Breast Feeding Peer Councelling

Breastfeeding Peer Counseling: From Efficacy through Scale-up
Donna J. Chapman, Ph.D., R.D.,

University of Connecticut Center for Eliminating Health Disparities Among Latinos Department of
Nutritional Sciences 3624 Horsebarn Road Extension Storrs, CT 06269-4017 Phone:
860-486-0630 Fax: 860-486-3674 donna.chapman@uconn.edu
Katherine Morel, M.S.,
Senior Nutritionist Hispanic Health Council 175 Main Street Hartford, CT 06106
katiew@hispanichealth.com
Alex Kojo Anderson, Ph.D., MPH, CPH,
Assistant Professor Dept. of Foods and Nutrition The University of Georgia 280 Dawson Hall
Athens, GA 30602 Phone: 706-542-7614 Fax: 706-542-5059 Anderson@fcs.uga.edu
Grace Damio, MS, CD/N, and
Deputy Director, NIH Export Center for Eliminating Health Disparities Among Latinos Director,
Center for Community Nutrition; Center for Women & Childrens Health Hispanic Health Council
175 Main Street Hartford, CT 06106 Telephone: 860-527-0856 ext. 274 Fax: 860-724-0437
graced@hispanichealth.com
Rafael Prez-Escamilla, Ph.D.
Professor of Epidemiology & Public Health Director, Office of Community Health Yale School of
Public Health 135 College Street, Suite 200 New Haven CT 06510 rafael.perez-
escamilla@yale.edu phone: (203) 737-5882 fax: (203) 737-4591 rafael.perez-
escamilla@yale.edu
Abstract
There are a growing number of publications evaluating various breastfeeding peer counseling (PC)
models. We have systematically reviewed a) the randomized trials assessing the effectiveness of
breastfeeding PC in improving rates of breastfeeding initiation, duration, exclusivity and maternal
and child health outcomes; and b) scientific literature describing the scale-up of breastfeeding PC
programs. Twenty-six peer-reviewed publications were included in this review. The overwhelming
majority of evidence from randomized, controlled trials evaluating breastfeeding PC indicates that
peer counselors effectively improve rates of breastfeeding initiation, duration and exclusivity. PC
interventions were also shown to significantly decrease the incidence of infant diarrhea and
significantly increase the duration of lactational amenorrhea. We conclude that breastfeeding PC
initiatives are effective and can be scaled up in both developed and developing countries, as part
of well-coordinated national breastfeeding promotion or maternal-child health programs.
Given the well documented health risks associated with poor breastfeeding outcomes, public
health policies that improve breastfeeding rates are urgently needed. Breastfeeding peer
counselors are local community women who have successfully breastfed, received training
in breastfeeding education, and work with their peers to improve breastfeeding outcomes.
Peer counselors reinforce breastfeeding recommendations in a socially and culturally
relevant context, since they understand the cultural and environmental barriers to
breastfeeding and often speak the native language of their clients. Their unique combination
Corresponding author: Donna J . Chapman, Ph.D., R.D..
NIH Public Access
Author Manuscript
J Hum Lact. Author manuscript; available in PMC 2011 August 1.
Published in final edited form as:
J Hum Lact. 2010 August ; 26(3): 314326.
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of successful breastfeeding experience, formal training and a real understanding of the
factors impacting breastfeeding in their community allows peer counselors to enhance the
capacity of clinical health teams.
Breastfeeding peer counseling (PC) has been used in developed and developing countries,
with examples ranging from La Leche League International to community health worker
models. Likely due to funding priorities, scientific research has primarily focused on the
effectiveness of PC in improving the breastfeeding outcomes of low-income women.
Lay support for breastfeeding has been addressed in previous reviews
1, 2
; however, it was
not the primary focus of those reports. Bhandari et al.
3
recently published a systematic
review regarding the scaling up of exclusive breastfeeding (EBF) (ie. increasing the number
of EBF promotion recipients, while maintaining quality and promoting sustainability
3
).
That useful review; however, concentrated on EBF promotion within the context of HIV/
AIDS in sub-Saharan Africa. Currently, there are a growing number of randomized trials
evaluating various breastfeeding PC models. Our objectives are to systematically review the
scientific literature evaluating: a) the effectiveness of breastfeeding PC in improving rates of
breastfeeding initiation, duration, exclusivity and maternal and child health outcomes; and b)
the scale-up of breastfeeding PC programs.
Methods
Manuscripts evaluated for this systematic literature review were obtained from Internet
database searches (PubMed, Web of Science), Cochrane Library systematic reviews
1, 2, 4
,
back-searching reference lists of relevant articles, and the authors personal files. In
September 2008 the following terms were searched in various combinations on internet
databases: PC, community health workers, lay support, volunteer, paraprofessionals,
breastfeeding, EBF, diarrhea, otitis media, amenorrhea, scale up, national programs,
translation, breastfeeding programs, national programs, WIC (Special Supplemental
Nutrition Program for Women, Infants and Children) and government. Abstracts published
in English, Spanish, French, or Portuguese were reviewed.
This review is organized in 5 sections (Initiation, Duration, Exclusivity, Maternal/Child
Health Outcomes, Scale-up). Identified abstracts were evaluated by an expert panel of 4
lactation researchers to determine if they met the following inclusion criteria. For the first
four sections, abstracts describing randomized controlled trials, in which breastfeeding was a
main focus of the PC intervention, were included. Because the terms used to describe
breastfeeding peer counselors in the literature varied, studies included in this review met
commonly accepted definitions of lay health workers
4
or community health workers
5
who
are providing breastfeeding education and support. Studies were excluded if the intervention
exclusively utilized professional health workers such as nurses
6, 7
or if the intervention was
not primarily focused on breastfeeding
8
. For the section on the scale-up of breastfeeding
PC, abstracts were included if they described large-scale randomized trials evaluating a
breastfeeding PC intervention or the development/evaluation of regional or national
breastfeeding PC programs or programs including a PC component.
