Review Article

Iran J Public Health, Vol. 45, No.8, Aug 2016, pp.970-977

Breastfeeding Education: Where Are We Going? A Systematic

Review Article
Maria Adriana BURGIO1, *Antonio Simone LAGAN2, Angela SICILIA3, Romana
PROSPERI PORTA4, Maria Grazia PORPORA4, Helena BAN FRANGE 5, Giovanni DI
VENTI 6, Onofrio TRIOLO6
1. Unit of Obstetrics and Gynecology, ASST Cremona, Cremona, Italy
2. Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood G. Barresi, University of
Messina, Messina, Italy
3. School of Midwifery, University of Messina, Messina, Italy
4. Dept. of Gynecology, Obstetrics and Urology, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
5. Dept. of Reproduction, University Medical Center Ljubljana, Ljubljana, Slovenia
6. Unit of Nursing and Midwifery Administration, A.O.U. Gaetano Martino, Messina, Italy
*Corresponding Author: Email: antlagana@unime.it
(Received 20 Feb 2016; accepted 24 Jun 2016)

Abstract
Background: UNICEF (United Nations International Children's Emergency Fund) and WHO estimate that if all
babies were breastfed for at least the first six months of their lives, the rate of morbidity and malnutrition would significantly decrease all over the world. In this view, these two organizations promoted a worldwide campaign for
breastfeeding, creating the Baby Friendly Hospital Initiative (BFHI) that encourages good practices for the promotion
of breastfeeding in hospitals. The aim of our study was to review the available evidence regarding the positive effects
of breastfeeding, in order to suggest to most appropriate strategy to support it.
Methods: The main databases including Scopus, PubMed, MEDLINE, Google scholar and Science Direct were researched to obtain the original papers related to breastfeeding education. The main terms used to literature search
were "Breastfeeding education", Breastfeeding support", and Breastfeeding healthcare policy. The timeframe included the obtained articles was from 1980 to 2015.
Results: Our analysis confirms that healthcare providers play a pivotal role in education and encouraging mothers to
begin and continue breastfeeding. In this view, the adequate training of healthcare providers seems to be mandatory in
order to support this practice. Moreover, adequate facilities are needed in order to promote and support breastfeeding.
Conclusion: Considering the available evidence, breastfeeding should be supported among all the mothers. Based on
the positive data emerging from the public awareness campaign in different Countries of the world, we strongly encourage an accurate training for doctors and midwives and the implementation of adequate facilities in order to support breastfeeding.
Keywords: Breastfeeding, Education, Strategy

Introduction
After childbirth, lactation should be considered a
physiological event for the mother, as well as
breastfeeding should be for the mother-baby
dyad. Human milk has immunological action on
970

the newborn considered as the best available option for feeding: on one hand, breastfeeding allows an appropriate relationship between mother
and child; on the other hand, human milk conAvailable at:

http://ijph.tums.ac.ir

Burgio et al.: Breastfeeding Education: Where Are We Going

tains all the nutrients needed for the child to

grow healthy. Indeed, mature milk contains less
proteins and more lipids, carbohydrates, enzymes
and minerals than the colostrum (1). Furthermore, their high levels of immunoglobulin maintain milk sterile, protect the newborn from neonatal infections and help to prevent mastitis.
Physiologically, the production of colostrum lasts
for the first 4-5 days of puerperium. It has higher
quantity of lactoglobulin, lactalbumin and immunoglobulins than in mature milk: in particular,
lactoglobulin and lactalbumin are easier to digest
than the casein, which makes colostrum particularly suitable for the first days of life. Finally yet
importantly, colostrum contains large amount of
B-lymphocytes which can synthetize IgA and
contribute to the humoral immunodefense. Although the positive effects of human breastfeeding were already clearly demonstrated, a survey of
Human Relations Area Files (2) showed that in
about 50 different cultures colostrum is considered as a dirty substance, poisonous and polluted, so breastfeeding begins after the milk
supply and, in the meanwhile, the baby is fed
with glucose water or bottled milk. Accumulating
evidence suggests that the adoption of policies to
minimize interventions during delivery is associated with healthier mother-baby dyads, optimally prepared to breastfeed.
We already know that delivery and childbirth
should be considered a consequent dualism, since
mothers and babies form an inseparable biological and social unit; the health and nutrition of
one group cannot be divorced from the health
and nutrition of the other (3). Nevertheless,
childbirth represents a key moment for the separation of newborn from the mother, so the severance period should be kept as short as possible by healthcare providers. Considering this
element, separation of pregnancy from postpartum and separation of mother from the newborn
within the medical and nursing training institutions may play a detrimental role on breastfeeding. Although responsibility for the breastfeeding
mother-infant dyad is multidisciplinary, the midwife could be identified as the key figure to provide care to the healthy woman and baby during
Available at:

