Breastfeeding: Primary Care Behavioral Counseling Interventions -- Pregnant and postpartum women

Importance

The association between breastfeeding and health benefits in children has been previously well established;¹ health benefits have also been found for women who breastfeed.² However, breastfeeding rates in the US are relatively modest; as of 2021, 59.8% of infants at age 6 months are breastfed and 27.2% of infants at that age are exclusively breastfed.³ Healthy People 2030 has set a goal to increase the proportion of infants who are breastfed exclusively through age 6 months to 42.4%⁴ and the proportion of infants who are breastfed any amount at 1 year to 54.1%⁵ Breastfeeding rates differ according to race, age, level of education, and other sociodemographic factors.^3,6 Variables associated with lower breastfeeding rates include Black race; being younger than 30 years; participating in the Special Supplemental Nutrition Program for Women, Infants, and Children; being unmarried; living in a nonmetropolitan area; or having high school as the highest education level achieved.^3,6 Disparities are present by race, with 73.9% of Asian infants, 51.7% of Black infants, 56.1% of Hispanic infants, and 63.4% of White infants being breastfed at 6 months.³

There are complex historical, structural, and economic factors that research has shown to contribute to disparities in rates of breastfeeding. Examples include lasting psychological impact and stigma of enslaved Black women being forced to act as wet nurses;^7-10 the marketing tactics of formula companies;^11,12 and societal messaging that emphasizes the use of breasts for sexual purposes rather than nutrition.^8-10 Studies have shown that Hispanic and Latina communities may have a perception that providing both breast milk and formula gives infants twice the benefits, which contributes to lower breastfeeding rates.^13-15 Research also has shown that Black and Hispanic and Latina individuals, as well as individuals with lower socioeconomic status, may work in jobs that make it difficult to continue breastfeeding while working.^14,16-18 For example, Black women often report returning to work early, at 6 to 8 weeks postpartum, which may make it more difficult to breastfeed their infants.^9,16,19

Studies also have identified multiple factors that limit access to breastfeeding support. Zip codes that have higher proportions of Black residents are less likely to have birthing facilities with supportive breastfeeding practices, such as early initiation of breastfeeding, rooming in, limited use of breastfeeding supplements, limited use of pacifiers, and postdischarge support.²⁰ Additionally, in a large population study, Black, Hispanic, and Indigenous women reported higher rates of mistreatment by health care professionals during pregnancy, including having their preferences ignored.²¹ Research has also documented that women belonging to racial and ethnic minorities may be less likely to receive breastfeeding support than White women.^22-25

USPSTF Assessment of Magnitude of Net Benefit

The US Preventive Services Task Force (USPSTF) concludes with moderate certainty that behavioral counseling interventions to support breastfeeding have a moderate net benefit. Therefore, clinicians should provide behavioral counseling interventions or referrals to support breastfeeding.

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.²⁶

Update of Previous USPSTF Recommendation

This recommendation updates the 2016 recommendation statement on primary care interventions to support breastfeeding. The current recommendation is consistent with the 2016 recommendation; both are B recommendations.

Table 1. Summary of USPSTF Rationale

Abbreviation: USPSTF, US Preventive Services Task Force.

Practice Considerations

Patient Population Under Consideration

This recommendation applies to all adolescents and adults who are pregnant or postpartum, and their infants and children. Interventions to support breastfeeding may also involve partners, other family members, and friends. This recommendation does not apply in circumstances in which there are contraindications to breastfeeding (eg, certain maternal medical conditions or infant metabolic disorders, such as galactosemia). The USPSTF did not review evidence on interventions directed at breastfeeding of preterm infants.

Definitions of Breastfeeding

For the purposes of this recommendation statement, breastfeeding includes both feeding at the breast and feeding expressed breast milk through a bottle. Rates of breastfeeding are described in terms of initiation (starting breastfeeding or introducing breast milk, at or within 1 week after birth), duration (the number of months breastfeeding or consumption of breast milk lasts), and exclusivity (consumption of only breast milk, whether from the breast or bottle, and without other liquid or food supplementation).

Behavioral Counseling Interventions and Implementation Considerations

Behavioral counseling interventions that help increase breastfeeding rates include breastfeeding education and support. Breastfeeding education typically includes a formalized program to convey general breastfeeding knowledge and focuses on the benefits of breastfeeding, practical breastfeeding skills (eg, latching), and the management of common breastfeeding complications. These programs may also offer family members encouragement and advice on how to provide support. Breastfeeding support can include providing information about the benefits of breastfeeding, psychological support (encouragement, reassurance, and discussing questions and problems), and direct support during breastfeeding observations (helping with the positioning of the infant and observing latching). Interventions are often provided by professionals such as nurses, midwives, clinicians, or lactation care providers. Support may also be provided by trained peers. Interventions that occur over multiple periods (ie, during the prenatal, peripartum, and postpartum periods) tend to have greater effects compared with those that occur over a single period (just 1 trimester of pregnancy). Effective interventions have varied in terms of delivery setting—in person vs remote delivery (via video, telephone, or text), in-home visit vs in hospital or in medical office, and delivery to an individual vs a group.

