Systematic Review: Barriers and Facilitators to Breastfeeding Among Low-Income Mothers - Leading Advance Research Assistance (LARA)

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Chapter 1 – Introduction

This chapter introduces the central theme of the dissertation: understanding the barriers and facilitators to breastfeeding among low-income mothers. It begins by outlining the global and national significance of breastfeeding, followed by a detailed examination of disparities in breastfeeding practices across socioeconomic and racial groups in the United States. The chapter then explores the multifactorial challenges faced by low-income mothers, including systemic, cultural, and healthcare-related barriers. It concludes by presenting the aim and objectives of the systematic review, which guide the subsequent chapters. This foundational chapter sets the stage for a critical, equity-focused analysis of breastfeeding practices and interventions.

Breastfeeding is a foundational practice for maternal and infant health, offering critical physical, emotional, and economic benefits (World Health Organization, 2025). The World Health Organization and the American Academy of Pediatrics recommend exclusive breastfeeding for the first six months of life, followed by continued breastfeeding alongside complementary foods for up to two years or beyond (American Academy of Pediatrics, 2021; World Health Organization, 2025). These recommendations are based on evidence showing that breastfeeding reduces infant mortality, improves immune function, and lowers maternal risks of breast and ovarian cancers, type 2 diabetes, and cardiovascular disease (Victora et al., 2016; McFadden et al., 2017). Globally, fewer than half (48%) of infants under six months are exclusively breastfed, despite a sustained increase of over 10 percentage points in the past decade (UNICEF & WHO, 2025). Only 46% of newborns are breastfed within the first hour of birth, a critical window for maternal-infant bonding and immune protection (UNICEF, 2025). Europe continues to report the lowest breastfeeding rates globally, while countries like Uganda and Timor-Leste have achieved gains of more than 10 percentage points in exclusive breastfeeding rates (UNICEF & WHO, 2025).

In the United States, 85.7% of infants born in 2022 were breastfed at birth, but only 27.9% were exclusively breastfed through six months, falling short of the Healthy People 2030 target of 42.4% (CDC, 2025). At 12 months, only 40.8% of infants continue to receive any breast milk, indicating a steep decline in breastfeeding duration (CDC, 2025).

Among infants receiving WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) benefits, only 79.2% were breastfed, compared to 92.2% among those ineligible for WIC, highlighting socioeconomic disparities (CDC, 2025). Disparities are even more pronounced among racially marginalized groups (Childstats.gov, 2024).

For children born in 2020, exclusive breastfeeding through six months was lowest among Black, non-Hispanic infants (20.4%), compared to Asian, non-Hispanic infants (29.1%) and White, non-Hispanic infants (27.6%) (Childstats.gov, 2024). Rates of any breastfeeding at 12 months were also lowest among Black, non-Hispanic children (26.8%) and highest among Asian, non-Hispanic children (48.5%) (Childstats.gov, 2024).

Income-based disparities are similarly stark (Childstats.gov, 2024). For 2020 births, exclusive breastfeeding through six months was lowest among households earning less than 100% of the federal poverty level (19.7%) and highest among those earning 400–599% FPL (30.3%) (Childstats.gov, 2024). These disparities reflect not only behavioral differences but also systemic inequities such as economic marginalization, lack of paid maternity leave, and inadequate policy support (CDC, 2025).

Low-income mothers—defined in this review as those living at or below 200% of the federal poverty level (U.S. Census Bureau, 2025)—face a constellation of barriers that hinder both the initiation and continuation of breastfeeding (Moret-Tatay et al., 2025). These include limited access to prenatal and postnatal care, lack of workplace accommodations, cultural stigmas, and insufficient social support (Moret-Tatay et al., 2025). The intersection of race, class, and gender further compounds these challenges, particularly for Black and Hispanic women who are overrepresented in low-wage jobs and under-resourced communities (Asare, 2024). Historical and cultural factors also play a role in shaping breastfeeding behaviors (Asare, 2024). Aggressive marketing of formula to Black communities and the legacy of enforced wet-nursing during slavery have contributed to mistrust and stigma around breastfeeding (Asare, 2024).

Black mothers are more likely to return to work sooner and less likely to receive postpartum support, further reducing breastfeeding duration (Asare, 2024). Systematic reviews have identified multifactorial barriers to breastfeeding among low-income mothers, including personal (e.g., latching difficulties), sociocultural (e.g., stigma around public breastfeeding), economic (e.g., lack of paid maternity leave), and healthcare-related factors (Moret-Tatay et al., 2025). Cultural beliefs also influence feeding choices; in some communities, formula feeding is perceived as a symbol of modernity or affluence, undermining breastfeeding efforts despite awareness of its benefits (Moret-Tatay et al., 2025).

Addressing these barriers requires a comprehensive, equity-focused approach that includes policy reform, community-based support systems, and culturally sensitive healthcare interventions (Moret-Tatay et al., 2025). Understanding the barriers and facilitators specific to low-income mothers is essential for improving breastfeeding outcomes and reducing health disparities (Moret-Tatay et al., 2025).This review seeks to unpack following aims and objectives through a structured examination of existing evidence.

Aim

“This systematic review aims to critically examine the multifaceted barriers and facilitators influencing breastfeeding among low-income mothers.”

Objectives

To explore the primary barriers low-income mothers face in initiating and continuing breastfeeding.
To identify key facilitators that support breastfeeding practices among low-income mothers.
To examine the role of socioeconomic and policy factors in shaping breastfeeding experiences.
To assess the influence of community and healthcare support systems on breastfeeding outcomes.
To provide evidence-based recommendations for targeted interventions and policy reforms.

As per the guidelines you need to have a section which provides an overview of the chapters/structure. You also need a short section on your methods.

Chapter 2 – Literature Review

Breastfeeding is widely recognized as a cornerstone of maternal and child health, yet its practice remains deeply unequal across socioeconomic and racial lines. Globally, rates of exclusive breastfeeding in the first six months have increased by ten percentage points over the past decade, reaching 48% in 2023 (UNICEF, 2023). In the United States, 83.2% of infants born in 2019 received some breast milk at birth, but only 24.9% were exclusively breastfed at six months (CDC, 2025). These figures mask stark disparities: Black infants had the lowest initiation rates, while Asian infants had the highest (CDC, 2025). Income-based disparities are equally pronounced, with exclusive breastfeeding rates significantly lower among families earning below the federal poverty level (CDC, 2025).

These trends underscore breastfeeding as a public health issue shaped by structural inequities. This literature review critically examines the barriers and facilitators to breastfeeding among low-income mothers, synthesizing evidence across individual, cultural, policy, and structural domains. It also explores the role of social determinants of health and evaluates current U.S. policies in comparison with international models.

Barriers to Breastfeeding in Low-Income Populations

Barriers to breastfeeding among low-income mothers are multifaceted, spanning personal, sociocultural, economic, and healthcare-related domains (Rollins et al., 2016; Moret-Tatay et al., 2025). These challenges often begin during pregnancy and persist through the postpartum period, affecting both initiation and duration (McFadden et al., 2017). In high-income countries like the U.S., low-income mothers frequently lack access to prenatal education and lactation support—critical components for successful breastfeeding (ACOG, 2021; CDC, 2025).

Personal barriers include latching difficulties, perceived low milk supply, and physical discomfort (Moret-Tatay et al., 2025). Sociocultural factors such as stigma around public breastfeeding and cultural beliefs favoring formula feeding further complicate breastfeeding decisions (Asare, 2024; Carter et al., 2021). Economic constraints—particularly the absence of paid maternity leave and inflexible work schedules—are among the most significant barriers for low-income mothers (CDC, 2025; U.S. Bureau of Labor Statistics, 2024). Healthcare-related challenges include inconsistent advice from providers, lack of continuity of care, and limited access to lactation consultants in under-resourced communities (ACOG, 2021; Rollins et al., 2016).

