Interventions for supporting the initiation and continuation of breastfeeding among women who are overweight or obese

Multicomponent perinatal breastfeeding support in women with BMI >25: The Latch On multi-centre randomised trial

OBJECTIVE

To investigate the effectiveness of a multicomponent breastfeeding support intervention on breastfeeding prevalence at 3 months among women with a body mass index (BMI) >25 kg/m2.

DESIGN

Multicentre multicomponent randomised controlled trial.

SETTING

Four maternity centres in Ireland.

POPULATION

A total of 225 primiparous women and their nominated support partners. Participants were aged 18 years and over, with BMI ≥25 kg/m2, carrying a singleton pregnancy and without contraindication for breastfeeding.

METHODS

The intervention included an antenatal group breastfeeding education session for participants and their support partners, followed by a planned postnatal breastfeeding assessment and telephone support for up to 6 weeks by a lactation consultant.

MAIN OUTCOME MEASURES

Any breastfeeding at 3 months postpartum.

RESULTS

Any breastfeeding prevalence was 68.7% (n = 68) in the intervention group and 62.1% (n = 59) in the control group at 3 months postpartum (odds ratio 1.33, 95% confidence interval 0.72-2.46, p = 0.36). Any and exclusive breastfeeding rates did not significantly differ at any other time point. More women in the control group accessed support from private lactation consultants (intervention 23.5% [n = 12], control 45.3% [n = 24], p = 0.02).

CONCLUSIONS

The control group had higher than expected breastfeeding rates, and the study found no evidence of effect on the primary outcome. Providing comprehensive education and support for women intending to breastfeed remains of paramount importance.

A longitudinal study of breastfeeding relationships at home during the COVID-19 pandemic: A grounded theory method

AIMS

To describe the process of breastfeeding relationships among stay-at-home mother and infant dyads at 1, 3, 5 and 6 months.

DESIGN

A longitudinal qualitative online survey design was used.

METHODS

Data were obtained at 1, 3, 5 and 6 months from 26 breastfeeding mothers who stayed home with their infants and directly breastfed at least once a day for the first 6 months between June 2022 and August 2023. Mothers' written responses to 3 open-ended questions were analysed to assess breastfeeding experiences at home, thoughts/comments while directly breastfeeding and breastfeeding concerns/problems and strategies they used. Based on grounded theory, inductive content analysis was used to analyse the data. Trustworthiness of results was established by coding to consensus, formal peer debriefing and maintaining an audit trail.

RESULTS

'Breastfeeding Relationships at Home,' the core construct, was identified and organized the process of breastfeeding relationships into 5 domains: (1) mothers' emotional well-being while breastfeeding, (2) infant-led feeding, (3) alternatives to breastfeeding, (4) evaluation of breastfeeding and (5) changes in breastfeeding as infants grow older.

CONCLUSION

Breastfeeding is not simply about feeding breast milk but also involves nurturing and developing a relationship between mother and infant. Across the domains, mutual responsiveness, a central element of the breastfeeding relationship was clear. Mothers who were committed to breastfeeding with embedded infant suckling reached emotional well-being in return for their engagement which has potential to reduce maternal stress and prevent postpartum depression.

IMPACT

Findings from the current study add to nurses' knowledge about the relationship building process between stay-at-home mothers and their infants in the first 6 months of breastfeeding during the COVID-19 pandemic. Nurses must remain sensitive to aid the development of breastfeeding relationships in the home environment to maximize mutual responsiveness.

PATIENT OR PUBLIC CONTRIBUTION

No patients or public involved.

Teleintervention's effects on breastfeeding in low-income women in high income countries: a systematic review and meta-analysis

BACKGROUND

Many mothers in high-income countries (HIC) do not breastfeed to the World Health Organisation's recommendation of two years. This is particularly true for low-income women (LIW). They often face additional socio-structural barriers that encourage early discontinuation and are inadequately supported by current healthcare interventions. Teleinterventions are flexible and widely used following the global pandemic and increase maternal autonomy over intervention delivery. They show promise in improving other maternal conditions in LIW, including postpartum depression. Teleinterventions can increase breastfeeding rates in the wider maternal population, however their efficacy for this underserved population has not yet been systematically assessed. This meta-analysis aimed to identify if teleinterventions increase 'exclusive' or 'any' breastfeeding by LIW in HIC at 1-, 3-4, and 6-months postpartum.

