Step 10: the breastfeeding support paradox – Authors' reply
Authors: Marcel Yotebieng, Frieda Behets
Journal: The Lancet Global Health (2015)

Pat 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. Indeed, relieving hospital and primary care facilities of the responsibility and cost of setting up and maintaining such services might spur larger-scale implementation of Steps 1–9, which have consistently been shown to be effective in promoting breastfeeding. However, concerns about breastfeeding that arise in the first weeks after hospital discharge are the strongest predictors of cessation of exclusive, or all, breastfeeding.1Wagner EA Chantry CJ Dewey KG Nommsen-Rivers LA Breastfeeding concerns at 3 and 7 days postpartum and feeding status at 2 months.Pediatrics. 2013; 132: e865-e875Crossref PubMed Scopus (137) Google Scholar The most prevalent of those concerns––infant feeding difficulty, pain while breastfeeding, and milk quantity––might be resolved with timely and appropriate support intervention. There is an urgent need for research to identify the most cost-effective approach to answer those concerns. Targeted support programmes, such as that pilot-tested by Hoddinott and colleagues2Hoddinott PL Maclennan CG Boyers D Vale L The FEeding Support Team (FEST) randomised, controlled feasibility trial of proactive and reactive telephone support for breastfeeding women living in disadvantaged areas.BMJ Open. 2012; 2: e000652Crossref Scopus (46) Google Scholar through active telephone contacts and home visits seem promising, but they have not been rigorously evaluated. We disagree with Hoddinott's claim that results from our two trials3Yotebieng 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 (58) Google Scholar, 4Hoddinott 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 (57) Google Scholar are counter to Cochrane systematic review evidence,5Renfrew 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 which reports that any additional support, professional or lay, increases the duration of exclusive breastfeeding. Our studies tested two approaches for implementation of Step 10: support from health professionals in well baby clinics and peer-support groups. Both these approaches have important limitations, including the requirement for mothers to attend clinic visits or group support sessions. Other approaches, such as home-visits and telephone support have been pilot tested, but evidence from reviews of these interventions has been inconclusive.6Yonemoto N Dowswell T Nagai S Mori R Schedules for home visits in the early postpartum period.Cochrane Database Syst Rev. 2013; 7 (CD009326)PubMed Google Scholar, 7Lavender T Richens Y Milan SJ Smyth RM Dowswell T Telephone support for women during pregnancy and the first six weeks postpartum.Cochrane Database Syst Rev. 2013; 7 (CD009338)Google Scholar Furthermore, in our study, breastfeeding support provided by health professionals (Step 1–9) was very effective and consistent with the results of the Cochrane review and that of a recent trial of individual peer support in our region.8Tylleskär T Jackson D Meda N et al.Exclusive breastfeeding promotion by peer counsellors in sub-Saharan Africa (PROMISE-EBF): a cluster-randomised trial.Lancet. 2011; 378: 420-427Summary Full Text Full Text PDF PubMed Scopus (186) Google Scholar We 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 paradoxIn the cluster randomised controlled trial by Marcel Yotebieng and colleagues (August, 2015)1 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 2007.2 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. Full-Text PDF Open Access