title: Breastfeeding education and support for women with twins or higher order multiples.
abstract: There are rising rates of multiple births worldwide with associated higher rates of complications and more hospital care, often due to prematurity. While there is strong evidence about the risks of not breastfeeding, rates of breastfeeding in women who have given birth to more than one infant are lower than with singleton births. Breastfeeding more than one infant can be more challenging because of difficulties associated with the birth or prematurity. The extra demands on the mother of frequent suckling, coordinating the needs of more than one infant or admission to the neonatal intensive care unit can lead to delayed initiation or early cessation. Additional options such as breast milk expression, the use of donor milk or different methods of supplementary feeding may be considered. Support and education about breastfeeding has been found to improve the duration of any breastfeeding for healthy term infants and their mothers, however evidence is lacking about interventions that are effective to support women with twins or higher order multiples.
  
  
  
  To assess effectiveness of breastfeeding education and support for women with twins or higher order multiples.
  
  
  
  We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2016), ClinicalTrials.gov (30 June 2016), the WHO International Clinical Trials Registry Platform (ICTRP) (1 July 2016), the excluded studies list from the equivalent Cochrane review of singletons, and reference lists of retrieved studies.
  
  
  
  Randomised or quasi-randomised trials comparing extra education or support for women with twins or higher order multiples were included.
  
  
  
  Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We planned to assess the quality of evidence using the GRADE approach, but were unable to analyse any data.
  
  
  
  We found 10 trials (23 reports) of education and support for breastfeeding that included women with twins or higher order multiples. The quality of evidence was mixed, and the risk of bias was mostly high or unclear. It is difficult to blind women or staff to group allocation for this intervention, so in all studies there was high risk of performance and high or unclear risk of detection bias. Trials recruited 5787 women (this included 512 women interviewed as part of a cluster randomised trial); of these, data were available from two studies for 42 women with twins or higher order multiples. None of the interventions were specifically designed for women with more than one infant, and the outcomes for multiples were not reported separately for each infant. Due to the scarcity of evidence and the format in which data were reported, a narrative description of the data is presented, no analyses are presented in this review, and we were unable to GRADE the evidence.The two trials with data for women with multiple births compared home nurse visits versus usual care (15 women), and telephone peer counselling versus usual care (27 women). The number of women who initiated breastfeeding was reported (all 15 women in one study, 25 out of 27 women in one study). Stopping any breastfeeding before four to six weeks postpartum, stopping exclusive breastfeeding before four to six weeks postpartum, stopping any breastfeeding before six months postpartum andstopping exclusive breastfeeding before six months postpartum were not explicitly reported, and there were insufficient data to draw any meaningful conclusions from survival data. Stopping breast milk expression before four to six weeks postpartum, andstopping breast milk expression before six months postpartum were not reported. Measures ofmaternal satisfaction were reported in one study of 15 women, but there were insufficient data to draw any conclusions; no other secondary outcomes were reported for women with multiple births in either study. No adverse events were reported.
  
  
  
  We found no evidence from randomised controlled trials about the effectiveness of breastfeeding education and support for women with twins or higher order multiples, or the most effective way to provide education and support . There was no evidence about the best way to deliver the intervention, the timing of care, or the best person to deliver the care. There is a need for well-designed, adequately powered studies of interventions designed for women with twins or higher order multiples to find out what types of education and support are effective in helping these mothers to breastfeed their babies.
authors.affiliation: Mother and Infant Research Unit, School of Nursing and Health Sciences, Dundee Centre for Health and Related Research, University of Dundee, 11 Airlie Place, Dundee, Scotland, UK, DD1 4HJ.
authors.forename: Heather M
authors.initials: HM
authors.lastname: Whitford
authors.affiliation: Capacity Research Unit, Liverpool School of Tropical Medicine, Liverpool, UK.
authors.forename: Selina K
authors.initials: SK
authors.lastname: Wallis
authors.affiliation: Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, First Floor, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, UK, L8 7SS.
authors.forename: Therese
authors.initials: T
authors.lastname: Dowswell
authors.affiliation: Institute of Psychology, Health and Society, The University of Liverpool, Liverpool, UK.
authors.forename: Helen M
authors.initials: HM
authors.lastname: West
authors.affiliation: Mother and Infant Research Unit, School of Nursing and Health Sciences, Dundee Centre for Health and Related Research, University of Dundee, 11 Airlie Place, Dundee, Scotland, UK, DD1 4HJ.
authors.forename: Mary J
authors.initials: MJ
authors.lastname: Renfrew
mesh_terms: D001942:Breast Feeding; D061186:Breast Milk Expression; D003376:Counseling; D005260:Female; D006792:House Calls; D006801:Humans; D007223:Infant; D009035:Mothers / Q000193:education*; D009099:Multiple Birth Offspring; D016032:Randomized Controlled Trials as Topic; D013689:Telephone; D014427:Twins