Background: The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) i.e. feeding infants breastmilk and no other foods or liquids for the first 6 months of life. In Australia, the initiation rate of breastfeeding is high (90.4%). Yet, breastfeeding duration and exclusivity is well below the WHO recommendation. This scoping review examines the efficacy and characteristics of interventions aimed to improve the duration of breastfeeding whether exclusive or in combination up to 6 months of age in Australia.

Methods: Online databases Medline and Embase were searched for relevant studies. Studies were included if they were undertaken in Australia during the last 10 years, and included educational, support-based or in-hospital breastfeeding interventions and documented duration of breastfeeding.

Results: 11 studies met the imposed criteria. Most interventions improved breastfeeding rates, for example from 6.5% to 19% for EBF when assessed at 6 months, from 75% to 82% for breastfeeding at 6 weeks. The interventions included: accreditation for breastfeeding friendly hospitals, breastfeeding classes, nurse home visits and drop-in clinics, breastfeeding support in primary care, telephone support, breastfeeding smartphone applications, relevant websites and text-messaging services. Interventions that were successful, provided support for mothers beyond their postnatal period. Most common enablers reported were program facilitators that were volunteers who were peers with similar experiences, rather than breastfeeding professionals, in addition to interventions that focussed on psychological factors that influenced breastfeeding outcomes.

Conclusions: While the interventions to date were promising, further prospective randomised controlled trials are needed to determine which interventions would be best in prolonging breastfeeding. The findings would help support the commendable intentions to breastfeed expressed by most Australian mothers shortly after the birth of their infant.

Keywords: breastfeeding, duration, interventions – community/father/internet-based, baby-friendly hospitals

EBF, exclusive breastfeeding; WHO, world health organization; RCT, randomised controlled trial; BFHI, baby friendly hospital initiative; MCHN, maternal child health nurse

Successful breastfeeding is a global public health priority. The World Health Organization (WHO) recommends ‘exclusive breastfeeding’ (EBF), defined as feeding infants’ breastmilk and no other foods or liquids for the first six months of life, followed by breastfeeding and the addition of solid or semi-solid foods until two years of age.¹ This guideline is based on the premise that breastfeeding in developing countries is essential for the survival of the infant. However, in developed countries EBF despite its proven benefits, is influenced by the ready availability of breastmilk substitutes Table 1.²

The benefits of breastfeeding for both mother and infant are well documented and extend beyond the initial protection against infectious diseases as breastmilk has both immunological and anti-bacterial properties.³ When compared with formula fed infants, it protects against gastrointestinal illnesses, otitis media and respiratory tract infections, in addition to reducing the incidence of necrotising enterocolitis in neonates.³ Breastmilk has been associated with lower blood pressure readings in adolescents, and a reduced risk of obesity and hypercholesterolaemia in adults.^3,4 There is also compelling evidence that breastfeeding enhances mothers’ post-partum recovery through accelerated uterine contraction. In addition, it provides some protection against ovarian cancer and pre-menopausal breast cancer.^3–5

Initiation of EBF in Australia is comparatively high, at a rate of 90.4% following hospital discharge.⁶ This percentage differs from other developed countries such as Canada (69-83%) and the USA, where initiation rates are historically low (27-69.5%).⁷ Despite a high initiation rate and the proven benefits of breastmilk for both mother and infant, the duration of the breastfeeding follows a steep decline. The Australian National Infant Feeding Survey conducted in 2010 reported only 39% of infants were exclusively breastfed at 4 months, and at 6 months only 15% of infants were exclusively breastfed, though 60% still received some breastmilk at 6 months.⁶ A more recent study found that almost half of infants were exclusively breastfed at 4 months with 68% breastfed at 6 months.⁸ There are many factors which influence the successful establishment and maintenance of breast feeding. Breastfeeding outcomes are consistently poorer in mothers that are under 24 years of age, have a lower level of education or socio-economic status, or are overweight or obese.⁶ Furthermore, barriers to long term breastfeeding include early return to work, limited family support and suboptimal breastfeeding education.^4,9,10 Mothers tend to lose motivation to breastfeed when they encounter lactation difficulties such as an insufficient milk supply, nipple pain and breast engorgement.¹⁰ Educating mothers in the antenatal period about latching and feeding technique helps reduce the frequency of such problems.¹¹

