Multicomponent Breastfeeding Interventions in Women with a Body Mass Index > 25 

By Ahizechukwu C. Eke, MD, PhD, MPH

Associate Professor in Maternal Fetal Medicine, Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore

SYNOPSIS: The study found no statistically significant differences in breastfeeding outcomes between the intervention and control groups at various postpartum time points, although the intervention group received more hospital-based support, while the control group sought more private lactation support.

SOURCE: O’Reilly SL, McNestry C, McGuinness D, et al. Multicomponent perinatal breastfeeding support in women with BMI >25: The Latch On multi-centre randomized trial. BJOG 2024;131:1197-1206.

Breastfeeding is recognized universally as a cornerstone of neonatal and infant well-being, providing essential nutrients and immune protection critical for optimal growth and development.¹ In the United States, the significance of breastfeeding support has become increasingly crucial as healthcare systems strive to improve breastfeeding initiation and duration rates.² Consequently, the Healthy People 2030 (HP2030) initiative has set national targets to increase exclusive breastfeeding rates to 42.4% at six months and 54.1% at one year.³ Despite the HP2030 objectives and the extensively documented benefits of breastfeeding, many women encounter substantial barriers to breastfeeding, ranging from inadequate prenatal education to limited postpartum support, including lack of adequate paid parental leave from work. Addressing these challenges requires a multifaceted approach that includes tailored support from healthcare providers, access to lactation consultants, and culturally sensitive interventions that empower women throughout the period they choose to breastfeed, as well as societal changes.

The landscape of breastfeeding support is influenced by a range of factors, including body mass index (BMI), socioeconomic status, healthcare access, and social norms.^1,4 Disparities in breastfeeding rates among different racial and ethnic groups underscore the need for targeted interventions that address the specific challenges faced by marginalized communities.⁵ Multicomponent breastfeeding support, as one such targeted intervention, plays a crucial role in improving breastfeeding rates by meeting the diverse needs of mothers through a combination of synergistic strategies.⁶ This approach typically encompasses prenatal education, hospital-based practices, postpartum follow-up, and community support, all of which contribute to a mother’s ability to successfully initiate and sustain breastfeeding. While the relationship between BMI and breastfeeding has been explored, research on the effectiveness of multicomponent breastfeeding support in women with a BMI > 25 kg/m² is limited.⁴ To address this gap, O’Reilly and colleagues designed the “Latch On” study to evaluate the effect of a multicomponent breastfeeding support intervention on breastfeeding outcomes among women with a BMI ≥ 25 kg/m².⁷

The Latch-On study was a prospective, randomized controlled trial of a multicomponent breastfeeding education and support intervention for women with a BMI ≥ 25 kg/m², conducted between June 4, 2019, and Nov. 26, 2021, at four centers in Ireland: the National Maternity Hospital, Dublin; St Luke’s Hospital, Kilkenny; Wexford General Hospital, Wexford; and Midlands Regional Hospital, Mullingar.⁷ Women were included if they were primigravid, were 18 years of age or older, had a BMI ≥ 25 kg/m², were carrying a singleton pregnancy, were between 16 and 36 weeks of gestation, spoke sufficient English, and had a support partner willing to participate in the study.⁷ Exclusion criteria were preterm delivery (i.e., < 37 weeks of gestation), and medical conditions or use of medication for which breastfeeding was contraindicated.

Randomization was conducted through scheduled phone calls by the research team, with participants allocated to either group using a computer-generated randomization sequence in a 1:1 ratio, stratified by study site and BMI categories. The intervention was designed as a multicomponent approach, beginning with an invitation for women and their support partners to attend a breastfeeding education class during pregnancy developed by the study team. Postnatally, a lactation consultant provided individualized breastfeeding assessments during the hospital stay and continued support for six weeks postpartum through weekly telephone calls, offering targeted support and advice at each interaction. If a lactation consultant was unavailable during the hospital stay, participants received a telephone consultation as soon as possible after discharge. The control group received usual care, which included access to optional antenatal education classes.

The primary outcome was any breastfeeding at three months postpartum assessed using a modified version of the Questionnaire on Infant Feeding and the Breastfeeding Experience Scale. Secondary outcomes included intention to breastfeed after the antenatal intervention component; motivation to breastfeed; breastfeeding initiation rates; exclusive and any breastfeeding prevalence at hospital discharge, at six weeks, and at six months; maternal and support partner attitudes toward breastfeeding; and participant breastfeeding self-efficacy.⁷

To achieve a statistical power of > 80%, assuming a type-1 error rate of 5% (two-sided), and an attrition rate of 10%, a sample size of at least 220 women (110 women per group) was required to allow for the detection of a 20% difference on the primary endpoint, assuming a 32.5% to 45.7% prevalence in breastfeeding rates. The primary analysis was by intention-to-treat.

