support parenting (e.g., breastfeeding clinics, infant-parenting groups, parenting centres) should be provided during this telephone contact. Sword et al. (2001), in a five site Ontario study of postpartum health and social service utilization, reported that healthy mothers and newborn infants rely mainly on primary medical care and community nursing services during the first four weeks post discharge from hospital. The patterns of utilization are variable from site to site and depend upon the mothers, the newborn infant and provider practice patterns. It was also reported that healthy mothers in the first month of motherhood are experiencing significant information gaps which are relevant to appropriate health and social services utilization. Specific breastfeeding implications for policy makers, program managers, service delivery personnel and the public are included in the Ontario Mother and Infant Survey (Sword, 2001). Studies have also shown the value of home visiting services both prenatally and in the postpartum period. Ciliska et al. (1999) conducted a systematic review to assess the effectiveness of home visiting as a program delivery strategy for prenatal and postnatal clients. Twenty relevant articles reporting twelve studies of strong or moderate quality were found. The studies were all trials except one, which was a cohort design, and considered to be of moderate quality. Two studies targeted prenatal clients, and four included interventions for both the pre and postnatal period. The most effective interventions were those that: involved multiple community agencies and primary care service; were more intensive with weekly home visits at least initially, either during pregnancy or after the birth of the child; and had a greater impact on those who 49 Nursing Best Practice Guideline would be considered at risk due to social disadvantage. Implications for practice included: multiple intervention strategies are most effective; and home visiting interventions with women at high risk due to social circumstances, age, income or education have a greater impact than those directed to more advantaged clients. Recommendation • 7 Nurses with experience and expertise in breastfeeding should provide support to mothers. Such support should be established in the antenatal period, continued into the postpartum period, and should involve face-to-face contact. (Level of Evidence I) The length of such support programs should be determined based on local needs (evidence on the duration of support programs is not conclusive). Discussion of Evidence Sikorski, Renfrew, Pindoria and Wade (2001) reviewed thirteen studies that examined the effectiveness of breastfeeding support services on breastfeeding duration rates. The design of the studies included in the review were randomized or quasi-randomized controlled. In these studies, the breastfeeding support offered to mothers was in addition to the standard care the mothers usually receive. Therefore, the support was provided specifically to facilitate the continuation of breastfeeding. In the studies that were analyzed, breastfeeding support was provided either in both the antenatal and postnatal period or exclusively in the postnatal period. Twelve of the studies involved face-to-face breastfeeding support intervention, whereas one study examined telephone support provided by volunteers. The findings of the studies demonstrated that breastfeeding support, provided by health professionals who are specifically skilled in relation to breastfeeding, resulted in mothers breastfeeding until two months and more mothers exclusively breastfeeding to two months. In particular, breastfeeding support interventions that were offered in both the antenatal and postnatal period were more effective than interventions just delivered in the postnatal period. However, from the studies reviewed, the effectiveness of support interventions on breastfeeding duration over the longer term (more than two months) remains unclear. In addition, the effectiveness of telephone support by volunteers was unsubstantiated. A recent study by Steel O’Connor et al. (2003) compared routine home visiting by a public health nurse (PHN) and a screening telephone call to determine need for further intervention. They concluded: “a critical component of the initial telephone contact is careful assessment of the need for further PHN intervention” (pg. 103). 50 Breastfeeding Best Practice Guidelines for Nurses Recommendation • 7.1 Organizations should consider establishing and supporting peer support programs, alone or in combination with one-to-one education from health professionals, in the antenatal and postnatal periods. (Level of Evidence I) Discussion of Evidence In the Fairbank et al. (2000) systematic review, two randomized controlled trials (RCTs) (Kistin et al., 1994; McInnes, 1998) were identified. Both RCTs found evidence for the use of peer support programs in assisting women to start and maintain exclusive breastfeeding for at least six weeks, as well as assistance in breastfeeding effectively. Peer support did not change the behaviour of women who had decided to bottle-feed. Education Recommendations Recommendation • 8 Nurses providing breastfeeding support should receive mandatory education in breastfeeding in order to develop the knowledge, skills and attitudes to implement