Randomised controlled trial of support from volunteer counsellors for mothers considering breast feeding
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《英国医生杂志》
1 Department of General Practice and Primary Care, Barts and the London, Queen Mary, University of London, London E1 4NS, 2 Statham Grove Surgery, London N16 9DP, 3 St George's Hospital Medical School, London SW17 0QT
Correspondence to: Dr J Graffy, General Practice and Primary Care Research Unit, Institute of Public Health, University of Cambridge, Cambridge CB2 2SR jonathan.graffy@phpc.cam.ac.uk
Abstract
Breast feeding makes an important contribution to the health of mothers and babies, but in the United Kingdom only 69% of infants born in 2000 were initially breast fed.1 2 By four months, only 28% were still given any breast milk, even though most of the mothers would have preferred to continue.2
Several strategies have been used to promote breast feeding, such as setting standards for maternity services (for example, the joint World Health Organization and Unicef baby friendly hospital initiative), public education through media campaigns, and peer led initiatives to support individual mothers.3-5 Voluntary organisations such as the National Childbirth Trust, Breastfeeding Network, and La Leche League have long played a part in supporting women. In 2000 they helped 8% of mothers in the United Kingdom.2 We investigated whether offering voluntary support to all women considering breast feeding would increase the duration of any breast feeding, and their satisfaction with doing so.
Methods
We identified 5193 women from the practices' records and issued questionnaires for 4364 who were still pregnant and registered at 28 weeks' gestation (figure). Completed questionnaires were returned by 2439 women, but recruitment seemed to depend on the continuity and commitment of practice staff.
Trial profile
Overall, 720 of the 2439 (30%) women who completed the antenatal questionnaire satisfied the inclusion criteria and were recruited. Of these, 363 were allocated to receive additional support and 357 to receive usual care. Although these groups were similar in most respects (table 1), there was a slight difference in the numbers of women who were undecided about breast feeding (16 in the intervention group compared with six in the control group). We performed a sensitivity analysis, adjusting for breastfeeding intent, because we considered this likely to be our strongest confounder.
Table 1 Maternal characteristics and feeding intentions at recruitment during last trimester of pregnancy. Values are numbers (percentages)
Follow up and uptake of counselling
At six weeks, 350 women remained in each group. The same number in each group completed questionnaires at six weeks (336, 96%) and at four months (310, 89%; table 2). Five women withdrew from the intervention group, two babies in the intervention group died and one in the control group, and 12 women (six in each group) delivered too early to receive the intervention. Women who had discontinued breast feeding were significantly more likely to need a telephone reminder to return the questionnaire at six weeks (74/209 (35%) v 57/422 (13.5%); 2 = 40.7, P < 0.001).
Table 2 Counsellors' records of contacts during antenatal and postnatal periods with 336 women in intervention group who returned six week questionnaires. Values are numbers (percentages)
Counsellors reported antenatal contact with 80% (n = 269) of the 336 women in the intervention group who returned questionnaires at six weeks. They visited 254, but had difficulty contacting others. No associations between personal factors and antenatal contact were noted.
Postnatally the counsellors visited 67 (20%) of the women at least once, spoke with 143 (43%) by telephone, and had no contact with 126 (38%). Women who left school at an earlier age were significantly less likely to arrange a postnatal visit (2 for trend = 9.61, P = 0.002). The questionnaire at six weeks showed that 179 (53%) women in the intervention group and 48 (14%) in the control group had tried to contact a counsellor after the birth.
Effect of intervention
Overall, 320 (95%) women in the intervention group breast fed initially compared with 324 (96%) in the control group (relative risk 0.99, 95% confidence interval 0.84 to 1.16, P = 0.44; table 3). At six weeks, 218 (65%) women in the intervention group and 213 (63%) in the control group were still giving some breast feeds (1.02, 0.84 to 1.24; P = 0.69). By four months, 143 (46%) of the 310 women who responded in the intervention group were breast feeding compared with 131 (42%) of the 310 women in the control group (1.09, 0.86 to 1.39; P = 0.33).
