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Virtual Breastfeeding Peer Support and Encouragement

Danielle Lopez
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Danielle Lopez is a Registered Nurse at Mayo Clinic Arizona in the Department of
Neurology
She has no known conflict of interest to disclose.
Correspondence should be addressed to Danielle Lopez, Edson College of Nursing and
Health Innovation, Arizona State University, Downtown Campus, 550 N. 3rd Street, Phoenix, AZ
85004. Email: dsandler@asu.edu

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Abstract

Background: Breastmilk is the optimal source of nutrition for infants as recommended by the
American Academy of Pediatrics and the World Health Organization (WHO). Despite proven
benefits, rates of breastfeeding have shown to decrease drastically at six months of age.
Purpose: The purpose of this project is to assess the effectiveness of virtual peer support and
infant education in increasing/improving a mother’s wellbeing and breastfeeding relationship.
This project was guided by the theory of self-efficacy.
Methods: Participants were recruited utilizing flyers that were posted to social media and
distributed at a breastfeeding center in Southwestern United States. Six breastfeeding mothers
were recruited, and each participated in four, one-hour peer support sessions that were held
weekly via Zoom. Participants completed the WHO Well Being Index and the Breastfeeding
Relationship scale before and after the intervention. Pre- and post-implementation scores were
compared.
Ethical Considerations: The research was approved by the IRB board at Arizona State
University and was in compliance with ethical considerations and standards of the institution.
Results: Descriptive analysis conducted on the WHO Well-Being Index showed the same results
or improvement for 80% of the questionnaire. Descriptive analysis conducted on the
Breastfeeding Relationship Scale showed improvement on 81% of questions.
Conclusions/Discussion: Breastfeeding can be taxing and overwhelming for mothers leading
them to discontinue earlier than planned. Peer support has been identified to be substantial to
women going through this process in helping them initiate and continue to breastfeed their
infant.
Keywords: breastfeeding, peer support, breastmilk, infant nutrition

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Virtual Breastfeeding Peer Support and Encouragement
Breast milk is nutrient rich and provides protective nourishment for an infant. The most
current recommendations from the American Academy of Pediatrics [AAP] (2012), state that
exclusively breastfeeding an infant for at least the first six months of life is optimal. This
information parallels the recommendations made by the World Health Organization (n.d.). In
2020, The Centers for Disease Control and Prevention [CDC], released data from 2017 stating
that in the United States (U.S.), exclusive breastfeeding rates decreased by more than half by the
time the infant was six months old. McFadden et al. (2017) conducted a systematic review and
concluded that when a mother was offered and provided with professional and/or peer support,
breastfeeding retention rates improved. The dramatic decrease in exclusive breastfeeding rates
highlights the need to explore strategies and interventions to support mothers and infants in
exclusive breastfeeding for the first six months of life.
Problem Statement
Breastmilk is the optimal choice for infant nutrition due to its quality nourishment.
Global and national initiatives strongly recommend exclusive breastfeeding for the first six
months of an infant’s life. The American Pregnancy Association, most recently released data in
2012, describing the benefits of breastmilk. Infants benefit from the tailored nutrients created
from breastmilk to help fight infections, reduce risk of future asthma, diabetes, and obesity.
Mothers benefit from cultivating a special connection with their child as well as decreasing their
risk of breast and ovarian cancer (American Pregnancy Association, 2012). Several factors
influence a mother’s decision to discontinue breastfeeding. Li et al. (2008) conducted pivotal
research highlighting these decisions, which include latching difficulties and perceived
inadequate milk supply. Internationally, the WHO concludes that 40% of infants are exclusively

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breastfed at six months of life (WHO, 2018). The U.S. has dramatically lower retention rate of
exclusive breastfeeding; 25.6% of infants are exclusively breastfeeding at six months of age
(CDC, 2020).
Purpose and Rationale
Exclusive breastfeeding rates drop by nearly 60% by the time an infant is six months old
(CDC, 2020). Breastmilk is the ideal source of nutrition for infants. Breastmilk provides
protection against infectious diseases which may cause diarrhea, respiratory infections, and otitis
media (Victora et al., 2016). Mothers also receive health benefits of breastfeeding, including
reduced risk of cardiovascular disease, certain cancers, hypertension, and hypercholesterolemia
(American College of Obstetrics and Gynecology [ACOG], 2021). Providing peer support to
new mothers could positively influence breastfeeding retention rates which would in turn
improve health outcomes for infants and mothers. McFadden et al. (2017) concluded that when
support is offered, either professionally or through peer support, breastfeeding retention rates
improved.
Background and Significance
New Mothers
New mothers find themselves going through many changes during the post-partum
period. The initial weeks of breastfeeding can seem foreign to new mothers navigating this novel
experience. Common breastfeeding challenges that women face may include sore nipples,
engorgement, feeling of inadequate supply, fatigue, and in some cases even embarrassment
(McFadden et al, 2017). Additionally, the American Pregnancy Association (2020) lists similar
challenges adding that mothers also identify a perceived inadequate milk supply such has
frequent feedings, breasts not feeling as full, fussy child, and not pumping much after a feeding.

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Outwardly these may seem to be signs of inadequate milk supply, but commonly have unrelated
reasons (American Pregnancy Association, 2020).
Global and National Recommendations
Authorities agree and endorse exclusive breastfeeding for optimal infant health (AAP,
2012; CDC, 2020; WHO, n.d.). Healthy People 2030 (n.d.) released data stating that in 2015,
24.9% of infants were exclusively breastfed at 6 months of life with an objective for national
breastfeeding rates to increase to 42.4% of infants being exclusive breastfed at six months of life.
The WHO (2014) has identified a target for 2025 of at least 50% of infants being exclusively
breastfed at 6 months of age globally. Arizona currently falls below these objectives, data from
2017 showed that 24.6% of infants were exclusively breastfed for the first six months of life
(CDC, 2020). The CDC (2020) released data from 2017 stating that in the US, 84% of infants
had ever been breastfed, but only 25.6% of infants were exclusively breastfed at six months old.
Peer Support
Breastfeeding is a skill and to become comfortable with the process, it can take time and
patience from the mother. The WHO and United Nations Children’s Fund (UNICEF) created
The Baby-Friendly Hospital Initiative (BFHI) and was first introduced to the U.S. in 1996 to
increase breastfeeding by providing new mothers with the education and skills to successfully
breastfeed their infant without the bias of commercial interest (Baby-Friendly USA, Inc., n.d.).
Following discharge from the hospital, a new mother may seek out additional breastfeeding
support. From a systematic review of the benefits of breastfeeding peer support, researchers
indicated that peer support from women with previous breastfeeding experience and formal
breastfeeding and support education could be beneficial for breastfeeding mothers (Kaunonen et
al., 2012). Another systematic review concluded that peer support increased breastfeeding

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retention rates in low to middle income countries compared to those that did not receive support
(Shakya et al., 2017).
Standard Support and Education
Over 20,000 hospitals and birthing centers across the globe partake in the BFHI to
promote and support breastfeeding (Baby-Friendly USA, Inc., n.d.). The U.S. Department of
Human and Health Services released The Surgeon General’s Call to Action, most recently
released a statement in 2011, stating that continued support for mothers after being discharged
from the hospital is essential. Unfortunately, inadequate and imprecise material on breastfeeding
is sometimes included in medical texts. (U.S. Department of Human and Health Services, 2011).
One study found that mothers lacked the education on breastfeeding and breastmilk benefits as
well as a lack professional support during the postpartum period when initiating breastfeeding
(McFadden & Toole, 2006). The U.S. Department of Health and Human Services (2011) also
highlighted an education deficit to new mothers on breastfeeding.
Increasing Exclusive Breastfeeding Rates
The U.S. Department of Health and Human Services (2011) found that support is
fundamental to mothers in order to allow them to successfully breastfeed. Education on
breastfeeding should begin during pregnancy, however mothers may not know where to find
educational classes or that they are even an option. Resources should be available to mothers
who wish to learn more. Additionally, mothers should feel comfortable seeking supplementary
support and education if needed during their breastfeeding journey. Often times, mothers need to
seek out their own support when they find they need help with breastfeeding (U.S. Department
of Health and Human Services, 2011). ACOG (2021) recommends a multidisciplinary approach

