Authors' objectives: Breastfeeding impacts positively on multiple health outcomes, but < 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding. To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS. Breastfeeding impacts positively on multiple health outcomes across the lifespan. Global and UK infant recommendations are that infants should receive breastmilk exclusively for 6 months and as part of a mixed diet until 2 years. However, fewer than half of UK women are breastfeeding at 6–8 weeks, with a marked social gradient. This study aimed to synthesise global and UK evidence in order to co-create with stakeholders a framework to guide the implementation and evaluation of cost-effective breastfeeding support interventions in the NHS: Update the Cochrane review ‘Support for healthy breastfeeding mothers with healthy term babies’ (McFadden A, Gavine A, Renfrew MJ, Wade A, Buchanan P, Taylor JL, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev 2017;2:CD001141). Synthesise process evaluations of breastfeeding support interventions. Conduct an economic evaluation of interventions to enable women to breastfeed. Conduct a systematic review of breastfeeding support interventions for women with long-term conditions (LTCs). Synthesise evidence of barriers to and facilitators of breastfeeding support for women with LTCs. Conduct a systematic review of economic evaluations of breastfeeding support interventions. Co-create a NHS-tailored implementation and evaluation strategy framework to increase breastfeeding rates in the UK. Contribute to methodological development on involving stakeholders in systematic reviews.

Authors' results and conclusions: We found considerably more interventions designed for healthy women (review 1) than aimed at women with long-term conditions (reviews 1 and 4); approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and the impact of support may be different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) and involving these sources in the provision of breastfeeding support for women with long-term conditions. In reviews 3 and 6, there was uncertainty about the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence. ‘Breastfeeding only’ support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for ‘breastfeeding plus’ interventions is less consistent, but these may reduce the number of women stopping exclusive breastfeeding at 4–6 weeks and at 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good-quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women’s and supporters’ needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK. We found considerably more interventions designed for healthy women (review 1) than aimed at women with LTCs (review 2). ‘Breastfeeding only’ interventions probably have a small effect in reducing the number of healthy women stopping breastfeeding. However, ‘breastfeeding plus’ and interventions for women with LTCs probably have little or no effect on breastfeeding outcomes. In both reviews, approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and it is possible that the impact of support is different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed participants’ suggestions of potential strategies to improve breastfeeding support, the most widely reported being the need to involve wider sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) in supporting women with LTCs to breastfeed. In reviews 3 and 6, there was uncertainty in the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence. More specific findings from each review are presented below. Review 1 This updated review includes 125 interventions reported in 116 trials with more than 98,816 mother–infant pairs. Ninety-one interventions were ‘breastfeeding only’ and 34 were ‘breastfeeding plus’. The overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions, and, as studies used self‐report breastfeeding data, there is also a risk of bias in outcome assessment. Moderate‐certainty evidence indicated that ‘breastfeeding only’ support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at 6 months [relative risk (RR) 0.93, 95% confidence interval (CI) 0.89 to 0.97]; stopping exclusive breastfeeding at 6 months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4–6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4–6 weeks (RR 0.83, 95% CI 0.76 to 0.90). The evidence for ‘breastfeeding plus’ was less consistent. Interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4–6 weeks (RR 0.73, 95% CI 0.57 to 0.95, very uncertain evidence) and 6 months (RR 0.79, 95% CI 0.70 to 0.90, moderate-certainty evidence). However, ‘breastfeeding plus’ support probably results in little to no difference in other breastfeeding outcomes. We conducted meta‐regression to explore substantial heterogeneity for the primary outcomes. Minimal differential effects were found except for a schedule of four to eight visits possibly associated with more beneficial effects. There was a lack of evidence for UK effective interventions. ‘Breastfeeding only’ support can increase the duration and exclusivity of breastfeeding in healthy women. For ‘breastfeeding plus’ and interventions for women with LTCs the evidence is less certain and there is probably little effect on breastfeeding outcomes. As the mixed-methods synthesis and stakeholder work identified that women with LTCs face additional challenges when breastfeeding, more research is needed to develop effective and cost-effective support. Evidence for the effectiveness and cost-effectiveness of breastfeeding support interventions in the UK is lacking. Implications for health care Decision-makers and frontline practitioners can use the toolkit to inform implementation efforts, to overcome barriers specific to their settings and to tailor evidence-based interventions to their populations. Key to success will be addressing health system barriers and enhancing the skills, knowledge and confidence of practitioners. Regarding women with LTCs, stakeholder engagement suggested health services could integrate infant-feeding specialists with the multidisciplinary team to give infant feeding a higher profile in obstetric and medical care.

Authors' recommendations: Development and evaluation of breastfeeding support interventions for women with LTCs and multimorbidities, particularly mental health conditions, overweight/obesity and gestational diabetes. Focus on understanding the components of breastfeeding support interventions that make them effective, including which components would be more effective in populations at risk of poorer breastfeeding outcomes (e.g. areas of high socioeconomic deprivation), and understanding why ‘breastfeeding plus’ interventions are less effective. Implementing and evaluating effective breastfeeding support in the UK for all women. This could evaluate the prototype intervention proposed in this report tailored to local contexts via implementation and effectiveness and cost-effectiveness studies or using quality improvement methodology.

Authors' methods: Evidence syntheses with stakeholder engagement. Systematic reviews examined effectiveness of breastfeeding support for (1) healthy women and (2) women with long-term conditions using Cochrane Pregnancy and Childbirth Group methods. Mixed-methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women and experiences of receiving/providing support for breastfeeding women with long-term conditions. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following National Institute for Health and Care Excellence guidance. All searches were conducted from May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were 23 stakeholders, 16 parents in the parents’ panels, 15 women in the focus groups and 87 stakeholders who attended the workshops. There was a lack of evidence for the effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information reported about intervention characteristics. The study comprised two meta-analyses of breastfeeding support interventions, two mixed-methods evidence syntheses and two economic evaluations with embedded stakeholder engagement, including parents’ panels, stakeholder working groups, focus groups and workshops. Stakeholders interpreted and adapted the international evidence to ensure its relevance to UK settings and co-produced the toolkit. Review 1: update of Cochrane review ‘Support for healthy breastfeeding mothers with healthy term babies’ The Cochrane Pregnancy and Childbirth Group’s Trials Register was searched in May 2021. Healthy women and babies were those who did not require additional medical care. Interventions could be delivered as standalone breastfeeding support interventions (‘breastfeeding only’) or as part of a wider maternal and newborn health intervention (‘breastfeeding plus’) where additional services (e.g. vaccination, intrapartum care) are provided. Primary outcomes were stopping any or exclusive breastfeeding at 6 months and 4–6 weeks postpartum. We used standard Cochrane methods for data extraction, risk-of-bias assessment and statistical analysis. We used meta-regression to investigate statistical heterogeneity.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR130995

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/DGTP5702

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/DGTP5702

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk