Introduction Breastfeeding has a major role to play in public health. It promotes health and prevents disease in both the short and long term, for both infant and mother. But breastfeeding, especially the prolonged, exclusive breastfeeding that results in the greatest benefits, is far from universally practised in the UK and other western cultures. Breastfeeding initiation rates in the UK are around the lowest in Europe, with rapid discontinuation rates for those who do start. Further, initiation and continuation rates are lowest among families from lower socio-economic groups, adding to inequalities in health and contributing to the perpetuation of the cycle of deprivation. The reasons for this are multifaceted and include the influence of society and cultural norms, as well as clinical problems, the organisation of health services and the lack of preparation of health professionals and others to support breastfeeding effectively.This paper summarises the findings of a systematic review of interventions to enable women to continue breastfeeding, with special reference to women from disadvantaged groups where rates are lowest. Full details are in NICE (2005). It follows on from the previous Health Development Agency (HDA) review of systematic reviews of interventions to promote the initiation of breastfeeding (Protheroe et al., 2003). This information will be of interest to pregnant women, new mothers, health and social care professionals, and lay advisers supporting women in their decision to start and continue breastfeeding. This systematic review will inform the development of the following NICE guidance:

  • Antenatal and postnatal mental health: clinical management and service guidance
  • Postnatal care: routine postnatal care of recently delivered women and their babies
  • Intrapartum care: management and delivery of care to women in labour
  • Guidance for midwives, health visitors, pharmacists and other primary care services to improve the nutrition of pregnant and breastfeeding mothers and children in low-income households.

Methods The identification of studies that can inform practice and policy for the support of breastfeeding among women from disadvantaged groups was a priority for the review. A thorough search, data extraction and analysis were conducted. All included papers were reviewed by at least two members of the team. Around 55,000 citations were identified from the electronic search and a further 8,000 from hand searching; 940 papers were pre-screened and full data extraction was carried out on 138 papers. A total of 80 eligible studies (including three reviews) were finally included. Only 17 studies (21%) examined the needs of women from disadvantaged groups. Only 10 studies (12.5%) were conducted in the UK.
Findings One of the main findings of this review is the great extent of the evidence gap relating to disadvantaged groups. Ways of raising breastfeeding rates among groups where the rates are lowest remain to be explored further.

Although there are evidence gaps identified across all the sections, they are widest in clinical issues, public policy and those that address women’s key concerns and problems. There is an urgent need for research into clinical problems, including ‘insufficient milk’, sore nipples, engorgement and the breastfeeding needs of babies and mothers with particular health needs. There is very little research to inform any aspect of public policy. Two other important findings emerge across all sections. First, there are effective and ineffective interventions. Second, a gap in the evidence base identified across all the reviews is an understanding of the views of those most involved – childbearing women and their families, and the staff who care for them – whose voices are largely silent in relation to the interventions that might be effective.

  • Practices and policies that have been shown to be effective/beneficial for enhancing breastfeeding duration.
  • Forms of care/practices/policies that appear to be promising and well rounded in theory for enhancing the duration of breastfeeding.
  • Forms of care/practices/policies shown to be ineffective or harmful for breastfeeding duration.

Conclusion The extent of the work needed to change the current patterns of infant feeding should not be underestimated. These patterns have been developed over the past century and are now embedded in the thinking and behaviour of several generations of practitioners and in society as a whole. A coordinated and well-supported programme will The effectiveness of public health interventions to promote the duration of breastfeeding be needed if real culture and practice change is to occur. To enable women to breastfeed the evidence suggests that the following changes are needed:
  • Coordination of national with local policy so that departmental policy is funded, enabled and monitored at the level of, for example, PCTs, Sure Starts, and acute trusts, with a two-way flow of information to enable both a bottom-up and a top-down approach
  • Ongoing monitoring of rates of variation in infant feeding, with agreed definitions and timing of followup, combined with socio-demographic data.
It will also require the wholehearted involvement and support of:
  • Clinical professionals in community and hospital settings
  • Community based workers including Sure Start staff
  • Managers with responsibility for health and social services and staff
  • Those with responsibility for collecting health and health service-related data
  • Educators in the fields of health and social services; schoolteachers and those responsible for the school curriculum in primary and secondary schools
  • Employers in large and small organisations
  • Politicians and policy makers at local, regional and national levels
  • Those with influence over public opinion
  • Families and the public at large.