METHODS

We searched five online databases for randomised controlled trials assessing breastfeeding teleinterventions for LIW in HIC. Risk ratios (RR) were used to calculate the average effect of teleinterventions on 'any' and 'exclusive' breastfeeding at at 1-, 3-4, and 6-months postpartum using random effects meta-analysis. Study bias was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB2), and outcome quality was evaluated against GRADE criteria.

RESULTS

Nine studies met inclusion criteria: six providing telephone calls, two text messages and one an online support group. All the studies were conducted in the United States, with small sample sizes and a high risk of bias. Pooled results indicate teleinterventions modestly increase 'any' and 'exclusive' breastfeeding at all time points, with a statistically significant increase in 'exclusive' breastfeeding after 3-4 months (RR 1.12, 95% CI [1.00,1.25]). At 3-4 months teleinterventions providing peer support were more effective than educational teleinterventions at promoting any and exclusive breastfeeding. Evidence for all outcomes were rated 'low' or 'very low' quality using the GRADE tool, mainly due to high attrition and low power.

CONCLUSIONS

Despite insufficient high-quality research into breastfeeding teleinterventions for LIW, our results suggest teleinterventions may improve exclusive and any breastfeeding. Given breastfeeding is particularly low in LIW population from HIC, our findings are promising and require further exploration by larger, methodologically sound trials in other HIC.

Breastfeeding and Antepartum Breast Milk Expression (BABE): A Randomized Control Trial Utilizing an Electric Breast Pump and its Effect on Postpartum Breastfeeding

Objective: To evaluate the effect of antenatal breast milk expression (ABE) on exclusive breastfeeding. Materials and Methods: A randomized control study was performed with the primary outcome being formula use during the postpartum hospital stay. Secondary outcomes were the exclusive breastfeeding rate at 6 months postpartum and peripartum safety outcomes. Participants included multiparous and nulliparous patients who planned to breastfeed. Exclusion criteria included exclusively breastfeeding in prior pregnancies for greater than 6 months, medical contraindications for breastfeeding, multiple gestation, history of preterm delivery, or any contraindication to vaginal delivery. ABE group participants were instructed to pump for 20 minutes, three times daily, starting at 37 weeks of gestation. Results: Three-hundred four participants from two clinics were enrolled. There was no significant difference in formula use during hospital admission (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.34-1.22) or in exclusive breastfeeding at 6 months postpartum (OR 0.66, 95% CI 0.34-1.29). Colostrum use was more prevalent in the ABE group (OR 5.31, 95% CI 2.63-10.76). ABE participants were more likely to present in spontaneous labor (OR 2.09, 95% CI 1.05-4.14). Conclusion: ABE did not significantly improve exclusive breastfeeding rates, but safely provides women opportunities to become familiar with breastfeeding before delivery and can provide readily available colostrum. There was no negative secondary safety outcome related to ABE identified. Prenatal care providers can consider recommending ABE to patients with minimal to no experience with breastfeeding.

Educational intervention for the main caregiver of primiparous women to promote breastfeeding and the association between prolactin and nutritional parameters

Background

In the last two years, breastfeeding rates have experienced a notable decline worldwide. Only 46% of women breastfeed their children, the figure being much lower in primiparous women. Breastfed milk is the ideal food for babies; its benefits for the health of mothers and babies are scientifically proven. Several studies show that babies who are not breastfed have a higher risk of getting sick. This fact gives rise to an important public health problem. The aim of this paper is to describe the association between presence of the caregiver in health education and increasing rates of breastfeeding.

Methods

We conducted an observational study (cohort) in a population of primiparous pregnant women (n = 88), and their main caregivers belonging to a region of central Spain. The development, content and implementation of the intervention consisted of: 1) obtaining the blood levels of pregnant women (prolactin, folic acid, vitamin B12 and transferrin) before health education (13-26 weeks of pregnancy), 2) carry out health education with two groups: A (44 pregnant women with caregivers) and B (44 without caregivers), 3) obtain the same blood levels as in the first intervention, 15 days after delivery, and finally the evaluation of the intervention with breastfeeding rates.