After identifying abstracts meeting the inclusion criteria, the expert panel selected the
relevant manuscript section(s) for each abstract. Full text articles were obtained for all
abstracts rated by at least 2 panel members as applicable to a specific section. Section
authors evaluated each manuscript identified as relevant for their section to determine if the
inclusion criteria were met. When necessary, authors of the included studies were contacted
via email for clarifications.
Chapman et al. Page 2
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Although authors of the PC randomized trials developed their own questionnaires to assess
breastfeeding outcomes, their definitions of these outcomes were consistent with the
following definitions, unless otherwise noted. Initiation reflects ever breastfed.
Postpartum breastfeeding rates indicate the infant received any breastmilk at the specified
time frame. EBF complied with the WHO definition of EBF
9
which only allows the
provision of breastmilk, medications, and vitamin/mineral drops. Studies were classified as
low-intensity if they contained either only prenatal education, or if postpartum contact was
primarily via telephone support. Studies that included at least 3 contacts, provided both
prenatal and postpartum support, and delivered most contacts in person were considered
high-intensity interventions.
Results
Initiation
Details of the 7 studies included in this section are shown in Table 1
1016
. Three of the four
high-intensity interventions improved breastfeeding initiation rates. In a study evaluating a
PC intervention among low-income, primarily minority women delivering in Hartford,
Connecticut, Chapman et al
12
found women in the PC group were significantly more likely
to initiate breastfeeding as compared to controls (90% vs. 77%, respectively). When testing
a more intensive PC intervention (3 prenatal, daily perinatal, 9 postpartum home visits) in
this community, Anderson et al
10
found similar results, with significantly higher
breastfeeding initiation rates among those in the intervention group versus controls (90% vs.
76%, respectively).
A study by Caulfield and colleagues
11
evaluated 3 separate interventions, 2 of which
included a peer counselor, among African American WIC recipients in the Baltimore,
Maryland region. The first intervention was a breastfeeding motivational video with
accompanying posters and WIC staff breastfeeding counseling. The second intervention was
a PC intervention initiated prenatally in the WIC clinic. The third intervention was a
combination of the first 2, and all were compared to the control group. After controlling for
hospital practices, feeding intention and delivery mode, only the second intervention (ie.
having a peer counselor) significantly increased breastfeeding initiation rates as compared to
controls (OR: 3.84, 95% CI: 1.44 10.21). Results of this study should be interpreted with
caution since 70% of the intervention group did not have peer counselor contact during the
critical period of the first week postpartum.
In one high-intensity intervention, there was no statistically significant difference in
breastfeeding initiation rates between study groups. Morrow et al
15
investigated the effect
of six versus three prenatal and postpartum peer counselor home visits in a low-income
neighborhood in Mexico City to determine their effect on breastfeeding initiation.
Breastfeeding initiation was nearly universal (6 visit group: 100%, 3 visit group: 98%,
controls: 94%), thus no effect of the intervention was observed for this outcome.
The 3 low-intensity interventions were not successful. Graffy et al
13
evaluated an
intervention in which volunteers provided prenatal and postpartum telephone and in-person
support to British women considering breastfeeding. The majority of contacts were via
telephone. No significant differences in breastfeeding initiation were observed between the
intervention and control groups. Muirhead and colleagues
16
in Ayrshire, Scotland found no
significant difference in breastfeeding initiation rates between their PC and control groups.
This intervention provided one prenatal visit of unspecified length and did not include peer
counselor contact in the hospital, which is often a critical time for breastfeeding initiation. In
the third study, MacArthur et al
14
delivered a peer support intervention in Birmingham, UK
involving 2 antenatal support sessions. There was no difference in initiation rates between
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the peer counselor and control groups (69% and 68%, respectively). It should be noted that
this study had limited PC coverage (41% of intervention group received both visits), brief
counseling sessions (mean duration of first session =13 minutes). Initiation data were
obtained from medical record reviews.
These studies suggest that it is important to include both antenatal and perinatal PC within
interventions designed to increase breastfeeding initiation rates, with the majority of contact
being in person.
Duration
There were a total of 13 papers included in this section (Table 2), 7 of which were
previously described in the Initiation section. Four of the 6 new studies included in this
section delivered a high intensity intervention. Agrasada and colleagues
17
evaluated a PC
intervention targeting mothers of low birth weight infants born in the Philippines. At 6
months postpartum, those receiving the PC intervention were significantly more likely to be
breastfeeding compared to the reference and control groups. (63% vs 31% and 29%,
respectively).
Leite et al
18
evaluated the impact of PC in a population of otherwise healthy low
birthweight (<3.0 kg) infants born in Brazil and discharged within 5 days postpartum.
Compared to the intervention group, they observed significantly higher rates of
breastfeeding cessation at 4 months postpartum in the control group (20% vs 33%,
respectively).
In a study of otherwise healthy NICU infants born in Boston, Massachusetts, Merewood and
colleagues
19
observed significantly higher odds of any breastfeeding at 12 weeks
postpartum in their intervention group, which received weekly peer counselor visits for 6
weeks, as compared to controls (OR: 2.81, 95% CI: 1.11 7.14).
Pugh and colleagues
20
evaluated a unique combination of a peer counselor partnered with a
nurse. In this small study (N=41) conducted in the US mid-Atlantic region, the PC group
tended to have higher breastfeeding rates at 6 months than controls (45 vs. 35%,
respectively). However the difference between the groups was not significant, possibly due