A total of 225 women and their support partners were randomized to intervention (n = 112) or usual care (n = 113) between June 4, 2019, and Nov. 26, 2021. The baseline characteristics were comparable between groups. At three months postpartum, the primary outcome (prevalence of any breastfeeding) was 68.7% (n = 68) and 62.1% (n = 59) in the intervention and control groups, respectively (odds ratio [OR], 1.33; 95% confidence interval [CI], 0.72, 2.46; P = 0.36). There were no statistically significant differences between the intervention and control groups regarding initiation of breastfeeding (adjusted OR, 0.76; 95% CI, 0.43, 1.37; P = 0.63), any breastfeeding, exclusive breastfeeding, exclusive formula feeding, breastfeeding self-efficacy, and infant feeding attitude at hospital discharge, six weeks, three months, and six months postpartum. The intervention group received more hospital-based support (adjusted OR, 7.30; 95% CI, 3.82, 13.96; P < 0.01), and the control group sought more private lactation support (adjusted OR, 0.37; 95% CI, 0.16, 0.86; P = 0.02).

COMMENTARY

The findings from this study indicate that while the multicomponent breastfeeding support intervention led to a slight increase in breastfeeding prevalence at three months postpartum compared to usual care (68.7% vs. 62.1%), the difference was not statistically significant. This suggests that while such interventions may offer some benefit, they may not be sufficient on their own to significantly improve breastfeeding outcomes across various measures, including initiation and exclusivity. The notable increase in hospital-based support in the intervention group suggests that accessibility and the type of support provided can vary significantly depending on the intervention’s design. Additionally, the higher reliance on private lactation support in the control group points to potential gaps in support services that might be addressed by more comprehensive public health strategies. These findings underscore the complexity of breastfeeding support and the need for multifaceted approaches that address not only hospital-based but also community and private support systems to optimize breastfeeding outcomes.

Breastfeeding presents unique challenges for obese women in the United States with a BMI ≥ 25 kg/m², a population that is at an increased risk of obesity-related complications.⁸ These women often experience delayed onset of lactogenesis II, which is the initiation of copious milk production, typically occurring within 72 hours postpartum.⁹ Delays in lactogenesis II are associated with decreased breastfeeding initiation and shorter duration of exclusive breastfeeding.⁹ The physiological mechanisms underlying these delays include insulin resistance, hormonal imbalances such as elevated levels of progesterone and insulin, and inflammation, all of which can impede the establishment of full milk supply postpartum.¹⁰ Additionally, women with a higher BMI may face anatomical challenges, such as larger breast size and nipple-areola complex, which can make latching more difficult for the infant. These physical challenges often are compounded by social and psychological factors, such as lower breastfeeding self-efficacy and higher rates of postpartum depression, which are more prevalent in women with higher BMI. Consequently, these women are less likely to meet breastfeeding recommendations, which can negatively affect both maternal and infant health outcomes.

The public health implications of lower breastfeeding rates among women with a BMI ≥ 25 kg/m² are significant, given the established benefits of breastfeeding for both mothers and infants.^1,3 Breastfeeding is associated with reduced risks of chronic conditions, such as type 2 diabetes, cardiovascular disease, and certain cancers in mothers, and with lower incidences of obesity, asthma, and infections in infants.¹ However, the barriers faced by women with a higher BMI often prevent them from realizing these benefits. Healthcare providers may not be adequately trained to address the specific breastfeeding needs of these women, and the healthcare system may lack the resources necessary to provide tailored breastfeeding support. Moreover, societal stigmas related to body image and weight can further discourage breastfeeding among this population. Addressing these challenges requires a multifaceted approach, including targeted breastfeeding interventions that account for the physiological, psychological, and social barriers faced by women with a higher BMI.¹¹ Such interventions could include enhanced lactation support, counseling on body image and breastfeeding self-efficacy, and policies that promote a supportive environment for breastfeeding in both healthcare settings and the broader community. By recognizing and addressing the unique challenges faced by women with a BMI ≥ 25 kg/m², public health efforts can help to close the breastfeeding gap and promote better health outcomes for both mothers and their infants.

In summary, the findings from the Latch On study are significant in the context of public health efforts to improve breastfeeding rates, particularly among women with a higher BMI, who are known to face additional challenges in initiating and maintaining breastfeeding. The results suggest that hospital-based multicomponent support may effectively address breastfeeding challenges in women with BMI ≥ 25 kg/m², leading to improved breastfeeding outcomes. This is particularly important given the well-documented benefits of breastfeeding for both maternal and infant health, including reduced risk of chronic diseases for mothers and lower rates of infections and improved cognitive development for infants.

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