Results

The levels of prolactin (288.57 ± 107.46 nanogrammes per millilitre (ng / ml)), folic acid (16.93 ± 4.09 ng / ml), vitamin B12 (505.05 ± 213.97 picogrammes (pg) / ml) and transferrin (296.82 ± 67.61 milligrammmes per decilitre (mg / dl)) were higher in pregnant women who attended the health education program with a caregiver than in pregnant women who attended alone: prolcoactin (103.61 ± 45.48 ng / ml), folic acid (7.16 ± 5.88 ng / ml), vitamin B12 (160.59 ± 36.92 pg / ml) and transferrin (223.86 ± 44.14 mg / dl). Of the sample size of 44 primiparous people who attended the talks with caregivers, 35 (79.54%) breastfed their babies, while the other 44 primiparous women who attended alone, only seven (15.91%) established breastfeeding successfully.

Conclusions

The implications for public health research are that the presence of a caregiver in health education programs modifies levels of prolactin, folic acid, vitamin B12, and transferrin, as well as increasing breastfeeding rates.

Exploring Successful Breastfeeding Behaviors Among Women Who Have High Body Mass Indices

BACKGROUND

Women with high body mass indices are at risk of lower breastfeeding rates but the drivers of successful breastfeeding in this population are unclear.

RESEARCH AIM

We aimed to (a) explore the barriers and enablers to breastfeeding among women with high body mass indices and (b) map specific behaviors suitable for intervention across the antenatal to postpartum periods.

METHODS

This was a prospective, cross-sectional qualitative study. We conducted semi-structured interviews with women with high body mass indices who successfully breastfed for 6 months or more (n =20), partners (n = 22), and healthcare professionals (n =19) in Ireland during 2018. Interviews were audio recorded, and transcribed verbatim. Data were inductively coded using reflexive thematic analysis and deductively mapped within the Capability, Opportunity, Motivation-Behavior model.

RESULTS

The three themes developed were knowledge, support, and self-efficacy. Knowledge supported a participant's psychological and physical capability to engage in breastfeeding. Support was related to the social and physical opportunity to enable performance of breastfeeding behaviors. Self-efficacy influenced reflective and automatic motivation to perform breastfeeding behaviors. A multifactorial intervention design is needed to support successful breastfeeding.

CONCLUSION

The barriers and enablers identified for participants with high body mass indices were similar to those for the broader population; however, the physicality and associated social bias of high body mass indices mean that additional support is warranted. Antenatal and postpartum breastfeeding services need a multifaceted, inclusive, and high-quality program to provide the necessary support to women with higher body mass indices.

Interventions for promoting and optimizing breastfeeding practices: An overview of systematic review

Background

Optimal breastfeeding (BF) practices are essential for child survival and proper growth and development. The purpose of this overview is to evaluate the effectiveness of different interventions for promoting and optimizing breastfeeding.

Methods

We included systematic reviews (SRs) [including trials from Low-Income (LICs) and Low Middle-Income countries (LMICs)] that have evaluated the effect of various interventions for promoting and optimizing breastfeeding and excluded non-systematic reviews, and SRs based on observational studies. We searched various electronic databases. We followed the standard methodology as suggested by the Cochrane Handbook for Systematic Reviews of Interventions. Two sets of reviewers undertook screening followed by data extraction and assessment of the methodological quality of included SRs.

Result

We identified and screened 1,002 Cochrane SRs and included six SRs in this overview. Included SRs reported only two of the primary outcomes, early initiation of breastfeeding (EIBF) and/or exclusive breastfeeding (EBF). None of the included SR reported continued BF up to 2 years of age. The results were evaluated using two major comparisons groups: BF intervention against routine care and one type of BF intervention vs. other types of BF intervention. Overall results from included SRs showed that there were improvements in the rates of EIBF and EBF among women who received BF intervention such as BF education sessions and support compared to those women who received only standard care. However, BF intervention via mobile devices showed no improvements. In Target Client Communication (TCC) via mobile devices intervention group, no significant improvements were reported in BF practices, and also the reported evidence was of very low certainty.

