiple-cultures specifically any religion, ethnicity, and family structure.
The program will be equipped to serve English speaking populations. The
physical characteristics for the target audience are females of child bearing
age and breastfeeding mothers. This program looks to target pregnant
women who are interested in breastfeeding.
The program will recruit participants through referrals from childbirth
classes, hospitals, physician offices, WIC program, churches, and word-ofmouth. The participants will be invited through to learn about breastfeeding
their child through small group educational classes. At the small group
sessions, women who have successfully breastfed, who the participants can
identify with, will share their experiences to encourage the participants to
breastfeed. In addition, nutritionists and lactation consultants will inspire
expecting or new mothers to make breastfeeding part of their childrens
nutritional plan. When a participant cannot physically breastfeed, the
program will set them up with a WIC nutritionist to get loaner breastpump so
they can still feed their babies breastmilk. The health communication
program will partner with Women, Infants, and Children (WIC). Since 1972,
WIC has been serving vulnerable populations by providing nutrition
education and supplemental nutrition to low-income pregnant,

breastfeeding, and post-partum women, infants and children who are found
to be at nutritional risk.4
The intervention program will seek to increase breastfeeding through a
variety of means such as education, continuity of care, breastfeeding
equipment, social support, and employer support. The organization of the
review will be broken down into the above intervention categories. The
primary prevention intervention will be education classes to reach out to
mothers before, during, and after birth of their baby. In addition, staff will
work with local employers to provide new mothers with breastfeeding
supplies.
A comprehensive electronic literature search was conducted using
ProQuest and hand searches of article references. The literature search was
limited to articles published in English between November 2007 and
November 2015. Articles were excluded if they had conflicts of interest
relevant to breastfeeding. Keywords and medical subject headings used for
searching were breastfeeding and low-socioeconomic status. The initial
search yielded 2,107 hits. After reviewing the citations and abstracts of the
2,107 articles, the articles that did not pertain to the subject or meet the
inclusion criteria were filtered out.

Body of Evidence
Of the 10 articles used in this literature review, eight were case studies
and two were reviews.

It was unanimous in all ten articles that social determinants of health

exist that impact whether or not a mother breastfeeds. These social
determinants include social support and socioeconomic factors such as
maternal educational attainment, maternal income, and unemployment.
These social determinants are a vicious cycle and continuously influence
each other. The qualitative case study by Jacobson and Wetta evaluated the
breastfeeding interventions of eighteen public health departments in
Kansas.2 During this study many health departments reported that WIC
clients used their program often.2 In addition, many studies have showen an
association between the WIC program and low rates of breastfeeding
initiation since the WIC clientele present most of the risk factors for not
breastfeeding.5 In order to qualify as a WIC client, the individual must be lowincome; therefore, using the WIC program as a partner in the intervention is
justified.4 A prospective cohort study by Flacking and colleagues in Sweden
and a secondary analysis in Australia examined the effect of socioeconomic
status on breastfeeding duration.6, 7 These studies determined that all
socioeconomic factors were strongly associated with breastfeeding
duration.6,7 Research shows that mothers with low educational attainment
wean their children earlier than those of higher education.6
In addition to the disparity in breastfeeding initiation and duration, a
study by Alexander and colleagues explain low-income African American
women have the lowest rates of breastfeeding initiation at 61.4% compared
to other women at 74.2%.8 In addition, low-income African American women

have the lowest rate of exclusive breastfeeding until 6 months at 6.5%

compared to other women at 11.9%.8
Four articles proposed the prenatal education a mother receives
influences her decision to initiate and continue breastfeeding making
education a worthwhile intervention.3 Reviews by both the U.S. Preventive
Services Task Force and Cochrane review found that education on
breastfeeding is the most effective intervention for increasing breastfeeding
initiation.3 The CDC reports that prenatal education on breastfeeding can
change a mothers decision to consider it as a feeding option.3 Successful
educational interventions use problem solving and role-play activities. A
study in Australia found that interventions that incorporated breastfeeding
problem solving activities showed 92% of women breastfeeding at 6 weeks
compared to 29% in the control group.9 A prospective study examining
women in the ECI program, Canadas version of WIC, found that women who
participated in the prenatal educational classes were positively associated
with breastfeeding initiation.10

Peer support and advice from others is a commonly mentioned reason

for making the decision to initiate or continue to breastfeed as discussed in
five articles.3 A strong system of peer support is a good predictor of
successful breastfeeding plan.3 The goal of this portion of the intervention is
to use individual counseling and support from other mothers to encourage
pregnant women to initiate breastfeeding and support mothers currently

breastfeeding. This intervention is necessary as many women receive

negative support from their spouses. The prospective cross sectional study,
What Do Pregnant Low-Income Women Say About Breastfeeding?, found
that many fathers discouraged the mother from breastfeeding. Some of the
reasons the fathers gave the mothers include, I dont know, you dont
want to know, boy will be a sissy, baby will be spoiled, and I wants to
participate in feeding the baby.8 Additionally, a case study by Vaaler and
colleagues suggested that lack of support from fathers sways the mother to
chose formula as the feeding type.11 The peer support groups offered in this
intervention are intended to improve a mothers self-efficacy through
guidance and support of peers with similar experiences. A review by Susan
Tawia suggests women with a high self-efficacy are 1.6 times more likely to
be breastfeeding at 4 months compared to women with low self-efficacy.9
There were four articles that discussed the effect of the work
environment on early cessation of breastfeeding. According to the CDC,
women with low income are more likely to return to work earlier and be in a
job setting that makes it more challenging to breastfeed.3 In addition, Tawia
suggests that the earlier a mother returns to work, the less likely she is to
breastfeed.9 A study by Mandal and colleagues found that women who return
to work one week earlier than average, stopped breastfeeding two thirds of a
week earlier than the average.12 The health communication intervention will
work with employers to provide essential breastfeeding supplies such as
small refrigerators, rocking chairs, and ottomans. This will allow mothers to

use the loaner pumps to provide breast milk for their children even when
they are at work.

Summary and Conclusions

The American Academy of Pediatrics recommends that mothers
exclusively breastfeed for the first six months of life followed by continuous
breastfeeding until the infant is one while introducing age appropriate
foods.2,11 The current research shows that women of low socioeconomic
status have the lowest rates of breastfeeding. 2,3,6,7,8,9,10,12 A breastfeeding
intervention aimed at this population would be justified.
Research shows that early termination of breastfeeding is associated
with lack of prenatal education, returning to work, lacks of social support,
lack of timely postpartum follow-up care, and school responsibilities.2,3 The
interventions discussed in this literature review are aimed at breastfeeding
factors that are modifiable. These interventions intend to provide guidance
and support, boost a mothers confidence and self-esteem to inspire her to
initiate breastfeeding.
All of the references found in this literature review agreed that the
factors that make up low socioeconomic status are associated with a lower
rate of breastfeeding initiation and duration. In addition, all of the studies
that examined educational program and peer support had evidence to show
that prenatal education increases rates of breastfeeding initiation. However,
it should be noted that four of the case studies were not performed in the

United States. One of the studies was performed in Sweden, one in Canada,
and two in Australia. Although these studies focused on low-income women,
the populations are from different countries.