a systematic review of peer support interventions for breastfeeding

REVIEW

A systematic review of peer support interventions for breastfeeding

Marja Kaunonen, Leena Hannula and Marja-Terttu Tarkka

Aims and objectives. The objective of this systematic review was to describe peer support interventions supporting breastfeeding

during pregnancy and the postnatal period.

Background. Breastfeeding is an effective way to promote infants’ health. Including a peer support element in breastfeeding

programmes is a highly successful way to increase breastfeeding.

Design. A systematic literature review.

Methods. The review was conducted from the CINAHL, MEDLINE and the Cochrane Library databases from year 2000 until

the end of February 2008. According to the inclusion criteria, the adopted studies focused on breastfeeding, breastfeeding

support interventions and education of healthy mothers and infants from the perspective of mothers or family members.

Additionally, the studies had to be conducted in Europe, North America, Australia or New Zealand to meet the criteria. Articles

combining peer support and professional support were also included in the study.

Results. The results indicated that during pregnancy, hospitalisation and the postnatal period, individual support and edu-

cation were used most commonly. Peer support was strongly associated with the postnatal period. The combination of

professional support and peer support by trained and experienced peer supporters was effective in ensuring the continuation

of breastfeeding.

Conclusions. Only continuous breastfeeding support produces effective results. Diverse types of interventions are needed

during different phases of motherhood. The role of peer support is most important during the postnatal period. If profes-

sional support is not available for mothers, peer support could provide an alternative worth considering.

Relevance to clinical practice. Professionals require breastfeeding education to act as breastfeeding supporters as well as the

support of their organisations in this work. Moreover, professionals need to gain knowledge of the role of peer support

regarding the efficient combination of professional support and peer support to increase breastfeeding.

Key words: breastfeeding, intervention, midwifery, nurses, nursing, peer support, systematic review

Accepted for publication: 13 December 2011

Introduction

In-depth research on the process of peer support for breast-

feeding mothers is still scarce. The perspectives of peers,

mothers and healthcare professionals have not been studied

extensively to explain the effectiveness of peer support.

However, peer support for breastfeeding is growing in

popularity throughout the UK (Britten et al. 2006), and

careful evaluation is needed of the process of peer support

from the viewpoint of all participants, and of its cost-

effectiveness and the impact on breastfeeding rates to ensure

appropriate service development.

Authors: Marja Kaunonen, PhD, RN, Professor, School of Health

Sciences, University of Tampere, Tampere University Hospital/

Science Center, Tampere; Leena Hannula, PhD, Researcher and

Senior Lecturer, Faculty of Health Care and Nursing, Helsinki

Metropolia University of Applied Sciences, Metropolia; Marja-Terttu

Tarkka, PhD, RN, Adjunct Professor, School of Health Sciences,

University of Tampere, Tampere, Finland

Correspondence: Marja Kaunonen, Professor, School of Health

Sciences, University of Tampere, Tampere FI-33014, Finland.

Telephone: +358 40 190 1454.

E-mail: [email protected]

� 2012 Blackwell Publishing Ltd

Journal of Clinical Nursing, 21, 1943–1954, doi: 10.1111/j.1365-2702.2012.04071.x 1943

Mothers receive professional social support for breastfeed-

ing, especially when they initiate breastfeeding. However, the

availability of and access to professional support vary. When

developing new breastfeeding promotion programmes, a

good way to increase the success of the programme is to

include a peer support element (Hannula et al. 2008).

Peer support can be defined as systematic support between

two persons or in a group. The participants are regarded as

equals. They act in the role of a supporter, or they receive

support. A peer supporter is a person who supports breast-

feeding, excluding healthcare professionals. For example,

partners, grandmothers, relatives, friends or other breast-

feeding mothers may act as peer supporters (Rossmann

2007). Attitudes and support from partners, relatives and

peers affect the initiation of breastfeeding, and social support

from close relatives and peers has an impact on its contin-

uation. In particular, partners were the most important

source of social support for many mothers (Tarkka et al.

1998, Hannula 2003, Swanson & Power 2005). Mothers

who received doula support during labour were more likely

to initiate breastfeeding and were more satisfied with the care

they received during their hospital stay than those in the

control group (Campbell et al. 2007). Female relatives, such

as grandmothers, influenced decision-making in giving solid

food earlier than recommended (Barton 2001). Similarly, the

availability of babysitting by female relatives increased the

rate of early breastfeeding discontinuation in England (Bick

et al. 1998). Efforts have been made to educate partners,

grandmothers and peers to give breastfeeding support, but

the evidence on this kind of effective support from peers is

scarce. The same applies to education of peers. Because of the

limited resources in health care today, a great need exists to

improve breastfeeding support by combining professional

and peer support.

The purpose of this systematic literature review (Chalmers

& Altman 1995, Khan et al. 2003) was to describe peer

support interventions supporting breastfeeding during preg-

nancy and the postnatal period. The following were the study

questions:

1 Who are the peer supporters and what kind of training do

they need?

2 How did peers support breastfeeding a) during pregnancy b)

at maternity hospital and c) during the postnatal period?

3 How effective are peer support interventions in supporting

breastfeeding?

