Introduction

Breastfeeding is a topic of global attention. It is considered as the best way to feed a baby and has been shown to have substantial short- and long-term benefits forboth mothers and infants [1,2,3,4,5,6]. In view of the beneficial effects of breastfeeding, the World Health Organisation (WHO)/ United Nations Children’s Fund (UNICEF) Global Strategy on Infant and Young Child Feeding specifically recommended that governments protect, promote, and support breastfeeding [7]. The World Health Assembly has also developed a ‘comprehensive plan for mother, infant and child nutrition’ with the goal of increasing the rate of exclusive breastfeeding during the first six months to at least 50% by 2025. In mainland China, the Chinese State Council stated in its Programme for the Development of Children in China (2011–2020) that the goal of having 50% of infants breastfeed exclusively during their first six months should be reached by year of 2020 [26,27,28,29]. Only one study measured the attitudes of midwives one year post training [25]. Moreover, factors such as policy changes and staff turnover may also affect long-term evaluation results. Therefore, to sustain the impact of such training programmes, regular in-service training is likely necessary.

The effects of breastfeeding training programmes on breastfeeding initiation, duration, and rates among postnatal mothers

The definition of exclusive breastfeeding varied in five studies in terms of how secondary outcomes were measured [30,31,32,33,34]. Two studies followed the WHO definition of breastfeeding: ‘exclusive breastfeeding means no other food or drink, not even water, except breastmilk (including milk expressed or from a wet nurse) for the first six months of life, with the exception of rehydration solution (ORS), drops and syrups (vitamins, minerals and medicines)’ [30, 34]. In contrast, three studies used the definition of breastfeeding provided by the National Board of Health and Welfare, which was revised to align with the WHO definition of breastfeeding: ‘exclusive breastfeeding is breastfeeding with occasional use of water, breast milk substitutes (not more than a few times), and/or solids (not more than one tablespoon per day)’ [31,32,33].

Additionally, the length of the follow-up period also varied among the studies. Three studies reassessed the outcomes at three days, three months, and nine months postpartum [31,32,33], while one study followedup at three, six, and 12 months postpartum, or until discontinued [30]. In contrast Shamim et al. was a pragmatic clustered RCT with repeated cross-sectional surveys conducted six months apart [34]. Therefore, meta-analysis of these studies was not possible, and the results should be interpreted with caution.

Three studies assessed breastfeeding initiation [30, 33, 34]. Shamim et al. and Zakarija-Grkovic et al. reported opposite results relating to breastfeeding initiation rate [30, 34]. In terms of the rate of exclusive breastfeeding, both Shamim et al. and Zakarija-Grkovic et al. reported that it was not statistically significantly different between the intervention and control groups [30, 34]. This suggests that the breastfeeding training programmes had limited effects on breastfeeding initiation and rates. In a systematic review by Balogun et al., among all six studies included, only one examined the effects of breastfeeding training programmes for healthcare professionals on secondary outcomes and reported that the rate of exclusive breastfeeding increased [18]. However, no statistically significant differences were found in breastfeeding initiation rates, which differed from the results of the current review.

For other secondary outcomes, longer breastfeeding durations [31, 33], less and later introduction of breast milk substitutes without medical reasons [31, 33, 34], fewer breastfeeding challenges [32, 33], and higher maternal satisfaction were reported [32, 33]. This suggests that breastfeeding training programmes for midwives were effective in improving some breastfeeding outcomes.

Breastfeeding training programme design

The results of this review suggest that the inclusion of counselling skills training, in addition to breastfeeding knowledge and skills training led to statistically significant positive effects on both primary and secondary outcomes. Besides, it was found that all training formats were effective in improving both primary and secondary outcomes.

Breastfeeding training programmes of different durations all resulted in increased KAP of midwives. Courses of longer duration correlated with more statistically significant effects on secondary outcomes [25, 31,32,33].

The course providers and teaching materials were often not reported. Despite this, the quality of the teachers and materials statistically significantly affected the effectiveness of the training programmes. More studies should be conducted to explore the effects of teachers’ characteristics (e.g. working years, experience, teaching ability) and teaching materials on breastfeeding training programme outcomes.

Limitations

Some limitations of this review should be noted. First, the literature in this field is limited and all of the included studies had some methodological weaknesses. Second, in this review, the breastfeeding training programmes varied widely in terms of target audience, duration, content, providers, materials, and teaching methods. Thus, subgroup analyses to compare the effects of training duration, course contents, teaching methods, and teacher characteristics were not feasible. In addition to the heterogeneity of the training programmes, the measurement tools, assessment strategies, and outcome definition also varied, making meta-analysis not feasible for many outcomes. Lastly, only studies published in Chinese or English were included in this review, and expanding the analysis to other languages may provide additional evidence to support our conclusions.

Conclusions

This systematic review has demonstrated that breastfeeding training programmes can improve midwives’ KAP towards breastfeeding. However, the breastfeeding training programmes had limited effects on breastfeeding initiation and rates.

More RCTs are required to explore the appropriate scientific content, methods, duration and provider of breastfeeding training for midwives, in addition to the effects of these variables on outcomes. Longitudinal studies are also warranted to examine the long-term effects of breastfeeding training programmes on midwives’ KAP, and breastfeeding initiation and rates towards breastfeeding. We suggest that future breastfeeding training programmes should incorporate counselling skills alongside breastfeeding knowledge and skills training.