Early cessation of breastfeeding in Australia has been recognised and has led to the development of a broad range of innovative initiatives. The major strategy at an institutional level has been the Baby-Friendly Hospital Initiative (BFHI), a structured program used in hospitals worldwide and underpinned by ten infant-friendly practices as set by the WHO.^12,13 Implemented in Australia in 1992, the BFHI ensures health care staff educate pregnant women about the benefits of breastfeeding, guide mothers on how to breastfeed, prevent newborns receiving milk other than breastmilk, and practice ‘rooming-in’ which allows infants to remain with their mothers throughout.^13,14 Non-institutional or community interventions come in a variety of forms and contexts, and may be educational, supportive or both. Educational interventions deliver breastfeeding information in the antenatal and/or postnatal period. They aim to improve knowledge about breastfeeding, which is positively associated with longer EBF duration.^4,15 Breastfeeding support on the other hand is usually emphasised in the postnatal period and involves such psychological tasks as listening to and encouraging the mother.¹⁵ That in turn may improve her breastfeeding self-efficacy, defined as confidence in her perceived ability to breastfeed, which is a strong predictor of breastfeeding duration.¹⁶ Breastfeeding attitudes in particular from the mother’s partner, have been shown to be a strong enabler or barrier to breastfeeding.^4,17 Women who perceived their partners to be supportive of breastfeeding were more likely to initiate breastfeeding and breastfed for longer than those whose partners favoured formula feeding.¹⁷ 

Prolonging breastfeeding remains an issue in Australia. This review focuses on interventions that seek to lengthen the duration of breastfeeding rather than focussing on the initiation of breastfeeding. It aims to examine the efficacy and characteristics of interventions to prolong breastfeeding whether exclusive or predominant up to 6 months of age when compared with standard care. Not all high-income countries are comparable as they differ in their societal attitudes extent of standard care. This review summarises local breastfeeding education and support in a multitude of contexts.^18–27

A scoping reviewed was undertaken to study what interventions have been undertaken within Australia to prolong breastfeeding.³¹ The online databases Medline (Ovid) and Embase were searched in June and July 2022 using the keywords in Table 2.

Inclusion and exclusion criteria

Papers reviewed were those that included pregnant women or couples aged 18 year and over who had expressed their intention to breastfeed or had already initiated breastfeeding at the time of recruitment.

Types of interventions

Only interventions that provided breastfeeding education or breastfeeding support were included. The intervention could be carried out in a primary care setting, a drop-in centre, during a home visit or in-person class, over the phone or via a smartphone application, text message or website. Interventions were implemented in the antenatal and/or postnatal periods. Studies where no intervention occurred, or only identified risk factors resulting in the cessation of breastfeeding were excluded.

Outcomes

Studies measuring breastfeeding rates, whether it was exclusive, fully, complementary or any breastfeeding, from birth to 6 months of age were included if they reported on the duration of breastfeeding

Location, year of publication and study design

To narrow the scope of this review only studies analysing Australian data over the last 10 years were included. The reference lists of these reviews were further screened for studies performed within Australia that had not been identified in the initial search.

Eleven studies were included in this review. Five studies were randomised controlled trials (RCTs), four were cohort studies and two were of quasi-experimental design. All studies were conducted in Australia with publication dates ranging between 2013 and 2021. Sample sizes varied; one study had a particularly small sample size (n=46)²⁴ while others ranged from 234 to 7039. Many studies recorded rates of ‘any’ breastfeeding, with six studies also recording EBF rates. Eight studies measured outcomes to 6 months of age while the others stopped earlier. Strategies implemented in the studies included: antenatal educational classes (n=3), telephone support (n=2), smartphone application (n=3), text-messaging service (n=1), website (n=2), nurse home-visits and drop-in clinics (n=1), hospital-accreditation (n=1), and support in primary care (n=1). All control groups received standard care which varied according to location Figure 1.

Figure 1 PRISMA flow diagram.