Conclusion

Community Based Intervention Packages (CBIP) delivered to pregnant and reproductive-age women during their Antenatal care (ANC) and/or Postnatal care (PNC) periods by Ancillary Nurse-Midwives reported the highest improvement in EIBF compared to women who received standard care. However, insufficient evidence was reported to suggest that BF intervention showed improvements in EBF in both the comparison groups. This overview highlighted the gaps in primary research regarding the uncertainty about the settings such as LICs or LMICs, lack of evidence from LMICs, and also identified gaps in the availability of reliable up-to-date SRs on the effects of several BF interventions to promote and optimize practices.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020174998, PROSPERO [CRD42020174998].

Predicting the earliest deviation in weight gain in the course towards manifest overweight in offspring exposed to obesity in pregnancy: a longitudinal cohort study

BACKGROUND

Obesity in pregnancy and related early-life factors place the offspring at the highest risk of being overweight. Despite convincing evidence on these associations, there is an unmet public health need to identify "high-risk" offspring by predicting very early deviations in weight gain patterns as a subclinical stage towards overweight. However, data and methods for individual risk prediction are lacking. We aimed to identify those infants exposed to obesity in pregnancy at ages 3 months, 1 year, and 2 years who likely will follow a higher-than-normal body mass index (BMI) growth trajectory towards manifest overweight by developing an early-risk quantification system.

METHODS

This study uses data from the prospective mother-child cohort study Programming of Enhanced Adiposity Risk in CHildhood-Early Screening (PEACHES) comprising 1671 mothers with pre-conception obesity and without (controls) and their offspring. Exposures were pre- and postnatal risks documented in patient-held maternal and child health records. The main outcome was a "higher-than-normal BMI growth pattern" preceding overweight, defined as BMI z-score >1 SD (i.e., World Health Organization [WHO] cut-off "at risk of overweight") at least twice during consecutive offspring growth periods between age 6 months and 5 years. The independent cohort PErinatal Prevention of Obesity (PEPO) comprising 11,730 mother-child pairs recruited close to school entry (around age 6 years) was available for data validation. Cluster analysis and sequential prediction modelling were performed.

RESULTS

Data of 1557 PEACHES mother-child pairs and the validation cohort were analyzed comprising more than 50,000 offspring BMI measurements. More than 1-in-5 offspring exposed to obesity in pregnancy belonged to an upper BMI z-score cluster as a distinct pattern of BMI development (above the cut-off of 1 SD) from the first months of life onwards resulting in preschool overweight/obesity (age 5 years: odds ratio [OR] 16.13; 95% confidence interval [CI] 9.98-26.05). Contributing early-life factors including excessive weight gain (OR 2.08; 95% CI 1.25-3.45) and smoking (OR 1.94; 95% CI 1.27-2.95) in pregnancy were instrumental in predicting a "higher-than-normal BMI growth pattern" at age 3 months and re-evaluating the risk at ages 1 year and 2 years (area under the receiver operating characteristic [AUROC] 0.69-0.79, sensitivity 70.7-76.0%, specificity 64.7-78.1%). External validation of prediction models demonstrated adequate predictive performances.

CONCLUSIONS

We devised a novel sequential strategy of individual prediction and re-evaluation of a higher-than-normal weight gain in "high-risk" infants well before developing overweight to guide decision-making. The strategy holds promise to elaborate interventions in an early preventive manner for integration in systems of well-child care.

What Works to Improve Nutrition and Food Sustainability across the First 2000 Days of Life: A Rapid Review

Informed by the Innocenti framework, this rapid review of systematic reviews (n = 60) and sentinel grey literature (n = 27) synthesises the evidence of what works to improve nutrition and food sustainability across the first 2000 days. Most systematic reviews focused on interventions targeting the behaviour of parents and caregivers (n = 49), with fewer reviews focusing on the personal (n = 7) and external (n = 4) food environments. No reviews focused on food supply-chain activities. Most reviews were rated as critically low (n = 28, 47%) or low (n = 21, 35%) quality using AMSTAR 2. Evidence supports the effectiveness of multi-component breastfeeding interventions, interventions delivered in home and child-care settings, particularly when involving parents, interactive skill building and repeated exposure to vegetables. Food vouchers and access to local farmers markets and community gardens have potential for improving access and availability to healthier foods, while evidence supports interventions improving the external food environment, including fiscal strategies such as the SSB tax, restrictions on marketing and advertising of discretionary products and improved food labelling. Overall, this review highlights the importance of action across a range of settings and sectors at the international, national and local levels to improve young children’s diets.