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to increasing breastfeeding rates, having families, health care professionals, and the community
assemble and support the new mother in her breastfeeding journey.
Internal Evidence
A breastfeeding center, located in Arizona, offers lactation consulting and breastfeeding
support to women in their community. The breastfeeding center has concerns that the pandemic
has affected peer support provided to women. Breastmilk provides tailored nutrition to an infant
and is important for optimal growth and health development. The CDC (2017) reports that in
Arizona, 24.6% of infants are exclusively breastfed at six months, which is slightly lower than
the national percentage of 25.6%. Factors influencing early discontinuation include worry over
adequate milk supply, latching difficulty, pain associated with breastfeeding, and the concern of
infant not being satiated by breastmilk (Li et al., 2008). Currently, the breastfeeding center
provides information on breastfeeding resources, virtual breastfeeding classes, and
individualized lactation consulting to support breastfeeding mothers. To increase access, they
believe that providing virtual peer support to mothers during their breastfeeding journey will
improve breastfeeding retention rates. This inquiry leads to the PICOT question, in mothers (P),
how do virtual peer support breastfeeding groups (I), compare to current practice (C), influence
exclusive breastfeeding over a three-month period?
Search Strategy
An extensive search of the literature was conducted to answer the PICOT question. The
three databases used were chosen due to their reputability. The following databases were
searched, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed,
and the Cochrane Library. Boolean phrases such as AND and OR were used to along with MeSH
terms when searching. Keywords used in the search include breastfeeding, breastmilk, mothers,

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peer support, social support, group support, online support, and online education. Searches were
restricted to articles published in the last five years, full text availability, published in academic
journals. Exclusion criteria included non-English language. An evaluation of the titles and
abstracts was conducted determine which articles were relevant to the topic of peer support in
breastfeeding women. Final articles were the chosen based on an in-depth review of validity,
reliability, and applicability to the PICOT question.
CINAHL
The initial CINAHL search produced 890 results by searching the terms breastfeeding
AND mothers AND peer support OR social support OR support group. The results were
condensed to 220 once limits were applied, including limiting the year of publication to 20152021, articles only published in academic journals, and full text availability. These titles of these
articles were then screened for relevancy and 31 studies were chosen for further review.
PubMed
PubMed was searched and initially produced 579 results by using the search terms
breastfeeding AND peer support. These results were narrowed down to 243 once limits were
applied, including limiting the publication to the last five years, articles only published in
academic journals, and full text availability. The studies provided were then reviewed for
significance and 29 articles were then chosen for further review.
Cochrane Library
The initial Cochrane Library search and initially yielded 1,129 studies by using the search
terms breastfeeding AND support. The results were narrowed down to 163 studies by searching
terms breastfeeding AND peer support. To further condense results, limits were applied,
including restricting results to those studies published within the last five years, and the terms

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breastfeeding AND peer support AND mothers were searched to yield 39 studies, which were
evaluated further.
Critical Appraisal & Synthesis of Evidence
To evaluate literature reviewing this topic, the Melnyk and Fineout-Overholt’s (2019)
rapid critical appraisal tool was used to assess articles. This evaluation resulted in 10 high quality
articles included in the critical appraisal of this topic. To ensure the most up to date information,
all studies were all published within the last five years. Five of the studies were based in the
United Kingdom, two of the studies were based in the United States, two of the studies were
based in Australia, and one was based in Iran. None of the studies identified any bias. Five of the
studies did not identify funding. The study designs consisted of randomized controlled trials,
cross sectional-surveys, semi-structured interviews, qualitative studies, netnography, mixed
methods, retrospective analysis, systematic reviews, Cochrane systematic review, and metaanalysis studies. Due to the nature of the topic, in addition to quantitative studies reviewed(see
Appendix A, Table A1), qualitative evidence was critical to include in order evaluate thoughts
and feelings of mothers who are currently breastfeeding (see Appendix A, Table A2).
Additionally, a synthesis table (see Appendix A, Table A3) was completed in order to provide an
overview of the evidence that was complied.
The interventions of the quantitative studies were various forms of peer support provided
to mothers who are breastfeeding or intending to breastfeed. The interventions ranged from faceto-face support, telephonic support, and online support. The qualitative studies surveyed women
on what type of support was desired during their breastfeeding journey as well as their thoughts
of breastfeeding peer support and its benefits. The study participants consisted of mothers who
breastfed and peer supporters or peer counselors. A qualitative study by Phillips et al. (2018)

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surveyed individuals on different ways to employ motivational interviewing when providing peer
support to mothers. This study was unique in that it identified different techniques that peer
supporters can help mothers. The variables measured in the studies focused on the duration of
breastfeeding associated with peer support interventions as well as psychosocial aspects of the
effect of peer support on the mother. Psychosocial benefits were important to include to evaluate
mother’s perspective of the support groups. A study by Brown and Shenker (2020) evaluated
how peer support effected women based on their level of education, at home partner, parity, and
ethnicity in order to identify if any of these characteristics had any impact on breastfeeding.
The studies identified that peer support offered through peer counselors, the community,
and peer support groups were generally beneficial in increasing the duration of breastfeeding as
well as providing psychosocial benefits. The studies did not identify which forms of peer support
were more beneficial. The qualitative studies identified that women would like peer support
offered to them while they are breastfeeding for encouragement, support, education, and a sense
of community.
Theory Application
Theory frameworks help guide researchers in creating interventions and searching for
potential outcomes. In this research study, self-efficacy theory aligns with the subject matter.
Bandura (1977) created the self-efficacy theory, which describes that actions are a direct
inspiration of perceived self-efficacy (see Appendix B, figure 1). Self-efficacy affects an
individual’s determination to pursue an action that is introduced which is then vital to creating
persistent achievements. When individuals face challenges completing the action, self-efficacy
expectations establish how much time and energy is used on successfully fulfilling the activity.
The theory of self-efficacy has four main components, which include: performance

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accomplishments, vicarious experience, verbal persuasion, and emotional arousal. Performance
accomplishments occur when an individual has recurrent achievements. These successes expose
individuals to more activities, which may translate to additional difficult tasks, ensuring attempts
at new activities and enhancing successes. Vicarious experience allows individuals to view
others accomplished tasks and gives them the ability to view themselves as being able to have
the same achievements. Verbal persuasion is encouragement from others. Others who have
completed the task inspire the individual to be able to successfully accomplish the task. Due the
individual not having first had experience with the action, this component of self-efficacy is not
as strong. Emotional arousal indicates that a stress response to an action may hinder the
individual’s ability to cope with the activity, which can ultimately obstruct their performance and
effect their self-efficacy. This potential undesirable effect is important to understand so that
individuals can combat the potential negativity.
Education on the benefits of breastmilk and breastfeeding needs to be provided to
pregnant mothers so that they can make an informed decision on breastfeeding their infant.
Motivation is crucial when initiating breastfeeding due to its potential complexities. Self-efficacy
is vital for mothers to begin and continue to breastfeed. Several challenges may arise causing
potential self-doubt, which could trigger emotional arousal and a stress response. Having
previous successful experiences, seeing others successfully breastfeeding, and words of
encouragement can help a mother when working through anxieties of breastfeeding. A strong
sense of self-efficacy is crucial when breastfeeding, as this can be supported through social
support groups.
Implementation Framework