to the small sample size.
In a low-intensity primarily telephone-based intervention conducted in Montreal, Mongeon
et al
21
evaluated a volunteer PC model which provided one prenatal home visit, weekly
telephone contact for the first 6 weeks postpartum, followed by biweekly telephone calls
through 5 months postpartum. They observed no significant differences in breastfeeding
rates through 5 months postpartum between study groups. Conversely, when evaluating a
low-intensity telephone-based intervention Dennis et al
22
observed significantly higher
rates of any breastfeeding in the intervention group at 4, 8 and 12 weeks postpartum. At 12
weeks postpartum, 81% of intervention vs 67% of controls were breastfeeding (p=0.01). The
success of this low intensity intervention may be partially attributed to the study population,
which was comprised of predominantly white, educated women in Toronto, Canada.
Among the studies previously described in the initiation section, 2 of the 5 high intensity PC
interventions
1012, 15, 23
resulted in significantly higher rates of any breastfeeding, versus
controls. The 3 other high intensity studies
1012
reported higher breastfeeding rates in their
intervention (vs control) groups; however the difference was not statistically significant. The
2 previously described low-intensity PC interventions
13, 16
showed no significant difference
in breastfeeding rates during the postpartum period. In total, 5 out of 9 high-intensity PC
interventions significantly improved breastfeeding rates, while only 1 of 5 low-intensity
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interventions achieved this. This highlights the importance of ongoing, in-person PC support
to improve breastfeeding duration.
Exclusive Breastfeeding
Our search identified 12 relevant studies (Table 3) examining the efficacy of PC on EBF
rates. Seven randomized controlled trials were specifically designed to evaluate the
effectiveness of breastfeeding peer counselors promoting EBF
10, 15, 17, 2427
, and each
found the intervention to be effective. The first of these was conducted by Davies-Adetugbo
et al.
24
in Osun State, Nigeria among mothers of young infants suffering from acute
diarrhea. The intervention group received 3 breastfeeding peer counselor contacts plus
advice for diarrhea management while controls only received the latter. The proportion of
mothers exclusively breastfeeding was significantly (p<0.0001) higher in the intervention
group than in controls at day 7 (49% vs. 6%) and day 21 (46% vs. 8%) after seeking care for
acute diarrhea. A key limitation of this study was that follow-up data collection was
conducted by individuals who delivered the intervention, thus introducing a potential bias.
Haider et al.
25
conducted a community-based randomized trial in Dhaka, Bangladesh to
assess the effect of PC on EBF rates. Women receiving this intensive intervention (15 home
visits) were significantly more likely to exclusively breastfeed throughout 5 months
postpartum, compared to controls.
In a study conducted in Mexico, Morrow et al
15
compared 2 intensity levels of PC vs
controls. Rates of EBF from birth to 3 months were highest in the group receiving six home
visits, followed by those receiving three home-visits, and lowest in the control group. The
EBF rate of the intervention groups (combined) was significantly greater than that of
controls.
Bhandari and colleagues evaluated the effectiveness of a community-based intervention
promoting EBF in Haryana State, India,. This intervention utilized multiple channels,
including traditional birth attendants, community health workers, community
representatives, nurse midwives and other health-care workers, to deliver EBF messages.
Significantly more intervention infants were exclusively breastfeeding at 3, 4, 5 and 6
months postpartum, compared to controls.
Research conducted in the Philippines by Agrasada et al.
17
demonstrated that rates of EBF
at 6 months postpartum were significantly higher among mothers in the PC group (44%),
compared to the reference (7%) and control groups (0%).
In a study of predominantly low income, inner-city Latinas in Hartford, CT, Anderson
10
and colleagues showed that women in the PC group were significantly more likely to
exclusively breastfeed throughout the study compared to controls. At 3 months postpartum,
mothers in the PC group were almost 15 times more likely to be exclusively breastfeeding
compared to controls.
Most recently, Hopkinson et al
26
conducted a unique trial in Houston, TX among mothers
of full-term, Latino infants at low risk for hyperbilirubinemia, who were receiving both
breastmilk and formula. The trial sought to determine if assigning mixed feeders to a
breastfeeding clinic appointment, where they met with a peer counselor within 1 week
postpartum, would increase EBF rates. Significantly more intervention mothers were
exclusively breastfeeding at 4 weeks postpartum versus controls (17% vs. 10%, respectively;
p=0.03).
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Five randomized trials evaluated breastfeeding PC interventions that promoted
breastfeeding, but were not designed to impact EBF rates
12, 13, 16, 18, 22
. Two of these trials
demonstrated significant improvements in EBF rates. In a home-based PC trial promoting
breastfeeding among mothers of low birth weight infants in Brazil, Leite et al.
18
observed
significantly higher rates of EBF at 4 months postpartum in the intervention (vs. control)
group. Similarly, in the telephone-based PC intervention evaluated by Dennis et al EBF rates
were significantly higher throughout the study in the intervention (vs control) group. These
studies suggest that, in some settings, PC programs, which are designed to promote initiation
or duration, may actually improve breastfeeding exclusivity as well.
Two
13, 16
of the 5 studies which were not specifically designed to promote EBF reported
improved EBF rates in their intervention group, but this difference was not statistically
significant. Muirhead
16
also observed that mothers in the PC group tended to be more likely
to avoid using formula at 16 weeks postpartum (14%), compared to controls (8 %). There
was no difference in EBF rates at 1 month postpartum in the study by Chapman et al
12
.
In conclusion, the overwhelming majority of studies evaluated in this section found a
positive impact of peer counselors on EBF practices. Those that did not report a significant
impact of peer counselors on EBF were not designed to improve this outcome.
Health Outcomes