Table 3 Prevalence of breast feeding at birth, six weeks, and four months
Kaplan-Meier survival analysis confirmed that the duration of breast feeding was not significantly different between the women in the intervention and control groups (median 110 days v 96 days; log rank statistic 0.58; P = 0.445). (Confidence intervals exceeded recording period.) Similarly, the time at which the two groups introduced formula feeds after birth was not significantly different (median 28 days, 95% confidence interval 21 to 35 v 28 days, 22 to 34; log rank statistic 2.03; P = 0.154).
Sensitivity analysis
To assess the impact of the small imbalance at recruitment in intention to breast feed, we used Cox regression to compare the association between group allocation and feeding duration taking intention into account. For any breast feeding, the estimated hazard ratio (chance of stopping breast feeding in intervention group to chance of stopping in control group) was 0.893 (0.717 to 1.112) when intention was not taken into account and 0.886 (0.712 to 1.104) when it was. For introducing formula feeds, the hazard ratio was virtually unchanged: 0.858 (0.716 to 1.029) when intention was not taken into account and 0.861 (0.718 to 1.032) when it was. Thus the small imbalance at baseline made a negligible difference to the results.
Maternal satisfaction and common feeding problems
Women in the intervention group were less likely to believe they were not making enough milk (mean rank 322 v 294; P = 0.038), but on most measures there seemed to be no difference (table 4; also see bmj.com). Small between group differences in embarrassment about feeding in front of others and confidence in the ability to breast feed were in the expected direction but were not significant.
Table 4 Satisfaction with breast feeding and incidence of common feeding problems in intervention and control groups combined
Mothers' perspectives on support from counsellors
At six weeks the 179 women in the intervention group who had tried to contact a counsellor postnatally were asked whether they found the counsellor helpful. Of the 169 respondents, 123 (73%) found her very helpful, 28 (17%) fairly helpful, 12 (7%) a little helpful, and six (4%) not helpful. Also, 161 women made comments in a free text section: most valued the relationship with their counsellor, learning more about breast feeding or practical suggestions for problems.
When asked about the most helpful advice they received from any source, 141 (44%) of the 250 women in the intervention group who responded said it came from a counsellor compared with 75 (23%) who cited advice from a midwife; the next most valued source.
Association between counselling uptake and feeding behaviour
Only 63% (210/336) of the women in the intervention group made contact with a counsellor postnatally. The 20% (67/336) who met with counsellors during the postnatal period were significantly more likely to continue breast feeding than those in contact by telephone (43%, n = 143) or those who had no contact (37%, n = 126). At six weeks, 76% (51/67) of those visited were still breast feeding compared with 64% (92/143) of those who telephoned and 60% (75/126) of those not in contact (2 for trend = 4.89, P = 0.027).
Discussion
Standing Committee on Nutrition of the British Paediatric Association. Is breastfeeding beneficial in the UK? Arch Dis Child 1994;71: 376-80.
Hamlyn B, Brooker S, Oleinikova K, Wands S. Infant feeding 2000. London: Stationery Office, 2002.
Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, et al. Promotion of Breastfeeding Intervention Trial (PROBIT). JAMA 2001;285: 413-20.
Sikorski J, Renfrew MJ, Pindoria S, Wade A. Support for breastfeeding mothers. Cochrane Library, Issue 3. Oxford: Update Software, 2002.
Tedstone A, Dunce N, Aviles M, Shetty P, Daniels L. Effectiveness of interventions to promote healthy feeding in infants under one year of age: a review. London: Health Education Authority, 1998.
Breastfeeding Promotion Group. Code of conduct for breastfeeding counsellors and trainees. London: National Childbirth Trust, 1992.
National Childbirth Trust. Breastfeeding: a good start. London: NCT, 1990.
Health Education Authority. Breastfeeding: your questions answered by the Health Education Authority. London: HEA, 1992.
Graffy JP. Evaluating breastfeeding support: a randomised controlled trial of support from breastfeeding counsellors. . Birmingham: University of Birmingham, 2002.
Graffy JP. Mothers' attitudes to and experience of breastfeeding: a primary care study. Br J Gen Pract 1992;42: 61-4.
