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Systematic review of peer support for breastfeeding continuation: metaregression analysis of the effect of setting, intensity, and timing

BMJ 2012; 344 doi: (Published 25 January 2012) Cite this as: BMJ 2012;344:d8287
  1. Kate Jolly, senior lecturer in public health and epidemiology1,
  2. Lucy Ingram, research midwife1,
  3. Khalid S Khan, professor of women’s health and clinical epidemiology2,
  4. Jonathan J Deeks, professor of biostatistics1,
  5. Nick Freemantle, professor of clinical epidemiology and biostatistics3,
  6. Christine MacArthur, professor of maternal and child epidemiology1
  1. 1Department of Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham B15 2TT, UK
  2. 2Barts and the London School of Medicine, London, UK
  3. 3Department of Primary Care and Population Health, University College London, London, UK
  1. Correspondence to: K Jolly C.B.Jolly{at}
  • Accepted 31 October 2011


Objective To examine the effect of setting, intensity, and timing of peer support on breast feeding.

Design Systematic review and metaregression analysis of randomised controlled trials.

Data sources Cochrane Library, Medline, CINAHL, the National Research Register, and British Nursing Index were searched from inception or from 1980 to 2011.

Review methods Study selection, data abstraction, and quality assessment were carried out independently and in duplicate. Risk ratios and 95% confidence intervals were calculated for individual studies and pooled. Effects were estimated for studies grouped according to setting (high income countries, low or middle income countries, and the United Kingdom), intensity (<5 and ≥5 planned contacts), and timing of peer support (postnatal period with or without antenatal care), and analysed using metaregression for any and exclusive breast feeding at last study follow-up.

Results Peer support interventions had a significantly greater effect on any breast feeding in low or middle income countries (P<0.001), reducing the risk of not breast feeding at all by 30% (relative risk 0.70, 95% confidence interval 0.60 to 0.82) compared with a reduction of 7% (0.93, 0.87 to 1.00) in high income countries. Similarly, the risk of non-exclusive breast feeding decreased significantly more in low or middle income countries than in high income countries: 37% (0.63, 0.52 to 0.78) compared with 10% (0.90, 0.85 to 0.97); P=0.01. No significant effect on breast feeding was observed in UK based studies. Peer support had a greater effect on any breastfeeding rates when given at higher intensity (P=0.02) and only delivered in the postnatal period (P<0.001), although no differences were observed of its effect on exclusive breastfeeding rates by intensity or timing.

Conclusion Although peer support interventions increase breastfeeding continuation in low or middle income countries, especially exclusive breast feeding, this does not seem to apply in high income countries, particularly the United Kingdom, where breastfeeding support is part of routine postnatal healthcare. Peer support of low intensity does not seem to be effective. Policy relating to provision of peer support should be based on more specific evidence on setting and any new peer services in high income countries need to undergo concurrent evaluation.


  • We thank T Tylleskar and colleagues for sharing the results of their study before publication.

  • Contributors: KJ, CM, KSK, and LI conceived the study. LI designed the search strategy. LI and KJ selected the papers for inclusion and abstracted the data. CM and KSK resolved differences in inclusion and abstraction. JJD and NF provided advice about the meta-analysis. JJD, KJ, and LI undertook the meta-analyses. KJ, CM, and LI wrote the first draft. All authors commented on and approved the final version. KJ is the guarantor.

  • Funding: KJ, CM, and LI are part funded by the National Institute for Health Research through the Collaborations for Leadership in Applied Health Research and Care for Birmingham and Black Country (CLAHRC-BBC) programme. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research, the Department of Health, University of Birmingham, University College London, or the CLAHRC-BBC steering group.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; CM, KJ, KSK, NF, and LI were investigators of one of the included trials.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

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