Although the value of providing infants with human milk has long been understood, a torrent of studies published in the last decade have provided undeniable evidence that breast-feeding reduces morbidity and mortality during the first year of life, not only in developing countries but in North America and Europe as well.1,2,3,4 The list of protective effects includes decreased incidence of acute and chronic infections, allergy, Crohn's disease, celiac disease, childhood cancers and childhood-onset diabetes.5,6 A host of reports support the conclusion that breast-fed infants are more developmentally advanced than their bottle-fed counterparts.7 Many national and international organizations strongly recommend breast-feeding.1,2,3 The American Academy of Pediatrics recommends exclusive breast-feeding for the first 6 months, continued breast-feeding while weaning foods are added through the first year, and then as long thereafter as mother and infant wish.1 In May 2001 the World Health Organization confirmed the policy that infants worldwide should be exclusively breast-fed for 6 months.8
Unfortunately, few women breast-feed beyond 3 months. Data in Canada indicate that less than 35% are exclusively breast-feeding at 4 months, and only 30% to 40% continue to breast-feed at all at 6 months.2 Similar numbers are reported in the United States, with 59.7% breast-feeding at hospital discharge and 21.6% doing so at 6 months, and these data are for any amount of breastfeeding (data for exclusive breast-feeding were not reported).9
The reasons for this sharp drop in breast-feeding are complex, but lack of support and assistance once a woman leaves the hospital have been key. The World Health Organization and UNICEF established the Baby-Friendly Hospital Initiative in 1985 (www.unicef.org), which outlines 10 steps to ensure a hospital provides adequate breast-feeding support to the mother and infant before discharge.10 The initiative also recommends referral to breast-feeding support groups but has focused on increasing the number of women who leave the hospital breastfeeding. The literature, however, on enhancing the duration of breast-feeding is lean despite the clear benefits to breast-feeding beyond the first few weeks.
In this issue (page 21) Cindy-Lee Dennis and colleagues11 report the results of their randomized controlled trial designed to evaluate whether peer support of new mothers to encourage them to continue breast-feeding would increase the number and duration of infants exclusively breast-fed at 3 months post partum. Peer supporters (women who had breast-fed successfully themselves and volunteered to attend a short training program) were assigned to assist breast-feeding women with whom they were matched demographically. The peer volunteer counsellor was asked to contact the mother by phone at least once within 48 hours after discharge and then as often thereafter as mutually agreeable. Significantly more mothers in the peer support group than in the usual care group (81.1% v. 66.9%) were breast-feeding at the 3-month follow-up, and this difference was evident at 4 and 8 weeks as well. Half of the mothers in the peer support group, however, while continuing to breast-feed, were using supplements by 3 months. More mothers in the peer support group than in the control group were satisfied with their experience and planned to breast-feed their next baby. On average, the peer volunteer counsellors made at least 5 contacts per mother. There were health care referrals in 38 cases (9.3%), 16 (3.9%) of which were made by the peer volunteer counsellor.
Peer support is not a new concept. The anthropologist Dana Raphael described it elegantly and used the term doula, which comes from the Greek meaning “a friend from across the street.”12 The concept of peer counselling is that someone who is a true peer of the breast-feeding mother, not a health care professional, is involved as a support person. It is this concept upon which La Leche League International was founded by 7 breast-feeding mothers in 1957 (www.lalecheleague.org). The heart and soul of La Leche League and many other breast-feeding advocate organizations is peer counselling.13
Although La Leche League has spread internationally and blossomed in the last 40 years, the one problem that remained was that women who tended to join the League were well-educated and were professional and knowledgeable individuals. This meant that lower-income women with less education were not their peers and were unserved by this volunteer group. To address this problem, an innovative peer support program was started in low-income neighbourhoods of Augusta, Ga., in the 1970s (Wanda Grogan, University of Georgia at Augusta: personal communication). The idea spread and since then has been used in the the Women's, Infants' and Children's (WIC) Program of the US Department of Agriculture. Although never formally evaluated, the WIC has proven to be very successful in helping less educated mothers breast-feed throughout most of the first year of their infant's life. The La Leche League now participates in training peer support mothers.
The study by Dennis and colleagues, using a very well-controlled, scientifically conducted model, carefully supplies the needed evidence that indeed peer support does make a difference in the long-term outcome of breast-feeding. Some mode of training is necessary as well as some screening of the volunteer candidates. Experientially, it has been shown that, in any group of breast-feeding advocates, there are always a few zealots who push the group philosophy in an intimidating manner, and there may be an occasional person who oversteps her bounds as a peer counsellor, encroaching on the practice of medicine, as was described by Dennis and colleagues. But those individual problems can be identified and solved, if not prevented, by careful screening and training.
Dennis and colleagues used peer volunteer supporters. As we try to extend these programs, however, to populations where income levels are very low and candidate peer supporters are often single mothers working in low-paid jobs with long and irregular hours, it may be necessary and even desirable to pay peer supporters. In our as yet unreported experience with peer counselling, where the peer counsellors were paid a small stipend, we found that the program not only facilitated breast-feeding for the mothers but it increased the self-esteem of the peer counsellors. Continual turnover among peer counsellors occurred not because they were dissatisfied with the program but because they had achieved sufficient self-esteem to realize that they could indeed enter the work force as productive members of society.
It is essential, in my view, that this work and that of Dennis and colleagues continue. Breast-feeding is important. We need to improve our understanding of how to encourage women to continue exclusive breast-feeding to 3 months, and even to 6 months of age.