869601

research-article2019
JHLXXX10.1177/0890334419869601Journal of Human LactationHongo et al.

Original Research
Journal of Human Lactation

The Influence of Breastfeeding Peer

1­–11
© The Author(s) 2019
Article reuse guidelines:
Support on Breastfeeding Satisfaction sagepub.com/journals-permissions
DOI: 10.1177/0890334419869601
https://doi.org/10.1177/0890334419869601

Among Japanese Mothers: A Randomized journals.sagepub.com/home/jhl

Controlled Trial

Hiroko Hongo, MSW, MHSc, IBCLC1 , Joseph Green, DMSc1, Akira

Shibanuma, MID1, Keiko Nanishi, MD, PhD, IBCLC1,
and Masamine Jimba, MD, MPH, PhD1

Abstract
Background: Peer support may help mothers to feel satisfied with their breastfeeding and to continue breastfeeding.
However, previous researchers have not examined the influence of peer support on the three breastfeeding-satisfaction
domains.
Research aim: We aimed to examine the influence of telephone-based peer support on the following three domains
of breastfeeding satisfaction among Japanese mothers: maternal satisfaction, perceived benefit to the infant, and lifestyle
compatibility with breastfeeding.
Methods: Breastfeeding mothers were recruited at four maternity hospitals in Japan to participate in a randomized
controlled trial. Data were collected 1 month and 4 months postpartum. Among all of the participants (N = 114), those in
the intervention group (n = 60) received telephone-based peer support until 4 months postpartum, and participants in the
control group (n = 54) received conventional support. Breastfeeding satisfaction was measured using the short version of
the revised Japanese Maternal Breastfeeding Evaluation Scale. Generalized estimating equations and effect size analyses were
used to examine the influence of the intervention.
Results: On the subscale measuring lifestyle compatibility, participants with peer support had a higher score than those
without peer support: regression coefficient 1.54 (95% confidence interval [0.03, 3.04]). The effect size was 0.40 standard
deviations among participants with low and mid-level scores at baseline.
Conclusion: Although peer support did not change maternal satisfaction or perceived benefit to the infant, it did increase
lifestyle compatibility with breastfeeding among these Japanese mothers. This is evidence in favor of increasing the use of
peer support.

Keywords
breastfeeding, La Leche League International, lactation counseling, randomized controlled trials, social support