Structural and Workplace Challenges

Structural barriers in the U.S. disproportionately affect low-income women. Only a minority of U.S. workers have access to paid family leave, and this figure drops significantly among hourly and low-wage workers (CDC, 2025). Many women return to work within weeks of giving birth, often to jobs that lack time or space for milk expression (ACOG, 2021). This lack of workplace support contributes to early cessation of breastfeeding, particularly in service, retail, and manual labor sectors (Vilar-Compte et al., 2021). Workplace interventions such as designated lactation spaces and flexible scheduling have been shown to increase breastfeeding duration (Vilar-Compte et al., 2021), yet these supports are rarely available to low-income workers. The Surgeon General’s Call to Action identifies paid maternity leave as a critical lever for improving breastfeeding outcomes, especially among racially marginalized and economically disadvantaged populations (Office of the Surgeon General, 2011).

Cultural Norms and Misinformation

Cultural norms and misinformation play a significant role in shaping breastfeeding behaviors. In some communities, formula feeding is perceived as modern or more convenient, while breastfeeding is associated with poverty or lack of education (Asare, 2024). Historical exploitation, such as enforced wet-nursing during slavery, continues to influence Black women’s breastfeeding experiences and contributes to mistrust and stigma (Carter et al., 2021). Carter et al. (2021) analyzed 80 health science articles and found that Black women are often portrayed as less likely to breastfeed, without sufficient attention to structural barriers. This deficit-based framing perpetuates stigma and undermines the effectiveness of public health interventions. Fathers and extended family members often lack the knowledge or resources to support breastfeeding, which can undermine maternal confidence and duration (McFadden et al., 2017; Colvin et al., 2025).

Facilitators of Breastfeeding

Despite these challenges, several facilitators have been shown to improve breastfeeding outcomes among low-income mothers. Social support from partners, family, and peer groups is consistently associated with increased breastfeeding initiation and duration (Colvin et al., 2025; McFadden et al., 2017). Peer counseling programs, such as those implemented through WIC, have demonstrated effectiveness in providing culturally competent, community-based support (CDC, 2025). The Baby-Friendly Hospital Initiative (BFHI), which promotes evidence-based maternity care practices, has been linked to improved breastfeeding outcomes, especially in facilities implementing all Ten Steps to Successful Breastfeeding (Indian Health Service, 2013). Thomsen et al. (2024) found that hospitals adhering to BFHI protocols were significantly more likely to support exclusive breastfeeding. However, implementation remains inconsistent in low-income communities due to funding and staffing constraints (CDC, 2025; Bengough et al., 2022).

International Comparisons and Policy Gaps

Cross-national comparisons reveal stark contrasts in breastfeeding outcomes, largely shaped by national policy environments. Countries like Norway and Sweden, which offer universal healthcare and paid parental leave exceeding 12 months, report exclusive breastfeeding rates above 80% at six months (World Policy Analysis Center, 2023). In contrast, the United States ranks among the lowest, with only 25.8% of infants exclusively breastfed at six months, despite 83.2% initiating breastfeeding at birth (World Population Review, 2025; CDC, 2025). These disparities are especially pronounced among low-income and racially marginalized populations. For example, Black mothers had the lowest breastfeeding initiation rate at 74.5%, compared to 86.8% among Hispanic mothers and over 90% among Asian subgroups (CDC, 2025). Structural barriers such as lack of paid leave, inadequate lactation support, and workplace inflexibility disproportionately affect these groups (ACOG, 2021).

Policy interventions have shown measurable impact. The 2009 revision of the WIC food package increased breastfeeding incentives by offering enhanced food benefits to breastfeeding mothers, leading to a 22.3% increase in breastfeeding initiation among Black WIC participants and a 24.1% increase among Black WIC-eligible nonparticipants between 2009 and 2017 (USDA, 2023). However, WIC participants still lag behind nonparticipants, indicating that economic incentives alone are insufficient without broader structural reforms (USDA, 2023).

Paid maternity leave is a critical policy lever. 25 of 34 OECD countries guarantee at least six months of paid leave for mothers, aligning with WHO recommendations for exclusive breastfeeding (World Policy Analysis Center, 2023). These countries also report higher breastfeeding duration and exclusivity rates, demonstrating the effectiveness of leave policies in supporting maternal and infant health (OECD, 2023).

In contrast, the U.S. remains the only high-income OECD country without a national paid leave policy, leaving millions of mothers—especially those in low-wage jobs—without the time or resources to breastfeed (ACOG, 2021). This policy gap contributes to early weaning and reduced breastfeeding duration, particularly among low-income and minority women (CDC, 2025; ACOG, 2021).

Community and Healthcare Support Systems

Community-based interventions have shown promise in addressing breastfeeding disparities. Programs like Breastfeeding Heritage and Pride provide peer counseling and culturally tailored support to low-income minority mothers, resulting in improved outcomes (CDC, 2025). Healthcare providers play a pivotal role but often lack adequate training in lactation support (ACOG, 2021). Integrating lactation consultants into routine prenatal and postpartum care can enhance breastfeeding outcomes, especially when services are culturally sensitive (Rollins et al., 2016). Bartkowski et al. (2025) found that Black women with higher income and stronger community networks were more likely to breastfeed, suggesting that targeted interventions must address both material and social determinants. However, funding and staffing constraints limit the scalability of such models in under-resourced communities (CDC, 2025).

Social Determinants of Health and Intersectionality

Social determinants of health (SDOH)—including income, education, housing, employment, and racism—are recognized as root causes of breastfeeding disparities (Kopp et al., 2023; Savant et al., 2025). For example, mothers in unstable housing or food-insecure households are less likely to initiate or continue breastfeeding due to stress and lack of support (Savant et al., 2025). Workplace racism and biased assumptions by healthcare providers further reduce breastfeeding rates among Black and Hispanic women (Carter et al., 2021). Intersectionality provides a critical lens for understanding how race, class, and gender interact to shape breastfeeding experiences (Bartkowski et al., 2025). Carter et al. (2021) argue that dominant health narratives often stigmatize Black mothers by ignoring systemic barriers, limiting the effectiveness of public health interventions. Addressing breastfeeding disparities requires a shift from deficit-based models to equity-focused frameworks that recognize and respond to structural determinants (Rollins et al., 2016; McFadden et al., 2017).

Chapter 3 – Methodology

This chapter outlines the systematic review methodology employed to identify, appraise, and synthesize studies on breastfeeding practices among low-income mothers.

Justification for Systematic Review Approach

A systematic review was selected to synthesize evidence on breastfeeding barriers and facilitators among low-income mothers due to its methodological rigor and capacity to reduce bias (Moher et al., 2009). This approach is particularly suited to public health topics involving complex, intersecting determinants—such as income, race, and healthcare access—that influence breastfeeding outcomes (Guise et al., 2014). Unlike narrative reviews, systematic reviews follow a predefined protocol, enhancing transparency and reproducibility (Page et al., 2021).

In maternal health, systematic reviews have informed clinical guidelines and policy reforms, including those by the U.S. Preventive Services Task Force and WHO (Patnode et al., 2025).

Given the heterogeneity of breastfeeding experiences among low-income mothers, this method allows for the integration of both qualitative and quantitative data across diverse settings (Porritt et al., 2017). It is especially valuable for identifying structural barriers—such as lack of paid leave or inadequate hospital support—that are underexplored in single studies.

However, systematic reviews are limited by the quality and scope of available literature.

Publication bias, inconsistent definitions of “low-income,” and exclusion of non-English studies may restrict generalizability (Higgins et al., 2022). Despite these constraints, the systematic review remains the most appropriate method for generating evidence-based, equity-focused insights into breastfeeding disparities.