Methods

We searched the CINAHL, MEDLINE and the Cochrane

Library databases from year 2000 until the end of February

2008. The search terms included in CINAHL: Exp *Breast

Feeding/and Patient Education/or Health Education/or Par-

enting education/or counseling/or anticipatory guidance/or

couples counselling/or peer counselling/or exp support, Psy-

chosocial/or exp Health Promotion/; in MEDLINE: *Breast

Feeding/and Patient Education/or Health Education/or coun-

selling/or directive counselling/or social support/or exp

Health Promotion/; and in Cochrane Library: ‘Breastfeeding’

or’ breast feeding’ and ‘patient education’ or ‘health educa-

tion’ or ‘counselling’ or ‘directive counselling’ or ‘social

support’ or ‘health promotion’. According to the inclusion

criteria, the studies focused on breastfeeding, breastfeeding

peer support interventions and education of healthy mothers

and infants from the perspective of mothers or family

members. The studies had to be conducted in Europe, North

America, Australia or New Zealand to meet the inclusion

criteria. Articles combining peer support and professional

support were also included in the study. The review was

limited to articles representing original studies or reviews.

The total number of references that came up with the

search terms used was 960, of which 321 were from the

CINAHL, 543 from MEDLINE and 96 from the Cochrane

Library (Fig. 1). Three reviewers independently reviewed all

the titles and abstracts for inclusion using the following

exclusion criteria. First, the study was conducted in develop-

ing countries. Second, it described breastfeeding statistics,

health benefits of breastfeeding, using formula supplements,

famine prevention, breastfeeding of sick mothers and

Database selection: CINAHL1, Medline2, Cochrane3

Keyword selection

Total search results (titles): 3211 + 5432 + 963 = 960

Articles included by the title (abstracts)Articles excluded by the title

183 + 311 + 43 = 537138 + 232 + 53

Articles included by the abstracts Articles excluded by the abstracts

421 + 382 + 133 = 93 141 + 273 + 30 = 444

Articles included by the full text:Articles excluded by the full text

91 + 282 + 83 = 45(n = 2)

Articles included after the qualityscreening n = 43

Articles excluded by their quality(n = 9)

Articles to be analysed (n = 34)

Figure 1 Data extraction.

M. Kaunonen et al.


1944 Journal of Clinical Nursing, 21, 1943–1954

newborns, breastfeeding of premature newborns or breast-

feeding attitudes of various groups. Third, the article was

conducted solely from the perspective of professionals.

After the exclusion of the unsuitable articles based on the

above-mentioned criteria, 537 (the CINAHL, 183; MED-

LINE, 311; and the Cochrane Library, 43) abstracts were

subject to scrutiny, leaving 93 full texts to read. Duplicate

articles were excluded from the study. Hence, 45 articles of

peer support for breastfeeding or combination of professional

and peer support were selected for a thorough analysis. After

applying the inclusion criteria, we were left with 43 articles.

Quality assessment of the articles resulted in omitting nine

articles, leaving 34 articles for the final analysis (Table 1). If

we had doubts about some articles, their exclusion was

retained for the next stage of the selection process.

Evaluation criteria of the articles

Two independent evaluators rated all the articles by using the

following scheme to rate the strength of evidence, that is,

levels of evidence (Finnish Nurses Association, http://www.

sairaanhoitajaliitto.fi/, Current Care Guidelines Manual,

http://www.kaypahoito.fi):

A (I) Evidence from meta-analyses, well-conducted system-

atic reviews.

B (II) Evidence from systematic reviews, one randomised

controlled trial (RCT) or several well-conducted quasi-

experimental studies demonstrating overall consistency of

results.

C (III) Evidence from one well-conducted quasi-experimental

study or several other quasi-experimental studies demon-

strating overall consistency of results or several quantita-

tive descriptive or correlative studies demonstrating overall

consistency of results or several well-conducted qualitative

studies demonstrating overall consistency of results.

D (IV) Evidence from other well-conducted studies, case

studies, consensus reports and expert opinions.

In total, two (6%) articles belonged to class A, nine (27%)

to class B, 11 (32%) to class C and 12 (35%) to class D.

Results

General description

In this review, 30 studies and four literature reviews were

analysed. Altogether 50% (n = 17) of the studies were

quantitative, 18% (n = 6) qualitative, 21% (n = 7) used a

combination of qualitative and quantitative methods and

12% (n = 4) were literature reviews. The data had been

collected using one or more questionnaires, structured

interviews, medical records and a combination of several

data collection methods. Computerised search methods were

used in the literature reviews (Fairbank et al. 2000, Dennis

2002b, Sikorski et al. 2003) (Table 2).

Peer supporters and their training

Trained peers (Ahluwalia et al. 2000, Fairbank et al. 2000,

McInnes & Stone 2000, McInnes et al. 2000, Philipp et al.

2001, Dennis 2002a,b, Dennis et al. 2002, Martens 2002,

Alexander et al. 2003, Finigan 2003, Raine 2003, Scott &

Mostyn 2003, Sikorski et al. 2003, Chapman et al. 2004,

Graffy et al. 2004, Anderson et al. 2005, Muirhead et al.

2006, Kruske et al. 2007, Meier et al. 2007, Rossmann 2007)

were most often mentioned to be peer supporters. It was less

common for peers and professionals to work together

(Ahluwalia et al. 2000, McInnes & Stone 2000, Vari et al.

2000, Philipp et al. 2001, Pugh et al. 2002, Alexander et al.

2003, Finigan 2003, Raine 2003, Hoddinott et al. 2006a,b,

Kruske et al. 2007). Peer supporters could be spouses with

(Wolfberg et al. 2004, Pisacane et al. 2005) or without

training (Haneuse et al. 2000, Ekstrom et al. 2003, Swanson

& Power 2005, Kruske et al. 2007), spouses and grand-

mothers with antenatal education (Ingram & Johnson 2004)

or grandmothers without breastfeeding training (Haneuse

et al. 2000, Ekstrom et al. 2003, Grassley & Escheti 2007,

Kruske et al. 2007). Some studies described breastfeeding

friends, other breastfeeding mothers in the community or

members in the social support network (Ahluwalia et al.