Institutional influences

Institutions may provide a structured and multi-component programme for health care establishments to follow, such as the Baby Friendly Hospital Initiative (BFHI). While breastfeeding initiation rates were high (96%) in both BFHI and non BFHI-accredited hospitals in Queensland, Brodribb et al. suggested there was little or no difference in the rate and duration of breastfeeding in either institutions.²⁴ Kinnear however strongly disputed these conclusions suggesting that the data provided showed at 1 month 81.1% of women from BFHI-accredited hospitals were breastfeeding with 57.6% EBF.³² So that 23.5% were having supplementary feeds compared with 32.4% in non BFHI-accredited hospitals.³²  The infant-friendly practices that underpin BFHI-accreditation now extend to a varying extent into non-BFHI hospitals influencing clinical practice including breastfeeding rates.^24,33 Brodribb et al.,²⁴ nevertheless reported that the rates of any breastfeeding at 1 and 4 months increased in a dose-dependent manner as the number of infant-friendly practices as reported by the mother increased.²⁴ These findings suggest that BFHI implementation does little to extend EBF duration at least to 6 months in an Australian context despite the initiation rates being high. More attention may need be paid to providing community-centred support for breastfeeding mothers beyond the early postpartum period.^24,33

Community influences

Community intervention aimed to improve knowledge about breastfeeding and imbue a desire to breastfeed, whilst providing support to the mother and enriching her interpersonal relationships, may both influence breastfeeding outcomes.²⁰ Three studies investigated community interventions to prolong the duration of breastfeeding through breastfeeding education classes, telephone support, drop-in centres and primary care settings.^18–20 Successful community interventions focussed beyond the postnatal period and relied on multiple face-to-face encounters over a longer 3 to 6 months and included both ongoing education and supportive measures.  To continue breastfeeding, women need to juggle a range of psychological and personal factors over and above their intention to breastfeed, attain self-efficacy further helped by ongoing social support.³⁴ The two community-based studies that succeeded in prolonging breastfeeding duration, paid close attention to addressing these factors in their intervention.^18,20 For example, one study investigated the combination of antenatal education sessions and postnatal telephone support. It encouraged participants to invite friends and family to the sessions. Take-home activities were designed to initiate discussion and build a committed group of support people.¹⁸ These interventions successfully increased EBF rates at 6 months from 6.5% to 19%. However the study only included those who had previously expressed a desire to breastfeed. Any change in the participants’ feelings of self-efficacy, or the increased availability of social supports were not measured.¹⁸

Further characteristics that were consistent amongst the studies were interventions that were proactive and delivered by trained providers. All three community support studies involved trained health workers (predominantly nurses) to deliver breastfeeding support. Elliot-Rudder et al. reported that general practice nurses trained in motivational interviewing techniques used those techniques to encourage mothers to continue breastfeeding. That resulted in a significantly increased rate of EBF at 4 months.²⁰ McLachlan et al.,²⁵ found that proactive interventions established contact with the mothers and provided anticipatory support, rather than waiting for mothers to request such support.¹⁹ All three studies involved telephoning participants in response to their concerns while providing encouragement. In addition, such telephone consultations allowed for identifying mothers who were likely to stop breastfeeding and resulted in organising a home-visit within 1 week of hospital discharge.¹⁹ Embedding community interventions into clinical practice by integrating them into pre-existing health care settings rather than creating new infrastructures was found to be more cost effective. McLachlan et al.,²⁵ created staffed drop-in centres for breastfeeding advice and education, but were unable to elicit any difference in breastfeeding outcomes.¹⁹ This result was largely attributed to poor attendance at the centres, compounded by staff shortages, while the wider community were generally unaware of the new service.¹⁹ This finding contrasted to that of Elliot-Rudder et al.,²⁰ which used pre-existing general practice nurses to deliver breastfeeding support to mothers while attending with their infants for their routine vaccination at 2, 4 and 6 months.²⁰ Taking advantage of such attendance at regular intervals proved effective and allowed for delivery of a meaningful service delivery which contributed to a demonstrable improvement in breastfeeding practice.²⁰