The maternal and child health benefits of breastfeeding have long been recognized. We
identified 5 trials (Table 4) examining the effect of breastfeeding PC on rates of infant
diarrhea. Bhandari et al
27
evaluated the effectiveness of a community-based EBF
intervention in Haryana, India, utilizing prevalence of infant diarrhea as the primary
outcome. Results showed significantly less incidence of diarrhea in the past week at both 3
and 6 months after the intervention in the intervention vs control infants (22% vs. 30% and
25 vs. 28%, respectively). The incidence of diarrheal episodes requiring treatment was
significantly lower in the intervention group (vs controls) at both timepoints.
Four trials evaluated infant diarrhea as a secondary outcome. Morrow and colleagues
15
reported that control group infants were significantly more likely to experience diarrhea
through 3 months postpartum, compared to infants whose mother received the intervention
(26% vs. 12%). Similarly, in a study conducted in Hartford, CT, Anderson and colleagues
10
found control group infants were significantly more likely to experience 1 or more diarrhea
episodes as compared to those in the PC group (38 vs 18%, respectively; RR=2.15, 95% CI
1.16 3.97). These findings were confirmed by Agrasada et al
17
who reported that infants
in their childcare reference group and control group experienced rates of diarrhea that were
nearly twice that of the PC group (28%, 31% and 15%, respectively). Furthermore, infants
in this trial who were exclusively breastfed experienced no diarrhea. Davies-Adetugbo
observed a non-significant reduction in the number of new cases of diarrhea within 21 days
of their intervention (12% intervention, 22% controls). Thus, all 5 studies which assessed
infant diarrhea demonstrated reduced rates of diarrhea among infants whose mothers
received the PC intervention, with the difference being significant in 4 of 5 studies.
Anderson et al
10
also investigated differences in rates of maternal amenorrhea as a
secondary outcome in their PC trial. Extended duration of lactation-induced maternal
amenorrhea is associated with decreased fertility rates, which is important for women who
are not using modern methods of contraception. Anderson reported significantly more
women in the PC group remained amenorrheic through 3 months postpartum, compared to
controls (53% vs 33%, respectively).
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Peer counselor training
The training provided to breastfeeding peer counselors in these randomized trials varied
widely and is summarized in Table 5. In several studies, few details were provided regarding
the training process.
Scale Up
We define scaling up as delivery of improved [ breastfeeding program(s)] to a large number
of beneficiaries, with expanding geographical coverage, national level policy/advocacy, and
intent to address sustainability in the program design
28
. There were 8 studies (Table 6)
which met this sections inclusion criteria.
Examples of Scale-up
A project conducted in Bolivia, Ghana, and Madagascar
28, 29
identified the impact of
community based programs at improving the rates of Timely Initiation of Breastfeeding
((TIBF), i.e. breastfeeding within one hour after birth) and EBF during the first month.
Evaluators used a longitudinal study design lasting 34 years. In all 3 countries, the scaling
up process involved formative research, policy analysis and advocacy, materials
development, training of health care providers including community health workers, social
marketing, and multisectorial partnerships. In Madagascar, 12,000 community volunteers
were trained in breastfeeding promotion. Results from repeated representative community
surveys showed statistically significant improvements in both TIBF and EBF during the first
6 months associated with the scaling up interventions. Improvements were detected as early
as 9 months after the beginning of the implementation. The impact on these outcomes was
sustained during the 34 years that the study was conducted.
A recent feasibility project in the Philippines demonstrated it was possible to develop a
network of well trained breastfeeding peer counselors at the barangay level (smaller
administrative unit), based on a community-driven initiative with strong support from
national and local authorities
30
. A pre/post study design showed that 3 PC home visits to
women with children less than 2 months who were not exclusively breastfeeding lead to
impressive improvements in the rates of any and EBF. As a result, the PC program has been
replicated in nine additional barangays. This program is being tied to the ongoing effort by
the countrys department of health to improve healthcare services to 1 million people living
in low-income urban areas.
A study in predominantly rural areas in Pakistan suggests that community health workers
(known as lady health workers) responsible for the delivery of diverse home and primary
healthcare-based education and services can significantly improve rates of colostrum
feeding
31
. This model is of interest for scaling up as it suggests that it is possible to improve
some breastfeeding outcomes through existing national or regional community health
worker programs, without forming a new cadre of breastfeeding peer counselors.
Brazil has launched the Baby Friendly Primary Health Care Unit Initiative (BFPHCI), in an
attempt to adhere to the 10
th
step of the Baby Friendly Hospital Initiative. This new
initiative includes 10 steps
32, 33
which should be met at the local primary health care unit
(ie. Not at the hospital level) in order to promote and support breastfeeding at the
community level. Some of these steps include breastfeeding training for all primary health
care unit (PHCU) staff, including community health agents (equivalent to peer
counselors)
34
and the formation of breastfeeding support groups. In the state of Rio de
J aneiro, where BFPHCI has been scaled up
32, 33
EBF rates among children <6 months
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were significantly higher among primary health care units with better BFPHCI
implementation.
In the USA, breastfeeding PC has been scaled up by the government through the WIC
program that serves low-income pregnant and postpartum women and their children
3537
.
The WIC breastfeeding PC program was gradually implemented in Mississippi starting in
1990. By 1993 the program was in place in 51 out of 140 WIC clinics, providing an
opportunity to assess its impact through a quasi-experimental design. Breastfeeding
