Breastfeeding Initiation and Birth Setting Practices: A Review of the Literature

Della A. Forster, RN, RM, PhD; Helen L. McLachlan, RN, RM, PhD


J Midwifery Womens Health. 2007;52(3):273-280. 

In This Article

Abstract and Introduction


A number of practices during the intrapartum and very early postnatal period may affect breastfeeding initiation. All women should be encouraged to breastfeed soon after birth, with extra attention paid to the identification and offer of extra support for those women at higher risk of not successfully initiating and continuing breastfeeding. Factors that affect breastfeeding initiation include: implementation of the Baby-Friendly Hospital Initiative Ten Steps to Successful Breastfeeding at a service level; avoidance of the use of intramuscular narcotic analgesia, particularly near the end of the first stage of labour; not separating mothers and babies after birth for routine procedures; and placing healthy newborns on their mothers' chest/abdomen (skin-to-skin) routinely. Single strategies are unlikely to increase breastfeeding initiation as stand-alone measures.


A number of practices during the intrapartum and very early postnatal period may affect breastfeeding initiation. It is a period of time during which care providers can influence what practices take place, and a relatively large body of evidence exists to guide practice. This article presents the evidence regarding practices in the birth setting that can affect breastfeeding initiation.

The World Health Organization (WHO) recommends that all infants be exclusively breastfed from birth to 6 months of age,[1] followed by the gradual introduction of other forms of nutrition and continued breastfeeding into the second year and beyond. In the United States, approximately 70% of women initiate breastfeeding, but by 6 months, less than 40% feed their infants any breast milk at all.[2] The US Healthy People 2010 initiative has set objectives that 75% of babies are to be breastfed initially; that 50% receive some breast milk by 6 months of age; and that 25% of babies receive some breast milk by 12 months of age.[3]

A number of factors have an influence on breastfeeding initiation. Women's breastfeeding intentions are a strong predictor of breastfeeding outcome. A review by Donath et al.[4] found that maternal infant feeding intention was a stronger predictor of breastfeeding initiation and duration than the standard demographic factors combined. There is evidence to suggest that many women decide how they will feed their baby before they are pregnant or in very early pregnancy,[5] and that the earlier the decision to breastfeed is made, the more likely breastfeeding will be initiated.[6] A decision to breastfeed made before pregnancy may be even more predictive.[7] In general, breastfeeding initiation is closely related to social class, income, and education, and as stated in the 2003 Cochrane meta-analysis of interventions used to promote breastfeeding: "despite the widely documented health benefits of breastfeeding, initiation rates remain relatively low in many high-income countries, particularly among women in lower income groups."[8]

This article explores the evidence for practices that enhance breastfeeding initiation in the birth setting and is divided into two specific sections: 1) service-wide approaches to enhancing breastfeeding initiation (i.e., guidelines and education that should be in place before the commencement of the birth episode), and 2) considerations for care during each stage of labour and birth. The literature on breastfeeding initiation is extensive, and priority has been given to: 1) studies where data had been systematically collected prospectively as part of cohort studies or randomized controlled trials; 2) recent significant articles of relevant subject areas (e.g., where a substantial literature review had been undertaken); and 3) studies that adjusted for confounding factors.


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