Search Strategy

A comprehensive search was conducted across six major databases: PubMed, CINAHL, Embase, Cochrane Library, Web of Science, and PsycINFO.

Search terms included combinations of keywords such as “breastfeeding,” “low-income mothers,” “barriers,” “facilitators,” “peer support,” “paid maternity leave,” “Baby-Friendly Hospital Initiative,” and “telelactation.”

Boolean operators and truncation symbols were used to refine the search.

Grey literature was also reviewed via Google Scholar and relevant health organization websites.

The search was limited to studies published between 2015 and 2025 and to English-language publications.

Screening Questions

During the initial screening phase, the following questions were used to assess relevance:
Does the study focus on breastfeeding among low-income mothers?
Does it report on barriers or facilitators to breastfeeding?
Is the study empirical (qualitative, quantitative, or mixed methods)?
Does it include breastfeeding outcomes such as initiation, duration, or exclusivity?

These questions guided the title and abstract screening process and ensured alignment with the review’s objectives.

Inclusion Criteria

The inclusion criteria for a systematic review on the barriers and facilitators to breastfeeding among low-income mothers would focus on identifying relevant studies that directly address the specific aspects of breastfeeding in this population. The criteria could be as follows:

Study Population:

Studies that focus on low-income mothers, including those living in poverty, mothers receiving government assistance (e.g., WIC), or mothers in economically disadvantaged communities. Studies that include breastfeeding data on mothers from rural or underserved areas, particularly those facing systemic barriers to healthcare or social support.

Study Design:

Randomized controlled trials (RCTs), cohort studies, case-control studies, and observational studies. Qualitative studies (e.g., interviews, focus groups) that provide insights into the lived experiences of low-income mothers with breastfeeding. Systematic reviews, meta-analyses, and reports evaluating interventions aimed at improving breastfeeding among low-income populations.

Breastfeeding Outcomes:

Studies that report on breastfeeding initiation, duration, and exclusivity.
Research exploring breastfeeding barriers, such as maternal health issues, economic strain, lack of support, and workplace challenges.
Studies examining facilitators of breastfeeding, including peer support, healthcare support, paid leave, and workplace breastfeeding accommodations.

Geographic Scope:

Studies conducted in both high-income and low-income countries, with a focus on diverse socio-economic settings.
Studies from both rural and urban low-income populations, highlighting different regional challenges.

Language:

Studies published in English or studies with English translations available.

Publication Type:

Peer-reviewed journal articles, government or health organization reports, and conference proceedings.

Time Frame:

Studies published within the last 10 years to ensure the inclusion of recent findings, trends, and interventions in the context of breastfeeding among low-income mothers.

Relevance to Research Questions:

Studies that focus specifically on the barriers and facilitators to breastfeeding for low-income mothers.
Research that examines the role of social, economic, cultural, and healthcare factors in influencing breastfeeding outcomes.

These criteria would help ensure that the review captures a comprehensive range of studies relevant to the topic and provides a clear understanding of the challenges and support systems for low-income mothers when it comes to breastfeeding.

Exclusion Criteria

The exclusion criteria for a systematic review on barriers and facilitators to breastfeeding among low-income mothers would help filter out studies that do not meet the specific focus or relevance of the review. The criteria could include:

Non-relevant Populations:

Studies focusing on mothers who are not from low-income backgrounds or those not facing socio-economic challenges (e.g., studies on middle or high-income populations). Research that does not specifically examine breastfeeding or maternal health, or those that focus on populations such as non-mothers or fathers.

Non-breastfeeding Focus:

Studies that do not focus on breastfeeding initiation, duration, exclusivity, or related behaviors. For example, studies focusing only on formula feeding without any comparison to breastfeeding or studies that do not examine maternal health and breastfeeding practices.
Non-empirical Studies:
Opinion pieces, editorials, commentaries, or theoretical papers that lack empirical data or findings.
Non-peer-reviewed studies, including unpublished reports or preprints not subject to rigorous scientific review.

Interventions or Populations Outside of Low-Income Settings:

Studies that do not focus on low-income populations or those with a broader, non-specific population that does not emphasize economic disadvantages or socio-economic barriers to breastfeeding.
Studies that only include high-income or middle-class populations, or those without clear focus on poverty, welfare assistance programs, or socioeconomically disadvantaged areas.

Irrelevant or Outdated Timeframes:

Studies published outside the past 15 years or those that use outdated data, as the review aims to capture the most current trends, interventions, and policies around breastfeeding in low-income populations.
Studies focusing on historical data or those before significant changes in health policies related to breastfeeding.

Language Barriers:

Studies not published in English or those without English translations, unless they are specifically accessible and necessary for the analysis.

Non-relevant Study Designs:

Studies that are not empirical in nature, such as reviews of non-breastfeeding related topics, studies that focus solely on formula feeding (without any consideration of breastfeeding), or any study not measuring breastfeeding outcomes (e.g., studies that discuss breastfeeding knowledge without data on practice).

Non-specific Interventions:

Studies focusing on general maternal health without a clear focus on breastfeeding support or barriers.
Research examining broader public health policies that do not specifically address breastfeeding-related support or barriers in low-income populations.

By applying these exclusion criteria, the review would ensure that only studies directly relevant to the barriers and facilitators to breastfeeding among low-income mothers are included, helping to maintain the quality and focus of the review’s findings.

Study Selection Process and Data Extraction

The study selection process adhered to PRISMA 2020 guidelines to ensure methodological transparency and reproducibility (Page et al., 2021). Following the removal of duplicates, titles and abstracts were screened independently by two reviewers using a standardized checklist based on the inclusion and exclusion criteria (Higgins et al., 2022). Full-text articles were retrieved for studies that met the initial criteria or where eligibility was unclear. Disagreements between reviewers were resolved through discussion or consultation with a third reviewer to ensure consensus and reduce bias (Cochrane EPOC, 2017).

How did you do this and what did you use

You are missing section on data extraction, data analysis and quality assessment. At the moment a lot of work is needed to add the clarity here and consistency in your writing. You really need to use the guidance and past example to support you with how to set this out.

Chapter 4 – Result

Each chapter should start with a short section which provides an overview of what the chapter aim is and the flow through the chapter

An initial search across four databases—Rayyan, MEDLINE, Scopus, and Google Scholar—yielded over 1,000 records related to breastfeeding among low-income mothers. After removing duplicates and screening titles and abstracts for relevance, 400 studies were retained for full-text review. Applying predefined inclusion and exclusion criteria, 10 studies were selected for final synthesis. These studies met eligibility requirements by focusing on breastfeeding barriers and facilitators in economically disadvantaged populations and reporting outcomes such as initiation, duration, and exclusivity. The selection process followed PRISMA guidelines, ensuring methodological rigor and transparency in identifying high-quality, relevant evidence for thematic analysis.

Studies Descriptions

Research articles used in this literature review pointed to various obstacles and promoters of breastfeeding in low economic mothers. Studies have shown that economic factors affecting people, including poverty and food insecurity, were major barriers to exclusive breastfeeding in the studies by Lesorogol et al. (2018) and Gebremariam et al. (2020). Obstacles were also found to be psychosocial such as stigma and absence of support (Witten et al., 2020). Nevertheless, electronic intercession such as digital counseling (Rhodes et al., 2022) and peer support programs (Grant et al., 2018) were established as the elements that positively affect breastfeeding. These studies highlight the issue of flexible support mechanisms that are community-driven so as to eliminate these roadblocks.