incidence increased significantly more among mothers attending WIC clinics offering
breastfeeding PC
38
. A study in the state of Georgia, USA
39
also found that including PC in
WIC clinics was associated with an increase in breastfeeding initiation rates; however, there
were no differences in prevalence rates at 8 weeks postpartum. WIC findings need to be
understood within the context that peer counselor contact was predominantly via telephone
or mail and that this breastfeeding promotion effort is happening within a program that is the
largest distributor of free infant formula in the world.
Cost-effectiveness
The cost-effectiveness of scaled up EBF promotion programs was recently estimated in
South Africa
40
. Data were derived from a prenatal and postnatal intervention that included
breastfeeding peer counselors, seeking to promote EBF among HIV-positive and HIV-
negative women. The cost analyses modeled the cost of scaling up the intervention from
study site to the provincial level under three scenarios: a) Full: up to 4 prenatal home visits,
14 visits between birth and 6 months postpartum, b) simplified: less home visits and more
clinic-based support and c) basic: entirely clinic-based. Results showed that the simplified
scenario was the most cost effective in terms of cost per increased month of EBF.
In summary, it is possible to scale up cost-effective breastfeeding PC as part of national
breastfeeding promotion efforts. Countries which have scaled up breastfeeding PC have not
offered it as a stand alone service. In each country, there has been an existing health
program or initiative which is used as the vehicle for delivery of breastfeeding PC services.
Some countries have used the Baby Friendly Hospital Initiative (step 10) as this vehicle,
while others have used government-funded programs addressing family planning or
nutrition.
Discussion
This comprehensive review of breastfeeding peer counseling randomized trials and scale-up
efforts indicates that peer counseling has been successfully used in demonstration projects
and at the regional and national levels to improve breastfeeding outcomes. Although success
has been demonstrated internationally, the scale up of breastfeeding peer counseling is still
limited. As research in the effectiveness and cost-effectiveness of breastfeeding peer
counseling continues, future PC studies should address some key issues.
Few publications adequately described peer counselor training, supervision and
compensation. A thorough review (Table 5) of peer counselor training protocols revealed a
wide variety in the content, duration, and curriculum used. This highlights the importance of
developing a standardized training program for breastfeeding peer counselors which
provides up-to-date scientific information and skills (clinical and communication)
development, and includes a process for ongoing education. Additionally, few studies
provided details of peer counselor activities when interacting with mothers and infants.
Since it is possible that outcomes vary based on the specific peer counselor protocols, future
publications should include these details.
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With the exception of some US studies
10, 12, 38
, the involvement of International Board
Certified Lactation Consultants (IBCLC) in PC models remains largely unknown. It is
important to fill this gap in knowledge. Peer counselors should be trained to recognize the
scope of their role and should have access to the expertise of a supervising IBCLC.
As breastfeeding PC efforts are scaled up, salary guidelines will be necessary. Although
community volunteers were used in some studies
13, 17, 21, 22
, better results were usually
achieved in studies that reported providing compensation to peer counselors. Given the
valuable service they provide, breastfeeding peer counselors should receive compensation,
with rates comparable to those of other community health worker positions in their setting.
Additionally, future publications evaluating PC interventions should clearly define their
breastfeeding outcomes, and comply with the standard definition of EBF
9
. In order to better
understand the full benefits of PC, we strongly recommend that future trials collect data on
maternal and child health outcomes.
Finally, research on breastfeeding PC has focused primarily on models serving low-income
women. This focus is likely due to funding priorities, and should not be interpreted to imply
that only low-income women benefit from PC. In settings with limited healthcare resources,
PC may represent the only feasible means to provide breastfeeding education and support.
The response to PC may vary, based on local breastfeeding customs and income level. There
were too few studies evaluating PC in privileged populations to evaluate the effectiveness of
PC by income level. In the single study evaluating a PC model serving upper-income
women, the intervention was effective and well-received
22
.
Conclusions
The overwhelming majority of the evidence from randomized, controlled trials evaluating
breastfeeding PC indicates that peer counselors effectively improve rates of breastfeeding
initiation, duration and exclusivity. Despite major environmental differences in infant
feeding practices, health care access/delivery, and the availability of breastmilk substitutes,
PC has been shown to be effective in improving breastfeeding outcomes and decreasing
rates of infant diarrhea in both developed and developing countries. In one study,
breastfeeding PC also positively impacted maternal health, by significantly increasing the
duration of lactational amenorrhea
10
. These improved health outcomes are achieved, not by
trained medical professionals, but by mothers who have a passion for breastfeeding and have
received adequate training to provide lactation management, as well as emotional/social
support, to the women in their community.
Although some national breastfeeding promotion programs explicitly recognize the role of
peer counselors and/or breastfeeding support groups, their specific roles and contributions
have not been well documented at a national level. Because of the central role that peer
counselors can play at extending support beyond the hospital walls in a cost-effective
manner, it is essential that future scaling up analyses pay special attention to this vital
component of national breastfeeding promotion programs. The challenge for further
improving the scaling up process of breastfeeding PC is to better define, through well
designed studies the optimal: (a) breastfeeding peer counselor training programs and role