Jones DA, West RR. Effect of a lactation nurse on the success of breastfeeding: a randomised controlled trial. J Epidemiol Community Health 1986;40: 45-9.
Rajan L. The contribution of professional support, information and consistent correct advice to successful breast feeding. Midwifery 1993;9: 197-209.
Leff EW, Jefferis RN, Gagne MP. The development of the maternal breastfeeding evaluation scale. J Hum Lact 1994;10: 105-11.
Morrow AL, Guerrero ML, Shults J, Calva JJ, Lutter C, Bravo J, et al. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet 1999;353: 1226-331.
Haider R, Ashworth A, Kabir I, Huttly SRA. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. Lancet 2000;356: 1643-7.
Houston MJ, Howie PW, Cook A, McNeilly AS. Do breastfeeding mothers get the home support they need? Health Bull 1981;39: 166-72.
Bunton R, Murphy S, Bennett P. Theories of behavioural change and their use in health promotion: some neglected areas. Health Educ Res 1991;6: 153-62.
McInnes RJ, Stone DH. The process of implementing a community-based peer breast-feeding support programme: the Glasgow experience. Midwifery 2001;17: 65-73.
Dennis CL, Hodnett E, Gallop R, Chalmers B. The effect of peer support on breast-feeding duration among primiparous women: a randomized controlled trial. Can Med Assoc J 2002;166: 21-8.
Barros FC, Halpern R, Victora CG, Teixeira ABM, Beria JU. A randomised intervention trial to increase breast-feeding prevalence in southern Brazil. Rev Saude Publica 1994;28: 277-83.
World Health Organization Secretariat. Infant and young child nutrition; global strategy on infant and young child feeding. Resolution WHA55/15. Geneva: WHO, 2002. www.who.int/gb/EB_WHA/PDF/WHA55/ea5515.pdf (accessed 25 Sept 2003).
(Accepted 7 November 2003)
Related Articles
Volunteer counsellors for supporting breast feeding: Support for breast feeding must be proactive
Annette E Hay
BMJ 2004 328: 349.
Volunteer counsellors for supporting breast feeding: Peer support is worth further investigation
Carol M A Campbell
BMJ 2004 328: 349.
Volunteer support does not change breastfeeding rates
BMJ 2004 328: 0.(Jonathan Graffy, senior l)
Correspondence to: Dr J Graffy, General Practice and Primary Care Research Unit, Institute of Public Health, University of Cambridge, Cambridge CB2 2SR jonathan.graffy@phpc.cam.ac.uk
Abstract
Breast feeding makes an important contribution to the health of mothers and babies, but in the United Kingdom only 69% of infants born in 2000 were initially breast fed.1 2 By four months, only 28% were still given any breast milk, even though most of the mothers would have preferred to continue.2
Several strategies have been used to promote breast feeding, such as setting standards for maternity services (for example, the joint World Health Organization and Unicef baby friendly hospital initiative), public education through media campaigns, and peer led initiatives to support individual mothers.3-5 Voluntary organisations such as the National Childbirth Trust, Breastfeeding Network, and La Leche League have long played a part in supporting women. In 2000 they helped 8% of mothers in the United Kingdom.2 We investigated whether offering voluntary support to all women considering breast feeding would increase the duration of any breast feeding, and their satisfaction with doing so.
Methods
We identified 5193 women from the practices' records and issued questionnaires for 4364 who were still pregnant and registered at 28 weeks' gestation (figure). Completed questionnaires were returned by 2439 women, but recruitment seemed to depend on the continuity and commitment of practice staff.
Trial profile
Overall, 720 of the 2439 (30%) women who completed the antenatal questionnaire satisfied the inclusion criteria and were recruited. Of these, 363 were allocated to receive additional support and 357 to receive usual care. Although these groups were similar in most respects (table 1), there was a slight difference in the numbers of women who were undecided about breast feeding (16 in the intervention group compared with six in the control group). We performed a sensitivity analysis, adjusting for breastfeeding intent, because we considered this likely to be our strongest confounder.