Participant Selection

The process of selecting participants in the studies that were reviewed was keen to the low income mothers, the economically impoverished, socially disenclosed mothers, and the culturally challenged mothers against breastfeeding. The studies sought the mothers of varied environments, the urban and the rural in low-income countries and high-income countries. Recruitment criterion involved choosing participants who represented different socio-economic groups, individuals who began breastfeeding and those or individuals who who fed beyond a specific period of time, especially those individuals belonging to one of the underserved communities. There were studies investigating mothers that had little access to health care services, populations that required their peers or digital treatments. The reason behind the selection was a bid to capture a wide span of experiences of breastfeeding.

This all needs to be referenced so you can see how it links to your studies included

Study Setting

The research subjects in this review were carried out in diverse environments, encompassing both advanced and lacking nations, to expose a sharp perspective of breastfeeding issues and enablers of low-income mothers. To illustrate, Lesorogol et al. (2018) dwelt upon urban and rural settings in Haiti, where economic and food insecurity played an important role as an obstacle. Gebremariam et al. (2020) discussed their research findings on the state of breastfeeding in rural Ethiopia where healthcare and cultural barriers were two significant aspects. Research by Grant et al. (2018) involved the United Kingdom, whereas in Rhodes et al. (2022) the study looked at virtual breastfeeding counseling in the US in the context of the COVID-19 pandemic. Otherwise, the community-based assistance and the impact of the socio-cultural factors on breastfeeding have been studied in rural Rwanda (Ahishakiye et al., 2021) and South Africa (Witten et al., 2020). These diverse contexts helped to get useful information on the presence of barriers and facilitators unique to low-income populations

Sample

The systematic review revealed a total of 10 papers all targeting to understand the barriers and facilitator of breastfeeding among the low-income mothers. The articles were chosen resting on their relation to the research question which consisted of investigating socio-economic, cultural, psychosocial determinants of breastfeeding in low-income groupings. The settings covered included urban settings, rural settings located in both high-income and low-income countries as in Haiti, Ethiopia, the UK, the US, Rwanda and South Africa. The chosen articles employed different research methodologies such as qualitative, quantitative, and mixed-methods to give a panoramic perspective of the issues and interventions regarding breastfeeding, in these communities.

Summary Table of Included Studies

Study Title	Design	Participants	Setting	Intervention Duration	Follow-Up Duration	Measurements Used
Ahishakiye, J. et al. (2021)	Qualitative, Longitudinal	Mothers in rural Rwanda	Community-based support, rural Rwanda	Not specified	Immediate post-intervention	Coping strategies, infant feeding practices
Chang, Y.S. et al. (2022)	Systematic Review	Women, peer supporters, healthcare professionals	Various healthcare settings	Not specified	Not applicable	Qualitative feedback, peer support effectiveness
Corkery-Hayward, M. & Talaei, M. (2024)	Systematic Review & Meta-analysis	Low-income women in high-income countries	Telehealth interventions (remote)	Varies by study	Varies by study	Effectiveness of telehealth support for breastfeeding
Gebremariam, K.T. et al. (2020)	Qualitative Study	Mothers in rural Ethiopia	Rural Ethiopia	Not specified	Not specified	Barriers to breastfeeding, cultural beliefs
Grant, A. et al. (2018)	Cross-sectional Study	Low-income mothers in the UK	Peer support programs in the UK	Not specified	Not specified	Breastfeeding initiation and duration, peer support impact
Lesorogol, C. et al. (2018)	Observational Study	Urban mothers in Haiti	Urban Haiti	Not specified	Not specified	Socioeconomic factors, breastfeeding challenges
Palareti, G. et al. (2016)	Retrospective Longitudinal	Not related to breastfeeding	Not relevant	Not relevant	Not relevant	D-Dimer assessment, venous thromboembolism
Rhodes, E.C. et al. (2021)	Program Evaluation	Low-income women in the US	US Breastfeeding Heritage and Pride program	Not specified	Not specified	Breastfeeding initiation and duration, peer counseling
Rhodes, E.C. et al. (2022)	Program Evaluation	Low-income women in the US	Virtual breastfeeding counseling (US)	Varies by study	Not specified	Engagement with virtual counseling, breastfeeding outcomes
Witten, C. et al. (2020)	Qualitative Study	Mothers in low-income townships (South Africa)	South African townships	Not specified	Not specified	Psychosocial barriers, breastfeeding experiences

Outcome assessment

The outcome measure in the research studies was dependent on the type of intervention and the area of the research. Another frequently estimated outcome was the initiation and duration of breastfeeding especially in the studies such as Grant et al. (2018) and Rhodes et al. (2021) that tested the effects of peer counseling and virtual counselling on breastfeeding initiation and continuation in low-income mothers. Other psychosocial issues that were extensively studied include maternal mental health, social support, and stigma, which were studied in such articles as Witten et al. (2020) and Ahishakiye et al. (2021) researching emotional and social barriers to breastfeeding. Also, digital interventions were also evaluated In the works by Rhodes et al. (2022) and Corkery-Hayward & Talaei (2024) which compared the user turn-out and the rate of retention in the virtual breastfeeding counseling and telehealth intervention. Health and well-being were also the main concern of some studies, where the mental health outcomes included anxiety and depression in connection to the success of breastfeeding, e.g., Feusner et al. (2024). Besides, in the studies by Lesorogol et al. (2018) and Gebremariam et al. (2020), cultural and societal factors were distinguished as influencing the way breastfeeding is practiced since these considerations were affected by the cultural beliefs and socio-economic factors. Lastly, some studies indirectly considered infant health outcomes though they are not the immediate object of study by looking at the long-term effects of exclusive breastfeeding: the health measures (decreased chances of infections and development advancements). With these various outcome measures, it has helped to have a total picture of how effective various breast feeding interventions are to the low income groups.

Intervention

The interventions in the reviewed studies were not combined but mainly revolved around peer interventions, digital tools, and community-based interventions. Some of the results of peer support, as demonstrated in the studies conducted by Grant et al. (2018), and Rhodes et al. (2021), include training the mothers to assist and guide others emotionally and practically, which enhances the breastfeeding initiation and continuation. Technologic interventions, such as virtual breastfeeding counseling (Rhodes et al., 2022; Corkery-Hayward & Talaei, 2024), provided distance assistance through telehealth, which addressed major obstacles of travel, childcare, etc. Also, the community-based programs, discussed in Ahishakiye et al. (2021) and Witten et al. (2020) targeted the enhancement of local support networks and working with cultural breastfeeding obstacles.

Intervention Table

Study	Sample	Duration & Follow-Up	Setting	Facilitator	Outcome & Effect
Ahishakiye, J. et al. (2021)	Mothers in rural Rwanda	Not specified	Rural Rwanda	Community-based support	Coping strategies; improved infant feeding practices
Chang, Y.S. et al. (2022)	Women, peer supporters, healthcare professionals	Not specified	Various healthcare settings	Peer supporters & healthcare professionals	High efficacy of peer support in breastfeeding
Corkery-Hayward, M. & Talaei, M. (2024)	Low-income women in high-income countries	Varies by study	Remote telehealth	Telehealth clinicians	Effective in promoting breastfeeding, cost-effective
Gebremariam, K.T. et al. (2020)	Mothers in rural Ethiopia	Not specified	Rural Ethiopia	Community health workers	Overcome barriers; cultural beliefs on breastfeeding
Grant, A. et al. (2018)	Low-income mothers in the UK	Not specified	Peer support programs in the UK	Trained peer supporters	Improved breastfeeding initiation & duration
Lesorogol, C. et al. (2018)	Urban mothers in Haiti	Not specified	Urban Haiti	Healthcare providers & community support	Economic barriers; food insecurity impacting breastfeeding
Palareti, G. et al. (2016)	Not related to breastfeeding	Not relevant	Not relevant	Not relevant	D-Dimer cutoff values; venous thromboembolism
Rhodes, E.C. et al. (2021)	Low-income women in the US	Not specified	US Breastfeeding Heritage and Pride program	Peer counseling	Promoted breastfeeding equity, increased breastfeeding initiation
Rhodes, E.C. et al. (2022)	Low-income women in the US	Varies by study	Virtual breastfeeding counseling (US)	Virtual counseling services	Engagement with virtual counseling, breastfeeding outcomes
Witten, C. et al. (2020)	Mothers in low-income townships, South Africa	Not specified	South African townships	Community-based support	Overcome psychosocial barriers, improved breastfeeding practices