2000, Haneuse et al. 2000, Ekstrom et al. 2003, Raine 2003,

Hoddinott et al. 2006a,b, Anderson et al. 2007) as well as

peers in an e-mail list for adoptive mothers (Gribble 2001) to

be peer supporters (Table 3).

The requirement for the length of the peers’ previous

breastfeeding experience varied from some breastfeeding

(Vari et al. 2000, Pugh et al. 2002, Raine 2003, Graffy et al.

2004), to three (McInnes & Stone 2000, McInnes et al. 2000,

Scott & Mostyn 2003) and at least six months’ (Dennis

2002a, Chapman et al. 2004) breastfeeding experience. Also,

the peer supporters’ length and contents of their training

varied greatly. Some peers had attended a WHO Breastfeed-

ing Counselling Training course (Ahluwalia et al. 2000,

Fairbank et al. 2000, Philipp et al. 2001, Finigan 2003) or La

Leche League (LLL) training (Raine 2003, Chapman et al.

2004), or some had only a few hours of breastfeeding training

(Dennis 2002a, Dennis et al. 2002). One intervention

programme (Meier et al. 2007) consisted of two days of

interactive training during a standard breastfeeding course.

The aim was to increase the comfort level of talking about

breastfeeding and to develop skills in breastfeeding

Review Support for breastfeeding


Journal of Clinical Nursing, 21, 1943–1954 1945

Table 1 List of articles included in the review

1. Anderson AK, Damio G, Young S, Chapman DJ & Perez-Escamilla R (2005) A randomized trial assessing the efficacy of peer counseling on

exclusive breastfeeding in a predominantly Latina low-income community. Archives of Pediatrics & Adolescent Medicine 159, 836–841.

2. Chapman DJ, Damio G, Young S & Perez-Escamilla R (2004) Effectiveness of breastfeeding peer counseling in a low-income, predominantly

Latina population: a randomized controlled trial. Archives of Pediatrics & Adolescent Medicine 158, 897–902.

3. Dennis CL (2002) Breastfeeding peer support: maternal and volunteer perceptions from a randomized controlled trial. BIRTH 29, 169–176.

4. Dennis CL, Hodnett E, Gallop R & Chalmers B (2002) The effect of peer support on breast-feeding duration among primiparous women: a

randomized controlled trial. Canadian Medical Association Journal 166, 21–28.

5. Graffy J, Taylor J, Williams A & Eldridge S (2004) Randomised controlled trial of support from volunteer counsellors for mothers

considering breast feeding. BMJ (Clinical research ed.) 328, 26–31.

6. Pugh L, Milligan R, Frick K, Spatz D & Bronner Y (2002) Breastfeeding duration, costs, and benefits of a support program for low-income

breastfeeding women. BIRTH 29, 95–100.

7. Wolfberg AJ, Michels KB, Shields W, O’Campo P, Bronner Y & Bienstock J (2004) Dads as breastfeeding advocates: results from a

randomized controlled trial of an educational intervention. American Journal of Obstetrics and Gynecology 191, 708–712.

8. McInnes RJ, Love J & Stone D (2000) Evaluation of a community-based intervention to increase breastfeeding prevalence. Journal of Public

Health Medicine 22, 138–145.

9. Dennis CL (2002) Breastfeeding initiation and duration: a 1990–2000 literature review. JOGNN – Journal of Obstetric, Gynecologic, &

Neonatal Nursing 31, 12–32.

10. Scott JA & Mostyn T (2003) Women’s experiences of breastfeeding in a bottle-feeding culture.

Journal of Human Lactation 19, 270–277.

11. Raine P (2003) Promoting breast-feeding in a deprived area: the influence of a peer support initiative. Health and Social Care in the

Community 11, 463–469.

12. Ekstrom A, Widstrom A & Nissen E (2003) Breastfeeding support from partners and grandmothers: perceptions of Swedish women. BIRTH

30, 261–266.

13. Martens PJ (2002) Increasing breastfeeding initiation and duration at a community level: an evaluation of Sagkeeng First Nation’s

community health nurse and peer counselor programs. Journal of Human Lactation 18, 236–246.

14. Haneuse S, Sciacca J, Ratliff M, Alexander D & Rivero ME (2000) Factors influencing breast-feeding rates among Arizona WIC partici-

pants. American Journal of Health Behavior 24, 243–253.

15. Vari PM, Camburn J & Henly SJ (2000) Professionally mediated peer support and early breastfeeding Journal of Perinatal Education 9, 22–

30.

16. Pisacane A, Continisio GI, Aldinucci M, D’Amora S &Continisio P (2005) A controlled trial of the father’s role in breastfeeding promotion.

Pediatrics 116, e494–8.

17. Swanson V & Power KG (2005) Initiation and continuation of breastfeeding: theory of planned behaviour. Journal of Advanced Nursing 50,

272–282.

18. Ingram J & Johnson D (2004) A feasibility study of an intervention to enhance family support for breast feeding in a deprived area in Bristol,

UK. Midwifery 20, 367–79.

19. Sikorski J, Renfrew MJ, Pindoria S & Wade A (2003) Support for breastfeeding mothers: a systematic review. Paediatric and Perinatal

Epidemiology 17, 407–417.

20. Alexander J, Anderson T, Grant M, Sanghera J & Jackson D (2003) An evaluation of a support group for breast-feeding women in Salisbury,

UK. Midwifery 19, 215–220.

21. Finigan V (2003) Providing breastfeeding support to ethnically diverse groups of mothers. Professional Nurse 18, 524–528.