Breastfeeding Practices and Problems Among Obese Women Compared with Nonobese Women in a Brazilian Hospital

Background: Women who are obese have lower rates of breastfeeding initiation and duration and are less likely to breastfeed exclusively compared with women who are not obese. To develop programs to improve breastfeeding practices among this group of women, we investigated the association between maternal obesity and breastfeeding practices and problems in the first days postpartum. Methods: We analyzed medical records from postpartum women at a rooming-in maternity ward in State of São Paulo, Brazil, between 2016 and 2018. We included those who had intended to exclusively breastfeed, had given birth to a singleton and were admitted to rooming-in. We analyzed exclusive breastfeeding and nonexclusive breastfeeding each day of hospitalization and the presence of breastfeeding problems, comparing women in the obese category (body mass index [BMI] ≥30 kg/m2) to normal and overweight women (≥18.6 to ≤29.9 kg/m2). Results: Two hundred and twenty-four postpartum women participated, including 86 women in the obese category. More than 50% of women with obesity reported a breastfeeding problem in the first and second postpartum days (p = 0.026 and p = 0.017, respectively) compared with the 41% and 38% nonobese group. Children of obese women were 2.8 times more likely to have poor latch during breastfeeding (95% confidence interval [CI]: 1.29-6.10) compared with the nonobese group on the third day. Conclusion: Maternal obesity increased the probability of breastfeeding difficulties and nonexclusive breastfeeding at discharge. Professionals need to support breastfeeding techniques in the days immediate after delivery to improve breastfeeding outcomes for mothers with obesity.

Effectiveness of a Pilot Breastfeeding Educational Intervention Targeting High BMI Pregnant Women

INTRODUCTION

Overweight and obesity during pregnancy are associated with adverse health outcomes leading to increased maternal and neonatal morbidity and mortality. Women with a high body mass index (BMI) also experience low breastfeeding rates. There is limited evidence of effective educational programs that aim to improve length of breastfeeding among this population. The main objective of this pilot educational intervention was to determine knowledge and skills retention at six weeks after completion of a breastfeeding class.

METHODS

A two-hour breastfeeding class was offered during the second and third trimester of pregnancy targeting high BMI women. A longitudinal, survey study design was conducted using two data collection points. No comparator group was employed.

RESULTS

Baseline mean age of respondents was 26.6 years (SD = 5.7). Respondents who completed post-intervention surveys were largely white (69.2%) followed by Hispanic (15.4%) and non-Hispanic black (15.4%), some college (57.1%), earned less than $50,000/year (64.3%), had employer-provided insurance (53.8%), and did not receive WIC benefits (78.6%). Most respondents had a pre-pregnancy BMI category of overweight (28.6%) or obese (57.1%). The intervention appeared to have some impact on responses. The following were observed: an increased understanding that baby may be fussy in the evening hours and wants to nurse more often (p < 0.002), how to bring baby to the breast (p = 0.004), knowing what to do if breastfeeding hurts (p = 0.031), and knowing what to do when baby has trouble breastfeeding (p = 0.021).

CONCLUSION

Consistent with previous findings, all participants in our study reported increased knowledge to breastfeed. Thus, women's confidence to breastfeed their infant is enhanced through knowledge obtained from breastfeeding education. Additional studies are underway to assess breastfeeding behaviors.

Exclusive Breastfeeding Rates at 6 Weeks Postpartum as a Function of Preconception Body Mass Index Are Not Impacted by Postpartum Obstetrical Practices or Routines