delineation in various settings; (b) salary ranges and supervisory structures; (c) prenatal,
perinatal, and postnatal service delivery modes (phone, hospital/clinic based, home visits);
(d) support/educational approaches (individual counseling, support groups), and (e) dosage
needed (number of contact/visits, time per contact/visit) for achieving specific breastfeeding
outcomes (breastfeeding initiation, any breastfeeding and EBF duration)
3537, 4144
. Future
studies should carefully document the components of the peer counselor training programs
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and clearly define their breastfeeding outcomes. We conclude that breastfeeding PC
initiatives are effective and can be scaled up in both developed and developing countries, as
part of well coordinated national breastfeeding promotion or maternal-child health
programs.
Summary Statement: The overwhelming majority of evidence from this systematic
review of the breastfeeding peer counseling scientific literature indicates that peer
counselors effectively improve rates of breastfeeding initiation, duration and exclusivity.
In addition to improving breastfeeding outcomes, peer counseling programs significantly
decreased rates of infant diarrhea and lengthened the duration of maternal amenorrhea.
We conclude that breastfeeding peer counseling initiatives are effective and can be scaled
up as part of well-coordinated national breastfeeding promotion or maternal-child health
programs.
Biography
Donna J Chapman is the Assistant Director of the Connecticut NIH EXPORT Center for
Eliminating Health Disparities Among Latinos and Asst. Professor-in-Residence in the
Department of Nutritional Sciences at the University of Connecticut. Katherine Wetzel is a
Research Associate II and coordinator of an ongoing breastfeeding research study at the
University of Connecticut. Alex Anderson is an Asst. Professor in the Department of Food
and Nutrition at the University of Georgia. Grace Damio is the Deputy Director of the
Connecticut NIH EXPORT Center for Eliminating Health Disparities Among Latinos and
Directors of the Centers for Community Nutrition and Women & Childrens Health at the
Hispanic Health Council. Rafael Prez-Escamilla is Director of the Connecticut NIH
EXPORT Center for Eliminating Health Disparities Among Latinos. He is also Director of
the Office of Community Health at the Yale School of Public Health, and Professor of
Epidemiology and Public Health at Yale University.
Acknowledgments
This project was supported by award P20MD001765 fromthe National Center on Minority Health and Health
Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official
views of the National Center on Minority Health and Health Disparities or the National Institutes of Health. The
authors thank Lisa Phillips, Khara Leon and Ellen Meisterling for administrative assistance.
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Table 1
Randomized Trials evaluating impact of breastfeeding peer counseling on breastfeeding initiation
Reference Location/Sample Study Groups Intervention Initiation Results
Anderson (10) -Hartford, CT USA
-N=182 healthy, low-income
women considering BF &
delivering healthy, term
singleton
1:BF PC (n=90) 2:Control
(n=92)
-3 prenatal and 9 pp home visits +
daily in-hospital visits
-Topics covered: Benefits of EBF,
BF logistics, avoidance of artificial
teats, feeding cues, BF video viewed
BF PC: 91%
*
Controls: 76%
Caulfield (11) -Baltimore, MD USA
-N=242 low-income African
American women, delivering
singleton
1:BF video (n=64)
2:PC (n=55)
3:Video+PC (n=66)
4:Control (n=57)
Video: Presented BF benefits and
shown in WIC waiting area; WIC
staff discussed video & provided
written materials
PC: 3 prenatal and wkly pp contacts
through 16 wks pp
Topics covered:
Infant feeding attitudes,
misconceptions, support sessions.
PC: 62%
*
Video: 50%
Video+PC: 52%
Control: 26%
Chapman (12) -Hartford, CT
-N=219 low-income women
considering BF, who
delivered healthy, term
singleton
1:PC (n =113)
2:Control (n =106)
-1 prenatal and 3 pp home visits;
daily in-hospital visits; unlimited
phone access to PC; free breastpump
Topics covered:
BF benefits, myths and logistics; PP
hands-on help
PC: 91%
*
Controls: 77%
Graffy (13) -London and South Essex,
England.
-N=720 women considering
BF who had <6 wks prior
BF experience; delivered
terminfant, SES level varied
1:Intervention (n=363)
2:Control (n=357)
-1 prenatal visit
-PP phone calls, home visits if
requested
Intervention: 95%
Control: 96%
MacArthur (14) -Birmingham, UK
-N=2398 low-income
women delivering at selected
antenatal clinics.
1:Peer support (n=1083)
2:Control (n=1315)
*
2 antenatal contacts (1 in clinic, 1 at
home).
Topics covered:
BF benefits, support to address
cultural barriers to BF
PC: 69%
Controls: 68%
Morrow (15)
1 -San Pedro Martir, Mexico
-N=130 low-income
pregnant women delivering
healthy infant;
1: 6 visit group (n=44)
2: 3 visit group (n=52)
3: Control (n=34)
6 visit group: mid and late
pregnancy, and wks 1, 2, 4, and 8 pp.
3 visit group: late pregnancy, and
wks 1 and 2 pp.
Topics covered:
-Benefits of EBF, positioning, myths,
lactation anatomy & physiology; PP
visits to establish BF
6-visit: 100%
3-visit: 98%
Control: 94%
Muirhead (16) -Ayrshire, Scotland
-N=225 pregnant women,
SES not specified
1:Peer support (n=112)
2:Control (n=113)
1 prenatal visit, no in-hospital
contact, pp contact every other day
by phone or in person to day 28;
extra support fromday 28 to 16 wks
if requested
PC: 54%
Controls: 53%
1
Duration percentages reflect the two intervention group BF rates combined.
BF, breastfeeding; PC, peer counseling; EBF, exclusive breastfeeding, WIC, Special Supplemental Nutrition Programfor Women, Infants, and
Children; pp, postpartum
SES: Socio-economic status
*
p<0.05
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Table 2
Randomized trials evaluating the impact of breastfeeding peer counseling on breastfeeding rates
Reference Location/Sample Study Groups Intervention BF Rates
Agrasada (17) -Manilla, Philippines
-N=204 low-income
primiparae, vaginal
delivery, LBW singleton
1:BF PC(n=68)
2:Childcare (n=67)
3:Control (n=69)
*
8 visits at 35, 710 and 21 d,
1.5, 2.5, 3.5, 4.5 and 5.5
months pp.
Topics covered: Benefits of
EBF, preventing BF problems.
6 months
***
PC: 63%
Childcare: 31% Controls: 29%
Anderson (10) See Table 1 See Table 1 See Table 1 3 months
PC group: 49%, Controls: 36%
Caulfield (11) See Table 1 See Table 1 See Table 1 BF at 710 days pp; OR (95%
CI)
Video: 0.79 (0.25, 2.52)
PC: 1.11 (0.34, 3.61)
Video +PC: 1.52 (0.50, 4.59)