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Rosswurm and Larrabee (1999) created a model for evidence-based practice that provides
an organized procedure for practitioners to use when making a modification to evidence-based
practice (see Appendix B, figure 2). The model consists of six steps that guide the evidencebased change, which include: assess the need for change; link problem with interventions and
outcomes; synthesize best evidence; design a change in practice; implement and evaluate the
practice change; and integrate and maintain the practice change. Assessing the need for change
includes identifying the issue at hand, collecting data, and identifying the stakeholders. Linking
the problem includes identifying prospective interventions and outcomes for the issue at hand.
Synthesizing the best evidence requires conducting an in-depth literature review of the issue as
well as interventions that have been published. Designing a change encompasses outlining the
desired change, intervention, and outcomes for the issue. Implement and evaluate the practice
change occurs when the intervention is put into practice and evaluated properly by those who
designed the potential solution. Integrate and maintain the practice change occurs once the
intervention has been proven valuable. This model is adaptable and applies well to increasing
breastfeeding duration through peer support groups.
Currently, breastfeeding statistics are low with an international incentive to increase rates
and duration of breastfed infants. An intervention that is referred to frequently in the literature
and requested by mothers is providing peer support to women who are intending to breastfeed as
this may be an isolating process. This is evident in the literature as listed in this paper. The
stakeholders in this case are mothers and infants who will be partaking in the intervention. Peer
support can come in many ways, including face to face interactions, telephonically, or through
online support. The COVID-19 pandemic has brought challenges to in person peer support due
to social distancing and masking requirements. Therefore, at this time, peer support would be

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best provided through a virtual platform to ensure participant safety. The next steps include
implementing this intervention and collecting data on whether peer support groups are
efficacious for mothers to continue breastfeeding. The outcomes to be evaluated include the
duration of breastfeeding and breastfeeding knowledge.
Implications for Practice Change
Implementing a social support program to mothers who are breastfeeding or intending to
breastfeed can be vital in increasing breastfeeding initiation, duration, education, as well as
creating a sense of community for new mothers experiencing this new phenomenon. The
evidence demonstrated that peer support may be beneficial to mothers who are breasting or who
intend to breastfeed. Having support provided by peers and those with vast breastfeeding
experience can provide invaluable advice and encouragement to new mothers who are navigating
this new experience. When mothers are looking for education, community, friendships, or
advise, sharing commonalities can be therapeutic during this hectic time.
During the COVID-19 pandemic, social distancing and masking guidelines have made
peer support groups difficult to attend. Many were cancelled or began using alternative
platforms. Aside from the pandemic, mothers may also choose to avoid in-person support groups
to avoid exposing their newborn to illnesses as their immunity is immature. Online support
through social networks may be a helpful platform to provide advice and encouragement. Social
networks are not regulated and might provide mothers with false education and
recommendations. Real-time face to face support may be increasingly helpful in providing a
deeper connection between participants. Providing a virtual support group via video
conferencing may be extremely helpful in bridging the gap when in person social support groups
for breastfeeding mothers are inaccessible. Additionally, providing virtual conferences can help

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alleviate time constraint challenges mothers may face, they can choose to log on when available
or choose to mute or close video if feeling unprepared.
Ethical Considerations
It is vital to consider ethical principles to ensure the project’s integrity and the safety of
the participants. Four ethical principles will guide this project: beneficence, autonomy, nonmaleficence, and justice. Beneficence means that good quality outcomes will come from the
procedure or process that took place (Stanford University, n.d.). This is accomplished by having
healthcare providers stay up to date on training, education, and skills (Stanford University, n.d.).
In this study, the moderators of the group will ensure they have the most recent data, education,
skills, and knowledge regarding the benefits and techniques of breastfeeding so that they can be a
resource for participants. Additionally, the goal of the support group is to uplift breastfeeding
mothers and to provide encouragement. Autonomy calls for individuals to make independent
decisions without any bias or persuasion. During this study, participants will be provided with
transparent health information regarding the subject matter as well as support and encouragement
to move forward with the decision that is best for them without any bias. Non-maleficence means
that during procedures, no harm will be done (Stanford University, n.d.). Non-maleficence will
be accomplished in this study by being fully transparent about support that will be provided, with
the goal that the support group will be a safe place for mothers to come to discuss their
breastfeeding journey. Justice is the final principle and demands that all participants involved are
provided with equivalent advantages and disadvantages of clinical trials (Stanford University,
n.d.). The participants in this study will all attend the same support groups and receive the same
support, education, and encouragement.

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Participants will be fully informed of the goals of the support group. Patient’s will be
informed of their rights, risks, and options to leave the group if they feel they choose. Consent
will be obtained from each of the participants prior to attending the first support group. The
research was approved by the IRB board at Arizona State University and was in compliance with
ethical considerations and standards of the institution.
Population and Setting
A standalone lactation consultant center that is not affiliated with a hospital organization
receives referrals from different clinics across the valley. They provide one-on-one lactation
consultation, free online breastfeeding education classes, and provide informational resources to
mothers. The stakeholders include the organization’s CEO, lactation consultants, faculty mentor,
mothers, and infants. The CEO is also a lactation consultant and coordinates the organization’s
classes and resources. Lactation consultants are vital for this project as inevitably, questions will
be raised regarding breastfeeding technique or breastmilk knowledge. Participants will be
referred to lactation consultants should the need arise. Finally, the faculty mentor is vital for this
project as she is a Women’s Health Nurse Practitioner and has formal knowledge on
breastfeeding. She has volunteered to be available during the support group sessions as an
additional resource. Mothers are vital stakeholders as they will be receiving the peer support to
encourage their continuation of breastfeeding. Infants will benefit from this intervention as they
will be receiving optimal nutrition. The intervention will be completed virtually via the Zoom
application.
Project Description and Timeline
Peer support has been identified as being beneficial for breastfeeding mothers. For a
lactation consultant organization in Arizona, how do support groups benefit mothers in achieving

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their personal breastfeeding goals? To investigate this, first the women will be recruited through
flyers posted throughout the clinic building, flyers distributed in informational folders, virtual
flyers posted in private social media groups that cater to breastfeeding women, and a
pediatrician’s social media page. Next, the women will be provided with additional information
on the support group and will be presented with consent forms. Once consent is obtained, the
women will then complete a demographics questionnaire, the Breastfeeding Relationship Scale,
and WHO Well-Being Index. The women will be invited to attend support group sessions, each
lasting one hour, that will be held once a week for four weeks. The support group will be held on
a virtual platform to allow for flexibility.
The peer support groups will be an open session for women to ask for and provide
support for each other. The organizer/leader of the group will be a peer as well. If any specific
questions arise regarding breastfeeding technique or infant nutrition, these questions will be
referred to a lactation consultant or the infant’s pediatrician. After the four support group
sessions, the women will be invited to take the previous questionnaire’s: the WHO Well-Being
Index and the Breastfeeding Relationship Scale
Anticipated barriers to this intervention include participant retention and time constraints.
Life with a newborn may be stressful and leave mothers feeling like they do not have time to set
aside to attend a support group. Holding the groups on a virtual platform will hopefully allow
more flexibility to allow mothers to attend.
Data Collection and Data Analysis
The outcomes measured for this intervention include increasing breastfeeding peer
support to mothers who choose to breastfeed. The initial Breastfeeding Relationship Scale will
be used and will demonstrate a mother’s thoughts and feelings regarding current support being

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provided. The Breastfeeding Relationship Scale was demonstrated to have internal consistency
of 0.73-0.83. The participants will take the Breastfeeding Relationship Scale before and after the
peer support group intervention is completed, which will demonstrate how support has impacted
the breastfeeding relationship. Participants will also take the WHO Well-Being Index, which
demonstrates a person’s welfare over the last two weeks. The WHO Well-Being Index has been
demonstrated to be reliable with a Cronbach’s alpha of 0.83. Self-efficacy theory parallels and
influences this intervention, as the participants will explain their accomplishments, listen to
stories of other participants, and receive and provide encouragement to other contributors.
Descriptive analysis will be conducted on the data retrieved from both questionnaires.
Additionally, Rosswurm and Larrabee’s model for evidence-based practice continues to be
implemented, as the fifth step, implementing and evaluating the intervention, is carried out.
Budget
The direct and indirect cost of the project includes the educational content, printing
material, Zoom software, and RedCap Software (Appendix C). The educational content and
printing material was funded by the project lead. The Zoom Software and RedCap Software is
supplied by Arizona State University. The sessions are held virtually and led by the project lead,
who is receiving no compensation.
Results
Demographics
There were six total participants in the group. The demographics of the participants were
similar: 100% held an associate degree or higher, 100% were married or in a domestic
relationship, 83% identified their race as white. 83% were ages 20-34, and 50% of participants