Objective: Women with overweight/obesity have significantly lower rates of exclusive breastfeeding (EBF) at 6 weeks postpartum compared with women of normal weight. We sought to determine whether differences in Baby-Friendly Hospital Initiative (BFHI) adherence, obstetric practices, or social support explain these weight-related EBF disparities. Methods: One hundred forty-two healthy women who intended EBF (61 normal weight, 50 overweight, and 31 obese by preconception body mass index [BMI]) were enrolled in a cross-sectional study. Obstetric data were collected and participants completed modified Infant Feeding Practices Study II surveys at 6 weeks postpartum. Results: Women with obesity were significantly less likely to undergo spontaneous labor and more likely to receive synthetic oxytocin and epidural anesthesia compared with women with overweight or normal weight. Women who were overweight were less likely to report extended family support for breastfeeding compared with women with obesity or normal weight; however, BFHI components and composite BFHI score did not differ by maternal BMI. Furthermore, regardless of BMI, women with greater adherence to BFHI practices were more likely to be EBF at 6 weeks postpartum (p-value <0.001). Nonetheless, at 6 weeks postpartum, women with obesity were expressing milk more frequently and less likely to have met their own breastfeeding goals compared with women with overweight and normal weight. Conclusions: Differences in EBF rates by BMI were not explained by BFHI adherence or obstetric practices. These data suggest physiological differences, rather than intrapartum practices and support services, may explain differences in EBF rates by maternal overweight/obesity.

Interventions for supporting the initiation and continuation of breastfeeding among women who are overweight or obese

BACKGROUND

Exclusive breastfeeding is recommended for all infants until six months of age due to the many health benefits for both the mother and infant.Evidence suggests that mothers who are overweight (body mass index (BMI) 25.0 to 29.9 kg/m²) or obese (BMI ≥ 30.0 kg/m²) are less likely to initiate breastfeeding and to breastfeed for a shorter duration. Considering the rising prevalence of overweight and obesity globally and the known benefits of breastfeeding particularly in reducing the long-term risks of obesity and diabetes for infants, establishing effective ways to support and promote breastfeeding in women who are overweight or obese is paramount in achieving the goal of healthier communities.

OBJECTIVES

To assess the effectiveness of interventions to support the initiation or continuation of breastfeeding in women who are overweight or obese.

SEARCH METHODS

On 23 January 2019 we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) and reference lists of retrieved trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to support the initiation and continuation of breastfeeding in women who are overweight or obese. Interventions included social support, education, physical support, or any combination of these. Interventions were compared either with each other or against a control group.

DATA COLLECTION AND ANALYSIS

We assessed all potential trials identified from the search strategy. Two review authors extracted data from each included trial and assessed risk of bias. We resolved discrepancies through discussion with the third review author. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We found no trials comparing one type of support versus another. We included seven RCTs (including one cluster-RCT) involving 831 women. The number of women in each trial ranged from 36 to 226. The trials were conducted in high-income countries: USA (5 trials); Denmark (1 trial) and Australia (1 trial), between 2006 and 2015. Three trials only included women who were obese prior to pregnancy and four trials included both women who were overweight and women who were obese. We judged risk of bias in the included trials to be mixed; only one trial was judged to be low risk of bias for random sequence generation, allocation concealment and attrition bias.Physical breastfeeding support (manual or electric breast pump) versus usual care (no breast pump)Very low-certainty evidence from one small trial (39 women) looking at a physical support intervention (manual or electric breast pump) versus usual care (no pump) means it is unclear whether physical support improves exclusive breastfeeding at four to six weeks (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.20 to 1.51) or any breastfeeding at four to six weeks (RR 0.65, 95% CI 0.41 to 1.03). The trial did not report other important outcomes of interest in this review: non-initiation of breastfeeding, exclusive or any breastfeeding at six months postpartum.Multiple methods of breastfeeding support versus usual care Six trials (involving 792 women) used multiple methods of support including education and social support through telephone or face-to-face contact. One of these trials also provided physical support through providing a breast pump and a baby sling and one trial provided a small gift to the women at each trial visit. Support in the trials was provided by a professional (four trials) or a peer (two trials). One trial provided group support, with the other five trials supporting women individually. One trial (174 women) did not report on any of our main outcomes of interest.We are unclear about the effects of the intervention because we identified very low-certainty evidence for all of the important outcomes in this review: rate of non-initiation of breastfeeding (average RR 1.03, 95% CI 0.07 to 16.11; 3 trials, 380 women); exclusive breastfeeding at four to six weeks (average RR 1.21, 95% CI 0.83 to 1.77; 4 trials, 445 women); any breastfeeding at four to six weeks (average RR 1.04, 95% CI 0.57 to 1.89; 2 trials, 103 women); rate of exclusive breastfeeding at six months postpartum (RR 7.23, 95% CI 0.38 to 137.08; 1 trial, 120 women); and any breastfeeding at six months postpartum (average RR 1.42, 95% CI 1.08 to 1.87; 2 trials, 223 women).The included trials under the above comparisons also reported on some of this review's secondary outcomes but very low-certainty evidence means that we are unclear about the effects of the intervention on those outcomes.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the effectiveness of physical interventions, or multiple methods of support (social, educational or physical) for supporting the initiation or continuation of breastfeeding in women who are overweight or obese. We found no RCTs comparing one type of support to another type of support. All of our GRADE assessments resulted in very low-certainty evidence, with downgrading decisions based on limitations in trial design (e.g. risk of attrition bias), imprecision, inconsistency. The available trials were mostly of variable quality with small numbers of participants, confounded by poor adherence within both the intervention and control groups.Well designed, adequately powered research is needed to answer questions about the social, educational, physical support, or any combination of these interventions that could potentially help mothers who are overweight or obese to achieve optimal breastfeeding outcomes. We need trials that examine interventions designed specifically for women who are overweight or obese, delivered by people with training about how to overcome some of the challenges these women face when establishing and maintaining breastfeeding. Particular attention could be given to the assessment of antenatal interventions aimed at improving breastfeeding initiation in women with a raised BMI, and not just focusing on recruiting women who have an intention to breastfeed. Given that the majority of current trials were undertaken in the USA, further trials in a diverse range of countries and settings are required. Future trials need to give consideration to the theoretical basis of the intervention using established frameworks to enable replicability by others and to better determine the components of effective interventions.