Background lifestyle compatibility (Hongo, Green, Nanishi, & Jimba,

Despite the known benefits of breastfeeding, less than 50%
of infants are breastfed at 6 months old in high-income coun-
tries (Victora et al., 2016), and many mothers are dissatisfied
with their breastfeeding duration (Gregory, Buts, Ghazarian,
Gross, & Johnson, 2015). To provide mother-centered care,
mothers’ satisfaction should be considered when promoting
breastfeeding (Edwards, 2018). Maternal satisfaction with
breastfeeding is an important indicator of successful breast-
feeding itself (Edwards, 2018).
Mothers tend to breastfeed longer when their perceptions
of breastfeeding are positive in three domains: (a) maternal
satisfaction, (b) perceived benefit to the infant, and (c)
2017). Scores on maternal satisfaction reflect how satisfied
the mother felt with breastfeeding. Scores on perceived ben-
efit to the infant reflect the mother’s perception of the extent
1
University of Tokyo, Tokyo, Japan
Date submitted: November 6, 2018; Date accepted: July 16, 2019.
Corresponding Author:
Hiroko Hongo, MSW, MHSc, IBCLC, Department of Community and
Global Health, Graduate School of Medicine, University of Tokyo, 7-3-1,
Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
Email: hirokoh-ut@umin.ac.jp
2 Journal of Human Lactation 00(0)
to which breastfeeding benefited her infant. Scores on life-
style compatibility reflect the extent to which the mother
found breastfeeding to be compatible with other aspects of
her life. Some question items in the Lifestyle Compatibility
subscale refer to potentially negative aspects of breastfeed-
ing. When mothers perceive breastfeeding as beneficial to
their infants, they are more likely to be breastfeeding at 3 and
5 months postpartum (Hongo et al., 2017). Lifestyle compat-
ibility is also crucial. Despite breastfeeding’s potentially
negative aspects, for example, physical and mental fatigue,
mothers need to combine breastfeeding with other daily
activities (Hongo et al., 2017). Researchers have found that
all domains were positively associated with breastfeeding
without formula at 5 months (Hongo et al., 2017).
Although peer support increases breastfeeding duration
and exclusivity, the influence of peer support on breastfeed-
ing satisfaction remains unclear (McFadden et al., 2017).
Researchers who conducted a systematic review showed that
community-based peer support increased exclusive breast-
feeding duration (Shakya et al., 2017). In a randomized con-
trolled trial (RCT) done in Australia, first-time mothers were
more likely to be breastfeeding at 6 months postpartum when
they received telephone-based peer support (Forster et al.,
2019). In a Canadian RCT, the influence of telephone-based
peer support on breastfeeding satisfaction was mixed
(Dennis, Hodnett, Gallop, & Chalmers, 2002). Dennis et al.
(2002) summed the scores of 12 items from different satis-
faction domains and found no statistically significant differ-
ence between peer-support and control groups. However,
responses to an extra question showed that mothers without
peer support were more likely to be dissatisfied with overall
infant feeding than were those who had peer support (Dennis
et al., 2002).
In Japan, the importance of maternal emotional well-
being among postpartum mothers is recognized (Ministry of
Health, Labor, and Welfare, 2019). The government’s guide-
lines favor the establishment of conditions in which mothers
can easily achieve their breastfeeding goals. The guidelines
also favor the provision of emotional support to mothers
even when they cannot breastfeed exclusively (Ministry of
Health, Labor, and Welfare, 2019). Mothers may be more
satisfied with breastfeeding when they receive adequate sup-
port to continue. Satisfaction among Japanese mothers is low
when support at maternity hospitals is insufficient (Hongo,
Nanishi, Shibanuma, & Jimba, 2015). The influence of peer
support on maternal satisfaction has not been studied in
Japan.
Researchers have not examined the influence of peer sup-
port on the three breastfeeding-satisfaction domains. An
RCT used total scores from mixed domains (Dennis et al.,
2002); therefore, it is possible that the benefits of peer sup-
port occur in only one or two of the three domains. To
improve peer-support interventions, it is important to iden-
tify which domain should be emphasized. Therefore, we
aimed to examine the influence of telephone-based
Key Messages
•• No study has examined the influence of peer support
on the three domains of breastfeeding satisfaction:
maternal satisfaction, perceived benefit to the infant,
and lifestyle compatibility with breastfeeding.
•• In this randomized controlled trial, at follow-up,
the scores on the scale measuring lifestyle compat-
ibility were generally higher among the mothers
who had received peer support.
•• Peer support improved lifestyle compatibility
(e.g., ability to balance breastfeeding and other
activities) despite breastfeeding’s potentially nega-
tive aspects (e.g., physical and mental fatigue).
peer support on the following three domains of breastfeeding
satisfaction among Japanese mothers: maternal satisfaction,
perceived benefit to the infant, and lifestyle compatibility
with breastfeeding.
Methods
Design
In this two-group randomized, longitudinal trial, we aimed to
examine the influence of telephone-based peer support on
mothers’ satisfaction with breastfeeding, through self-report
surveys. We used this study design to evaluate the influence
of the intervention while minimizing any biases caused by
differences in background characteristics among partici-
pants. Support was provided from hospital discharge until 4
months postpartum. All procedures were approved by the
four hospitals involved and by the Research Ethics Committee
of the Graduate School of Medicine at the University of
Tokyo.
Setting
This study was conducted among mothers who were dis-
charged from four maternity hospitals in Tokyo and
Kanagawa prefectures in Japan. All four hospitals are located
in metropolitan areas. Regardless of sociocultural and eco-
nomic status, women can give birth at local maternity hospi-
tals because the public health care insurance system provides
a lump-sum allowance to cover the cost of delivery (Ministry
of Health, Labor, and Welfare, 2018). In Japan, mothers usu-
ally stay in the hospital for 4 to 7 days postpartum. In a
nationwide survey, most Japanese mothers continued breast-
feeding after hospital discharge: 85.9% at 4 months and
81.2% at 6 months postpartum (Ministry of Health, Labor,
and Welfare, 2016). Those high percentages may be partly
due to specific policies. For example, the Japanese Labor
Standards Act guarantees an 8-week maternity leave after
delivery, and working mothers with infants under 1 year old
Hongo et al. 3
can request 30 min of childcare time twice each day (Roudo-
kijun-hou, 1947). In accord with the Maternal and Child