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had one child. One individual attended all four sessions, two individuals attended three sessions,
two individuals attended two sessions, and one individual attended one session.
WHO Well-Being Index
The WHO Well-Being Index uses a Likert scale (Appendix D). Descriptive statistics
were calculated on the pre and post questionnaire. Due to low participation rate, data was not
statistically significant. However, question one and question five showed improvement. Question
4 showed a decline.
Breastfeeding Relationship Scale
The Breastfeeding Relationship Scale uses a Likert scale (Appendix D). Descriptive
statistics were calculated on the pre and post questionnaire. Due to a low participation rate, data
was not statistically significant. All responses in the poster questionnaire showed improvement
or had similar responses, except for question seven.
Potential Impact
The potential impact of this intervention is vast, with the main objective to increase
support provided to breastfeeding mothers. Breastmilk is extremely beneficial for infants as it is
tailored nutrition in addition to helping support their immune system. Furthermore, breastfeeding
may strengthen the bond between a mother and child. Support groups may entice more mothers
breastfeed if they feel unsupported in their personal network or if they lack the knowledge on the
benefits of breastmilk. If support groups are more readily available and further education can be
provided, increased breastfeeding rates can be reality. As breastfeeding support groups are not
always readily available, encouraging more providers to establish a support system for mothers
can be valuable. Creating future health policy focusing on breastfeeding support should also be

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considered in the future to continue to encourage breastfeeding and support the mother infant
dyad.
Sustainability
The virtual breastfeeding support groups can be sustained at the project site by having a
staff member, lactation consultant, or peer facilitate the support groups. As this group uses a
virtual platform, there is no need to find real estate to hold the support groups. More in-depth
infant education can be provided or be tailored to the groups preference for future sessions.
Discussion
The results of the project indicated that virtual breastfeeding peer support may be
beneficial to a mother’s well-being and breastfeeding relationship with their infant.
Recommendations for infants to receive breastmilk are consistent and evident throughout
international organizations (AAP, 2012; CDC, 2020; WHO, n.d.). Breastfeeding might be
challenging, taxing, isolating, overwhelming for mothers which may lead them to discontinue
earlier than intended. International and national campaigns have been launched to encourage
mothers to breastfeed their infant for at least six months (U.S. Department of Health Services,
2011; WHO, 2014). Peer support has been identified and demonstrated to be substantial to
women going through this process in helping them initiate and continue to breastfeed their child
(Brown & Shenker, 2020; Kaunonen et al., 2012; Phillips et al., 2018; Shaklya et al., 2017).
Additionally, the significance peer support offers may help mothers achieve a sense of
community surrounding them. Therefore, breastfeeding peer support programs are invaluable to
women who are planning on breastfeeding their child.
Strengths and Limitations

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The project was easily accessible to patients as a virtual platform was used. Participants
were able to join the group from the comfort of their own home or a location of their choosing.
The project was cost effective as minimal supplies were used, there was no need to rent space to
hold the groups and the facilitator volunteered her time. Limitation of the project include poor
participant engagement, as only one participant attended all four sessions, the small sample size,
and the intervention is only sustainable if a facilitator is available to host sessions.
Future Research
Further study may consider increasing the sessions over a longer period of time.
Although we did not measure breastfeeding rates, future projects may choose to measure this
outcome to evaluate the impact of peer support on breastfeeding retention.

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Victora, C. G., Bahl, R., Barros, A. J. D., França, G. V. A., Horton, S., Krasevec, J., Murch, S.,
Sankar, M. J., Walker, N., & Rollins, N. C. (2016). Breastfeeding in the 21st century:
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as%20many%20health%20benefits%20for%20both%20the%20mother%20and%20infant
.&text=Breastfeeding%20protects%20against%20diarrhoea%20and,obesity%20in%20chi
ldhood%20and%20adolescence

BREASTFEEDING

27
Appendix
Evaluation and Synthesis Table

Table A1
Evaluation Table Qualitative Studies
Citation

Theoretical/
Conceptual
Framework

Design/
Method/
Sampling

Sample/
Setting

Citation:
Snyder &
Worlton,
(2021).
Social
Support
During
COVID-19:
Perspectives
of
Breastfeeding
Mothers.

Social Support
Theory

Design: Crosssectional
phenomelogica
l qualitative

N: 29

Purpose:
Explore
perceptions of
social support
among
breastfeeding
mothers during
COVID-19
pandemic

Sample
Demographics:
100% Female
gender, 79%
Caucasian, 10%
Hispanic, 11%
Asian. Average
age 29.93, 10
FTM, 19 MMC

Country:
USA
Funding:
Creighton
University
Bias: Not
Recognized

Setting:
telephonic
interview

IC: Mothers
providing their
infant with
breastmilk
EC: Not
discussed
Attrition: Not
discussed

Major
Variables/
Research
Question
Research
Question:
1. What is the
mother’s
perception of
social support
of
breastfeeding
during the
COVID-19
pandemic?
2. Who
provides
support to the
mother?
3. How is
support
provided to
the mother?
4. How is the
support
desired?

Measurement/
Instrumentation

Data
Analysis

Findings/
Themes

Level of Evidence; Application
to practice/ Generalization

Open ended
interview

NVIVO
qualitative
analysis
software
used

Four
constructs
of social
support:
emotional,
information
al,
instrumenta
l, and
appraisal

LOE: Level VI

Approximately
15-minute
interview
Audio recorded
12 semi
structured
interview
questions focused
on the constructs
of social support
Data was
analyzed
concurrently as
interview was
conducted
Interview was
transcribed by
interviewer into
Word document

Immersion
and
crystalliza
tion

Strengths: thorough discussion
with mothers on viewpoint of
social support, who provides their
support, how support is provided,
and how support is desired
Weaknesses: Small sample size,
relative homogeneous participant
sampling, lack of measurable data
Conclusions: Social support is
affected by COVID-19, leaving
mothers with a desire for more
social support. Mothers are
feeling increased stress.
Application to patient
population: Identified
experiences of mothers on
breastfeeding support during
COVID-19 pandemic allowing
clinicians to address identified
issues

Key: BCW – Behavior Change Wheel; BF – Breastfeeding; COM-B - Capability, Opportunity, and Motivation model of Behavior; EC – Exclusion Criteria; FB – Facebook;
FTM – First Time Mom; IC – Inclusion Criteria; LOE – Level of Evidence; MI – Motivational Interviewing; MMC – Mothers of Multiple Children; N – Number of participants;
PS – Peer Support; UK – United Kingdom; USA – United States of America

BREASTFEEDING

28

Citation

Theoretical/
Conceptual
Framework

Design/
Method/
Sampling

Sample/
Setting

Major
Variables/
Research
Question

Measurement/
Instrumentation

Data
Analysis

Findings/
Themes

Level of Evidence; Application
to practice/ Generalization

Citation:
Regan. &
Brown
(2019).
Experiences
of Online
Breastfeeding
Support:
Support and
Reassurance
Versus
Judgement
and
Misinformati
on

Not recognized

Method:
Qualitative
Study; Semi
structured
interview

N: 14

Research
question:
What
experience
did
breastfeeding
mothers have
when seeking
online
support?

