Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement

Gavine, Anna; Farre, Albert; Lynn, Fiona; Shinwell, Shona; Buchanan, Shona; Buchanan, Phyllis; Marshall, Joyce; Cumming, Sara; Wallace, Louise; Wade, Angie; Ahern, Elayne; Hay, Laura; Cranwell, Marianne and McFadden, Alison (2023). Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement. NIHR, Action4Breastfeeding.

Abstract

Background
Breastfeeding impacts multiple health outcomes but less than 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding.

Objectives
To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS.

Design
Evidence syntheses with stakeholder engagement.

Review methods
Systematic reviews examined effectiveness of breastfeeding support for i) healthy women, and ii) women with long-term conditions using Cochrane Pregnancy and Childbirth group methods.

Mixed methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women, and experiences of receiving/providing support for breastfeeding women. Cross-study synthesis integrated qualitative and quantitative findings.

Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following NICE guidance. All searches were conducted May 2021 to October 2022.

Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were: 23 stakeholders, 16 parents in the parents panels, 15 women in the focus groups, and 87 stakeholders attended the workshops.

Results
We found considerably more interventions that were designed for healthy women (Review 1) compared to those aimed at women with long-term conditions (Reviews 1 and 4, approximately half the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and possibly the impact of support may be different in these populations. Despite this, studies from Review 2 found that women perceived the provision of support as positive, important and needed. Studies from Review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g., partners, family, friends, peers, external professionals, web-based resources) and involving them in the provision of breastfeeding support for women with long-term conditions. In Reviews 3 and 6, there was uncertainty in the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good quality evidence.

Limitations
There is lack of evidence for effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information about intervention characteristics reported.

Conclusions
‘Breastfeeding only’ support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for ‘breastfeeding plus’ interventions is less consistent but may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women’s and supporters’ needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK.

Future work
Evaluation of breastfeeding support for all women, in particular those at risk of poor breastfeeding outcomes (e.g., long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies.

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