For women who decide to breastfeed their infant via expressed milk, health insurance plans must cover the cost of a breast pump.²⁷ Additionally, most employees covered by the Fair Labor Standards Act have the right to a reasonable break time and place to express breast milk while at work.²⁸

Additional Tools and Resources

The Centers for Disease Control and Prevention provides information for families and public health programs (https://www.cdc.gov/breastfeeding/php/about/index.html; https://www.cdc.gov/breastfeeding/php/guidelines-recommendations/index.html) and on practices that support breastfeeding in maternity care settings (https://www.cdc.gov/breastfeeding/php/guidelines-recommendations/safety-in-maternity-care.html).

The US Department of Labor provides a fact sheet on Fair Labor Standards Act protections for employees to pump breast milk at work (https://www.dol.gov/agencies/whd/fact-sheets/73-flsa-break-time-nursing-mothers).

The Office of the Assistant Secretary for Health provides resources on how to support breastfeeding at work (https://womenshealth.gov/supporting-nursing-moms-work/resources).

Information on breast pumps and breastfeeding is available through the US Food and Drug Administration (https://www.fda.gov/consumers/womens-health-topics/pregnancy#Breast%20pumps%20and%20breastfeeding).

The Eunice Kennedy Shriver National Institute of Child Health and Human Development provides educational materials on breastfeeding for patients and families (https://www.nichd.nih.gov/health/topics/breastfeeding).

The US Department of Agriculture provides resources for breastfeeding support for women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (https://wicbreastfeeding.fns.usda.gov/).

The National Institutes of Health has created a drug and lactation database, LactMed, that contains information on drugs and other chemicals that may pass from breast milk to the infant (https://www.ncbi.nlm.nih.gov/books/NBK501922/).

Additional resources on breastfeeding for maternal and child health professionals are available through the Health Resources and Services Administration’s Maternal and Child Health Bureau (https://mchb.hrsa.gov/programs-impact/focus-areas/maternal-health/mchb-supports-breastfeeding).

Supporting Evidence

Scope of Review

The USPSTF commissioned a systematic review^29,30 to evaluate the benefits and harms of behavioral counseling interventions to support breastfeeding in all adolescents and adults who are pregnant or postpartum. This is an update to a systematic review that was commissioned for the USPSTF in 2016. The updated review focused on interventions that were initiated in, conducted in, or referable from primary care.

Benefits of Behavioral Counseling Interventions

Ninety trials representing data on more than 49,000 pregnant or postpartum women and their infants were reviewed.^29,30 Thirty-three of the trials were conducted in the US, 23 in Europe, 17 in Asia, 10 in Australia and New Zealand, and 7 in Canada.^29,30 The average age of study participants ranged from 16 to 33 years. The participants in the majority of the US-based studies (24/33) were predominantly Black and/or Hispanic and Latina women, including 6 studies that limited enrollment to Black women or Hispanic or Latina women.^29,30 Many of the US-based studies also required that participants have incomes in a lower income bracket to be able to enroll.^29,30 Almost half of the studies limited enrollment to women who were intending to breastfeed, and the majority of participants in the remaining studies intended to breastfeed at the beginning of the study.^29,30 Most of the studies delivered the intervention to individual participants, although 12 interventions included group sessions with other participants.^29,30 Trials varied widely in terms of when interventions were provided (prenatally, peripartum, or postpartum), who delivered the intervention (nurse, midwife, clinician, lactation care provider, or peer), and where the intervention was delivered (office, hospital, home, video, telephone, or text).^29,30 Few of the studies described whether interventions addressed use of expressed or donor breast milk. Few studies reported on the training and certification of lactation care providers. No studies reported outcomes by whether breastfeeding was at the breast vs through use of expressed or donor breast milk.

All but 1 of the 90 trials reported prevalence of breastfeeding at some time point after the intervention, although the number of studies reporting at a given time point (initiation, <3 months, 3 months to <6 months, and 6 months) varied from 27 to 51 trials (N analyzed, 10,622 to 17,580).^29,30 Based on pooled analyses evaluating follow-up up to 6 months, there was a statistically significant increased prevalence of any breastfeeding and exclusive breastfeeding in the intervention group at all time points, except for initiation of any breastfeeding. Effect sizes ranged from a risk ratio of 1.06 (95% CI, 1.03-1.08; 47 trials [n = 15,663]) for any breastfeeding at less than 3 months to a risk ratio of 1.46 (95% CI, 1.20-1.78; 37 trials [n = 14,398]) for exclusive breastfeeding at 6 months. Overall, at any given time point, risk ratios for exclusive breastfeeding were higher than they were for any breastfeeding, indicating that interventions may have a greater role in increasing exclusive breastfeeding. Generally, intervention effectiveness did not vary by provider type (nurse, midwife, clinician, lactation care provider), intervention content, timing, or setting. Exploratory analyses suggest that interventions may be more effective in women who were not initially intending to breastfeed and if they take place over multiple periods (ie, prenatal, peripartum, or postpartum).