10 semi
structured
interview
questions

Thematic
analysis
used to
identify
key terms

3 Major
themes and
11
subthemes
were noted

LOE: Level VI

Second
rater
reviewed
themes
with
agreement
of 90% of
cases.
Disagreem
ents were
discussed
until
agreed
upon

Major
themes Motivation
for using
online
forums;
benefits of
online
support;
limitations
of online
support

Country:
United
Kingdom
Funding:
Not listed
Bias: Not
recognized

Purpose:
Explore
positive and
negative impact
of social media
support on
women’s
experiences of
breastfeeding

Demographics:
100% female
gender, 100 %
white British
origin, average
age 33.12 years
Setting: inperson interview
based on
convenient time
and location
IC: Mothers 18+
with a child up to
3 years old who
BF or did BF

Interviews
transcribed by
interviewer

Strengths: in depth discussion
with mothers on positive and
negative experiences with social
support via social media forums
Weakness: small sample size,
relative homogeneous participant
sampling, participants were older
in age, lack of measurable data
Applicability: identified
additional areas for peer support
for mothers who breastfeed,
taking into consideration positive
and negative experiences

EC: inability to
consent, aged
<18 years, nonEnglish or Welsh
speaker
Attrition: Not
discussed
Definitions:
Breastfeeding
Support –
Facebook groups/
forums where

Key: BCW – Behavior Change Wheel; BF – Breastfeeding; COM-B - Capability, Opportunity, and Motivation model of Behavior; EC – Exclusion Criteria; FB – Facebook;
FTM – First Time Mom; IC – Inclusion Criteria; LOE – Level of Evidence; MI – Motivational Interviewing; MMC – Mothers of Multiple Children; N – Number of participants;
PS – Peer Support; UK – United Kingdom; USA – United States of America

BREASTFEEDING
Citation

Citation:
Phillips et al.
(2018).
Development
of a Novel
Motivational
Interviewing
(MI)
Informed
Peer Support
Intervention
to Mothers to
Breastfeed
Longer
Country:
UK
Funding:
National
Institute for
Health
Research
Health
Technology
Assessment
Program
Bias: Not
recognized

Theoretical/
Conceptual
Framework

BCW
Framework
and COM-B
Model

29
Design/
Method/
Sampling

Method:
Qualitative
interview
Purpose: To
develop and
characterize a
novel MI
informed
breastfeeding
peer-support
intervention

Sample/
Setting
information was
provided
passively online
N: 14 healthcare
professionals
Focus group
fathers 1 (N = 3)
Focus group
mothers 2 (N=14)
Focus group peer
supporters
(N=15)
Demographics: 2
health visitors, 2
midwifery
services
managers, 4
community
midwives, 3
postnatal/
hospital-based
midwives, 1 early
years
practitioner, 2
midwifery
support workers

Major
Variables/
Research
Question

Measurement/
Instrumentation

Data
Analysis

Findings/
Themes

Level of Evidence; Application
to practice/ Generalization

Research
question:
How does
novel MI
affect
behavior
changes in
breastfeeding
support
groups

Flexible Semi
structured topic
guides

Initial
coding
framewor
k was
developed
using the
BCW as a
guide

BCW stage
1:
understandi
ng behavior
– COM-B

LOE: Level VI

Interviews were
audio recorded
Qualitative data
was transcribed
verbatim,
anonymized, and
analyzed

NVIVO
was used
for
analysis
Sample
transcript
were
independe
ntly
double
coded to
assess
validity

Behavior
change
wheel stage
2:
Identifying
intervention
options –
Education,
training,
modeling,
restructurin
g the
environmen
t,
enablement,
persuasion,
incentivizat
ion

Strengths: Strong qualitative
design, informational
Weakness: intervention is
intensive, would require
additional resources to deliver,
relatively small sample size
Applicability: Identified MI
intervention to be used in peer
support groups for future research

Setting: 2 sites in
South Wales and
1 site in North
West of England

Key: BCW – Behavior Change Wheel; BF – Breastfeeding; COM-B - Capability, Opportunity, and Motivation model of Behavior; EC – Exclusion Criteria; FB – Facebook;
FTM – First Time Mom; IC – Inclusion Criteria; LOE – Level of Evidence; MI – Motivational Interviewing; MMC – Mothers of Multiple Children; N – Number of participants;
PS – Peer Support; UK – United Kingdom; USA – United States of America

BREASTFEEDING
Citation

Theoretical/
Conceptual
Framework

30
Design/
Method/
Sampling

Sample/
Setting

Major
Variables/
Research
Question

Measurement/
Instrumentation

Data
Analysis

Findings/
Themes

Level of Evidence; Application
to practice/ Generalization

Research
Question:
Study
attempted to
address gaps
via thematic
analysis of
interviews
and focus
groups of
users of a
closed FB
group used
specifically
for BF
support and
information

Open ended
questions

Theoretica
l thematic
analysis.
Themes
identified
at
semantic
level

Overarchin
g theme
was
support.
Four subthemes are
community,
complemen
tary,
immediate,
and
information

LOE: V

IC: Participants
had completed
formal training in
BF PS
EC: Not
discussed
Attrition: Not
discussed
Citation:
Bridges.
(2016). The
Faces of
Breastfeeding
Support:
Experiences
of Mothers
Seeking
Breastfeeding
Support
Online
Country:
Australia
Funding:
Not
identified

Maternal
Breastfeeding
Self Efficacy

Method:
Netnography
(online
ethnographic
research)
Purpose: In
order to
understand
experiences of
mothers using
closed FB
groups attached
to the
Australian
Breastfeeding
Association

N: 23 participants
Demographics:
administrators of
BF FB groups.
Additional data
was not collected
Setting: Online
interviews and
online focus
groups
EC: Not
discussed
Attrition: Not
discussed

Strengths: Large participation.
FB may be accessible to many
individuals. Consistent with
recent online support group
literature
Weakness: No demographic data
was collected. Researcher was a
volunteer with ABA, which may
have influenced the lens through
which the data was collected and
analyzed. The mitigate this, PhD
supervisors assisted with thematic
analysis
Feasibility: Closed online FB
group, low cost, constant
availability

Bias: Not
identified

Key: BCW – Behavior Change Wheel; BF – Breastfeeding; COM-B - Capability, Opportunity, and Motivation model of Behavior; EC – Exclusion Criteria; FB – Facebook;
FTM – First Time Mom; IC – Inclusion Criteria; LOE – Level of Evidence; MI – Motivational Interviewing; MMC – Mothers of Multiple Children; N – Number of participants;
PS – Peer Support; UK – United Kingdom; USA – United States of America

BREASTFEEDING

31

Table A2
Evaluation Table Quantitative Studies
Citation

Theoretical/
Conceptual
Framework

Design/
Method/
Purpose

Sample/
Setting

Variables

Measurement/
Instrumentation

Data Analysis

Results/
Findings

Citation:
Shakya et al.
(2017).
Effectiveness of
CommunityBased Peer
Support for
Mothers to
Improve Their
Breastfeeding
Practices: A
Systematic
Review and
Meta-Analysis

Theoretical/
Conceptual
framework not
identified

Design:
Systematic
Review and
Meta-Analysis

N = 47 total
studies; 28
RCT; 13 quasiexperimental; 6
observational
studies

IV1:
Community
Based Peer
Support

Confidence
Interval set at
95%; Tau², Chi²,
df, and I²
statistics used to
quantify
heterogeneity. Z
and P used for
total overall
effect

PRISMA; RoBANS
Critera

DV1: Chi2 =
153.22; df = 4,
(P<0.00001); I2
= 97.4%

Country:
United
Kingdom
Funding: Not
received
Bias: No bias
identified

Purpose: To
examine the
effectiveness of
communitybased peer
support for
mothers on their
breastfeeding
practices as
compared to
mothers who
have not
received
communitybased peer
support

DS: PubMed/
MEDLINE, The
Cochrane
Library;
CINAHL, Web
of Science,
SocINDEX,
PsycINFO
EC: Articles
excluded
include
intervention by
HCW;
Intervention not
clear; Outcome
variable
different than
interest of this
review;

DV1: Duration
of EB in LMIC
DV2: Duration
of EB in HIC
DV3: Initiation
of BF within
first hour of life
LMIC
DV4: Prelacteal
feeding in LMIC
DV5: EB at 6
months

DV2: Chi2 =
4.78; df = 4;
(P<0.31); I2 =
16.3%
DV3: Tau2 =
0.14; Chi2 =
126.19; df = 3
(P < 0.00001);
I2 = 98%; Z =
2.14 (P = 0.03)

Level of
Evidence;
Application to
practice/
Generalization
LOE: I
Strengths: first
systematic
review and
meta-analysis to
report
effectiveness of
peer support for
EBF mothers;
pivotal research

DV4: Tau2 =
0.01; Chi2 =
2.26; df = 1 (P
< 0.13); I2 =
56%; Z = 11.38
(P = 0.00001)

Weakness:
differences in
study
populations,
types of
interventions,
trainings. Quasiexperimental
studies may
increase risk of
bias