22. McInnes RJ & Stone DH (2000) The process of implementing a community-based peer breast-feeding support programme: the Glasgow

experience. Midwifery 17, 65–73.

23. Gribble KD (2001) Mother-to-mother support for women breastfeeding in unusual circumstances: a new method for an old model.

Breastfeeding Review 9(3), 13–19.

24. Philipp BL, Merewood A, Miller LW, Chawla N, Murphy-Smith MM, Gomes JS, Cimo S & Cook JT (2001) Baby-friendly hospital initiative

improves breastfeeding initiation rates in a US hospital setting. Pediatrics 108, 677–681.

25. Fairbank L, O’Meara S, Renfrew MJ, Woolridge M, Sowden AJ & Lister-Sharp D (2000) A systematic review to evaluate the effectiveness of

interventions to promote the initiation of breastfeeding. Health Technology Assessment 4(25), 1–171.

26. Ahluwalia IB, Tessaro I, Grummer-Strawn LM, MacGowan C & Benton-Davis S (2000) Georgia’s breastfeeding promotion program for

low-income women. Pediatrics 105(6), E85.

27. Rossmann B (2007) Breastfeeding peer counselors in the United States: helping to build a culture and tradition of breastfeeding. Journal of

Midwifery & Women’s Health 52, 631–637.

28. Meier ER, Olson BH, Benton P, Eghtedary K & Song WO (2007). A qualitative evaluation of a breastfeeding peer counselor program.

Journal of Human Lactation 23, 262–268.

29. Kruske S, Schmied V & Cook M (2007) The ‘Earlybird’ gets the breastmilk: findings from an evaluation of combined professional and peer

support groups to improve breastfeeding duration in the first eight weeks after birth. Maternal & Child Nutrition 3, 108–119.

M. Kaunonen et al.



promotion and support. The Bosom Buddies completed a six-

week training course (Alexander et al. 2003) and the Best

Breastfeeding Course consisted of five 3-h workshops (Fair-

bank et al. 2000, McInnes & Stone 2000). In postpartum

peer counsellor programme, the training included improving

communication skills and basic breastfeeding knowledge to

identify and discuss the barriers of breastfeeding. In addition,

the aim was to recognise dangerous signals requiring referring

the mother to the care of health professionals (Martens

2002). In a study of organised and supervised peer support

(Muirhead et al. 2006), the education consisted of two full

days and four evening sessions of education in breastfeeding,

transferable skills, safety and confidentiality as well as the

relationship with patients and professionals.

In one of the reviews (Rossmann 2007), the length of the

training for peers varied from 9 to 56 hours and was based on

the WHO Peer Counsellor, LLL Peer Counsellor or other

peer counsellor training. Peers were trained and supported by

NHS in Glasgow (Scott & Mostyn 2003), or peers chosen in

the intervention had had a previous Breastfeeding Counsellor

training (Philipp et al. 2001, Pugh et al. 2002, Graffy et al.

2004). Some studies (Ahluwalia et al. 2000, Fairbank

et al. 2000, McInnes et al. 2000, Vari et al. 2000, Anderson

et al. 2007) did not describe training at all.

Table 1 (Continued)

30. Anderson AK, Damio G, Chapman DJ & Perez-Escamilla R (2007) Differential response to an exclusive breastfeeding peer counseling

intervention: the role of ethnicity. Journal of Human Lactation 23, 16–23.

31. Hoddinott P, Chalmers M & Pill R (2006) One-to-one or group-based peer support for breastfeeding? Women’s perceptions of a breast-

feeding peer coaching intervention. BIRTH 33, 139–46.

32. Muirhead PE, Butcher G, Rankin J & Munley A (2006) The effect of a programme of organised and supervised peer support on the initiation

and duration of breastfeeding: a randomised trial. British Journal of General Practice 56(524), 191–197.

33. Hoddinott P, Lee AJ & Pill R (2006) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland. BIRTH 33, 27–36.

34. Grassley J & Escheti V (2007) Two generations learning together: facilitating grandmothers’ support of breastfeeding. International Journal

of Childbirth Education 22(3), 23–26.

Table 2 Research methods and data collection

Article number Frequency Percentage

Method

Qualitative 10, 11, 23, 28, 31, 34 6 18

Quantitative 1, 2, 3, 4, 5, 6, 7, 8, 12, 14, 15, 16, 17, 22, 24, 29, 30 17 50

Combination 13, 18, 20, 21, 26, 32, 33 7 21

Literature review 9, 19, 25, 27 4 12

Data collection

Questionnaire(s) 3, 12, 14, 15, 20, 22, 23, 32 8 24

Structured interview(s) or focus group 10, 16, 18, 28, 34 5 15

Computerised searches 9, 19, 25 3 9

Medical records 24, 29 2 6

Combination of data collection methods 1, 2, 11, 13, 17, 18, 21, 26, 30, 31, 33 11 32

Instrument

Previously validated, literature reference 4 1 3

Previously used, literature reference 6, 13, 15, 16, 26 5 15

Modified, piloted, validated 1, 5, 8, 12, 14, 21 6 18

Self-constructed, no mention about pilot study 17, 22, 24, 26 4 12

No description of the development or quality 2, 3, 7, 10, 18, 20, 23, 28, 29, 30, 31, 32, 33, 34 14 41

Sample size

<50 6, 9, 10, 11, 13, 15, 18, 19, 27, 28, 34 11 32

50–100 7, 20, 25 3 9

101–200 1, 2, 14, 21, 29, 30 6 18

201–500 3, 4, 12, 13, 16, 17, 22, 31, 32, 33 10 29

501–1000 5, 8, 24 3 9

>1000 26 1 3

Not stated 27 1 3

The number of the articles refers to the number in the Table 1.