To what extent does maternal body mass index predict intentions, attitudes, or practices of early infant feeding?

Public health guidelines recommend women establish and maintain exclusive breastfeeding to 6 months postpartum. Women with a body mass index (BMI, kg/m² ) in the overweight or obese range are less likely to initiate and continue breastfeeding than healthy weight women. Evidence for psychological mechanisms of this association using validated methods of measurement is limited, but factors such as attitudes and intentions for infant feeding are implicated. This study aimed to investigate the associations between maternal BMI, antenatal attitudes and intentions for infant feeding, and subsequent breastfeeding practices. A total of N = 128 women completed an online questionnaire antenatally, and n = 48 were followed-up in the first month postpartum. Validated measures of intentions (Infant Feeding Intentions Scale) and attitudes (Iowa Infant Feeding Attitude Scale) for infant feeding were used. One-way analysis of variance and multivariate regression analyses assessed study objectives. Infant feeding attitudes (p = .327) and intentions (p = .254) were similar among healthy weight, overweight, and obese women and did not differ significantly. In adjusted regression models, only intentions significantly predicted early breastfeeding behaviour (p = .036; AR²  = .301). Missing data analysis revealed no significant differences in the profile of completing versus noncompleting women. Evidence suggests postnatal factors contribute significantly to lower breastfeeding rates in cohorts of women with overweight or obese BMIs. Further investigations should consider using theory and methods from behavioural science to longitudinally investigate modifiable mechanisms of action responsible for lower breastfeeding rates among overweight and obese women to inform practices that support prolonged breastfeeding.

The association between psychological factors and breastfeeding behaviour in women with a body mass index (BMI) ≥30 kg m-2 : a systematic review

Breastfeeding can play a key role in the reduction of obesity, but initiation and maintenance rates in women with a body mass index (BMI) of ≥30 kg m^-2 are low. Psychological factors influence breastfeeding behaviours in the general population, but their role is not yet understood in women with a BMI ≥30 kg m^-2 . Therefore, this review aimed to systematically search and synthesize the literature, which has investigated the association between any psychological factor and breastfeeding behaviour in women with a BMI ≥30 kg m^-2 . The search identified 20 eligible papers, reporting 16 psychological factors. Five psychological factors were associated with breastfeeding behaviours: intentions to breastfeed, belief in breast milk's nutritional adequacy and sufficiency, belief about other's infant feeding preferences, body image and social knowledge. It is therefore recommended that current care should encourage women to plan to breastfeed, provide corrective information for particular beliefs and address their body image and social knowledge. Recommendations for future research include further exploration of several psychological factors (i.e. expecting that breastfeeding will enhance weight loss, depression, anxiety and stress) and evidence and theory-based intervention development.