DV5: Chi2 =
0.20; df = 1; (P
= 0.65); I2 =
0%

Feasibility: low
cost communitybased peer
support groups

Key: BAME – Black and Minority Ethnic; BF – Breastfeeding; DF – Degree of Freedom; DS – Databases Searched; EB – Exclusively Breastfeeding; EC – Exclusion Criteria;
F2F – Face to Face; HCW – Health Care Worker; HIC – High Income Country; HR – Hazard Ratio; IC – Inclusion Criteria; LMIC – Low-Middle Income Country; N – Number
of participants; OR – Odds Ratio; PC – Peer Counselor; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analysis; PSEI – Peer Support Evaluation
Inventory; RCT – Randomized Controlled Trial; REDCap – Research and Electronic Data Capture; RoBANS – Risk of Bias Assessment Tool for Nonrandomized Studies; UK –
United Kingdom; USA – United States of America; WHO – World Health Organization; WIC – Women, Infants, and Children

BREASTFEEDING
Citation

Theoretical/
Conceptual
Framework

32
Design/
Method/
Purpose

Sample/
Setting

Variables

Measurement/
Instrumentation

Data Analysis

Results/
Findings

Level of
Evidence;
Application to
practice/
Generalization
can be
implemented to
support mothers

IV: Telephone
calls from
RUBY RCT
trial volunteers

Pearson’s X2
used to compare
categorical
variables and ttests for
continuous
variables

REDCap; Stata
Statistical Software;
subscales of PSEI ;
Attride-Stirling
analytic tool;
Inductive analysis;
Likert-type scale

Agree to
strongly agree
Domain
Means:
DV1: 70.9%
DV2: 87.6%
DV3: 80.3%
DV4: 79.0%
DV5: 46.5%
DV6: 57.6%
DV7: 76.7%
DV8: 79.0%
DV9: 61.6
DV10: 9.6%

LOE: III

secondary of
included study
Attrition: Not
applicable
Definitions: Not
applicable
Citation:
McLardie-Hore
et al. (2020).
Proactive
TelephoneBased Peer
Support for
Breastfeeding;
A CrossSectional
Survey of
Women’s
Experiences of
Receiving
Support in the
RUBY
Randomized
Controlled Trial
Country:
Australia
Funding:
Philanthropic

Not identified

Design: Cross
Sectional
Survey; Mixed
Methods
Purpose:
Aimed to
evaluate
interventions
from the
participant
perspective of
the RUBY trial

N = 360
Demographics:
Women enrolled
in the RUBY
RCT
Setting:
Melbourne,
Australia in
participant
homes
EC: Not
identified
Attrition: Not
discussed

DV1: Intimacy
DV2: Trust
DV3: Perceived
Acceptance
DV4: Empathy
DV5:
Attachment
DV6: Closeness
DV7:
Commitment
DV8: Social
Competence
DV9: Social
Skills
DV10: Conflict

Findings/
Themes:
Empathetic,
non-judgmental
support; easy
way to be
support; more
than BF
support; early

Strengths: large
number of
participants;
quantitative
findings to
support
qualitative
findings
Weakness:
Those that
didn’t
participate likely
did not BF until
6 months, these
individuals may
not be happy
with experience
Feasibility:
Telephone
support is a low-

Key: BAME – Black and Minority Ethnic; BF – Breastfeeding; DF – Degree of Freedom; DS – Databases Searched; EB – Exclusively Breastfeeding; EC – Exclusion Criteria;
F2F – Face to Face; HCW – Health Care Worker; HIC – High Income Country; HR – Hazard Ratio; IC – Inclusion Criteria; LMIC – Low-Middle Income Country; N – Number
of participants; OR – Odds Ratio; PC – Peer Counselor; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analysis; PSEI – Peer Support Evaluation
Inventory; RCT – Randomized Controlled Trial; REDCap – Research and Electronic Data Capture; RoBANS – Risk of Bias Assessment Tool for Nonrandomized Studies; UK –
United Kingdom; USA – United States of America; WHO – World Health Organization; WIC – Women, Infants, and Children

BREASTFEEDING
Citation

Theoretical/
Conceptual
Framework

33
Design/
Method/
Purpose

Sample/
Setting

Variables

Measurement/
Instrumentation

Data Analysis

funding from
the Felton
Bequest and La
Trobe
University

Results/
Findings

support
beneficial

Level of
Evidence;
Application to
practice/
Generalization
cost
intervention,
especially when
staffed with
volunteer peer
supporters.

Bias: None
declared
Citation:
McCoy et al.
(2017).
Associations
Between Peer
Counseling and
Breastfeeding
Initiation and
Duration: An
Analysis of
Minnestoa
Participants in
the Special
Supplemental
Nutrition
Program for
Women,
Infants, and
Children (WIC)
Country: USA
Funding:
Minnesota

Self-Efficacy

Design:
Retrospective
Analysis
Purpose:
Compare bf
initiation and
time to
discontinuation
of breastfeeding
between those
who received
peer services
and those who
did not receive
services.

N = 31,709

IV: PC program

Demographics:
Pregnant women
or postpartum
women

DV1:
Breastfeeding
Initiation
Prenatally
Assigned PS,
Adjusted

Setting:
Minnesota
EC: infants
without
mothers’
information,
infants whose
mothers were
not on WIC
during
pregnancy,
multiple births,
twin births,
triplet births

DV2: Prenatally
assigned peer,
did not receive
PS, Adjusted
DV3: BF
Discontinuation,
Adjusted Month
1
DV4: BF
Discontinuation
Month 2-12

95% CI, OR, and
HR

Unconditional logistic
regression used to
estimate OR and 95%
CI
Cox regression
models to examine
the associations
between peer
counseling and
breastfeeding
continuation and to
estimate HR and 95%
CI

DV1: OR 1.66;
95% CI 1.192.32
DV2: OR 1.13;
95% CI 0.801.58
DV3: HR 0.45;
95% CI 0.330.61
DV4: HR 0.33;
95% CI 0.180.60

Level of
evidence: V
Strengths: large
sample size;
quantitative
analysis
Weakness: Bias
may be present
due to women
self-selecting to
receive PS
Feasibility:
Possible to
provide PS to
women
prenatally and
postnatally to
those interested
in these services
if PCs are
available

Key: BAME – Black and Minority Ethnic; BF – Breastfeeding; DF – Degree of Freedom; DS – Databases Searched; EB – Exclusively Breastfeeding; EC – Exclusion Criteria;
F2F – Face to Face; HCW – Health Care Worker; HIC – High Income Country; HR – Hazard Ratio; IC – Inclusion Criteria; LMIC – Low-Middle Income Country; N – Number
of participants; OR – Odds Ratio; PC – Peer Counselor; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analysis; PSEI – Peer Support Evaluation
Inventory; RCT – Randomized Controlled Trial; REDCap – Research and Electronic Data Capture; RoBANS – Risk of Bias Assessment Tool for Nonrandomized Studies; UK –
United Kingdom; USA – United States of America; WHO – World Health Organization; WIC – Women, Infants, and Children

BREASTFEEDING
Citation

Theoretical/
Conceptual
Framework

34
Design/
Method/
Purpose

Sample/
Setting

Department of
Health

Attrition: Not
discussed

Bias: None
identified

PC: women
from the
community with
personal bf
experience who
have a desire to
help fellow
women

Variables

Measurement/
Instrumentation

Data Analysis

Results/
Findings

Level of
Evidence;
Application to
practice/
Generalization

Receipt of PS:
one or more
contacts
between the
client and a PC
program staff
member and
could include
one or multiple
telephone, text,
email, or inperson contact
Peer Services:
one or more
contacts
regardless of
whether the first
contact was
prenatal or
postpartum
Key: BAME – Black and Minority Ethnic; BF – Breastfeeding; DF – Degree of Freedom; DS – Databases Searched; EB – Exclusively Breastfeeding; EC – Exclusion Criteria;
F2F – Face to Face; HCW – Health Care Worker; HIC – High Income Country; HR – Hazard Ratio; IC – Inclusion Criteria; LMIC – Low-Middle Income Country; N – Number
of participants; OR – Odds Ratio; PC – Peer Counselor; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analysis; PSEI – Peer Support Evaluation
Inventory; RCT – Randomized Controlled Trial; REDCap – Research and Electronic Data Capture; RoBANS – Risk of Bias Assessment Tool for Nonrandomized Studies; UK –
United Kingdom; USA – United States of America; WHO – World Health Organization; WIC – Women, Infants, and Children