Table 1 Maternal characteristics and feeding intentions at recruitment during last trimester of pregnancy. Values are numbers (percentages)
Follow up and uptake of counselling
At six weeks, 350 women remained in each group. The same number in each group completed questionnaires at six weeks (336, 96%) and at four months (310, 89%; table 2). Five women withdrew from the intervention group, two babies in the intervention group died and one in the control group, and 12 women (six in each group) delivered too early to receive the intervention. Women who had discontinued breast feeding were significantly more likely to need a telephone reminder to return the questionnaire at six weeks (74/209 (35%) v 57/422 (13.5%); 2 = 40.7, P < 0.001).
Table 2 Counsellors' records of contacts during antenatal and postnatal periods with 336 women in intervention group who returned six week questionnaires. Values are numbers (percentages)
Counsellors reported antenatal contact with 80% (n = 269) of the 336 women in the intervention group who returned questionnaires at six weeks. They visited 254, but had difficulty contacting others. No associations between personal factors and antenatal contact were noted.
Postnatally the counsellors visited 67 (20%) of the women at least once, spoke with 143 (43%) by telephone, and had no contact with 126 (38%). Women who left school at an earlier age were significantly less likely to arrange a postnatal visit (2 for trend = 9.61, P = 0.002). The questionnaire at six weeks showed that 179 (53%) women in the intervention group and 48 (14%) in the control group had tried to contact a counsellor after the birth.
Effect of intervention
Overall, 320 (95%) women in the intervention group breast fed initially compared with 324 (96%) in the control group (relative risk 0.99, 95% confidence interval 0.84 to 1.16, P = 0.44; table 3). At six weeks, 218 (65%) women in the intervention group and 213 (63%) in the control group were still giving some breast feeds (1.02, 0.84 to 1.24; P = 0.69). By four months, 143 (46%) of the 310 women who responded in the intervention group were breast feeding compared with 131 (42%) of the 310 women in the control group (1.09, 0.86 to 1.39; P = 0.33).
Table 3 Prevalence of breast feeding at birth, six weeks, and four months
Kaplan-Meier survival analysis confirmed that the duration of breast feeding was not significantly different between the women in the intervention and control groups (median 110 days v 96 days; log rank statistic 0.58; P = 0.445). (Confidence intervals exceeded recording period.) Similarly, the time at which the two groups introduced formula feeds after birth was not significantly different (median 28 days, 95% confidence interval 21 to 35 v 28 days, 22 to 34; log rank statistic 2.03; P = 0.154).
Sensitivity analysis
To assess the impact of the small imbalance at recruitment in intention to breast feed, we used Cox regression to compare the association between group allocation and feeding duration taking intention into account. For any breast feeding, the estimated hazard ratio (chance of stopping breast feeding in intervention group to chance of stopping in control group) was 0.893 (0.717 to 1.112) when intention was not taken into account and 0.886 (0.712 to 1.104) when it was. For introducing formula feeds, the hazard ratio was virtually unchanged: 0.858 (0.716 to 1.029) when intention was not taken into account and 0.861 (0.718 to 1.032) when it was. Thus the small imbalance at baseline made a negligible difference to the results.
Maternal satisfaction and common feeding problems
Women in the intervention group were less likely to believe they were not making enough milk (mean rank 322 v 294; P = 0.038), but on most measures there seemed to be no difference (table 4; also see bmj.com). Small between group differences in embarrassment about feeding in front of others and confidence in the ability to breast feed were in the expected direction but were not significant.
Table 4 Satisfaction with breast feeding and incidence of common feeding problems in intervention and control groups combined
Mothers' perspectives on support from counsellors
At six weeks the 179 women in the intervention group who had tried to contact a counsellor postnatally were asked whether they found the counsellor helpful. Of the 169 respondents, 123 (73%) found her very helpful, 28 (17%) fairly helpful, 12 (7%) a little helpful, and six (4%) not helpful. Also, 161 women made comments in a free text section: most valued the relationship with their counsellor, learning more about breast feeding or practical suggestions for problems.
When asked about the most helpful advice they received from any source, 141 (44%) of the 250 women in the intervention group who responded said it came from a counsellor compared with 75 (23%) who cited advice from a midwife; the next most valued source.