Health Act and the Child Welfare Act (Ministry of Health,
Labor, and Welfare, n.d.), after a new mother is discharged
from the hospital, she is entitled to a free home visit by a
health worker (e.g., midwife, public health nurse) once
within 4 months after delivery. The purpose of the visit is to
listen to the new mother’s concerns, give necessary informa-
tion regarding caring for her infant, and assess the child-rear-
ing environment.
Sample
The target population included both primiparas and multipa-
ras who were willing to breastfeed their infants. Eligible par-
ticipants were mothers who met these criteria: (a) were older
than 16 years, (b) achieved singleton live birth at a maternity
hospital, (c) were fluent in Japanese, and (d) expressed (in
hospital, after delivery) willingness to breastfeed exclusively
or partially after discharge from hospital. Exclusion criteria
were (a) serious illness or disability that could significantly
interfere with breastfeeding or study participation, (b) infant
in the neonatal intensive-care unit after mother’s hospital
discharge, or (c) prepartum enrollment with La Leche League
(LLL) Japan, a branch of La Leche League International, the
international mother-to-mother breastfeeding support orga-
nization; these mothers were excluded as they might have
already received peer support and had a stronger motivation
to breastfeed.
Four hospitals were selected because they had similar
breastfeeding-support practices. In Japan, breastfeeding sup-
port and exclusive breastfeeding statistics vary by hospital
(Ministry of Health, Labor, and Welfare, 2015). Although
none of the four hospitals was designated as baby-friendly,
all provided partial baby-friendly support, that is, full-time
rooming-in and employment of at least one International
Board Certified Lactation Consultant (IBCLC).
Among 1,340 mothers who delivered infants at four
maternity hospitals, 878 met the inclusion criteria and
received study packs. Among them, 753 did not submit the
consent form. On the basis of previous results (Hongo,
Green, Otsuka, & Jimba, 2013), the mean scores on the
breastfeeding-satisfaction subscales were expected to be 23
(SD = 5) for the control group and 26 (SD = 5) for the peer-
support intervention group. The sample size required to
detect that difference with a power of 80% and an alpha of
.05 was estimated to be 45 per group (Power and Precision
software Version 4, Biostat, Englewood, NJ, USA).
To obtain the estimated required sample size, the recruit-
ment period was extended from 2 months to 6 months, by
which time 125 mothers had submitted both the consent form
and the baseline questionnaire. Of the 125 participants, three
rescinded their consent, three were lost to follow-up, and five
were excluded from the analysis because of missing informa-
tion or because they met at least one exclusion criterion. Data
from 60 participants in the peer-support group and 54 partici-
pants in the control group were analyzed (Figure 1, flow
diagram).
Intervention
Each peer supporter assisted one to three participants. The
protocol for the contact schedule was adapted from an
Australian RCT protocol (Forster et al., 2014) and modified
for Japanese participants. The contact intervals were chosen
to coincide with “frequent days,” when infants undergo
growth spurts and want to nurse more frequently (Wiessinger,
West, & Pitman, 2010). Peer supporters helped participants
to continue breastfeeding while adjusting to life with a new
infant (Forster et al., 2014). Peer supporters listened to par-
ticipants’ concerns, acknowledged them, and provided infor-
mation or referrals to LLL Leaders or health care professionals
if needed. Participants were also encouraged to call peer sup-
porters any time they wished to talk or when they had breast-
feeding concerns.
Participants in the control group received conventional
care, which included breastfeeding support at hospitals and a
home visit by a health worker after hospital discharge.
Peer supporters.  Before the intervention, 48 peer supporters
were recruited through LLL Japan or other channels (e.g.,
distribution of flyers and by word of mouth). Of 21 peer sup-
porters recruited through LLL Japan, 10 were active LLL
Leaders, one was a retired LLL Leader, and 10 were mothers
who had used LLL for support. Eligible volunteer peer sup-
porters were mothers who had breastfed for more than 6
months and were interested in supporting new mothers. Peer-
supporter candidates were excluded if they were midwives
who provided professional breastfeeding-related services or
if they were associated with companies producing or distrib-
uting infant-feeding products.
Candidates who were eligible to become peer supporters
were invited to participate in a 2-day training course. The
curriculum was based on the LLL International Peer
Counselor Program, covering basic breastfeeding manage-
ment (3 hr), communication skills (6 hr), and confidentiality
(1 hr). Whereas the LLL International Peer Counselor
Program was originally 20 to 25 hr to cover topics from preg-
nancy to toddlerhood, including complementary feeding and
weaning, this short, 10-hr training covered the period from
hospital discharge to 4 months postpartum. Written breast-
feeding information was provided (information sheets and an
18-page manual), which included three points: (a) how to
determine whether breastfed infants are getting enough milk,
(b) how to increase milk supply, and (c) how to incorporate
breastfeeding into other aspects of life. Communication-
skills training comprised a role-playing workshop adapted
from LLL’s Communication Skills Training 1 (nonverbal
communication, and reading and identifying feeling and
meaning) and Training 2 (summarizing, asking clarifying
4 Journal of Human Lactation 00(0)
Figure 1.  Flow of Participants Through the Study.
questions, and imparting information). The training focused
only on one-to-one telephone counseling.
Measurement
All assessments were conducted using self-administered
questionnaires before hospital discharge, 1 month postpar-
tum, and 4 months postpartum. Participants received and
returned the latter follow-up questionnaires via post.
Demographic variables. Before hospital discharge, partici-
pants were asked about their demographic characteristics
and about their experiences during their hospital stay. Ques-
tions included prepartum intention to breastfeed exclusively
and also hospital practices (e.g., starting rooming-in within
3 hr).
Participants’ confidence was measured with the Japanese
version of the Breastfeeding Self-Efficacy Scale–Short Form
(BSES-SF), which was developed by the authors (Otsuka,
Dennis, Tatsuoka, & Jimba, 2008). The details of the psycho-
metric testing were published elsewhere (Otsuka et al., 2008;
Nanishi, Green, Taguri, & Jimba, 2015). The BSES-SF has
14 items with 5-point Likert-type response choices: 1 is not
at all confident and 5 is very confident. Thus, higher scores
Hongo et al. 5