BREASTFEEDING

35

Citation

Theoretical/
Conceptual
Framework

Design/
Method/
Purpose

Sample/
Setting

Variables

Measurement/
Instrumentation

Data Analysis

Results/
Findings

Citation:
McFadden et al.
(2017). Support
for Healthy
Breastfeeding
Mothers with
Healthy Term
Babies

Not identified

Design:
Cochrane
Systematic
Review

N: 73 (58
individually
randomized
trials; 15 cluster
randomized
trials)

IV: Intervention
(F2F contact,
telephone, both
F2F and
telephone)

The main
outcome
measure was the
effect of the
interventions on
stopping
breastfeeding by
specified points
in time. Results
presented with
Chi2, df, P, and
I2

Review Manager 5
Software. When
results were unclear,
attempt to contact
original authors was
made

DV1: Chi2 =
0.40, df = 2 (P
= 0.82), I2 =
0%

Country: UK
Funding: Grant
from the
Evidence and
Programme
Guidance Unit,
Department of
Nutrition for
Health and
Development,
WHO
Bias: None
Identified

Purpose: To
examine
interventions
which provide
extra support
for bothers who
are
breastfeeding or
considering
breastfeeding;
and to assess
their impact on
breastfeeding
duration and
exclusivity

DS: CENTRAL;
MEDLINE;
Embase;
CINAHL; hand
searches of 30
journals; weekly
current
awareness alerts
for a further of
44 journals, plus
monthly
BioMed Central
email alerts
EC: Studies
with more than
25% attrition

DV1: Cessation
of BF at up to 6
months
DV2: Cessation
of EBF at up to
6 months
DV3: Cessation
of any BF by 46 weeks
DV4: Cessation
of EBF by 4-6
weeks

DV2: Chi2 =
37.55, df = 2
(P<.00001, I2 =
94.7%
DV3: Chi2 =
0.91, df = 2 (P
= 0.64), I2 =
0%
DV4: Chi2 =
10.63, df = 2 (P
= 0.005), I2 =
81.2%

Level of
Evidence;
Application to
practice/
Generalization
LOE: I
Strength:
Multiple studies
of high quality
used in
systematic
review.
Independent
review was
conducted by 2
researchers.
Risk of bias
conducted.
Weakness: Risk
of bias is
subjective.
Particular biases
were not
conducted in 15
cluster
randomized
trials. Trials
may have been
missed if they
were
unpublished or
unregistered
Feasibility:
When support is
offered,

Key: BAME – Black and Minority Ethnic; BF – Breastfeeding; DF – Degree of Freedom; DS – Databases Searched; EB – Exclusively Breastfeeding; EC – Exclusion Criteria;
F2F – Face to Face; HCW – Health Care Worker; HIC – High Income Country; HR – Hazard Ratio; IC – Inclusion Criteria; LMIC – Low-Middle Income Country; N – Number
of participants; OR – Odds Ratio; PC – Peer Counselor; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analysis; PSEI – Peer Support Evaluation
Inventory; RCT – Randomized Controlled Trial; REDCap – Research and Electronic Data Capture; RoBANS – Risk of Bias Assessment Tool for Nonrandomized Studies; UK –
United Kingdom; USA – United States of America; WHO – World Health Organization; WIC – Women, Infants, and Children

BREASTFEEDING

36

Citation

Theoretical/
Conceptual
Framework

Design/
Method/
Purpose

Sample/
Setting

Variables

Measurement/
Instrumentation

Data Analysis

Results/
Findings

Level of
Evidence;
Application to
practice/
Generalization
exclusivity of
breastfeeding is
increased.
Providing
support to these
individuals may
be done F2F,
telephonically,
or both

Citation:
Azimi & Nasiri
(2019). The
Effect of Peer
Counseling on
Breastfeeding
Behavior of
Primiparous
Mothers: A
Randomized
Controlled
Field Trial

Not identified

Design:
Randomized
Controlled Field
Trial

N: 80 women (n
= 40
experimental;
n= 40 control)

IV: Intervention

Setting: health
center,
questionnaire
completed in
privacy

SPSS. McNemar’s
test used to compare
mother’s
breastfeeding
behavior in
experimental group
before and after
intervention. Chi2 or
Fisher’s exact test
applied to compare
frequency distribution
of demographic.
Level of significance
was considered at p <
.05

The mean score
of
breastfeeding
behavior in
experimental
group increased
from 13.5
before
intervention to
25.7 after 3
months,
indicating a
significant
increase of
12.85 unites.
Peer counseling
program,
breastfeeding
with an hour of
birth increased
from the
baseline 11% to

LOE: I

Purpose: To
investigate the
impact of peer
counseling on
the
breastfeeding
behavior of
primiparous
mothers in a
sample of
Iranian women

WHO B-R-E-AS-T-Feed
Observation
form used to
evaluate
breastfeeding
performance of
mothers.

Country: Iran
Funding: Not
listed
Bias: None
identified

IC: willingness
to participate;
accessibility;
reading and
writing literacy
in Persian;
newborn being
singleton;
primiparous;
non-presence of
a disabling
disease or

DV1:
Experimental
group
DV2: Control
group

Peer-led
counseling was
performed in a
separate room,
BF was a private
affair nonobservable by
others

Strength: Large
sample size.
Strong study
design.
Weakness:
Study results
may be biased
due to different
cultural norms.
Findings may be
better with
similar cultures
Feasibility:
Peer counseling
program could
improve
breastfeeding
behaviors in
mothers to

Key: BAME – Black and Minority Ethnic; BF – Breastfeeding; DF – Degree of Freedom; DS – Databases Searched; EB – Exclusively Breastfeeding; EC – Exclusion Criteria;
F2F – Face to Face; HCW – Health Care Worker; HIC – High Income Country; HR – Hazard Ratio; IC – Inclusion Criteria; LMIC – Low-Middle Income Country; N – Number
of participants; OR – Odds Ratio; PC – Peer Counselor; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analysis; PSEI – Peer Support Evaluation
Inventory; RCT – Randomized Controlled Trial; REDCap – Research and Electronic Data Capture; RoBANS – Risk of Bias Assessment Tool for Nonrandomized Studies; UK –
United Kingdom; USA – United States of America; WHO – World Health Organization; WIC – Women, Infants, and Children

BREASTFEEDING
Citation

Theoretical/
Conceptual
Framework

37
Design/
Method/
Purpose

Sample/
Setting

Variables

Measurement/
Instrumentation

Data Analysis

known breast
problem in the
mother; absence
of congenital
anomalies and
oral
abnormalities in
the newborn;
participation in
postpartum
classes in a
health center

Results/
Findings

71% after
intervention

Level of
Evidence;
Application to
practice/
Generalization
modify
breastfeeding
techniques

EC: mothers’
unwillingness to
continue
participation;
failure to answer
the counselor’s
phone calls;
relocation of the
mother
Citation:
Brown &
Shenker.
(2020).
Experiences of
Breastfeeding
During
COVID-19:
Lessons for

Method: Mixed
methods online
survey

Attrition: 15%
N: 1,219
participants;
mean age of
mother 30.92

IV:
Questionnaire
containing both
closed and open
questions

Questionnaire
containing both
open and closed
questions;

Quantitative data
analyzed using SPSS;
descriptive statistics
explored; T tests, chisquare, and
Spearman’s rho
calculated for
associations between
BF

DV1: Mothers
who were still
breastfeeding
were more
likely to have a
degree or
postgraduate
qualification
compared with