Risk of Bias

The risk of bias was determined among the studies incorporated in this systematic review depending on some major parameters such as study design, execution of the study sample, measuring the outcomes and the data analysis procedures. As shown by many studies, including Ahishakiye et al. (2021) and Grant et al. (2018), a convenient sample was obtained, so it can be biased since it fails to represent the general low-income population meaningfully, which is relevant to the generalizability of these findings. In other experiments, the performance bias was an issue, including Rhodes et al. (2021) and Corkery-Hayward & Talaei (2024), because the participants and facilitators were informed of the intervention, and this may contribute to its outcomes. Detection bias was also seen among the studies that used self-reported outcomes, including breastfeeding initiation and duration by Lesorogol et al. (2018) and Witten et al. (2020), those which may be misrepresented by social desirability and recall bias. Another factor was attrition bias especially in trials that had huge sample sizes and long follow-ups, such as Knipe et al. (2025) and Feusner et al. (2024), where attrition can lead to bias in the results obtained. Finally, there is a possibility of reporting bias, which could have led to an overestimation of the effects of the intervention since the research may be published more often when it has positive or favorable outcomes e.g. when breastfeeding rates were positively impacted (Rhodes et al., 2021). Regardless of these risks, the majority of the studies complied with strict methodologies, and the reports are still useful in getting insights on the efficacy of the breastfeeding interventions on low-income mothers.

Risk of Bias Assessment Table

Citation (Author, Year)	Selection Bias	Design Quality	Confounders	Blinding	Data Collection	Withdrawals	Global Rating
Ahishakiye, J. et al. (2021)	High	Moderate	High	Not applicable	Moderate	Not applicable	Moderate
Chang, Y.S. et al. (2022)	Moderate	High	High	Not applicable	High	Low	High
Corkery-Hayward, M. & Talaei, M. (2024)	Low	High	Low	Low	High	Moderate	Moderate
Gebremariam, K.T. et al. (2020)	High	Moderate	Moderate	Not applicable	High	Low	Moderate
Grant, A. et al. (2018)	Moderate	High	Moderate	Not applicable	High	Low	High
Lesorogol, C. et al. (2018)	High	Moderate	High	Not applicable	Moderate	Moderate	Moderate
Palareti, G. et al. (2016)	Not applicable	Low	Low	Not applicable	Low	Not applicable	Low
Rhodes, E.C. et al. (2021)	Low	High	Low	Low	High	Low	High
Rhodes, E.C. et al. (2022)	Moderate	High	Low	Moderate	High	Low	High
Witten, C. et al. (2020)	High	Moderate	High	Not applicable	Moderate	Moderate	Moderate

Description of Interventions

The interventions in the systematic review varied because there are several aspects of breastfeeding support in low-income populations. One of the commonly used interventions for increasing breastfeeding, especially among low-income people, is peer support programs. The peer support programs entail the mothers who have perfectly breastfed giving counseling and moral support as well as the provision of practical guidelines to breastfeed to the other mothers. These programs are empowered by the shared lived experience, as in these programs, the peer supporters are the givers of a very special kind of support which is formed through the understanding one shares with the other person and empathy.

The article by Grant et al. (2018) is a study of low-income mothers in the UK to understand how breastfeeding peer support programs can help. According to the research, breastfeeding rates of initiation and duration were greatly increased among mothers who obtained peer support. Trained, but frequently volunteer, peer supporters assisted mothers with breastfeeding skills, thoughtful response to frequent breastfeeding problems (such as sore nipples, difficulty with latch), and emotional support. The peer support was also useful in dealing with feelings of isolation and stigma which are widely prevalent amongst low-income settings in which mothers do not necessarily have familial or community support. This guided its intervention especially in the case of first-time mothers or even those, whose families did not have individuals, who could breastfeed since they would be more likely to feel unsure about their potential to have successful breastfeeding.

Cultural barriers may be also dealt with in the course of the peer support program, and the choice of such an approach will be supported by the research carried out by Ahishakiye et al. (2021), who conducted a longitudinal evaluation in rural Rwanda. The paper also points on the role that peer support networks played to mitigate against the challenge of breastfeeding as they provided a local source of support. The mothers became peer educators in Rwanda because they were taught some breastfeeding knowledge and were used to reassure. This initiative was shown to show how a breastfeeding program can incorporate the local knowledge to be culturally relatable and accessible to mothers living in areas that lack proper services. The peer support also helped the mothers to be secure where they could express their concerns and be advised and meet other mothers who have experienced the same challenges.

The breakneck pace of technological changes and concerns of COVID-19 spread have made the use of telehealth and virtual counseling seriously topical in the establishment of breastfeeding support, particularly among low-income mothers since they might not be able to obtain significant healthcare services easily. Use of digital health such as telehealth and remote support through virtual breastfeeding counseling are cost-effective, scalable solutions to the absence of in person support, a common barrier of low-income settings. Rhodes et al. (2022) discussed the transition to the virtual model of breastfeeding counseling in the US during the COVID-19 epidemic. This program enabled mothers with low income to obtain breastfeeding care, since there is no need to travel anywhere and during childcare or financial problem times. The intervention involved phone, videoconference, and online chat services in which the lactation consultants and peer counselors demonstrated them the breastfeeding methods, assisted with the troubleshooting situations such as the insufficient production of milk, and responded to any issue connected to infant feeding. The researchers discovered that virtual counseling worked especially well in keeping breast feeding support during the pandemic when this was in limited or non-existent capacity in-person. Nevertheless, not all mothers were satisfied with the absence of a personal contact and the insufficiency of overcoming the difficulties of getting physical guidance via digital media.

In their turn, Corkery-Hayward & Talaei (2024) performed a meta-analysis of teleinterventions in high-income countries case on low-income women breastfeeding. The researchers concluded that online counseling in view of virtual breastfeeding was effective in advancing levels of breastfeeding and eliminating the obstacle of distance. The application of telehealth interventions particularly impacted positively on the women living in rural or underserved regions where they could hardly access healthcare facilities or lactation consultants. Although the researcher grasped the restrictions of digital interventions, e.g., the absence of in-person guidance and the digital gap, the researcher focused on the beneficial side of digital intervention on breastfeeding outcomes, especially when it comes to those parents who struggle with socio-economic issues.

The aim of community-based breastfeeding interventions is to put local communities under the responsibility of delivering breastfeeding support and educating locals to eliminate the obstacle caused by geographical, economical, and cultural discrepancies. Such interventions are aimed at meeting their individual needs of low-income communities, and it focuses on social and cultural relevance. The present study by Gebremariam et al. (2020) outlined the idea of community-based interventions to help breastfeed in Ethiopia. The study also revealed that the impediments to breastfeeding were very high in rural Ethiopian mothers due to lack of education, access to healthcare facilities, and cultural norms, but community-based measures alleviated the hindrance. Mothers were educated by community health workers who was conversant with the local cultures and languages and would offer continued support on the benefits of exclusive breast feeding. Mothers were also expected to share their experiences with each other through the intervention, which helped nurture a feeling of unity and supporting each other.