Influences generated by fathers

Interventions which involved the fathers created an opportunity to address misinformation, ambivalence and/or negative attitudes towards breastfeeding.^35,36 Two studies explored the importance of educating fathers about breastfeeding using educational classes. A smartphone application (app), aimed to create online discussion between the fathers. Maycock et al. described a father-focused antenatal class which provided further information on infant feeding and to trouble-shoot I common problems that may arise from breastfeeding.²⁷ Although the study’s primary focus was on fathers, maternal attitudes were also influenced. A significant number of mothers in the intervention group subsequently developed favourable attitudes towards breastfeeding.²⁷ This change then translated to an increase in the breastfeeding rates at 6 weeks from 75% in the non-intervention group to 82% in the intervention group. However, it failed to influence the breastfeeding rates at 6 months.²⁷ Of note the intervention tended to be short lived and was undertaken in the antenatal period. This limitation was addressed by a study of Scott et al. that involved a similar antenatal class with an additional application that engaged fathers. It provided them with breastfeeding information and guidance via discussion boards until 6 months postpartum.²¹ Classes were run by trained peer facilitators who had a child under 3 years of age who they had breastfed for at least 3 months.²¹ However, extending the intervention’s duration and involving peer facilitators did not demonstrate any effect on breastfeeding outcomes. This disappointing finding may have been related to a drop in attendance and a self-selection bias as the participants were a socially advantaged and highly educated sample that was already familiar with the importance of breastfeeding and were strongly motivated even before entering the trial.²¹

Offsite interventions

Breastfeeding intervention may be provided via the telephone, internet websites, smartphone apps or text-messaging services, and may provide an inexpensive, time-efficient and more accessible alternative to face-to-face interventions.³⁷ A similar approach was used in 2 extensive Australia studies reviewing the feeding profile and growth implications of infants.^8,38 Breastfeeding support delivered remotely and on a one-on-one basis via regular telephone calls from a trained peer volunteer, produced an increase in the breastfeeding rates at 6 months.²⁵ The study provided further evidence of the strength of proactive intervention as the telephone calls were regular and initiated by the volunteer. The volunteers were mothers themselves and who had breastfed their infant until at least 6 months of age.²⁵ The efficaciousness of ‘peer delivery’ was proven in many studies,^39,40,41 may be that was perhaps due to a decrease in the perceived “power” differential in a professional-patient relationship. Instead, a friendly interaction occurred making it less stressful for the mothers to ask questions while at the same time forming a bond as both mother and volunteer had similar experiences.²³

Expecting couples are increasingly accessing the internet and social media platforms for information on pregnancy and early parenting. Such information allows for instantaneous and accessible information when it is most needed,²¹ though concern may be expressed about the accuracy of the information provided and how applicable it may be to a specific couple. Two studies provided breastfeeding information: via a smartphone app²⁶ and a website where participants could access information and post on discussion forums.²² A strength of the studies was that they focussed on mothers who lived in rural areas and had difficulty attending breastfeeding support services because of the distance.²⁶ Both studies reported an improvement in breastfeeding rates. The study of Wheaton et al.,²⁶ involved a small sample size of 46 participants and had no control group.²⁶ It was unclear in the study of Giglia et al.,²² as to how the intervention website was used.²²

A further remote intervention of Gallegos et al. utilised an automated two-way text messaging service to provide breastfeeding support.²³ A strength of that intervention was that it was proactive. The participants received a text message asking how their breastfeeding was going. If the response indicated a level of distress or a request for help, it prompted a trained breastfeeding counsellor to call within 24 hours.²³ The intervention was reported as having a positive influence on both the maternal psychological factors and EBF rates, though the outcomes were not measured at set infant ages, but at two random times before 3 months of age. Three of the four remote intervention studies reported that participants were self-recruited and/or already highly motivated to breastfeed when compared with the general population.^23,25,26 In two studies, breastfeeding rates in both trial arms were higher than national averages Table 3,4.^23,25