Several studies described professional and peer support

(Ahluwalia et al. 2000, McInnes & Stone 2000, Vari et al.

2000, Philipp et al. 2001, Pugh et al. 2002, Alexander et al.

2003, Ekstrom et al. 2003, Finigan 2003, Raine 2003,

Swanson & Power 2005, Hoddinott et al. 2006a,b, Kruske

et al. 2007). The breastfeeding support group BRAGG

(Finigan 2003) provided professional and peer support, and

it was based on the Baby Friendly Hospital Initiative (BFHI)

‘Ten Steps’. Three Bengali-speaking maternity aids were

trained to offer BF advice and to give support for parenting

(Finigan 2003), but their training was not explained in detail.

In a study carried out in rural Scotland, peers with no

breastfeeding education provided one-to-one support and

professionals provided group support (Hoddinott et al.

2006a,b).

For the male partners, the training was short: a two-hour

breastfeeding training (Wolfberg et al. 2004), or a 40-minute

face-to face training about infant feeding and difficulties in

BF, the management of breastfeeding and a leaflet (Pisacane

et al. 2005). Training for partners and grandmothers

included merely a one-to-one discussion and a booklet

(Ingram & Johnson 2004).

Peer support during pregnancy

Most of the studies included interventions in the antenatal or

postnatal periods, while the lowest number of interventions

was implemented during hospitalisation (Table 4). During

pregnancy, the peer support interventions were most com-

monly delivered through individual support and education

sessions (Fairbank et al. 2000, McInnes & Stone 2000,

McInnes et al. 2000, Dennis 2002b, Scott & Mostyn 2003,

Chapman et al. 2004, Graffy et al. 2004, Ingram & Johnson

2004, Anderson et al. 2005, 2007, Pisacane et al. 2005,

Meier et al. 2007). Home visits from peers to pregnant

mothers were often used as a way of giving support (McInnes

& Stone 2000, Dennis 2002b, Scott & Mostyn 2003,

Sikorski et al. 2003, Chapman et al. 2004, Graffy et al.

2004, Anderson et al. 2005, 2007, Meier et al. 2007,

Rossmann 2007). Moreover, educational classes were used

to educate peer supporters (Ahluwalia et al. 2000, Fairbank

et al. 2000, Vari et al. 2000, Ingram & Johnson 2004,

Wolfberg et al. 2004). However, mothers’ visits to clinics,

hospitals (Dennis 2002b, Rossmann 2007) or support group

meetings were less common and professionals often coached

them (Fairbank et al. 2000, Hoddinott et al. 2006b). Tele-

phone calls from peers were also used as a means of prenatal

support for mothers (McInnes & Stone 2000, Dennis 2002b,

Scott & Mostyn 2003, Meier et al. 2007, Rossmann 2007).

Teaching materials were often used to enhance the

personal support. The most common materials comprised

brochures or other written materials (Ahluwalia et al. 2000,

Fairbank et al. 2000, McInnes & Stone 2000, McInnes et al.

2000, Vari et al. 2000, Dennis 2002b, Martens 2002,

Chapman et al. 2004, Graffy et al. 2004, Ingram & Johnson

2004, Pisacane et al. 2005), but also videos or slides

(Fairbank et al. 2000, Martens 2002, Chapman et al. 2004,

Wolfberg et al. 2004, Anderson et al. 2005, 2007, Rossmann

2007), dolls (Vari et al. 2000, Ingram & Johnson 2004) and

pictures (Fairbank et al. 2000, Vari et al. 2000).

The BFHI educational programme was applied in the

training for peer support (Chapman et al. 2004, Anderson

et al. 2005, Pisacane et al. 2005), peer counsellor pro-

grammes (Fairbank et al. 2000, Anderson et al. 2007, Meier

Table 3 Description of peer support

Type of supporter Pregnancy Hospital Postnatal

Peer supporter with training 1, 2, 3, 4, 5, 8, 9,

10, 19, 22, 25, 27, 28

1, 2, 3, 19, 24,

25, 27, 28

1, 2, 3, 4, 5, 8, 9, 10,

11, 13, 19, 20, 21, 22,

24, 25, 26, 27, 28, 29, 32

Combination of peer and professional supporter 15, 33 6, 15, 24, 26 6, 11, 15, 20, 21, 22,

29, 31, 33

Support network

*Spouse 7, 12, 14, 17 7, 12, 14, 17, 29

*Spouse with breastfeeding education 7, 16

*Spouse and grandmother with antenatal education 18

*Grandmother 34 34 12, 14, 29, 34

*Friends 14 12, 14, 29

*Breastfeeding mothers in the community without training 33 30 11, 31, 33

Peers at e-mail list for adoptive parents 23 23 23

Community support 26 26 14, 26


M. Kaunonen et al.



et al. 2007, Rossmann 2007) or using the WIC (Women,

Infants and Children) policy as part of the intervention

(Ahluwalia et al. 2000, Fairbank et al. 2000). The interven-

tion included the training of spouses (Wolfberg et al. 2004,

Pisacane et al. 2005) as well as the training of spouses and

grandmothers (Ingram & Johnson 2004) during the antenatal

period to provide breastfeeding support (Table 4).

Peer support at maternity hospital

Individual support was the most common method of

supporting mothers (Ahluwalia et al. 2000, Philipp et al.

2001, Pugh et al. 2002, Ekstrom et al. 2003, Sikorski et al.