http://ijph.tums.ac.ir

pregnancy, birth and lactation, considering the

obvious biological, social and psychological complexities of the dyad (4). However, very often
midwives are supportive of breastfeeding but less
aware about specific management strategies.
Midwifery education (nursing, obstetric and pediatric education programs) does not necessarily
ensure their graduates have received up-to-date
and evidence-based knowledge of breastfeeding
management. Thus, these significant deficits in
breastfeeding knowledge may result in premature
supplementation or cessation of breastfeeding
during the mother's first few days in hospital. In
1982, a new professional expert in breastfeeding
was established in USA: the lactation consultant
(LC), a specialist trained to focus on the necessity
and concerns of breastfeeding and to prevent,
recognize, and solve breastfeeding difficulties.
Basing on the even growing importance of this
topic, the aim of our study was to review the
available evidence regarding the positive effects
of breastfeeding and the international interventions to promote and support it.

Methods
The main databases including Scopus, PubMed,
MEDLINE, Google scholar and Science Direct
were researched to obtain the original papers related to breastfeeding education. The main terms
used to literature search were "Breastfeeding
education", Breastfeeding support", and
Breastfeeding healthcare policy. The timeframe
included the obtained articles was from 1980 to
2015.

Results
The global initiatives

UNICEF (United Nations International Children's Emergency Fund) and WHO estimate that
if all babies were breastfed for at least the first six
months of their lives, the rate of morbidity and
malnutrition would significantly decrease all over
the world. In this view, these two organizations
promoted a worldwide campaign for breastfeed-

971

Burgio et al.: Breastfeeding Education: Where Are We Going

tains all the nutrients needed for the child to

grow healthy. Indeed, mature milk contains less
proteins and more lipids, carbohydrates, enzymes
and minerals than the colostrum (1). Furthermore, their high levels of immunoglobulin maintain milk sterile, protect the newborn from neonatal infections and help to prevent mastitis.
Physiologically, the production of colostrum lasts
for the first 4-5 days of puerperium. It has higher
quantity of lactoglobulin, lactalbumin and immunoglobulins than in mature milk: in particular,
lactoglobulin and lactalbumin are easier to digest
than the casein, which makes colostrum particularly suitable for the first days of life. Finally yet
importantly, colostrum contains large amount of
B-lymphocytes which can synthetize IgA and
contribute to the humoral immunodefense. Although the positive effects of human breastfeeding were already clearly demonstrated, a survey of
Human Relations Area Files (2) showed that in
about 50 different cultures colostrum is considered as a dirty substance, poisonous and polluted, so breastfeeding begins after the milk
supply and, in the meanwhile, the baby is fed
with glucose water or bottled milk. Accumulating
evidence suggests that the adoption of policies to
minimize interventions during delivery is associated with healthier mother-baby dyads, optimally prepared to breastfeed.
We already know that delivery and childbirth
should be considered a consequent dualism, since
mothers and babies form an inseparable biological and social unit; the health and nutrition of
one group cannot be divorced from the health
and nutrition of the other (3). Nevertheless,
childbirth represents a key moment for the separation of newborn from the mother, so the severance period should be kept as short as possible by healthcare providers. Considering this
element, separation of pregnancy from postpartum and separation of mother from the newborn
within the medical and nursing training institutions may play a detrimental role on breastfeeding. Although responsibility for the breastfeeding
mother-infant dyad is multidisciplinary, the midwife could be identified as the key figure to provide care to the healthy woman and baby during
Available at:

http://ijph.tums.ac.ir

pregnancy, birth and lactation, considering the

obvious biological, social and psychological complexities of the dyad (4). However, very often
midwives are supportive of breastfeeding but less
aware about specific management strategies.
Midwifery education (nursing, obstetric and pediatric education programs) does not necessarily
ensure their graduates have received up-to-date
and evidence-based knowledge of breastfeeding
management. Thus, these significant deficits in
breastfeeding knowledge may result in premature
supplementation or cessation of breastfeeding
during the mother's first few days in hospital. In
1982, a new professional expert in breastfeeding
was established in USA: the lactation consultant
(LC), a specialist trained to focus on the necessity
and concerns of breastfeeding and to prevent,
recognize, and solve breastfeeding difficulties.
Basing on the even growing importance of this
topic, the aim of our study was to review the
available evidence regarding the positive effects
of breastfeeding and the international interventions to promote and support it.

