Breastfeeding is the natural way to feed infants and exclusive breastfeeding is recommended through the first 6 months of life.1 There is ample evidence of its benefits for infants and mothers,2 and also evidence of the association of formula feeding with several health problems.3 Few countries achieve adequate proportions of exclusive breastfeeding (EBF) at 6 months of life. In developed countries, there has been a recent increase in the rate of initiation of EBF, but this is followed by a progressive decline through time, with very low percentages of EBF at 6 months.4 According to the latest National Health Survey, the prevalence of EBF at 6 months in Spain is 28.5%.5

The reasons for these very low percentages are varied, and often involve issues that are well outside the scope of our health care or health promotion activity. A series of risk factors for discontinuation of breastfeeding have been described in the literature, such as membership in specific ethnic groups, teen motherhood, single-parent household or caesarean delivery.3,6,7 Being aware of these risk factors allows health care professionals to be more alert when it comes to supporting EBF in these groups.

Multiple strategies have been tried in the general population and in at-risk groups to improve successful breastfeeding rates. The first days after birth are crucial and are the time when the awareness and training of professionals involved in maternity care is most important.8 After discharge, a long road starts during which quality information and support can ultimately determine the failure or success of EBF. A broad variety of strategies to promote breastfeeding have been tested, and many of them are beneficial.7,9–11 A proactive attitude7 and intervening as soon as possible12–14 are important factors. The support strategies that have been tried include support by health care professionals (especially midwives15 or nurses)16 and support by groups outside the health care system,17,18 and both types of intervention have proven useful.7,9 There is evidence that face-to-face support can be helpful,7 while studies on telephone-based support have shown favourable results in some instances,16,19–22 but found no clear effect in others.23–25 The combined use of several of these interventions enhances their effects and leads to better outcomes.12,26

Few studies on the promotion of EBF have been conducted in Spain.27 The studies we found28,29 showed that breastfeeding interventions were beneficial, although there were no clinical trials on the subject. The characteristics of our health care system, with paediatricians and paediatric nurses working in primary care settings, offer optimal conditions for the promotion of EBF and make it possible to implement universal interventions. For this reason, we decided to evaluate a telephone-based support programme delivered by paediatric nurses in the primary care system for mothers that were breastfeeding their children the first 6 months of life with the aim of improving the duration of breastfeeding.

There were 469 mothers that met the inclusion criteria. The main reason for exclusion was the presence of a language barrier (5.5% of eligible mothers). We randomly assigned the remaining 414 mothers to the 2 study groups (207 per group). A total of 193 mothers in the intervention group (93.2%) and 187 in the control group (90.3%) completed the 6 months of followup (Fig. 1). Losses to followup were mainly due to changes in residence of the patients that were accompanied by a change of primary care centre. One mother in the intervention group chose to leave the study and 2 mothers were withdrawn because they could not be reached by telephone.

Figure 1.

Flow chart.

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Table 1 compares the characteristics of the 2 groups under study.

Fig. 2 shows the proportions of the different types of feeding by age in the experimental and the control group, and their changes in the 6 months of followup.

Figure 2.

Proportions of EBF and EBF+MF by age. EBF, exclusive breastfeeding; MF, mixed feeding.

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After collecting the data, and using the method mentioned above, we assessed which of the variables could influence the effect of the intervention and ought to be included in the regression model. The only variable that met these conditions was “contact with a breastfeeding support group” (results not shown).

Table 2 presents the crude and adjusted ORs. We compare the ORs in the experimental group to those of the control group for EBF and for any type of breastfeeding (EBF+MF).

Last of all, Table 3 presents the ARRs for EBF and for any type of breastfeeding (EBF+MF) for each infant age.

The percentages of breastfeeding in all age groups were higher in the experimental group compared to the control group, but the adjusted ORs and their confidence intervals did not reflect a clear effect of the intervention. Our intervention did not have the expected results for either EBF or any breastfeeding (EBF+MF). Most similar studies in the literature have found a positive effect of the interventions, at least in the early months of life, with subsequent dampening.13,17,19 This was not the case in our study. Indeed, differences in parenting styles and social and cultural factors may result in one intervention having different effects in different places.7,19 Generalising the results of studies on health education, in general and on breastfeeding in particular, is challenging precisely because outcomes are influenced by all of these factors.

It would be hard to determine why our intervention did not have the desired effect. Due to the substantial accessibility of primary care services, mothers that are truly motivated to breastfeed and experience problems may take the initiative to seek the help of the paediatrician or nurse to try to resolve them. There is no way of knowing what happens when mothers do need help but lack the ability to seek it and need health professionals to be proactive instead. It is in this regard that we should have seen the difference in the outcomes of our study. And it seems that in this case, the effect of the intervention on these mothers was not strong enough.

The obtained ARRs were low, and their confidence intervals also indicated that the intervention was not effective. Taking into account that each mother received approximately 15 calls in the first 6 months post birth, and the time invested by the nursing staff on this activity, we needed to obtain much higher ARRs to consider the intervention worth implementing.

Previous studies have shown that the simultaneous combination of different interventions for breastfeeding promotion can enhance their effects.7,10 Thus, while the results of our study were not significant, it is possible that our intervention combined with another breastfeeding promotion strategy would be beneficial. Furthermore, certain interventions have proven effective on population subsets with specific social, ethnic or economic characteristics,17,18,24 so it is also possible that while our intervention had no effect on the general population, it may have been effective in specific population subsets. However, confirming these possibilities would require further research.

The main limitation in our study was the impossibility of masking the intervention. The intervention was designed for implementation in the primary care setting, of which one of the main advantages is the mutual knowledge and trust that can develop between users and health care workers. For this reason, we believed it would be best for the nurse assigned to the patient to be the professional delivering the intervention, with the aim of reinforcing this rapport and help further motivate mothers.

Another limitation in our study was that we found a percentage of EBF at 6 months that was lower than expected. We calculated the sample size based on the 32% of EBF observed in recent years in our area at 6 months post birth. Surprisingly, we found a percentage of EBF at 6 months of only 21.4% in the control group. Some external factor must have been at play to make this percentage decline this much in the past few years. With the number of patients included in the study, we only had a power of 67% in assessing whether the observed increase was significant. A larger sample would have allowed us to obtain more information with the rates of EBF that we finally obtained through the intervention. In any case, studies similar to our own that found improvements in the proportion of EBF reported increases of at least 10% in the experimental group,13,17,19 and we did not obtain increases this high in any age group.

Thus, we concluded that the telephone-based intervention implemented in our study did not have a large enough impact to be considered a useful measure worth implementing universally for improvement of breastfeeding rates.

The authors have no conflicts of interest to declare.