2003, Chapman et al. 2004, Anderson et al.2005, 2007,

Swanson & Power 2005, Meier et al. 2007, Rossmann 2007)

at hospital. Some peer supporters visited mothers at hospital

(Pugh et al. 2002, Chapman et al. 2004, Anderson et al.

2005, 2007, Meier et al. 2007), whereas some interventions

referred to the BFHI (Ahluwalia et al. 2000, Fairbank et al.

2000, Philipp et al. 2001), the WIC (Ahluwalia et al. 2000,

Fairbank et al. 2000, Haneuse et al. 2000) or a peer

counsellor programme (Anderson et al. 2007, Meier et al.

2007, Rossmann 2007) as part of the intervention package.

One of the studies (Philipp et al. 2001) described retrospec-

tively the outcome of a BFHI intervention initiated at

hospital. The variety of means of support included individual

support, support groups, educational classes at hospital,

hospital-based breastfeeding drop-in centres, pictures and

breast pump loans.

The training of professionals and peers together was

described (Fairbank et al. 2000, McInnes & Stone 2000) in

some studies as was the significance of social support

networks (partners, family, friends) to breastfeeding (Hane-

use et al. 2000, Ekstrom et al. 2003, Swanson & Power

2005) (Table 4).

Peer support during the postnatal period

All but two (Ingram & Johnson 2004, Pisacane et al. 2005)

of the support interventions extended a part of the interven-

Table 4 Different types of interventions during different phases of motherhood

Type of intervention Pregnancy Hospital Postnatal

Individual support and education 1, 2, 5, 8, 9, 10, 16,

18, 22, 25, 28, 30

1, 2, 6, 12, 17, 19,

24, 26, 27, 28, 30

1, 2, 3, 4, 5, 6, 8, 9, 10,

11, 12, 15, 17, 19, 22,

24, 25, 26, 28, 29, 30,

31, 32, 33

Home visit 1, 2, 5, 9, 10, 19, 22,

27, 28, 30

1, 2, 3, 9, 10, 13, 14, 19,

22, 27, 28, 30, 32

Educational class, discussion 7, 15, 18, 25, 26 24

Support groups 25, 33 24 9, 20, 21, 29, 31, 33

Clinic/hospital visit 9, 27 1, 2, 6, 28, 30 9, 27

Social support network (partner, family, friends) 12 12, 14, 17 11, 12, 14, 17

Telephone call 9, 10, 22, 27, 28 1, 2, 3, 4, 5, 6, 9, 10,

13, 14, 15, 19, 22, 24,

26, 27, 28, 29, 32

Video, slides 1, 2, 7, 13, 25, 27 20

Pictures 15, 25 24

Dolls 15, 18

Brochures, written material, books 2, 5, 8, 9, 13, 15, 16,

18, 22, 25, 26

9, 20

Breast pumps, facilities 24, 26 24, 26, 28

Breastfeeding drop-in centre 24 24

BFHI policy/training according to BF policy 1, 2, 16 24, 25, 26 21

Support via e-mail for adoptive mothers 23 23 23

Training professionals and peers 25 22, 25 13, 21

Training of spouse 7, 16

Training of spouse and grandmother 18

WIC programme 25, 26 14, 25, 26 9, 14, 15, 25, 26, 27

Peer counsellor programme 25, 27, 28, 30 27, 28, 30 20, 25, 27, 28, 30

Increase community support to BF, change attitudes 25, 26 25, 26 25, 26





tion package to the postnatal period. Individual support was

the most common method of intervention (Ahluwalia et al.

2000, Fairbank et al. 2000, McInnes & Stone 2000, McInnes

et al. 2000, Vari et al. 2000, Philipp et al. 2001, Dennis

2002a,b, Dennis et al. 2002, Pugh et al. 2002, Ekstrom et al.

2003, Raine 2003, Scott & Mostyn 2003, Sikorski

et al. 2003, Chapman et al. 2004, Graffy et al. 2004,

Anderson et al. 2005, 2007, Swanson & Power 2005,

Hoddinott et al. 2006a,b, Muirhead et al. 2006, Kruske

et al. 2007, Meier et al. 2007). Support was also given by

telephone conversations (Ahluwalia et al. 2000, Haneuse

et al. 2000, McInnes & Stone 2000, Vari et al. 2000, Philipp

et al. 2001, Dennis 2002a,b, Dennis et al. 2002, Martens

2002, Pugh et al. 2002, Scott & Mostyn 2003, Sikorski et al.

2003, Chapman et al. 2004, Graffy et al. 2004, Anderson

et al. 2005, Muirhead et al. 2006, Kruske et al. 2007, Meier

et al. 2007, Rossmann 2007), during home visits (Haneuse

et al. 2000, McInnes & Stone 2000, Dennis 2002a,b,

Martens 2002, Scott & Mostyn 2003, Sikorski et al. 2003,

Chapman et al. 2004, Anderson et al. 2005, 2007, Muirhead

et al. 2006, Meier et al. 2007, Rossmann 2007) or in support

group meetings (Dennis 2002b, Alexander et al. 2003,

Finigan 2003, Hoddinott et al. 2006a,b, Kruske et al.

2007). Some programmes, such as the WIC (Ahluwalia

et al. 2000, Fairbank et al. 2000, Haneuse et al. 2000,

Vari et al. 2000, Dennis 2002b, Rossmann 2007) and the

Peer Counsellor (Fairbank et al. 2000, Alexander et al. 2003,

Anderson et al. 2007, Meier et al. 2007, Rossmann 2007),

were implemented postnatally. Only a single article (Finigan

2003) mentioned the BFHI in the postnatal period.

Intervention combinations included breast pumps or

breastfeeding facilities (Ahluwalia et al. 2000, Philipp et al.

