Step 10: the breastfeeding support paradox
Authors: Pat Hoddinott
Journal: The Lancet Global Health (2015)

In the cluster randomised controlled trial by Marcel Yotebieng and colleagues (August, 2015)1Yotebieng M Labbok M Soeters HM et al.Ten Steps to Successful Breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trial.Lancet Glob Health. 2015; 3: e546-e555Summary Full Text Full Text PDF Scopus (51) Google Scholar the addition of Step 10 of the UNICEF Baby Friendly Hospital Initiative (BFHI)—that is, the provision of additional support for breastfeeding—did not enhance the effects of steps 1–9, and may even have lessened them. Consistent findings were reported for a trial of Step 10 in Scotland between 2005 and 2007.2Hoddinott P Britten J Prescott G Tappin D Ludbrook A Godden D Effectiveness of a policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care.BMJ. 2009; 338: a3026Crossref PubMed Scopus (56) Google Scholar In this large cluster-randomised trial, the BIG (Breastfeeding in Groups) trial, 14 primary care organisations were asked either to set up new breastfeeding support groups to cover their geographical area, or to leave their existing group provision for pregnant and postnatal women unchanged. More than 18 000 babies were followed up and there was no significant difference between the two groups in change from baseline in rates of exclusive, or any, breastfeeding 8 weeks after birth. In December, 2012, new standards for BFHI accreditation were introduced and the UNICEF UK 10 steps were updated. Before the BIG trial, Step 10 read: “Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic”. In the new standards this now reads: ”Identify sources of national and local support for breastfeeding and ensure that mothers know how to access these prior to discharge from hospital”.3Entwistle FM The evidence and rationale for the UNICEF Baby Friendly Initiative standards. UNICEF UK, London2013http://www.unicef.org.uk/Documents/Baby_Friendly/Research/baby_friendly_evidence_rationale.pdfGoogle Scholar This change removes the expectation that hospitals and primary care organisations should routinely establish breastfeeding support groups, with consequent cost savings to national health services. Findings from Yotebieng and colleagues' trial1Yotebieng M Labbok M Soeters HM et al.Ten Steps to Successful Breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trial.Lancet Glob Health. 2015; 3: e546-e555Summary Full Text Full Text PDF Scopus (51) Google Scholar and the BIG trial2Hoddinott P Britten J Prescott G Tappin D Ludbrook A Godden D Effectiveness of a policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care.BMJ. 2009; 338: a3026Crossref PubMed Scopus (56) Google Scholar are not consistent with Cochrane systematic review evidence that professional or lay support increases the duration of exclusive breastfeeding at 4–6 weeks (RR 0·74, 95%CI 0·61–0·89).4Renfrew MJ McCormick FM Wade A Quinn B Dowswell T Support for healthy breastfeeding mothers with healthy term babies.Cochrane Database Syst Rev. 2012; 5 (CD001141)Crossref PubMed Google Scholar Since 2000, no UK-based large-scale trials of additional support have reported a significant effect on breastfeeding outcomes. However, a pilot trial of intensive, proactive telephone-based care from a feeding team shows promise.5Hoddinott P Craig L MacLennan G Boyers D Vale L The FEeding Support Team (FEST) trial of proactive telephone support for breastfeeding women living in disadvantaged areas.BMJ Open. 2012; 2: e000652Crossref Scopus (44) Google Scholar, 6Hoddinott P Craig L MacLennan G Boyers D Vale L on behalf of the FEST project teamProcess evaluation for the FEeding Support Team (FEST) trial of proactive telephone support for breastfeeding women living in disadvantaged areas.BMJ Open. 2012; 2: e001039Crossref Scopus (19) Google Scholar This person-centred intervention is consistent with new UNICEF-UK standards that aim to avoid making women feel pressured to breastfeed, or judged to have failed as mothers if they do not breastfeed.3Entwistle FM The evidence and rationale for the UNICEF Baby Friendly Initiative standards. UNICEF UK, London2013http://www.unicef.org.uk/Documents/Baby_Friendly/Research/baby_friendly_evidence_rationale.pdfGoogle Scholar Attitudes and norms surrounding breastfeeding will vary not only between individuals, social groups, and health services but also differ considerably both within and between countries. These contextual factors, in addition to baseline breastfeeding prevalence, are likely to affect outcomes for interventions to promote breastfeeding. We cannot assume that results are generalisable, even those from rigorous systematic reviews. I declare no competing interests Ten Steps to Successful Breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trialIn the setting of health-care clinics in DR Congo with a high proportion of mothers initiating breastfeeding, implementation of basic training in BFHI steps 1–9 had no additional effect on initiation of breastfeeding but significantly increased exclusive breastfeeding at 6 months of age. Additional support based on the same training materials and locally available breastfeeding support materials, offered during well-child visits (ie, step 10) did not enhance this effect, and might have actually lessened it. Full-Text PDF Open AccessStep 10: the breastfeeding support paradox – Authors' replyPat Hoddinott welcomes the rewording of Step 10 in the WHO/UNICEF Baby Friendly Hospital Initiative in the UK that removes the expectation that hospitals and primary care organisations should routinely provide breastfeeding support groups for new mothers. We agree with Hoddinott that this reformulation of Step 10 should be applied globally, since when poorly devised or implemented, support groups established as part of the old Step 10 might have a detrimental effect on the overall goal of optimal breastfeeding. Full-Text PDF Open Access