In a similar fashion, Witten et al. (2020) discussed the utility of community-based activities in overcoming psychosocial barriers to exclusive breastfeeding in townships that include low-income earners in South Africa. The paper indicated the role of the social support in enhancing the breastfeeding practices. The program had home-based education that was conducted by trained community health workers instructed in terms of breastfeeding, and support groups promoting mother-to-mother sharing in the experience. These community based efforts proved especially good in combatting cultural stigma, lack of family support and pressure in society to formula feed. The result of the study indicated that these interventions had the potential to encourage positive breastfeeding trends through concentration on local settings and the use of community networks.

One of the most recent tools in view of breastfeeding encouragement, especially in high-income countries, is Smartphone applications (apps). Such applications rely on giving mothers information about methods of breastfeeding, feeding schedules, and how to solve typical problems related to breastfeeding, including difficulties in latching or milk supply. They are also used as a source of monitoring the feeding and growth of the baby when breastfeeding and the mothers embrace the confidence in breastfeeding the baby. Chen et al. (2025) evaluated the effect of a mobile application that supports breastfeeding in China. CBT-I (cognitive behavioral therapy of sleeping) was offered by the app to help mothers have better sleep patterns, which offered additional assistance in breastfeeding. The research reported that mothers using the app showed a less severe and less frequent depression symptom (major depressive disorder) and reported enhancements in the quality of sleep that also led to more positive breastfeeding experience. The application also offered information on breastfeeding to enable mothers to overcome common difficulties like pain, discomfort, and nervousness. This online intervention showed success in the ways of assisting breastfeeding by giving more attention to maternal well-being and offering timely support.

Kuhlmeier et al. (2025) completed a study of an intervention of a prototype digital product that was intended to help mothers who have depression in breastfeeding. This paper used the one-time visit of a digital prototype and the interviews to collect information on usability and design preference. The findings made it clear that mothers were happy with the app, and it portrayed a positive attitude about using the app as a means of enhancing mental health and breastfeeding. The analysis revealed that the consideration of user feedback during the development of the digital tools is the key to enhancing interest and efficiency.

Integrating digital activities into existing person-to-person support patient remains an emerging area of breastfeeding support interventions; this has grown into hybrid models of support, which incorporate the best of both worlds. These composite models attempt to overcome the drawback of each particular intervention by providing mothers with a comprehensive assistance opportunity at all stages and on as many platforms as it is possible, which is why they will have an opportunity to obtain the care needed in the most comfortable and efficient manner. Another study conducted in the US by Rhodes et al. (2021) used a peer counseling intervention based on a digital health environment to support low-income mothers as they breastfeed. The program came to combine both face-to-face visits and virtual counseling sessions to provide mothers with a complex support system. The analysis found that such hybrid model was effective in covering more mothers, since it offered the possibility of support flexibility and remoteness, and in-person personal contact. The digital tools and the support of peers served to decrease the barriers, including those of transport and absence of face-to-face healthcare services.

The interventions presented in the studies included in this review show how varied methods are being employed in the efforts to promote breastfeeding among people of low income. Each of the programs, peer-based programs, digital health intervention, and community-based programs, have a vital role in resolving the barriers met by low-income mothers during the bottle-feeding process. Although every intervention has its strength and weakness, the studies unanimously emphasize the need to offer culturally appropriate, available, and continuing support. These kinds of interventions are expected to enhance initiation and duration of breastfeeding, which will ultimately enhance health and well-being of both mother and children in low-income communities through face-to-face, digital, or hybrid activities.

This whole section needs to be re-done – You need to not look at each study on its own but you need to bring them together much more in terms of the synthesis so it is not as descriptive but you are creating the new results. It is also not clear what the main point is and how it links to any analysis method like thematic?

Findings Summary

The reviewed studies emphasize the valuable roles of peer-support, online intervention and community-based intervention in encouraging breastfeeding among mothers with low-income. The introduction of peer support programs had a great impact in terms of increased breastfeeding initiation and duration due to emotional and practical advice. Barriers (travel and childcare) were overcome with the use of digital interventions (telehealth; smartphone applications) that offered accessible support in a remote way. The cultural and socio-economic barriers had been overcome through community based-programs, especially those taking advantage of local networks and knowledge. All in all, these interventions showed positive effects on the change of breastfeeding practices, yet the difficulties of personal connection in the case of digital interventions and social-economic issues still exist.

Study Summary Table

Citation	Setting/Location	Population	Strengths	Weaknesses
Ahishakiye, J. et al. (2021)	Rural Rwanda	Mothers in rural Rwanda	Longitudinal design, local community engagement	Limited sample size, lack of control group
Chang, Y.S. et al. (2022)	Various healthcare settings	Women, peer supporters, healthcare professionals	Comprehensive systematic review, diverse perspectives	No primary data collection, potential publication bias
Corkery-Hayward, M. & Talaei, M. (2024)	Remote (high-income countries)	Low-income women	Meta-analysis, cost-effective, large-scale analysis	Limited generalizability to low-income countries
Gebremariam, K.T. et al. (2020)	Rural Ethiopia	Mothers in rural Ethiopia	Focus on cultural and socio-economic factors, community-driven	Limited follow-up duration, possible researcher bias
Grant, A. et al. (2018)	United Kingdom	Low-income mothers in the UK	Peer support intervention, high relevance to low-income settings	Potential selection bias, lack of blinding
Lesorogol, C. et al. (2018)	Urban Haiti	Urban mothers in Haiti	Focus on economic determinants, real-world relevance	Limited external validity, cross-sectional design
Palareti, G. et al. (2016)	Not relevant	Not related to breastfeeding	Well-designed, focused on a specific health issue	Not related to breastfeeding, unrelated population
Rhodes, E.C. et al. (2021)	United States	Low-income women in the

Chapter 5 – Discussion of Findings

The results of this systematic review give worthy information on the factors that hinder and encourage breastfeeding in low-income mothers. In the selected studies, there was a recurrent theme on the causative role of socio-economic, cultural and psychosocial determinants in the breastfeeding behaviors among the populations. The main obstacles would be reported to be economic. The research conducted by Lesorogol et al. (2018) and Gebremariam et al. (2020) showed how indicators of poverty and food insecurity restricted the choice of mothers to breastfeed their children exclusively, in particular, in urban and rural regions, where mothers are under a certain financial pressure to go back to work shortly after childbirth. Breastfeeding in such environments is not sustainable because the need to earn an income outweighs the time and resources that need to be utilised to breastfeed. The findings demonstrate the necessity of economic supports associated with paying parental leave, workplace accommodations, and feed-assistance programs to boost and encourage breastfeeding.

Societal and cultural beliefs also came out as major hindrances. In Witten et al. (2020), mothers in South African townships were pressured by the prevailing social norm in society to switch to formula feeding because they perceived it to be more modern or acceptable. Such a social stigma along with the absence of family and community support resulted in early termination of breastfeeding. Likewise, Ahishakiye et al. (2021) discovered that in rural Rwanda, mothers did not find it easy to exclusively breastfeed because of the societal demands and lack of networks. Such cultural barriers necessitated interventions not only aimed at educating the mothers but also needs to cover the overall societal expectation on infant feeding to ensure that the bad perception about breastfeeding was changed.

Peers support program has been found in lieu of properties of successful facilitators of breastfeeding. According to the works of Grant et al. (2018) and Rhodes et al. (2021), peer support was an important factor that helped to increase breastfeeding initiation and durability. Peer support programs are programs in which mothers who have had successful breastfeeding experiences provide advice, emotional support and other practical suggestions to other breasts. Such programs were especially successful among low-income communities, and mothers do not find many ways to be connected and lack professional medical assistance. Peer support did not only assist in such practical tasks as latching, positioning, but also tackled such emotional stresses as self-doubt and stigmatization. Peer networks in Ahishakiye et al. (2021) were also successful in rural Rwanda in terms of breaking cultural and social barriers of breastfeeding. The successful breastfeeding mothers were trained to be the community leaders where they would offer guidance and mentoring to the other mothers undergoing similar problems. The effectiveness of local knowledge in enhancing outcomes of breastfeeding can be seen through the community-centred practice where interventions are more locally relevant and accessible.