Methods
The main databases including Scopus, PubMed,
MEDLINE, Google scholar and Science Direct
were researched to obtain the original papers related to breastfeeding education. The main terms
used to literature search were "Breastfeeding
education", Breastfeeding support", and
Breastfeeding healthcare policy. The timeframe
included the obtained articles was from 1980 to
2015.

Results
The global initiatives

UNICEF (United Nations International Children's Emergency Fund) and WHO estimate that
if all babies were breastfed for at least the first six
months of their lives, the rate of morbidity and
malnutrition would significantly decrease all over
the world. In this view, these two organizations
promoted a worldwide campaign for breastfeed-

971

Iran J Public Health, Vol. 45, No.8, Aug 2016, pp.970-977

ing, creating the Baby Friendly Hospital Initiative

(BFHI) that encourages good practices for the
promotion of breastfeeding in hospitals. Nevertheless, each single hospital should follow "The
Ten UNICEF - WHO Steps for breastfeeding,
the Mother-friendly Childbirth initiative and

respect the International Code of marketing of

breastfeeding substitutes and relevant World
Health Assembly resolutions (5), in order to be
recognized as "Baby Friendly Hospital". Each of
the ten steps (Table 1) has its own individual evidence base (6).

Table 1: The ten steps of the Baby-Friendly Hospital initiative to promote successful breastfeeding
1
2
3
4
5
6
7
8
9
10

Have a written breastfeeding policy that is routinely communicated to all health care staff.
Train all health care staff in skills necessary to implement this policy.
Inform all pregnant women about the benefits and management of breastfeeding.
Help mothers initiate breastfeeding within half an hour of birth.
Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from
their infants.
Give newborn infants no food or drink other than breast milk, unless medically indicated.
Practice rooming-in - that is, allow mothers and infants to remain together - 24 hours a day.
Encourage breastfeeding on demand.
Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from
the hospital or clinic.

Maternity services, which demonstrate implementation and compliance with the ten steps through
a rigorous and systematic process, involving the
assessment of the knowledge and skills of multidisciplinary staff and interview with women
about their care, are accredited as baby friendly. To date, more than 20.000 healthcare organizations in the world have achieved full babyfriendly accreditation under the original program.
Accumulating evidence (7-9) suggests that this
initiative has the potential to influence the duration of breastfeeding: as evidenced by Merten et
al. (10) in a Swiss cohort analysis, 42% of children born in a "Baby Friendly Hospital" were
breastfed up to 5 months, while for infants born
in other clinical setting the percentage was about
34% (10). In some countries, other strategies
were planned to promote and help mothers who
want to breastfeed their children. In Georgia, for
example, the "Special Supplemental Nutrition
Program" launched 5 strategies for the promotion of breastfeeding: education, free breast
pumps, hospital-based programs, peer counseling
and community coalition. According to this last
program, breastfeeding education provides access

972

to a toll free number for women who want to

have more information about it and periodic
training of healthcare providers; breast pumps are
free for mothers who want to use them; peer
counseling involves other women who have previously participated in this program and who
have successfully breastfeed their children: indeed, these mothers are recruited to provide support and encouragement to current participants;
finally, the coalition is intended as a community project to cover the shortcomings of the territorial services of breastfeeding. In particular, the
results of this program showed a significant increase in the number of women who breastfed,
especially in women aged between 19 and 24
years old, unmarried and with a high education
(11). Among women who started to breastfeed,
the steepest decline in breastfeeding occurs between 2 and 6 weeks. The first 23 weeks of
breastfeeding constitute the critically important
learning period and the time when routine breastfeeding education and support from medical and
community sources is most needed (12, 13).
Therefore, the BFHI has an important impact on
breastfeeding rate, but other interventions are

Available at:

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Burgio et al.: Breastfeeding Education: Where Are We Going

needed after hospital discharge to meet the recommended targets at 6 months. To overcome
this gap, Baby-friendly Community Initiative
(BFCI), one of the one of the most challenging

program for community health care service, was

established in United Kingdom in 1998. In 2007,
the BFCIs recommendations were summarized
in the seven steps (Table 2).