Table 1.  Three Subscales of the Revised Japanese Maternal Breastfeeding Evaluation Scale, Short Version (JMBFES).

Latent Variable Measured by the

Name of the Subscale
Maternal Satisfactiona
Perceived Benefit to the
Infantb
Lifestyle Compatibilityc
Subscale
How satisfied the mother felt
with breastfeeding
How the mother perceived that
breastfeeding benefited her
infant
Lifestyle compatibility with
breastfeeding
Positive-Scored Items
7 (e.g., “With breastfeeding, I felt a
sense of inner contentment”)
6 (e.g., “Breastfeeding made my baby
feel secure”; “My baby gained weight
well with human milk”)
2 (“I could easily cope with my
baby’s breastfeeding and my
other activities”; “I could handle
other activities while enjoying
breastfeeding”)
Reverse-Scored Items
0
0
4 (e.g., “Breastfeeding
was physically draining”;
“Breastfeeding was emotionally
draining”)

Note. We used the JMBFES with permission from the developers of the original MBFES (Leff, Jefferis, & Gagne, 1994; see Hongo, Green, Otsuka, & Jimba,
2013 & Hongo, Green, Nanishi, & Jimba, 2017). See supplementary materials for full questionnaire.
a
Maternal Satisfaction subscale scores could range from 7 to 35, with higher scores indicating more maternal satisfaction with breastfeeding (internal-
consistency reliability [coefficient alpha] in this study, 1 month postpartum = .91). bPerceived Benefit to the Infant subscale scores could range from 6
to 30, with higher scores indicating more perceived breastfeeding benefit to the infant (internal-consistency reliability [coefficient alpha] in this study, 1
month postpartum = .86). cLifestyle Compatibility subscale scores could range from 6 to 30, with higher scores indicating more lifestyle compatibility
with breastfeeding (internal-consistency reliability [coefficient alpha] in this study, 1 month postpartum = .85).

indicate higher breastfeeding self-efficacy. The total possible defined as no liquid or solid food other than human milk
score ranges from 14 to 70 (internal-consistency reliability given to the infant in the last 24 hr (World Health Organization,
[coefficient alpha] was .95 in this study). 2010).