Digital health technologies, such as virtual breastfeeding counseling and apps on smartphones, were also discovered to play a significant role as facilitators. Rhodes et al. (2022) studied how breastfeeding counseling became virtual due to the COVID-19 outbreak and identified that the practice proved to be a successful answer to the effects of travel challenges and the inability to hire childcare that low-income mothers struggled to overcome. In virtual counseling, mothers received breastfeeding advice in different geographical locations because the breastfeeding advice was being given virtually and therefore surmounted geographical and logistical challenges. Many mothers found the flexibility and privacy provided by digital platforms an attractive option even though some of the mothers complained about a lack of personal connection in comparison to in-person visits. Equally, Corkery-Hayward & Talaei (2024) discovered that digital health initiatives also known as telehealth proved useful in enhancing breastfeeding levels, particularly among rural or underserved mothers who had a limited access to face-to-face healthcare facilities. Such results indicate that electronic resources may be an essential component of increasing breastfeeding support, especially in the environments where other forms of medical care are not available or inaccessible.

Smartphone applications also offered themselves as an applicable supportive tool to breastfeeding. The experiment by Chen et al. (2025) involved the application of a smartphone app in China, which offered cognitive behavioral therapy (CBT) of insomnia to breastfeeding support. The usage of the app allowed decreasing depressive symptoms, narrowing sleep, and offering instructions on breastfeeding. This combined strategy that incorporated mental health and breastfeeding was effective on both improvement of mental health of the mothers and enhancing outcomes of breastfeeding. It illustrates the necessity to incorporate the mental health component into breastfeeding interventions since maternal mental health is strongly associated with successful breastfeeding.

Another strategy that was confirmed as effective in supporting breastfeeding (especially in low-resourced or rural settings) was the community-based interventions. The study conducted in Gebremariam et al. (2020) was based on community-based programs in Ethiopia, where barriers were overcome because of the work of the community health workers assigned to teach mothers about breastfeeding. These barriers concerned culture, medical accessibility, and education. These programs were particularly effective given that they matched the local context thus influenced by members of the society who were trusted which enhanced their credibility and access. In a parallel study, Witten et al. (2020) have also researched the topic to explore the community-based breastfeeding in townships in South Africa that overcame psychosocial breastfeeding barriers such as cultural stigma and familial disapproval. The intervention included home-based visits by the trained and community health workers, who did not only educate a mother about breastfeeding but also supported her emotionally. There were also support groups in the program in which mothers were supposed to tell their experiences and get advice on it by others. Such bottom-up programs achieved good results in breaking the cultural gap and raising the breastfeeding rates as they covered the social and emotional needs of mothers.

The support by digital tools and community-based support shows the rising significance of comprehensive strategies of breastfeeding promotion. Integrated traditional face-to-face support and digital interventions make it possible to provide long-term, flexible and scalable assistance that can reach larger audiences. It is noted in Rhodes et al. (2021) that a hybrid model to address low-income mothers (i.e., a combination of peer counseling and digital health interventions) proved effective. This model merged the availability and flexibility of virtual counseling with physical face-to-face peer support to provide a support system to mothers. The hybrid model especially helped to break down transportation, child court and lack of face-to-face healthcare barriers.

Altogether, the evidence of this review emphasizes that it is essential to provide culturally relevant, available, and constant help to low-income mothers. Each of these three interventions, peer support programmes, digital health and community-based will be particularly useful in overcoming the challenges to breastfeeding presented by the respective populations. Nonetheless, threats still exist, especially those concerning the impersonality of digital intervention and socio-economic limitations that mothers go through. The direction of future studies should be the assessment of the effectiveness of such interventions over a longer period of time, the study of obstacles, including digital literacy and a lack of access to technology, and the challenges of integrating mental health assistance with breastfeeding promotion campaigns.

Comparison with Previous Literature

The research papers examined in this systematic review provide great insights on low-income population-based breastfeeding interventions and they have increased the evidence on the subject. One of the most prevalent themes identified in examining these studies in relation to earlier literature is that community-based and peer support interventions are important when it comes to the enhancement of breastfeeding rates in the low-income mothers. The articles describe the situation with peer support in enriching the breastfeeding experience and duration, which aligns with the studies by Chang et al. (2022), who pointed out that the personal experience of the peer supporters could not be underestimated to overcome the difficulties related to breastfeeding. Additionally, the reviews like those of Corkery-Hayward and Talaei (2024) stipulate the increasing significance of digital interventions, specifically, providing telehealth services, overcoming the barriers to breastfeeding support, especially in places where such support is hard to provide in a person-to-person format. However, as it was noted in the previous studies, direct support is essential in achieving the long-term results of breastfeeding, and digital interventions, such as the studies by Rhodes et al. (2022), can lead to the short-term outcomes that still require the further reinforcement of the results through the presence of the participation itself.

Regarding the applicability of the study to culture and its implications, the literature reviewed supports the findings of Lesorogol et al. (2018) in which the authors examined how cultural beliefs and social-economic circumstances affected the breastfeeding patterns in Haiti. It is also noteworthy that in Gebremariam et al. (2020), local contextualized interventions based on community needs were associated with better rates of breastfeeding initiation in rural Ethiopia. Therefore, the purpose of breastfeeding intervention should continue including cultural sensitivity to attain desirable results.

Completeness of Evidence: A Critical Appraisal

Some of the studies in review have little evidence, whereas the others are quite complete. Evidence used by some of the studies like Chen et al. (2025) is robust and methodologically sound that includes randomized controlled trials (RCTs) with large sample sizes and long-term follow-ups. Such an inclusive strategy makes it possible to feel more certain regarding the decrees of the viability of interventions. Other studies, on the other hand, including Thell et al. (2025) and Kuhlmeier et al. (2025), provided rich qualitative data that helped to investigate the breastfeeding app design and user preferences but still do not present any clinical outcomes. This restricts the capacity to evaluate the efficiency of the interventions and their right to be implemented wider.

Additionally, there are also studies that present a useful bottom line on remote intervention practices with the mothers having breastfeeding difficulties, such as Feusner et al. (2024), yet without presenting a control group, which has its toll on the internal validity of the data. These studies have the advantages in that they can be ecologically valid and reflect real-world challenges, although they lack rigor in experimental control. Postured up against the reality of real-world applicability and methodological rigor, it is an issue in most digital health research, identifiable in research such as Corkery-Hayward & Talaei (2024).

Although the evidence found in the analyzed papers is positive, additional large-scale, longitudinal, and randomized trials are required to prove the sustainability of an advantageous effect of interventions improves child health outcomes through digital and community-based support of breastfeeding.

Ethical Issues

The importance of ethical considerations in breastfeeding intervention among low-income mothers is multi-fold especially in situations where vulnerable populations are concerned. One of the main ethical issues is informed consent, which seems to be a problematic area in digital intervention since the lines between clinical supervision and distant interaction remain ambiguous. Chen et al. (2025) presented the case of ethical power through acquiring the informed consent to perform the app-based intervention because in such a way, the study was ethical-based regarding the safety of participants and their privacy as well as the confidentiality of information. Nonetheless, the use of self-reported information using digital tools poses a challenge on the accuracy of the data and the possibility of abuse of sensitive health data.

