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      Proactive Peer (Mother-to-Mother) Breastfeeding Support by Telephone (Ringing up About Breastfeeding Early [RUBY]): A Multicentre, Unblinded, Randomised Controlled Trial

      a , b , * , a , b , a , c , d , a , e , f , a , b , f , g , a , a , h , a , b



      ABA, Australian Breastfeeding Association, ACTRN, Australian New Zealand Clinical Trials Registry number, Adj. RR, Adjusted relative risk, AUD, Australian dollar(s), CI, Confidence interval, HR, Hazard ratio, RCT, Randomised controlled trial, RR, Relative risk, RUBY, Ringing Up about Breastfeeding earlY, sd, Standard deviation, Breastfeeding, Clinical trial, Peer support, Telephone intervention, Peer volunteer, Community-based

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          Breastfeeding rates are suboptimal internationally, and many infants are not receiving any breast milk at all by six months of age. Few interventions increase breastfeeding duration, particularly where there is relatively high initiation. The effect of proactive peer (mother-to-mother) support has been found to increase breastfeeding in some contexts but not others, but if it is shown to be effective would be a potentially sustainable model in many settings. We aimed to determine whether proactive telephone-based peer support during the postnatal period increases the proportion of infants being breastfed at six months of age.


          RUBY (Ringing Up about Breastfeeding earlY) was a multicentre, two-arm un-blinded randomised controlled trial conducted in three hospitals in Victoria, Australia. First-time mothers intending to breastfeed were recruited after birth and prior to hospital discharge, and randomly assigned (1:1) to usual care or usual care plus proactive telephone-based breastfeeding support from a trained peer volunteer for up to six months postpartum. A computerised random number program generated block sizes of four or six distributed randomly, with stratification by site. Research midwives were masked to block size, but masking of allocation was not possible. The primary outcome was the proportion of infants receiving any breast milk at six months of age. Analyses were by intention to treat; data were collected and analysed masked to group. The trial is registered with ACTRN, number 12612001024831.


          Women were recruited between Feb 14, 2013 and Dec 15, 2015 and randomly assigned to peer support ( n = 574) or usual care ( n = 578). Five were not in the primary analysis [5 post-randomisation exclusions]. Infants of women allocated to telephone-based peer support were more likely than those allocated to usual care to be receiving breast milk at six months of age (intervention 75%, usual care 69%; Adj. RR 1·10; 95% CI 1·02, 1·18). There were no adverse events.


          Providing first time mothers with telephone-based support from a peer with at least six months personal breastfeeding experience is an effective intervention for increasing breastfeeding maintenance in settings with high breastfeeding initiation.


          The Felton Bequest, Australia, philanthropic donation and La Trobe University grant.

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          Most cited references 9

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          Peer support within a health care context: a concept analysis.

          Peer support, and the integration of peer relationships in the provision of health care, is a concept of substantial significance to health scientists and practitioners today, as the focus shifts from the treatment of disease to health promotion. If the nursing profession is to effectively incorporate peer relationships into support-enhancing interventions as a means to improve quality care and health outcomes, it is essential that this growing concept be clearly explicated. This paper explores the concept of peer support through the application of Walker and Avant's (Strategies for Theory Construction in Nursing, 3rd Edition, Prentice-Hall, Toronto, 1995) concept analysis methodology. This analysis will provide the nursing profession with the conceptual basis to effectively develop, implement, evaluate, and compare peer support interventions while also serving as a guide for further conceptual and empirical research.
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            Socioeconomic status and rates of breastfeeding in Australia: evidence from three recent national health surveys.

             Lisa Amir,  S. DONATH (2008)
            To investigate whether the relationship between socioeconomic status and breastfeeding initiation and duration changed in Australia between 1995 and 2004. Secondary analysis of data from national health surveys (NHSs) conducted by the Australian Bureau of Statistics in 1995, 2001 and 2004-05. The Socio-Economic Indexes for Areas (SEIFA) classification was used as a measure of socioeconomic status. Rates of initiation of breastfeeding; rates of breastfeeding at 3, 6 and 12 months. Between the 1995 and 2004-05 NHSs, there was little change in overall rates of breastfeeding initiation and duration. In 2004-05, breastfeeding initiation was 87.8%, and the proportions of infants breastfeeding at 3, 6 and 12 months were 64.4%, 50.4% and 23.3%, respectively. In 1995, the odds ratio (OR) of breastfeeding at 6 months increased by an average of 13% (OR, 1.13 [95% CI, 1.07-1.19]) for each increase in SEIFA quintile; in 2001, the comparative increase was 21% (OR, 1.21 [95% CI, 1.12-1.30]); while in 2004-05, the comparative increase was 26% (OR, 1.26 [95% CI, 1.17-1.36]). Breastfeeding at 3 months and 1 year showed similar changes in ORs. There was little change in the ORs for breastfeeding initiation. Although overall duration of breastfeeding remained fairly constant in Australia between 1995 and 2004-05, the gap between the most disadvantaged and least disadvantaged families has widened considerably over this period.
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              Systematic review of peer support for breastfeeding continuation: metaregression analysis of the effect of setting, intensity, and timing.

              To examine the effect of setting, intensity, and timing of peer support on breast feeding. Systematic review and metaregression analysis of randomised controlled trials. 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. 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. 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.

                Author and article information

                06 March 2019
                February 2019
                06 March 2019
                : 8
                : 20-28
                [a ]Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia
                [b ]Royal Women's Hospital, 20 Flemington Rd, Parkville, Victoria 3052, Australia
                [c ]School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia
                [d ]Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Rd, Clayton 3168, Australia
                [e ]Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario M5T 1P8, Canada
                [f ]Australian Breastfeeding Association, Level 3, Suite 2,150 Albert Road, South Melbourne, Victoria 3205, Australia
                [g ]School of Health and Social Development, Deakin University, Geelong, Victoria 3220, Australia
                [h ]Monash Nursing and Midwifery, Monash University and Monash Health, Australia
                Author notes
                [* ]Corresponding author at: Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia. D.forster@
                © 2019 Published by Elsevier Ltd.

                This is an open access article under the CC BY-NC-ND license (

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