Outcome measures. The revised Japanese Maternal Breast-

feeding Evaluation Scale, short version (JMBFES; Hongo
et al., 2013, 2017; Leff, Jefferis, & Gagne, 1994), was used
to measure the three domains of maternal breastfeeding sat-
isfaction. We used the JMBFES with permission from the
creators of the original English version (Leff et al., 1994; see
Hongo et al., 2013, 2017). Validation testing and reliability
testing were done before this study among Japanese mothers
in Tokyo. The revised JMBFES has three subscales with 19
items, with possible total scores ranging from 19 to 95: The
Maternal Satisfaction subscale has seven positively worded
items (e.g., “With breastfeeding, I felt a sense of inner con-
tentment”), the Perceived Benefit to the Infant subscale has
six positively worded items (e.g., “Breastfeeding made my
baby feel secure”), and the Lifestyle Compatibility subscale
has two positively worded items (e.g., “I could easily cope
with my baby’s breastfeeding and my other activities”) and
four negatively worded items (e.g., “Breastfeeding was
physically draining”) (Hongo et al., 2017; see Table 1). Coef-
ficients of internal-consistency reliability (coefficient alpha)
for this study are given in Table 1. (A copy of the scale is in
the online supplementary material.) The JMBFES was not
administered while the participants were in the hospital
because at that time, they had had only limited experience
with breastfeeding, and therefore they could not yet accu-
rately respond to the JMBFES questions, particularly those
relating to lifestyle compatibility.
Breastfeeding status was measured at the first survey and
at 1 and 4 months postpartum. Exclusive breastfeeding was
Data Collection
Hospital staff first assessed mothers’ eligibility based on
medical records. Each mother was then given a study pack,
which included a trial information sheet, consent form,
self-administered baseline questionnaire, and stamped self-
addressed envelopes. All participants were informed about
the study aim and submitted an informed-consent form
before hospital discharge. Participants were assured of con-
fidentiality, participated voluntarily, and could withdraw
from the study at any time. Identification (ID) numbers
were used during data entry to ensure participants’ confi-
dentiality. Informed-consent forms with personal informa-
tion and a linkable table with ID numbers were kept in a
locked cabinet.
Mothers were considered participants once they provided
consent and sent relevant information (name, address, date of
infant’s birth, telephone number, and e-mail address) via
postal mail to the study team. Those who agreed to participate
submitted consent forms in envelopes with research ID num-
bers. As the research ID numbers identified the study hospi-
tals, the randomization list of peer-support participants was
dynamically allocated for each hospital (randomization ratio
of 1:1, peer support to conventional care), with a block size of
four distributed randomly (Forster et al., 2014). The block
randomization pattern was created by a biostatistician who
was not involved in recruiting participants. Randomized allo-
cation was conducted by research assistants who were not
involved in the study design or data analysis. Staff at each
6 Journal of Human Lactation 00(0)
hospital were blinded to the randomization of participants.
The researcher remained blinded to the allocation until after
the completion of data cleaning and initial analysis.
Research assistants informed peer supporters of their
assigned participant’s name, ID number, phone number, and
date of delivery. As the intervention, randomly selected par-
ticipants received peer support from 48 peer supporters in
addition to conventional hospital care. After collecting fol-
low-up data, the researcher reassessed the participants’ eligi-
bility using baseline questionnaires.
Data were collected according to the Consolidated
Standards of Reporting Trials (Schulz, Altman, & Moher,
2010) from October 2016 to September 2017.
Data Analysis
Demographic differences between the groups were examined
with Pearson’s chi-square test (or Fisher’s exact test, if neces-
sary) and t tests for independent samples. Sociodemographic
data (except age) and participants’ experiences as inpatients
are presented as proportions. The ages of participants and
their scores on the BSES-SF are presented as means and stan-
dard deviations.
To examine breastfeeding satisfaction, generalized esti-
mating equations were used. Intervention status and each
JMBFES subscale score measured 1 month postpartum were
included in the model. The influence of the intervention was
estimated as the coefficient of “time” (4 months postpartum,
as compared with 1 month postpartum) multiplied by “peer
support” (participants in the intervention group). The coeffi-
cient captured a net increase in the outcome score between 1
month and 4 months postpartum and between the interven-
tion and control groups. The main hypothesis was that par-
ticipants in the intervention group would have higher mean
JMBFES subscale scores than those in the control group.
Changes in scores from 1 month to 4 months postpartum
were computed for both groups, and between-group differ-
ences in those changes were computed. Standardized effect
sizes were obtained by dividing the differences in change
scores by their standard deviations (Copay, Subach,
Glassman, Polly, & Schuler, 2007).
It is possible that some of the intervention’s actual benefit
might not be reflected in the change in scores for the group as
a whole. Specifically, we consider the following situations:
(a) The intervention might have benefited those who had high
scores at baseline. A benefit to those who had high scores at
baseline would not have been clearly measurable because
their scores could not increase beyond the upper limit of the
measurement scale. (b) The intervention might have benefited
those who had lower scores at baseline. If only (a) occurred,
then the true benefit would be unmeasurable. If only (b)
occurred, or if both (a) and (b) occurred, then looking sepa-
rately at those with lower baseline scores might allow better
estimation, within the measurement range of the instrument
used, of the benefits to those participants who had low levels
of lifestyle compatibility. Therefore, effect sizes were com-
puted in three subgroups defined by their scores on lifestyle
compatibility at baseline, and for one analysis, the lower two
groups (i.e., the lower two thirds) were combined.
Additionally, changes in scores at the individual level
were computed, and then two cumulative distribution func-
tions were drawn, one for the intervention group and one for
the control group (Wyrwich, Norquist, Lenderking, Acaster,
& Industry Advisory Committee of International Society for
Quality of Life Research, 2013).
To facilitate the interpretation of results for each partici-
pant, minimal important differences (MID) in subscale
scores were computed for differences between 1-month and
4-month postpartum scores and were used at the individual
level. Because there is more than one definition of MID, two
of the most common definitions were used to allow for com-
parisons. Under the first definition of MID, if a participant’s
score increased by more than one standard error of the mea-
surement of the baseline score (using coefficient alpha at
baseline: .85), that change was regarded as a meaningful
improvement (Rejas, Pardo, & Ruiz, 2008; Wyrwich et al.,
2013). Under the second definition of MID, if a participant’s
score increased by more than half of the standard deviation
of the baseline score, that change was regarded as a meaning-
ful improvement (Norman, Sloan, & Wyrwich, 2003, 2004).
The data were analyzed with Stata Statistical Software:
Release 14 (StataCorp., 2015).
Results
Characteristics of the Sample
Participants’ characteristics did not differ significantly
between the two groups. The mean age of the participants
was 34.5 years (SD = 4.5) in the intervention group and 33.9
years (SD = 4.2) in the control group (p = .52). The mean
baseline BSES-SF scores in the intervention and control
groups were 40.1 (SD = 11.7) and 39.4 (SD = 12.1), respec-
tively (p = .77). Other characteristics are shown in Table 2.
Outcome Measures
The score of the subscale measuring lifestyle compatibility
increased significantly in the intervention group compared
with the control group (regression coefficient = 1.54; 95%
confidence interval [0.03, 3.04]). However, the intervention
had no statistically significant influence on the total JMBFES
score or on scores for the other two subscales (Table 3).
With data from all participants included in the analysis (N
= 114), on the Lifestyle Compatibility subscale, the between-
group standardized effect size was 0.37 standard deviations,
which is generally evaluated as small to medium. When data
from only those participants who had low and mid-level
scores at baseline (n = 94) were analyzed, the standardized
effect size was 0.40 standard deviations (Table 4).
Hongo et al. 7

Table 2.  Characteristics of the Participants by Group (N = 114).