LOE: IV

Strengths: large
sample size;
Demographics:
Initial coding
UK mothers
DV1: Education
was completed
who breastfed
by one
their baby aged
researcher, with
Key: BAME – Black and Minority Ethnic; BF – Breastfeeding; DF – Degree of Freedom; DS – Databases Searched; EB – Exclusively Breastfeeding; EC – Exclusion Criteria;
F2F – Face to Face; HCW – Health Care Worker; HIC – High Income Country; HR – Hazard Ratio; IC – Inclusion Criteria; LMIC – Low-Middle Income Country; N – Number
of participants; OR – Odds Ratio; PC – Peer Counselor; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analysis; PSEI – Peer Support Evaluation
Inventory; RCT – Randomized Controlled Trial; REDCap – Research and Electronic Data Capture; RoBANS – Risk of Bias Assessment Tool for Nonrandomized Studies; UK –
United Kingdom; USA – United States of America; WHO – World Health Organization; WIC – Women, Infants, and Children
Purpose: To
understand the
impacts of
COVID-19 on
BF that will

BREASTFEEDING
Citation

Future Practical
Emotional
Support
Country: UK
Funding: Not
identified
Bias: No
conflict of
interest
identified

Theoretical/
Conceptual
Framework

38
Design/
Method/
Purpose

Sample/
Setting

Variables

guide practice
and policy with
regards to
supporting
pregnant and
new mothers

0-12 at least
once during the
COVID-19
pandemic

DV2: Partner at
home

EC: Not
identified

DV4: Ethnicity

Attrition: Not
identified

DV3: Parity

Measurement/
Instrumentation

Data Analysis

Results/
Findings

continuation/cessation
and misinformation.
Chi-square and t tests
calculated between
feeding experiences
and demographic;
multivariable logistic
regression models
used to explore living
circumstances,
education, and BF
experience; thematic
analysis conducted
for qualitative data

those no longer
breastfeeding
(χ2 = 60.935, P
= 0.000)
DV2: living
with a partner
(χ2 = 8.665, P
= 0.005)
DV3:
Multiparous
(χ2 = 14.456, P
= 0.000).
DV4: BAME
mothers were
less likely to
still be
breastfeeding
compared with
White mothers
(χ2 = 10.770, P
= 0.001).
Themes
Positive: more
time to focus,
fewer visitors,

Level of
Evidence;
Application to
practice/
Generalization
a second
reviewing
themes and
subthemes.
Where
disagreement
occurred,
themes were
discussed until
agreed
Weakness:
individuals who
do not have
internet access
were not able to
participate;
weighted
towards mothers
with higher
education;
disproportionate
demographics
Feasibility:
Pandemic
effected BF and
highlighted need
for BF support,
which can be
done via lowcost methods

Key: BAME – Black and Minority Ethnic; BF – Breastfeeding; DF – Degree of Freedom; DS – Databases Searched; EB – Exclusively Breastfeeding; EC – Exclusion Criteria;
F2F – Face to Face; HCW – Health Care Worker; HIC – High Income Country; HR – Hazard Ratio; IC – Inclusion Criteria; LMIC – Low-Middle Income Country; N – Number
of participants; OR – Odds Ratio; PC – Peer Counselor; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analysis; PSEI – Peer Support Evaluation
Inventory; RCT – Randomized Controlled Trial; REDCap – Research and Electronic Data Capture; RoBANS – Risk of Bias Assessment Tool for Nonrandomized Studies; UK –
United Kingdom; USA – United States of America; WHO – World Health Organization; WIC – Women, Infants, and Children

BREASTFEEDING
Citation

Theoretical/
Conceptual
Framework

39
Design/
Method/
Purpose

Sample/
Setting

Variables

Measurement/
Instrumentation

Data Analysis

Results/
Findings

more privacy,
increased
responsive
feeding, greater
partner support,
delayed return
to work

Level of
Evidence;
Application to
practice/
Generalization
through support
methods

Negative: lack
of F2F support,
lack of social
and emotional
support, stress
of caring
without family
support, no
experience BF
in public, work
pressures,
increased focus
on BF

Key: BAME – Black and Minority Ethnic; BF – Breastfeeding; DF – Degree of Freedom; DS – Databases Searched; EB – Exclusively Breastfeeding; EC – Exclusion Criteria;
F2F – Face to Face; HCW – Health Care Worker; HIC – High Income Country; HR – Hazard Ratio; IC – Inclusion Criteria; LMIC – Low-Middle Income Country; N – Number
of participants; OR – Odds Ratio; PC – Peer Counselor; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analysis; PSEI – Peer Support Evaluation
Inventory; RCT – Randomized Controlled Trial; REDCap – Research and Electronic Data Capture; RoBANS – Risk of Bias Assessment Tool for Nonrandomized Studies; UK –
United Kingdom; USA – United States of America; WHO – World Health Organization; WIC – Women, Infants, and Children

BREASTFEEDING

40

Table A3
Synthesis Table
Study Author
Year
Design/LOE
LOE
Sample
n subjects
Country

Snyder &
Worlton
2021
CSP; Qualitative

Regan & Brown

Philips et al.

Bridges

Shakya et al.

McCoy et al.

VI

2017
Systematic
Review; Metaanalysis
I

McLardieHore et al.
2020
Cross Sectional
Survey; Mixed
Methods
IV

2018
Qualitative;
Interview

2016
Netnography

VI

2019
Qualitative; semistructured
interview
VI

VI

29
USA

14
UK

14
UK

Azimi & Nasiri

V

McFadden et
al.
2017
Cochrane
Systematic
Review
I

2019
Randomized
Controlled
Field Trial
I

Brown &
Shenker
2020
Mixed
Methods;
Online Survey
IV

23
Australia

47
UK

360
Australia

31,709
USA

73
UK

80
Iran

1,219
UK

2017
Retrospective
Analysis

Setting
Telephonic
In Person
Clinic
Community
Participant Homes
Online
Intervention
Observational
Social Media
Motivational
Interviewing
Community PS
Telephone Calls
PC Program
F2F
Measurement
Tools
Open Ended
Interview
Semi Structured
Interview
CI
Tau²
Chi²
df
I²
Z
P
Pearson’s X2,
t-test
OR
HR

X
X
X

X

X

X

X

X

X

X
X
X

X
X

X
X
X

X
X
X

X
X

X

X
X

X
X
X
X
X
X
X
X

X
X
X
X

X

X
X
X

X
X
X

Key: BCW – Behavior Change Wheel; BF - Breastfeeding; COM-B – Capability, Opportunity, and Motivation Model of Behavior; CSP – Cross Sectional Phenological; F2F –
Face to Face; LOE – Level of Evidence; N – Number of Participants; PC – Peer Counselor; PS – Peer Support; UK – United Kingdom; USA – United States of America

BREASTFEEDING
WHO B-R-E-A-ST-Feed
Observation form
Spearman’s rho
Framework

41
X

X

Social Support
Theory

N/A

BCW
Framework &
COM-B Model

Maternal
Breastfeeding Self
Efficacy

N/A

N/A

Self-Efficacy

N/A

N/A

N/A

Findings
Impact of PS on
BF
Increased BF
Duration
Increased BF
education
Education
Training
Intimacy
Trust
Acceptance
Attachment/
Closeness
PC increased BF
behavior
Partner Support
Emotional Support
Online Support
Benefit
Environment

X

X

X

X
X

X

X

X

X

X

X

X

X

X
X

X
X

X
X
X
X
X
X

X
X
X
X

Key: BCW – Behavior Change Wheel; BF - Breastfeeding; COM-B – Capability, Opportunity, and Motivation Model of Behavior; CSP – Cross Sectional Phenological; F2F –
Face to Face; LOE – Level of Evidence; N – Number of Participants; PC – Peer Counselor; PS – Peer Support; UK – United Kingdom; USA – United States of America

BREASTFEEDING

42
Appendix B
Models and Frameworks

Figure 1
Self-Efficacy Theory

Bandura (1977)

BREASTFEEDING
Figure 2
Rosswurm and Larrabee’s Model for Evidence-Based Practice

Rosswurm & Larrabee (1999)

43

BREASTFEEDING

44
Appendix C
Budget

BREASTFEEDING

45
Appendix D
Questionnaires

Figure 1
The WHO Well-Being Index

BREASTFEEDING

Figure 2
The Breastfeeding Relationship Scale

46