Despite many mothers initiating breastfeeding following hospital discharge, few mothers breastfeed exclusively for the recommended duration in Australia.⁶ The studies reviewed varied in both the nature of the interventions used and the measurement of breastfeeding outcomes. Considering the effectiveness of these interventions, studies which involved mothers over an extended period proved to have a significant impact on breastfeeding rates up to 6 months.^18,20,25 This outcome is congruent with reviews conducted globally that identified the postnatal phase to be the most effective time to promote exclusive breastfeeding.³⁹ Maternal breastfeeding confidence experienced during the antenatal period tends to wane following the birth of the infant when breastfeeding challenges are first encountered.⁴¹ Other characteristics which were shown to consistently improve breastfeeding outcomes were interventions that involved both education and support but which may be delivered in multiple settings - local health services, at home, or within the community at large.^39,42–44

Our review supported findings from elsewhere. Individualised, peer support appeared to be an effective way to improve breastfeeding confidence and ability. In addition, it would appear that one-on-one encounters with mothers were more effective than group sessions as mothers preferred non-judgemental, encouraging and individualised support.^39,44,45 Interventions delivered by peer counsellors were more successful in increasing EBF rates amongst young mothers.⁴⁶ The association between maternal mental health and breastfeeding outcomes has been consistently demonstrated.⁴⁷ Mothers need to manage a range of psychological and personal factors including breastfeeding intention and self-efficacy, both of which are influenced by the support received from her family and social network³⁰ As an example the Caring Mother Program, a Melbourne-based community initiative, involves weekly visits from peer volunteers aimed at providing emotional support to new mothers. Participants in the program felt that peer volunteers created a non-judgemental space allowing them to gain confidence and trust within themselves in meeting their baby’s needs. Supporting motherhood is a community effort and has been shown to improve EBF when efforts are made in enhancing breastfeeding intentions, self-efficacy and providing social supports.^18,20,47 A further example is a complementary residential service provided by an experienced grandmother for new mothers and their infants which also has been found to improve the mothers’ confidence and wellbeing providing the mothers a safe and quiet “dwelling space”.⁴⁸ It also allowed the mothers an opportunity to acquire mothercraft skills enhancing their breastfeeding efforts, in a non-threatening and supportive environment remembering that most women in Australia are discharged from hospital within 24 – 48 hours, maybe a day or two later if there is a surgical delivery or if confined in a private hospital.

This review specifically explored practices within Australia that helped prolong breastfeeding. A wider study would determine if similar findings are seen in other developed countries, influenced by differing practices, social customs and/or health care systems. This review did not explore why some mothers chose not to breastfeed or ceased breastfeeding early. The interventions assessed were varied and took place in a range of health care and community contexts making them difficult to compare with each other. Additionally, some studies did not provide definitions of standard care and what other services were also available. There was a lack of clear definition of breastfeeding outcomes. Focus was often placed on ‘any’ breastfeeding rather than EBF, creating a broad continuum of breastfeeding practices for infants and may have included those who had supplementary formula feeds. The timing of the assessments and therefore of the outcomes varied, some providing a snapshot of breastfeeding practices in the preceding 24 hours.  Other studies relied on maternal recall to record practices from birth. At risk groups such as young mothers or those who were obese were not specifically assessed in the studies reviewed.  Finally varying the search terms and exploring further databases such as CINAHL database, may have captured additional breastfeeding interventions.

This review evaluated the efficacy of educational and support interventions on breastfeeding outcomes. Proactive interventions that extended across the pregnancy and into the post-natal period, and which involved both educational and supportive components, while addressing psychological factors such as breastfeeding intentions, self-efficacy and the provision of social supports, were more successful in improving the duration of breastfeeding. At risk groups such as young or obese mothers need further study. In addition, future studies need describe the details of the interventions over and above that provided by standard care to allow for comparable assessments so as to better quantify outcomes.

The authors have no funding information to declare. There was no conflict of interest in the development of this work.

Ethics approval and consent to participate: Not applicable\Consent for publication: Not applicable

Availability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Authors’ contributions: EG composed the search strategy, analysis of included papers and drafted the work. SM revised and edited the work whilst providing guidance about scope and direction of the paper. All authors read and approved the final manuscript.

No funding to declare.

The authors declare there is no conflict of interest.

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