Control:1.00
Chapman (12) See Table 1 See Table 1 See Table 1 1 month
PC: 64%, Controls: 51%
3 months
Dennis (22) -Toronto, Canada
-N=258 primiparae with
local telephone access,
delivering terminfant;
mostly middle/high SES
1:Peer support
(n=132)
2:Control (n=126)
Telephone contact within 48
hrs pp and as needed
Topics covered:
BF support and help.
4 weeks
*
8 weeks
12 weeks
*
Graffy (13) See Table 1 See Table 1 See Table 1 6 weeks
Intervention:65%, Control: 63%
4 months
Intervention: 46%, Control:
42%
Gross (23)
1 -Baltimore, MD, USA
-N=116 African American,
low-income women who
initiated BF .
See Caulfield et al See Caulfield et al 710 days
Video:67%, PC:72%, Video
+PC: 80%, Control: 53%
8 weeks
*
12 weeks
*
Leite (18) -Fortaleza, Brazil
-N=1003 low-income
women delivering healthy,
LBW (3000g) singletons,
discharged 5 days pp.
1:Lay counselors
(n=503)
2:Control (n=500)
*
6 visits at 5, 12, 30, 60, 90 and
120 days pp
Topics covered:
Correct positioning, correcting
BF problems, discouraged use
of artificial teats/non-BM
liquids.
4 months
***
PC: 80%, Control: 67%
Merewood (19) -Boston, MA, USA
who delivered preterm(26
37 weeks gestation) &
intended to BF
1:PC (n=53)
2:Control (n=55)
-First visit 72 hrs pp & wkly
contact for 6 wks. In person
contact while infant in NICU
-Free electric breast pump.
-Written guidelines provided
for each contact
12 weeks OR (95% CI)
Intervention: 2.81 (1.117.14)
*
Control: 1.0
Mongeon (21) -Montreal, Quebec, Canada
-N=200 primiparous women
planning to BF; SES not
specified, 58% college-
educated
1. PC: (n=100)
2. Control (n=100)
-1 prenatal visit +weekly
telephone contact for first 6
wks pp, then biweekly calls
until 5 months pp
1 month
81%
3 months
57%
6 months
20%
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Reference Location/Sample Study Groups Intervention BF Rates
Morrow
2
(15)
See Table 1 See Table 1 See Table 1
3 months
*
85%
6 months
76%
Muirhead (16) See Table 1 See Table 1 See Table 1 10 days
6 weeks
16 weeks
Pugh (20) -Mid-Atlantic region, USA
2 groups:
1:Intervention
(n=21)
2:Control (n=20)
Nurse/PC teamprovided daily
hospital visits, home visits at 1,
2 and 4 wks pp, telephone
support twice weekly through
wk 8, and calls weekly through
month 6.
6 months
35%
1
This study analyzes the same dataset as Caulfield et al, but only includes data fromwomen who initiated BF.
2
Statistical analyses conducted using 1-sided tests, comparing combined intervention groups vs. controls.
*
p<0.05;
**
p<0.01;
***
p<0.001
LBW, low birth weight; BF, breastfeeding; PC, peer counseling; pp, postpartum; SES, socio-economic status; OR, Odds Ratio; CI, confidence
interval; WIC, Special Supplemental Nutrition Programfor Women, Infants, and Children; NICU, neonatal intensive care unit;
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Table 3
Randomized trials evaluating the impact of breastfeeding peer counseling on exclusive breastfeeding rates
Reference Location/Sample Study Groups Intervention EBF Rates
Agrasada
a
(17)
6 months
***
PC: 44%
Childcare counseling: 7%
Control: 0%
Anderson
b
(10)
3 months
*
Bhandari (27) -Haryana State, India
-N=1115 low-income
women delivering in study
villages
1:Intervention (n =552)
2:Control (n =473)
Community health workers
shared EBF information
frommonthly meetings at
monthly neighborhood
meetings targeting those
caring for children 2 y.
Topics covered:
Immediate BF after birth,
benefits of EBF for 6
months, BF frequency
3 months
****
48%
4 months
****
12%
5 months
****
6%
6 months
****
4%
Chapman (12) See Table 1 See Table 1 See Table 1 1 month RR (95% CI)
PC: 1.07 (0.90 1.27)
Controls: 1.0
Davies-Adetugbo (24) -Osun State, Nigeria
-N=161 low-income
mothers of infants 3
months; seeking care for
infants uncomplicated
diarrhea
1:PC (n=82)
2:Control (n=79)
1st visit at health care
facility & 2 home visits
(day 2 and 7 after initial
visit)
Topics covered:
EBF benefits, correct latch
& positioning, milk
expression
7 Days after first visit
****
21 Days after first visit
****
Dennis
b
(22)
4 weeks
*
8 weeks
12 weeks
*
Graffy (13) See Table 1 See Table 1 See Table 1 6 weeks
Haider (25) -Dhaka City, Bangladesh
-N=726 lower-middle and
low SES, pregnant women
with 3 living children,
delivering healthy
singleton
1:PC (n=363)
2:Controls (n=363)
2 prenatal & 13 pp home
visits through 5 months pp
Topics covered:
Benefits of EBF, early dyad
contact, discouraged pre
and post lacteal foods,
management of BF
problems.
5 months
****
Hopkinson
b
(26)
-Houston, TX, USA
-N=522 low-income
mothers feeding their low-
risk infant both breastmilk
& formula
1:Intervention (n=255)
2:Control (n=267)
1 BF clinic visit (37 d pp),
more visits/calls as needed.
Topics covered:
Breast exam, evaluation of
latch & milk transfer,
weight check, benefits of
EBF, concerns addressed
4 weeks
*
PC: 16%
*
, Control: 10%
Leite (18) See Table 2 See Table 2 See Table 2
4 months
*
Morrow
a,c
(15)
3 months
***
N
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Reference Location/Sample Study Groups Intervention EBF Rates
6-visit: 67%, 3-visit: 50%,
Control: 12%
Muirhead (16) See Table 1 See Table 1 See Table 1 8 weeks
16 weeks
EBF, exclusive breastfeeding; PC, peer counseling; BF, breastfeeding; pp, postpartum; SES, socio-economic status.
*
p<0.05,
**
p<0.01,
***
p<0.001,
****
p<0.0001
a
EBF rates in this table reflect infant-feeding practices over the previous 7 days
b
EBF rates in this table reflect infant-feeding practices during the previous 24 hours
c
Analyses conducted using 1-sided tests.
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Table 4
Randomized trials evaluating the impact of breastfeeding peer counseling on maternal and child health
outcomes
Reference Health Outcome
Agrasada (17) Infant diarrhea, incidence at 6 months pp
PC: 15%, Childcare group: 28%, Controls: 31%
Anderson (10)
Infant diarrhea, incidence at 3 months pp
*
Maternal amenorrhea at 3 months pp
*
Bhandari (27)
Infant diarrhea, 7 day prevalence at 3 months pp
*
Infant diarrhea, requiring specialized medical treatment at 3 months pp
****
Infant diarrhea, 7 day prevalence at 6 months pp
*
Infant diarrhea, requiring specialized medical treatment at 6 months pp
*
Davies-Adetugbo (24) Infant diarrhea, new episode of diarrhea within 21 days after counseling
Morrow (15)
Infant diarrhea, incidence at 3 months pp
*
PC, peer counseling; pp, postpartum
*
p<0.05,
**
p<0.01,
***
p<0.001,
****
p<0.0001
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o
n
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h
s
(
n
=
2
4
5
8
)
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n
e