2001, Meier et al. 2007). However, videos (Alexander et al.

2003) and written materials (Dennis 2002b, Alexander

et al. 2003) were used less in the postnatal support

(Table 4).

Effectiveness of the peer support interventions

The outcomes of the breastfeeding support interventions were

evaluated from various perspectives: initiation, continuation,

exclusiveness, maternal satisfaction and perception of the

intervention (Table 5). Most studies (Haneuse et al. 2000,

McInnes et al. 2000, Dennis et al. 2002, Martens 2002, Pugh

et al. 2002, Ekstrom et al. 2003, Chapman et al. 2004,

Ingram & Johnson 2004, Wolfberg et al. 2004, Anderson

et al. 2005, Pisacane et al. 2005, Swanson & Power 2005,

Hoddinott et al. 2006b, Muirhead et al. 2006, Kruske et al.

2007) evaluated the effect on the continuation of breastfeed-

ing, as did the literature reviews (Fairbank et al. 2000,

Dennis 2002b, Sikorski et al. 2003, Rossmann 2007). How-

ever, the effectiveness of the interventions was analysed only

from the original studies. They were all effective, except for

three interventions (McInnes et al. 2000, Wolfberg et al.

2004, Muirhead et al. 2006) failing to ensure the continua-

tion of breastfeeding. A two-hour breastfeeding course for

fathers during pregnancy increased the initiation of breast-

feeding but not the continuation (Wolfberg et al. 2004). Peer

support during pregnancy and the postpartum period

increased breastfeeding at maternity hospital but not after

six weeks of the postpartum period. When the hospital

practices did not support breastfeeding, peer support was not

fully effective in the continuation by itself (McInnes et al.

2000). In another study (Muirhead et al. 2006), the breast-

feeding initiation rate was low among the mothers both in the

study and in the control groups.

The effect of the interventions in the initiation of breast-

feeding was studied in articles (Ahluwalia et al. 2000,

Haneuse et al. 2000, McInnes et al. 2000, Philipp et al.

2001, Martens 2002, Chapman et al. 2004, Wolfberg et al.

2004, Anderson et al. 2005, Hoddinott et al. 2006b, Muir-

head et al. 2006) and reviews (Fairbank et al. 2000, Dennis

2002b, Sikorski et al. 2003, Rossmann 2007). The effect of

Table 5 Effectiveness of the intervention studies

Number of article

Effective intervention Non-effective intervention

Initiation 1, 2, 7, 8, 13, 14, 24, 26, 33 32

Continuation 1, 2, 4, 6, 12, 13, 14, 16, 17, 18, 20, 29, 33 7, 8, 32

Exclusive breastfeeding 1, 4, 12, 15, 16, 20, 24

Perceived milk insufficiency, less 16

Savings in healthcare costs 6

Positive perception on the support intervention 3, 4, 5, 10, 11, 12, 13, 18, 20, 21, 22, 23, 28

Satisfaction with BF, confidence 12, 13, 15, 20, 21, 22, 23, 28, 31

Empowering effect for lay supporters = BF mothers 3, 11


M. Kaunonen et al.



the interventions on exclusive breastfeeding was the focus in

some studies (Vari et al. 2000, Philipp et al. 2001, Dennis

et al. 2002, Alexander et al. 2003, Ekstrom et al. 2003,

Anderson et al. 2005, Pisacane et al. 2005) and reviews

(Fairbank et al. 2000, Dennis 2002b, Sikorski et al. 2003,

Rossmann 2007). All interventions, except for one (Muirhead

et al. 2006), were effective in initiation, and they were all

effective in increasing exclusive breastfeeding.

Those mothers who received peer support were 15 times

more likely to breastfeed exclusively throughout the three-

month follow-up study (Anderson et al. 2005). A review

study (Sikorski et al. 2003) concluded that peer support was

effective in increasing exclusive breastfeeding, but not neces-

sarily ensuring the continuation of breastfeeding.

Increased mothers’ satisfaction with breastfeeding and

their confidence was a goal reached in nine studies (McInnes

& Stone 2000, Vari et al. 2000, Gribble 2001, Martens 2002,

Alexander et al. 2003, Ekstrom et al. 2003, Finigan 2003,

Hoddinott et al. 2006a, Meier et al. 2007). Also, working as

a breastfeeding supporter had an empowering effect on lay

supporters who were also breastfeeding mothers (Dennis

2002a, Raine 2003). Only one study estimated the costs and

savings in the healthcare costs (Pugh et al. 2002). Mothers’

positive perception of the support intervention was concluded

in many studies (McInnes & Stone 2000, Gribble 2001,

Dennis 2002a, Dennis et al. 2002, Martens 2002, Alexander

et al. 2003, Ekstrom et al. 2003, Finigan 2003, Raine 2003,

Scott & Mostyn 2003, Graffy et al. 2004, Ingram & Johnson

2004, Meier et al. 2007).

Furthermore, the support from a partner or grandmother

proved effective (Haneuse et al. 2000, Ekstrom et al. 2003,

Wolfberg et al. 2004, Pisacane et al. 2005, Swanson &

Power 2005). The perceptions of breastfeeding of their

partner and midwife affected the mother’s decision to initiate

and continue breastfeeding (Swanson & Power 2005). The

support for breastfeeding from professionals and/or from

significant others, such as partners and grandmothers, as well

as the breastfeeding expectations of the significant others had

a great impact on breastfeeding. Teaching fathers how to

prevent and manage the most common lactation difficulties

was associated with higher rates of full breastfeeding and less

perceived milk insufficiency of mothers during the first

six months (Pisacane et al. 2005).