A much smaller number of the included trials reported on the direct impact of the breastfeeding support intervention on infant health outcomes (10 trials [n = 6592]) or maternal health outcomes (9 trials [n = 2334]). Generally, the number of participants analyzed for each of these outcomes was much smaller, making it difficult to determine if any differences between control and intervention groups existed, since many of these analyses were underpowered. However, the association between breastfeeding and improved health outcomes in infants has been well established by observational studies.² A recent review of these studies² found that “more” vs “less” breastfeeding was associated with a lower risk of acute otitis media, asthma,^31,32 rapid weight gain and obesity,^33-35 childhood leukemia,^36,37 moderate to severe respiratory tract infections and gastrointestinal tract infections in infants,³⁸ allergic rhinitis,³⁹ malocclusion,^40,41 inflammatory bowel disease,⁴² type 1 diabetes,^43,44 elevated blood pressure,⁴⁵ and infant mortality.^46,47 Although the evidence on improved health outcomes in women who breastfeed is less robust, breastfeeding has been associated with reduced risk for breast and epithelial ovarian cancer,^48,49 hypertension,⁴⁹ and type 2 diabetes.^49,50

Harms of Behavioral Counseling Interventions

Few trials (7 trials [n = 1404]) reported on harms of behavioral counseling interventions to support breastfeeding. Most reported no adverse events related to the intervention, although 1 trial reported greater feelings of anxiety and decreased confidence among participants in the intervention group. Twenty-two trials (n = 13,815) reported that participants in the intervention group experienced fewer breastfeeding problems or difficulties (such as mastitis or sore nipples or breasts), pointing to another potential benefit of these interventions.

Response to Public Comments

A draft version of this recommendation statement was posted for public comment on the USPSTF website from October 22 to November 18, 2024. Some comments requested that the recommendation include health system–level interventions. The USPSTF would like to clarify that it focuses on interventions that can be provided in primary care settings and has revised the title of the recommendation to make this clearer. Comments were also received asking for additional information on barriers to breastfeeding and for additional tools and resources on breastfeeding. Additional information has been added to the Importance section and the Practice Considerations section, as appropriate. Some commenters sought additional information on how interventions should be provided (eg, who should provide them and when). A high-level summary of intervention characteristics is provided in the Behavioral Counseling Interventions and Implementation Considerations section. No specific intervention provider type or intervention content, timing, or setting was found to be more effective. Further details of characteristics of individual interventions can be found in the accompanying evidence report.^29,30 A few commenters expressed concern that limiting the evidence base to randomized clinical trials was overly restrictive. The USPSTF follows consistent methodology on how it reviews and assesses the evidence for all its recommendations (see the USPSTF Procedure Manual²⁶). Following that methodology, the USPSTF did find adequate evidence on the benefits and harms of primary care interventions to support breastfeeding.

Research Needs and Gaps

See Table 2 for research needs and gaps related to primary care behavioral counseling interventions to support breastfeeding.

Recommendations of Others

Several organizations, including the American Academy of Pediatrics,⁵¹ the American College of Obstetricians and Gynecologists,⁵² the American Academy of Family Physicians,⁵³ the Academy of Breastfeeding Medicine,⁵⁴ and the 2020-2025 Dietary Guidelines for Americans,⁵⁵ recommend exclusive breastfeeding for approximately the first 6 months, followed by introduction of complementary foods and continued breastfeeding as long as mutually desired. Generally, these organizations also state that breastfeeding beyond the first^53,55 or second^51,52 year offers health benefits.

Table 2. Research Needs and Gaps for Primary Care Interventions to Support Breastfeeding

To fulfill its mission to improve health by making evidence-based recommendations for preventive services, the USPSTF routinely highlights the most critical evidence gaps for making actionable preventive services recommendations. The USPSTF often needs additional evidence to create the strongest recommendations for everyone and especially for persons with the greatest burden of disease. This table summarizes key bodies of evidence needed for the USPSTF to make recommendations for primary care behavioral counseling interventions to support breastfeeding. For each of the evidence gaps listed below, research must assess intervention effectiveness among different demographic characteristics such as race and ethnicity, geographic location, socioeconomic level, and working status. For additional information and detail on research needed to address these evidence gaps, see the Evidence Gaps Research Taxonomy table on the USPSTF website (https://www.uspreventiveservicestaskforce.org/home/getfilebytoken/5newnV_sfH4xnGCbpoh4Ma).

Abbreviation: USPSTF, US Preventive Services Task Force.

JAMA Patient Page: Behavioral Counseling Interventions to Support Breastfeeding