Table 2: The seven steps of the Baby-Friendly community initiative to promote successful breastfeeding
1
2
3
4
5
6
7

Have a written breastfeeding policy that routinely is communicated to all staff and volunteers.
Train all health care providers in the knowledge and skills necessary to implement the breastfeeding policy
Inform pregnant women and their families about the benefits and management of breastfeeding.
Support mothers to establish and maintain exclusive breastfeeding to six months.
Encourage sustained breastfeeding beyond six months to two years or more, alongside the introduction of
appropriate, adequate and safe complementary foods.
Provide a welcoming atmosphere for breastfeeding families
Promote collaboration among health services, and between health services and the local community

Thus, the BFHI and BFCI are 2 separate but

complementary initiatives promoted by UNICEF
in an integrated way as Together for breastfeeding: Baby Friendly Hospital and CommunityUnited for protecting, promoting and supporting
breastfeeding using a multistage approach similar to BF-UK (14). Another campaign, started in
2013, is the World Breastfeeding Costing Initiative (WBCI), which tries to raise awareness and
encourage breastfeeding, helping also to manage
the budget and the priorities for actions, since in
many countries, support is inadequate and there
is lack of local political attention and funding
(15).

Early breastfeeding

During the first postpartum days, healthcare providers skills, knowledge and attitudes towards
breastfeeding, as well as their ability to transfer
these skills to new mothers, can significantly influence breastfeeding experience. Considering
this perspective, healthcare providers should have
been trained according to international standards
and periodically monitored and evaluated. Furthermore, several other barriers to early breastfeeding may be present in hospitals: for example,
in several setting mothers and newborns are separated after delivery (16), although the importance of rooming-in during the hospital stay is
widely documented (12, 13, 17). In addition, the
WHO/UNICEF recommend skin-to-skin ear-

Available at:

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ly and undisturbed contact between mother and

child, in order to increase the outcome and duration of exclusive breastfeeding (18, 19). Early
skin-to-skin contact determines better cardiopulmonary stability, reduces infant stress, accelerates the baby's adaptation to extrauterine life,
reduces crying, increases the newborn's blood
glucose and temperature and so should be recommend also after cesarean section. This evidence was confirmed by a UK-based study,
which showed that this close contact between
mother and child seems to be an element that
promotes and prolongs the duration of breastfeeding (20). In this view, very often a successful
long-term breastfeeding depends upon an adequate trained staff.

Staff training

Healthcare providers play a pivotal role in education and encouraging mothers to begin and continue breastfeeding (21). In this view, the adequate training of healthcare providers seems to
be mandatory in order to support this practice. In
particular, mothers supported by trained
WHO/UNICEF members significantly prolong
breastfeeding (22). For this reason, the
WHO/UNICEF 20-hour course for maternity
staff was considered the standard by BFHCI. The
course consists of 15.5 hours of theory and 4.5
hours of practice about breastfeeding promotion
and support. At the time of the assessment to

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Iran J Public Health, Vol. 45, No.8, Aug 2016, pp.970-977

become BFHI, each hospital/community needs

to have minimum 80% of maternity staff with
this certification. Unfortunately, most healthcare
providers receive minimal (if any) education in
breastfeeding, either during their undergraduate
or postgraduate training.
Furthermore, during the meetings with pregnant
women it is important to involve the fathers, because the knowledge on the benefits of breastfeeding and the fact that this practice is seen by
the partners as a matter of course means that the
father will encourage and support the mother to
start and continue breastfeeding (23). Finally, it
was already showed that fathers involvement in
decision-making might improve mothers knowledge of breastfeeding and provide emotional
support (24, 25).