Peer Support Group Control Group

(n = 60) (n = 54)
Characteristic n (%) n (%) χ2 p
Education (beyond high school) 50 (83.3) 49 (90.7) 1.36 .24
Worried about money 31 (50.7) 26 (48.2) 0.14 .71
Have never smoked 46 (76.7) 44 (81.5) 0.40 .53
Planned to work within 6 months after delivery 10 (16.7) 12 (22.2) 0.56 .45
More than one child 28 (46.7) 27 (50.0) 0.13 .72
Antenatal intention to breastfeed exclusively 31 (51.7) 30 (55.6) 0.17 .68
Cesarean section 19 (31.7) 12 (22.2) 1.28 .26
Started rooming-in within 3 hr 25 (41.7) 18 (33.3) 0.84 .36
Had a husband or partner 60 (100) 54 (100) N/A N/A
Living with extended familya 4 (6.7) 2 (3.7) — .68
Exclusive breastfeeding while in hospital 19 (31.7) 13 (24.1) 0.81 .37

Note. To examine differences between the two groups, Pearson’s chi-square test or Fisher’s exact test was used. There were no missing values for any
variable. N/A = not applicable.
a
Fisher’s exact test used.

Table 3.  Results of GEE Modeling of the Differences Between the 1-Month JMBFES Scores and the 4-Month JMBFES Scores.

Scale/Subscale Score b (SE) 95% CI z statistic p

a
Breastfeeding Satisfaction (total score)  
 Intercept 74.69 (1.44) [71.87, 77.50] 52.04 <.001
  Time (4 months postpartum) 5.13 (1.12) [2.94, 7.32] 4.58 <.001
  Peer support −1.72 (1.98) [–5.60, 2.16] −0.87 .385
 Time × Peer Supportb 1.54 (1.54) [–1.49, 4.56] 1.00 .319
Maternal Satisfaction (subscale score)  
 Intercept 29.98 (0.57) [28.87, 31.09] 52.78 <.001
  Time (4 months postpartum) 1.43 (0.47) [0.50, 2.36] 3.01 .003
  Peer support −0.13 (0.78) [–1.67, 1.40] −0.17 .87
 Time × Peer Supportb 0.07 (0.65) [–1.20, 1.35] 0.11 .91
Perceived Benefit to Baby (subscale score)  
 Intercept 25.57 (0.55) [24.50, 26.64] 46.83 <.001
  Time (4 months postpartum) 1.57 (0.46) [0.67, 2.48] 3.42 .001
  Peer support −0.72 (0.75) [–2.20, 0.75] −0.96 .34
 Time × Peer Supportb −0.07 (0.63) [–1.32, 1.17] −0.12 .91
Lifestyle Compatibility (subscale score)  
 Intercept 19.13 (0.68) [17.79, 20.47] 27.97 <.001
  Time (4 months postpartum) 2.13 (0.56) [1.04, 3.22] 3.83 <.001
  Peer support −0.86 (0.94) [–2.71, 0.98] −0.92 .36
 Time × Peer Supportb 1.54 (0.77) [0.03, 3.04] 2.01 .045

Note. Number of observations = 114, both 1 month and 4 months postpartum. GEE = generalized estimating equation; JMBFES = revised Japanese
Maternal Breastfeeding Evaluation Scale, short version; CI = confidence interval.
a
Breastfeeding Satisfaction scale score (total score of three subscales) could range from 19 to 95, with higher scores indicating more overall breastfeeding
satisfaction. bThis estimate was obtained as the interaction term between the intervention and time (4 months postpartum). No missing values.

Similar to the effect size results, the results of analyses
using MIDs also showed a lifestyle compatibility benefit.
Under the first definition, the MID was 1.85. Scores
increased by more than 1.85 among half of the participants
in the control group but among three quarters of those in
the intervention group (27/54, 50.0%, vs. 46/60, 76.7%).
Under the second definition, the MID was 2.39. Scores
increased by more than 2.39 among fewer than half of the
participants in the control group but among three fifths of
those in the intervention group (25/54, 46.3%, vs. 36/60,
60.0%). Thus, regardless of the definition of MID, more
participants who received peer support had meaningful
improvements in their Lifestyle Compatibility scores
(Figure 2).
8 Journal of Human Lactation 00(0)

Table 4.  Group Changes in Lifestyle Compatibility Subscale Scores (N = 114).