Association between counselling uptake and feeding behaviour
Only 63% (210/336) of the women in the intervention group made contact with a counsellor postnatally. The 20% (67/336) who met with counsellors during the postnatal period were significantly more likely to continue breast feeding than those in contact by telephone (43%, n = 143) or those who had no contact (37%, n = 126). At six weeks, 76% (51/67) of those visited were still breast feeding compared with 64% (92/143) of those who telephoned and 60% (75/126) of those not in contact (2 for trend = 4.89, P = 0.027).
Discussion
Standing Committee on Nutrition of the British Paediatric Association. Is breastfeeding beneficial in the UK? Arch Dis Child 1994;71: 376-80.
Hamlyn B, Brooker S, Oleinikova K, Wands S. Infant feeding 2000. London: Stationery Office, 2002.
Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, et al. Promotion of Breastfeeding Intervention Trial (PROBIT). JAMA 2001;285: 413-20.
Sikorski J, Renfrew MJ, Pindoria S, Wade A. Support for breastfeeding mothers. Cochrane Library, Issue 3. Oxford: Update Software, 2002.
Tedstone A, Dunce N, Aviles M, Shetty P, Daniels L. Effectiveness of interventions to promote healthy feeding in infants under one year of age: a review. London: Health Education Authority, 1998.
Breastfeeding Promotion Group. Code of conduct for breastfeeding counsellors and trainees. London: National Childbirth Trust, 1992.
National Childbirth Trust. Breastfeeding: a good start. London: NCT, 1990.
Health Education Authority. Breastfeeding: your questions answered by the Health Education Authority. London: HEA, 1992.
Graffy JP. Evaluating breastfeeding support: a randomised controlled trial of support from breastfeeding counsellors. . Birmingham: University of Birmingham, 2002.
Graffy JP. Mothers' attitudes to and experience of breastfeeding: a primary care study. Br J Gen Pract 1992;42: 61-4.
Jones DA, West RR. Effect of a lactation nurse on the success of breastfeeding: a randomised controlled trial. J Epidemiol Community Health 1986;40: 45-9.
Rajan L. The contribution of professional support, information and consistent correct advice to successful breast feeding. Midwifery 1993;9: 197-209.
Leff EW, Jefferis RN, Gagne MP. The development of the maternal breastfeeding evaluation scale. J Hum Lact 1994;10: 105-11.
Morrow AL, Guerrero ML, Shults J, Calva JJ, Lutter C, Bravo J, et al. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet 1999;353: 1226-331.
Haider R, Ashworth A, Kabir I, Huttly SRA. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. Lancet 2000;356: 1643-7.
Houston MJ, Howie PW, Cook A, McNeilly AS. Do breastfeeding mothers get the home support they need? Health Bull 1981;39: 166-72.
Bunton R, Murphy S, Bennett P. Theories of behavioural change and their use in health promotion: some neglected areas. Health Educ Res 1991;6: 153-62.
McInnes RJ, Stone DH. The process of implementing a community-based peer breast-feeding support programme: the Glasgow experience. Midwifery 2001;17: 65-73.
Dennis CL, Hodnett E, Gallop R, Chalmers B. The effect of peer support on breast-feeding duration among primiparous women: a randomized controlled trial. Can Med Assoc J 2002;166: 21-8.
Barros FC, Halpern R, Victora CG, Teixeira ABM, Beria JU. A randomised intervention trial to increase breast-feeding prevalence in southern Brazil. Rev Saude Publica 1994;28: 277-83.
World Health Organization Secretariat. Infant and young child nutrition; global strategy on infant and young child feeding. Resolution WHA55/15. Geneva: WHO, 2002. www.who.int/gb/EB_WHA/PDF/WHA55/ea5515.pdf (accessed 25 Sept 2003).
(Accepted 7 November 2003)
Related Articles
Volunteer counsellors for supporting breast feeding: Support for breast feeding must be proactive
Annette E Hay
BMJ 2004 328: 349.
Volunteer counsellors for supporting breast feeding: Peer support is worth further investigation
Carol M A Campbell
BMJ 2004 328: 349.
Volunteer support does not change breastfeeding rates
BMJ 2004 328: 0.(Jonathan Graffy, senior l)