Breastfeeding and maternal diseases

Several maternal conditions might interfere with

breastfeeding, whereas it could be considered
safe in other ones. For example, maternal treatment with antiepileptic drugs such as benzodiazepines, lamotrigine and ethosuximide was considered dangerous for breastfeeding in the past;
conversely, recent prospective studies have failed
to demonstrate any negative effects in children
who were exposed to antiepileptic drugs through
breast milk. Therefore, mothers with epilepsy
should be encouraged to breastfeed, although the
newborn should be closely monitored (26). Furthermore, other conditions such as maternal infections can interfere with breastfeeding: although it was showed that breastfeeding is not
contraindicated in case of maternal hepatitis C
virus infection (27). Human Immunodeficiency
Virus (HIV) constitutes a serious worldwide
problem since it could be transmitted through
breast milk. In Africa more than 95% of children
are breastfeed, the average duration is long and
varies between 16 and 28 months. However, the
epidemic of Acquired Immune Deficiency Syndrome could threaten this practice. In order to
prevent mother to child transmission of HIV, the
WHO recommends formula feeding only if it is
acceptable, feasible, affordable, sustainable and
safe. Otherwise, mothers are encouraged to con974

tinue breastfeeding for the first months of life,

followed by an early and rapid weaning (28).
However, in countries with high child mortality
rate breastfeeding is recommended for mothers
with HIV, as it was found that mixed feeding increases the risk of contagion more than breastfeeding (29).

Contraception during breastfeeding and family planning

Although breastfeeding has a clear fertilityreducing effect, the nature of this effect is not
fully understood. In general, the infant's suckling
initiates a cycle of neuroendocrine events that
results in the inhibition of ovulation. In the past
few decades, demographers have been able to
quantify the degree of contraceptive protection
that results from breastfeeding. In populations
without access to modern methods of family
planning, the birth interval depends most on
breastfeeding (30).
In 1988, researchers from five continents gathered in Bellagio (Italy) to determine whether
their findings about women with very different
pattern of breastfeeding behaviors could be synthesized into a statement about how breastfeeding might predict women's recovery of fertility.
Among all, the highest pregnancy rate reported in
fully breastfeeding amenorrheic women during
the first 6 months postpartum was lower than 2%
(31, 32). The lactational amenorrhea method
(LAM) is a natural birth control technique, based
on the fact that breastmilk production causes
amenorrhea but its high contraceptive effectiveness (98%) depends on these following conditions (32, 33): exclusively breastfeeding on demand (day and night) and no longer than four
hours between feedings during the day and the
night; no supplemental feeding; no vaginal bleeding; delivery less than six months before. Controversy exists in the literature regarding hormonal
contraceptive effects on milk production and
evidence from randomized controlled trials about
this topic is still elusive (34).
Until better evidence will be provided, it is prudent to advise women that hormonal contraceptive methods may decrease milk production, esAvailable at:

http://ijph.tums.ac.ir

Burgio et al.: Breastfeeding Education: Where Are We Going

pecially in the early postpartum period. Hormonal methods should be discouraged in some circumstances: low milk production or history of
lactation failure; history of breast surgery; multiple birth (twins, triplets); preterm birth; maternal-fetal contraindications. Usually, combined
hormonal contraception in lactation is not recommended before 6 months after birth, but
intrauterine devices and oral progestin can be
used starting from the fourth week after delivery
(35). Regarding the latter, the gradual release of
progesterone efficiently suppresses ovulation and
is specifically designed for women who are
breastfeeding in the first year after delivery (36).
About use of barrier methods of contraception
(condom and diaphragm), there are not known
adverse effects on breastfeeding. Every woman
should be offered full information and support
about contraceptive options, so she depends on
her individual situation. This discussion should
address contraceptive efficacy and possible impact on breastfeeding outcomes, within the context of each womans desire to breastfeed, risk of
breastfeeding difficulties and risk of unplanned
pregnancy.

Conclusion
Considering the available evidence, breastfeeding
should be supported among all the mothers. Basing on the positive data emerging from the public
awareness campaign in different Countries of the
world, we strongly encourage an accurate training
for all healthcare providers in maternity services
and the adoption of adequate facilities in order to
support breastfeeding. Our public health
mandate, then, is to prevent and reduce excessive
and unnecessary formula feeding through promotion, protection, and support of breastfeeding.

Ethical considerations
Ethical issues (Including plagiarism, informed
consent, misconduct, data fabrication and/or falsification, double publication and/or submission,

Available at:

http://ijph.tums.ac.ir

redundancy, etc.) have been completely observed

by the authors.

Acknowledgements
All authors have no proprietary, financial, professional, or other personal interest of any nature in
any product, service, or company. The authors
alone are responsible for the content and writing
of the paper. No specific funding was obtained.

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