Change in Scores From 1 to 4 Months

Postpartum  

Intervention Group Control Group Difference in Changes

(n = 60) (n = 54) Between Groups
Subgroup M (SD) M (SD) M (SD) Effect Sizea
Lowest third (n = 54) 4.23 (4.55) 2.71 (4.32) 1.53 (4.43) 0.34
Middle third (n = 40) 4.00 (3.59) 2.16 (3.99) 1.84 (3.80) 0.49
Lowest two thirds (n = 94)b 4.14 (4.14) 2.47 (4.14) 1.67 (4.13) 0.40
Highest third (n = 20) 1.00 (3.39) 0.82 (3.68) 0.18 (3.54) 0.05
Total (N = 114) 3.67 (4.17) 2.13 (4.07) 1.54 (4.12) 0.37

Note. Subgroups are defined by scores 1 month postpartum. The Lifestyle Compatibility subscale score could range from 6 to 30, with higher scores
indicating more lifestyle compatibility with breastfeeding.
a
This effect size is a standardized measure of the difference between the control group and the intervention group, in standard deviation units. To
obtain it, the between-group difference was divided by its standard deviation. For example, for the lowest two thirds (n = 94), the between-group
mean difference was 1.67 and its standard deviation was 4.13. Thus, the standardized effect size was computed as follows: 1.67/4.13 = 0.40. bThis is the
combination of the lowest and middle subgroups.

Figure 2.  Cumulative Distribution Functions for Change in Scores on the Lifestyle Compatibility Subscale.
Note. This figure shows two cumulative distribution functions, one for the intervention group and the other for the control group. These functions show
distributions of changes in scores on the Lifestyle Compatibility subscale. Each of the two vertical lines near the middle shows the location of a minimum
important difference (MID) from zero change as computed by one of two methods. SEM = standard error of measurement (not standard error of the
mean). Whether the MID was defined as +1 SEM or as +0.5 standard deviations, more mothers in the intervention group than in the control group
improved by an amount greater than the MID.

Breastfeeding Status the intervention group, 63.3% of the participants (n = 38)