Combined support of professionals and trained and expe-

rienced peer supporters proved effective in increasing breast-

feeding initiation (Ahluwalia et al. 2000, Philipp et al. 2001,

Hoddinott et al. 2006b), continuation (Kruske et al. 2007), exclu-

siveness (Philipp et al. 2001, Alexander et al. 2003), satis-

faction with breastfeeding (Alexander et al. 2003, Finigan

2003) and saving in the healthcare costs (Pugh et al. 2002).

Professionally lead group support was highly valued and

increased confidence and satisfaction with breastfeeding,

although mothers did not prefer the one-to-one support of

untrained peers (Hoddinott et al. 2006a,b).

Discussion

This review consisted of 30 research articles and four reviews

published from the year 2000 until March 2008, focusing on

peer support for breastfeeding or the combination of profes-

sional and peer support. The validity of the study was

obtained by describing the data selection process in detail and

using three researchers as well as an expert group in the

analysis process. We followed the previously used evaluation

criteria developed by the Finnish Nurses Association (http://

www.sairaanhoitajaliitto.fi/). In total, 44% of the articles

were quantitative, 21% qualitative and 24% used a meth-

odological triangulation.

During pregnancy, individual support was common and

support groups were seldom used. Individual support was

provided during home visits or by telephone. In addition,

mothers received materials such as brochures or other written

materials. Videos, dolls and pictures were employed for

demonstrations. Educational classes were used to educate

partners and grandmothers to act as breastfeeding support-

ers. Support on the Internet was examined only in one article

describing the use of an Internet mailing list for adoptive

mothers wishing to breastfeed (Gribble 2001).

At maternity hospital, support was also offered individu-

ally. The BFHI practices, the WIC and the Peer Counsellor

Programme were often an effective part of the intervention

package. Effective interventions also included evidence-based

breastfeeding support during hospitalisation (Ahluwalia et al.

2000, Fairbank et al. 2000).

Peer support was strongly associated with the postnatal

period when individual peer support was more common than

support groups. The support was given by telephone, during

home visits or in support group meetings. The postnatal

support was not effective, if no support existed during

pregnancy or hospitalisation (Muirhead et al. 2006).

Peer supporters were other mothers with previous breast-

feeding experience, partners or grandmothers. The length of

the required breastfeeding experience varied from some

breastfeeding to at least six months of breastfeeding. Most

peers received some training for breastfeeding support, but

the length and contents of the training varied greatly. For the

most part, the training included the physiology and manage-

ment of breastfeeding, counselling and support skills as well

as some cultural aspects of breastfeeding. Some studies

mentioned the BFHI programme, the Peer Counsellor




Programme or the WIC. Moreover, several training

programmes included elements common to the BFHI. Unfor-

tunately, many of the reviewed studies did not provide

comprehensive descriptions of the training of peers, and some

studies had not examined training at all.

Peers benefit from training and it can have an empowering

effect on them (Dennis 2002a, Raine 2003). In general,

mothers were dissatisfied with peers who had no training

(Hoddinott et al. 2006a). It could prove advantageous to

educate peers by using the well-tested programmes such as

the WHO/UNICEF BFHI or LLL Peer Counsellor (Rossmann

2007). They have been previously used and tested, and they

include both evidence-based knowledge of breastfeeding and

counselling skills. Partners and grandmothers’ ability to give

breastfeeding support increased even with brief training or a

discussion. Breastfeeding education for partners and grand-

mothers should therefore be included in all parenting

education programmes.

The effective elements of peer support interventions involve

well-planned peer education, the continuance of support

(professional or unprofessional) from pregnancy to the

postpartum period, working together with professionals and

a good variety of means to give support. Combining the forces

of professional and peer support as well as cooperation during

the postnatal breastfeeding support would be very advisable.

Furthermore, evidence-based breastfeeding support during

hospitalisation (BFHI) is a very important component of all

successful interventions. Without the support given at hospital,

the postnatal peer support may be received too late. Profes-

sional support is important during the hospital stay and again if

the mother faces serious breastfeeding difficulties. However,

resources are limited in health care, and many of the problems

breastfeeding mothers are confronted with are related to issues

such as conflicts of combining breastfeeding with everyday life.

In these issues, peer supporters can offer better advice than

health professionals can.

Conclusions

Only continuous breastfeeding support provides effective

results starting from pregnancy, continuing at hospital and

throughout the postnatal period until the child is weaned.

Diverse types of interventions during different phases of

motherhood are needed. Professionals and peers have

different roles, and in an ideal situation, they can provide

a chain of continuous support for mothers. The role of peer

support is most important during the postnatal period.

Mothers need support, and if professional support is not

available, peer support could offer an alternative worth

considering.

The combination of professional support and peer support

provided by trained and experienced peer supporters proved

effective in increasing breastfeeding. Therefore, it would be

useful to educate peers, professionals and partners together or

at least use similar material in their education.

Relevance to clinical practice

The knowledge of the role of peer support for breastfeed-

ing is important for professionals working with mothers

both during pregnancy and after the delivery. Professionals

could educate fathers and grandmothers to increase their

ability to support breastfeeding even with brief training

sessions or discussions. In addition, professionals and peer

supporters should be working together to guarantee the

continuity of breastfeeding support, because it has been

proven the only way to achieve effective breastfeeding

results.

Acknowledgements

The study has been supported by the grants of the Finnish

Nurses Association and Finnish Ministry of Social Affairs and

Health.

Contributions

Study design: MK, LH, M-TT; data collection and analysis:

MK, LH and manuscript preparation: MK, LH, M-TT.

Conflict of interest

None.

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a systematic review of peer support interventions for breastfeeding

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