(
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b
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r
v
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n
a
l

s
t
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d
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)
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a
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y

F
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y

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1
3

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d

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r

(
s
c
o
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3
4
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1
1

r
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3
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(
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8
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p
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f
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a
b
y

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r
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(
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s

a
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e

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r

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t

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l
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(
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1
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a
k
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p
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1
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(
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=
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6
9
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(
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8
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)

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(
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(
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5

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A
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w
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(
3
9
)
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e
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r
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a
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S
A
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n
d
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y

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a
t
a

a
n
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l
y
s
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s
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9
9
2
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6

P
e
d
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S
;

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m
p
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d
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o
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b
y

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n
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9
9
3
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6

P
R
A
M
S
;

c
o
m
p
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d
B
F

r
a
t
e
s

a
t

8

w
k
s

a
m
o
n
g

W
I
C
p
a
r
t
i
c
i
p
a
n
t
s
-
F
o
c
u
s

G
r
o
u
p
s

(
n
=
1
3
)
-
G
e
o
r
g
i
a

W
I
C

i
m
p
l
e
m
e
n
t
e
d

5

B
F
s
t
r
a
t
e
g
i
e
s

s
t
a
r
t
i
n
g

i
n

1
9
9
1
:

B
F
e
d
u
c
a
t
i
o
n
,

b
r
e
a
s
t

p
u
m
p
s
,

m
a
t
e
r
n
i
t
y
w
a
r
d

b
e
d
s
i
d
e

s
u
p
p
o
r
t
,

p
e
e
r
c
o
u
n
s
e
l
i
n
g
,

c
o
m
m
u
n
i
t
y

c
o
a
l
i
t
i
o
n
s
1
9
9
2
9
6

c
h
a
n
g
e
s

i
n

B
F
i
n
i
t
i
a
t
i
o
n
,
%
S
t
a
n
d
a
r
d
:

3
0
/
3
3

E
d
u
c
a
t
i
o
n
:
3
3
/
4
1
P
u
m
p
s
:

5
6
/
4
9

P
C
:
4
0
/
5
0

B
e
d
s
i
d
e
:
3
0
/
5
2

C
o
a
l
i
t
i
o
n
:
2
4
/
3
0
-
N
o

c
h
a
n
g
e

i
n

W
I
C

B
F

r
a
t
e

a
t

8
w
k
s
-
P
e
d
N
S
S

h
a
d

h
i
g
h
p
e
r
c
e
n
t
a
g
e

o
f

m
i
s
s
i
n
g
d
a
t
a

f
o
r

B
F

i
n
i
t
i
a
t
i
o
n
-
P
o
s
s
i
b
l
e

c
o
n
f
o
u
n
d
i
n
g

b
y
p
a
r
a
l
l
e
l

B
F

p
r
o
m
o
t
i
o
n
e
f
f
o
r
t
s

n
o
t

r
u
l
e
d

o
u
t
1
E
B
F

a
m
o
n
g

i
n
f
a
n
t
s

1

m
o
n
t
h

o
l
d

o
r

l
e
s
s
2
E
B
F

a
m
o
n
g

i
n
f
a
n
t
s

6

m
o
n
t
h
s

o
l
d

o
r

l
e
s
s
C
H
W
,

c
o
m
m
u
n
i
t
y

h
e
a
l
t
h

w
o
r
k
e
r
;

T
I
B
F
,

T
i
m
e
l
y

i
n
i
t
i
a
t
i
o
n

o
f

b
r
e
a
s
t
f
e
e
d
i
n
g
;

E
B
F
,

e
x
c
l
u
s
i
v
e

b
r
e
a
s
t
f
e
e
d
i
n
g
;

P
H
C
U
,

p
r
i
m
a
r
y

h
e
a
l
t
h

c
a
r
e

u
n
i
t
;

P
C
,

P
e
e
r

c
o
u
n
s
e
l
i
n
g
;

O
R
,

o
d
d
s

r
a
t
i
o
;

C
I
,

c
o
n
f
i
d
e
n
c
e

i
n
t
e
r
v
a
l
;
L
H
W
,

l
a
y

h
e
a
l
t
h

w
o
r
k
e
r
;

F
F
,

f
o
r
m
u
l
a

f
e
e
d
i
n
g
;

P
e
d
N
S
S
,

P
e
d
i
a
t
r
i
c

N
u
t
r
i
t
i
o
n

S
u
r
v
e
i
l
l
a
n
c
e

S
y
s
t
e
m
;

W
I
C
,

S
p
e
c
i
a
l

S
u
p
p
l
e
m
e
n
t
a
l

N
u
t
r
i
t
i
o
n

P
r
o
g
r
a
m

f
o
r

W
o
m
e
n
,

I
n
f
a
n
t
s

a
n
d

C
h
i
l
d
r
e
n
;

P
R
A
M
S
,

P
r
e
g
n
a
n
c
y

r
i
s
k
a
s
s
e
s
s
m
e
n
t

m
o
n
i
t
o
r
i
n
g

s
y
s
t
e
m
;

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Breastfeeding Peer Counseling: From Efficacy through Scale-up

Donna J. Chapman, Ph.D., R.D.,

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