At 4 months postpartum, almost all of the participants in both were breastfeeding exclusively at 4 months postpartum,
groups continued any breastfeeding (96.7% in the interven- whereas in the control group the percentage was lower:
tion group [n = 58], 96.7% in the control group [n = 52]). In 53.7% (n = 29). There were no statistically significant
Hongo et al. 9
differences in exclusivity between the two groups, as the
baseline breastfeeding percentage was lower in the control
group (see Table 2).
Discussion
This is the first study to examine the influence of breastfeed-
ing peer support on three domains of breastfeeding satisfac-
tion separately. To improve peer-support interventions, more
focus may be needed on the compatibility of breastfeeding
with other aspects of new mothers’ lives in Japan. New moth-
ers may feel overwhelmed with the new responsibilities of
motherhood. Peer support can empower mothers by positive
feedback and nondirective information in the face of chal-
lenges during this life transition (McLeish & Redshaw, 2017).
The size of the effect was small among participants who
had higher baseline Lifestyle Compatibility scores. Peer sup-
port may ease mothers’ life adjustment among those who
find breastfeeding challenging. Japanese mothers who were
breastfeeding and using infant formula in combination felt
that infant feeding was more burdensome than did those who
were either exclusively breastfeeding or formula feeding
(Ministry of Health, Labor, and Welfare, 2016). Researchers
have found that Japanese mothers were more likely to use
infant formula at 1 month postpartum, even if mothers had
intended to breastfeed exclusively, when they lived with
members of their extended family (Hongo et al., 2015).
Previous research suggested that Japanese grandmothers
tend to consider supplementing infant formula when they
perceive that their grandchildren do not stop crying (Soyama,
Yoshida, & Yoneda, 2015). Peer support may be particularly
helpful to mothers who do not receive enough breastfeeding
support from family members.
A few participants in both groups discontinued breast-
feeding by 4 months postpartum: two in the peer support
group and three in the control group. The rate of any breast-
feeding is approximately 10% higher among the participants
in this study than is reported nationally: 85.9% at 4 months
postpartum (Ministry of Health, Labor, and Welfare, 2016).
By participating in the study, both those in the control group
and those in the intervention group may have become more
motivated to continue breastfeeding. That 10% difference
could also have been caused by the support available at the
study hospitals. Only 27.9% of participants in the national
nutrition survey reported rooming-in immediately after the
delivery of their infant (Ministry of Health, Labor, and
Welfare, 2016). Moreover, most of Japan’s 2,473 maternity
hospitals cannot hire IBCLCs, as there were only 947
IBCLCs in Japan in the year 2018 (International Board of
Lactation Consultant Examiners, 2019; Ministry of Health,
Labor, and Welfare, 2017).
In this study, we found no strong evidence that peer sup-
port improves overall breastfeeding satisfaction. This is in
line with the finding from a Canadian RCT, in which the sum
of 12 items from the Maternal Breastfeeding Evaluation
Scale was used and no significant difference was found
between mothers with and without peer support (Dennis
et al., 2002; Leff et al., 1994). Summing scores from differ-
ent domains might obscure the intervention’s influence in the
lifestyle compatibility domain. As each JMBFES subscale
measures a different latent variable, future studies should
also analyze data from each subscale separately.
Our intervention had no statistically significant influence
on total score of maternal satisfaction. Measuring overall
maternal satisfaction may not be sufficient to examine the
influence of a breastfeeding-support intervention. Previous
researchers who conducted a systematic review found that
breastfeeding support had no clear influence on maternal sat-
isfaction in controlled trials (Renfrew, McCormick, Wade,
Quinn, & Dowswell, 2012). Baby-friendly community health
services in Norway had no influence on maternal satisfaction
(Bærug et al., 2016). On the basis of the present results, we
recommend that future research on satisfaction with breast-
feeding should include measurement of all three of the com-
monly identified domains: maternal satisfaction, perceived
benefit to the infant, and lifestyle compatibility.
Among half of the participants in the control group,
Lifestyle Compatibility scores increased by more than the
MID. That increase may reflect a general adjustment to
breastfeeding and to living with an infant. Further, the con-
ventional breastfeeding support these participants received
in hospital and during the home visit by a health care pro-
vider might have increased their scores. Nevertheless, the
peer-support intervention improved the compatibility of
breastfeeding with other aspects of these participants’ lives.
Although the MID results indicate that peer support
increases lifestyle compatibility, interindividual variation in
changes in scores was wide in both groups. This may be
explained partly by the participants’ parity, prepartum inten-
tion to breastfeed exclusively, and hospital support (Hongo
et al., 2015). Given individual differences among breastfeed-
ing mothers, further research may be needed to explore
which mothers can benefit from peer support most and when
and how to reach them.
Limitations
This study has several limitations. Participants knew their
allocation group, and those in the intervention group may
have been more willing to continue breastfeeding. As the
first measurement of breastfeeding satisfaction was made at
1 month postpartum, breastfeeding satisfaction may have
increased between breastfeeding initiation and the first mea-
surement. Because we did not measure breastfeeding self-
efficacy at 4 months postpartum, we were not sure if peer
support helped to increase participants’ self-efficacy.
Many eligible mothers did not participate in the study.
Most participants were married, had schooling beyond
high school, and did not intend to return to work within 6
10 Journal of Human Lactation 00(0)
months. Those who did not participate may have had lower
JMBFES scores and a higher risk of discontinuing breast-
feeding, which could have decreased the apparent influ-
ence of the intervention. The loss of eligible participants at
recruitment needs to be reduced if the influence of the
intervention is to be assessed with greater external validity.
With the scales we used, some important between-group
differences might not have been measured. Three partici-
pants in the control group were lost to follow-up, and it is
not clear whether that loss was informative, which could
have caused the difference between the groups to be incor-
rectly estimated.
We also did not assess the knowledge and counseling
skills among the peer supporters before the intervention.
There could certainly have been some differences among
them, and the differences might have affected the overall
influence of peer support on participants’ satisfaction.
Participants’ feedback on their peer supporters would be
helpful to improve the program in the future.
Conclusion
Although this breastfeeding peer-support intervention did
not change maternal satisfaction or perceived benefit to the
infant, it improved lifestyle compatibility with breastfeeding
among mothers who were willing to breastfeed immediately
after delivery. This is evidence in favor of increasing the use
of peer support to benefit more mothers. When assessing
breastfeeding satisfaction in future studies, the three domains
need to be assessed separately.
Authors’ Note
A Japanese abstract is available in the online version of this
manuscript. The translated abstract was back-translated by Dr.
Katsumi Mizuno and compared with the English version for
accuracy. This RCT was registered (UMIN000019626) with the
University Hospital Medical Information Network (UMIN)
Clinical Trials Registry (Japan) on November 4, 2015. Hiroko
Hongo conducted the research when she was a PhD student at
the Department of Community and Global Health, Graduate
School of Medicine, University of Tokyo. Currently she is a vis-
iting researcher and a PhD candidate at the Department of
Community and Global Health, Graduate School of Medicine,
University of Tokyo.
Acknowledgments
The authors appreciate the cooperation of the four research hospi-
tals involved: Tokyo Kita Medical Center, Hamada Hospital,
Fuchu-no-mori Tsuchiya Obstetrics and Gynecology, and St. Maria
Clinic. The authors also thank the mothers who participated, the
volunteer peer supporters, and the hospital staff who helped recruit
the participants.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: The first
author used UT Grants for PhD Researcher Program at the University
of Tokyo and research funds from the Department of Community and
Global Health, Graduate School of Medicine, University of Tokyo.
ORCID iD
Hiroko Hongo https://orcid.org/0000-0002-4574-6928
Supplemental Material
Supplementary material may be found in the “Supplemental
Material” tab in the online version of this article.
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