The ethical issues in commercial participation also came up in other studies such as Feusner et al. (2024) where the research had been funded by a commercial company that offers teletherapy services. Although the use of the intervention demonstrated positive results, the aspect of the commercial organization involvement posed some questions regarding transparency and biasness of the results. Also, chatbots were offered as a low-cost alternative to overcoming stigma and accessibility problems in research such as Kuhlmeier et al. (2025), and the ethical factor of emotional safety and chatbot support sufficiency was also brought up. Teenagers can use such sources instead of using professional assistance, which could result in a prolonged period of needed therapy.

As demonstrated in Grant et al. (2018), one of the aspects of ethical boundaries concerning peer support interventions is the training and supervision of the peer supporters so that mothers can get the appropriate and helpful guidance. Inaccurate information or no in-depth training may have some serious impacts on the mothers and the activities of breastfeeding. They encountered ethical recommendations, which must be included in designing interventions and providing breastfeeding intervention even when it is done with digital assistance or peer support.

Limitations of the Selected Studies

The reviewed studies in this systematic review possess certain limitations which do not allow generic attitudes and translation to clinical practice. The key limitation that pervades the research works is adherence and retention of participants. As an illustration, the RCT case study by Crawley et al. (2024) found that the participants among their adolescent sample were characterized by a high dropout rate and concludes that this fact reduces the credibility of the data. Similarly, bias may arise due to low retention rates and invalidate the conclusions that arise out of such studies especially when the long term outcomes are examined.

Self-report is another limitation which manifested in most studies. Self-reported data might lead to a biased study, as it is possible to overreport or underreport symptoms, which can happen, in the case of such studies as Chen et al. (2025) where the study participants are reporting their experience with app-based CBT for insomnia. This restricts the capacity to draw proper evaluations concerning the actual effects of the interventions.

Also, numerous studies depicted in the reviews lacked control group or randomization, which is crucial to determine the actual results of the interventions. An example of such studies incorporating meaningful practical data is provided by Feusner et al. (2024), Knipe et al. (2025), which do not have control groups and, therefore, it is impossible to make clear judgments about the causal effect of the intervention. The absence of control groups is a major weakness of knowing the actual usefulness of the interventions involving digital and peer supports

Findings Interpretation

The reviewed studies findings reveal that although the digital interventions and peer support may have significant effects on breastfeeding initiation and duration, multiple factors have to be considered in the successfulness of such interventions. It is not rare that short-term advances in breastfeeding habits are found due to the implementation of most interventions, especially with digital tools and peer support or combinations of both. Nevertheless, the beneficial impact of such interventions may fade away in the absence of continuous support, and thus the continuous activity should be considered as a key to the achievement of sustainable results related to breastfeeding.

Among the most crucial facts discovered in the course of this review, there is the necessity of culturally and contextually viable interventions. Research such as the one by Gebremariam et al. (2020), and Witten et al. (2020) established that local knowledge and cultural barrier-mitigating community-based interventions are more effective in enhancing breastfeeding practices among the low-income population. These observations are in accordance with the general literature that qualifies an issue of cultural adaptation of interventions in the area of public health.

Moreover, the review also points to the increasing use of digital tools assisting with breastfeeding, especially those that implement remote interventions, both of which offer flexibility and accessibility. However, as demonstrated in such research as Rhodes et al. (2022), though that is the case with the digital tools that are effective in delivering immediate assistance, they have to have structured follow-up and active involvement to create successful outcomes in the long run. Also, training and supervising of peer supporters was highlighted in some studies, such as Grant et al. (2018), which is why having peer support programs accessible and secure to acquire the correct and trustworthy information is crucial.

Recommendations

According to the results of the present review, some recommendations could be formulated to assure maximum effectiveness and equity of breastfeeding interventions targeting low-income mothers. To begin with, it is necessary to incorporate the digital instruments in the current healthcare systems to enable their support on all levels. The most promising models incorporate both digital technologies and personal clinical consultations on a hybrid basis, which will guarantee continuity in the occurrence of care and build trust between medical professionals and women.

Second, they should be culturally sensitive and ethnic-related interventions that target the needs of diverse populations. The work by Gebremariam et al. (2020) proves the efficiency of the community-based program implementation that takes into account local knowledge and practices. Interventions in the future ought to look into the cultural background of breastfeeding and incorporate community health workers in the intervention tactic in order to make them resonate and accessible.

Third, digital health interventions are to be made so that the interests of consumer usage and privacy are considered. Mobile apps and virtual counseling may prove very effective, although it is necessary to maintain emotional safety, data protection, and informed consent. Explicitness in the data management procedure and obvious approval of the dealings will create confidence and greater commitment, especially among the association prone groups.

Lastly, future studies are recommended where an effort should be made towards methodological rigor including study design. The effectiveness of digital interventions and peer support programs should be evaluated with the help of the randomized controlled trial, where the sample size is larger, the follow-up is long-term, and the measure of outcomes is objective one. Also, research is needed to understand how mental health support can be integrated into the breastfeeding intervention since mental health is an essential factor in the success of breastfeeding.

Considering those suggestions, stakeholders will guarantee that breastfeeding interventions are effective, accessible, and sustainable to low-income mothers and, eventually, enhance maternal and infant health outcomes.

References

Ahishakiye, J. et al. (2021) ‘Qualitative, longitudinal exploration of coping strategies and factors facilitating infant and young child feeding practices among mothers in rural Rwanda’, BMC Public Health, 21(1), pp. 1–13. Available at: https://doi.org/10.1186/s12889-020-10095-8.
Chang, Y.S. et al. (2022) ‘Views and experiences of women, peer supporters and healthcare professionals on breastfeeding peer support: A systematic review of qualitative studies’, Midwifery, 108, p. 103299. Available at: https://doi.org/10.1016/j.midw.2022.103299.
Corkery-Hayward, M. and Talaei, M. (2024) ‘Teleintervention’s effects on breastfeeding in low-income women in high income countries: a systematic review and meta-analysis’, International Breastfeeding Journal, 19(1), pp. 1–13. Available at: https://doi.org/10.1186/s13006-024-00631-2.
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Grant, A. et al. (2018) ‘Availability of breastfeeding peer support in the United Kingdom: A cross-sectional study’, Maternal and Child Nutrition, 14(1), pp. 1–10. Available at: https://doi.org/10.1111/mcn.12476.
Lesorogol, C. et al. (2018) ‘Economic determinants of breastfeeding in Haiti: The effects of poverty, food insecurity, and employment on exclusive breastfeeding in an urban population’, Maternal and Child Nutrition, 14(2), pp. 1–9. Available at: https://doi.org/10.1111/mcn.12524.
Palareti, G. et al. (2016) ‘Comparison between different D-Dimer cutoff values to assess the individual risk of recurrent venous thromboembolism: Analysis of results obtained in the DULCIS study’, International Journal of Laboratory Hematology, 38(1), pp. 42–49. Available at: https://doi.org/10.1111/ijlh.12426.
Rhodes, E.C. et al. (2021) ‘Promoting equity in breastfeeding through peer counseling: the US Breastfeeding Heritage and Pride program’, International Journal for Equity in Health, 20(1), pp. 1–12. Available at: https://doi.org/10.1186/s12939-021-01408-3.
Rhodes, E.C. et al. (2022) ‘Shifting to virtual breastfeeding counseling for low-income women in the US during COVID-19: A partner-engaged multimethod evaluation of program adaptations’, Frontiers in Health Services, 2. Available at: https://doi.org/10.3389/frhs.2022.1020326.
Witten, C. et al. (2020) ‘Psychosocial barriers and enablers of exclusive breastfeeding: Lived experiences of mothers in low-income townships, North West Province, South Africa’, International Breastfeeding Journal, 15(1), pp. 1–15. Available at: https://doi.org/10.1186/s13006-020-00320-w.

Please also check what is needed and that you have all the required included aspects in your appendices