Table 3 Interventions’ description and study limitations

Sikander

2014, [42]RCT

no

Seven sessions of CBT were carried out, with women beginning from pregnancy up until six months postpartum. This intervention doubled the rate of exclusive breastfeeding at six months of life

Psycho-educational sessions integrated into the routine work of non specialist heath workers and delivered to all women in their catchment areas

Mothers in the intervention

group received 7 sessions of CBT, whereas the control group received an equal number of routine sessions.

This research revealed that the community health workers’ counselling had been too authoritarian, The authors acknowledge that further work is needed to refine the intervention so that it does not undermine the confidence of many women, and it can simultaneously address behaviour change.

Sreekumar 2018, [41]RCT

no

A single session of CBT in the third trimester: an intensive counselling session was carried out with the use of illustrations, along with detailed information regarding the usefulness of early initiation of breastfeeding, the right technique of feeding, and problems.

Specialist lactation counsellors

This study tested the effectiveness of a cognitive approach compared to routine counselling in the third trimester. By simple randomization, 26 mothers underwent cognitive counselling and 24 mothers underwent routine counselling.

Small sample size and the lack of follow-ups with the babies during the first 6 months. An improved LATCH score implies that the mother will have a more successful breastfeeding. However, more studies are needed to confirm the long-term benefits of a single session of CBT.

 Spinelli 2013, [36] RCT

yes

This study examined the comparative effectiveness of IPT and a parenting education program (PEP). Each participant received twelve weeks of an intervention. The PEP includes individual 45-min weekly lectures on pregnancy, postpartum, breastfeeding, and infant development.

A psychiatrist or a social worker.

Although breastfeeding education was not mandatory in the IPT group, a majority of IPT therapists provided breastfeeding encouragement. 83% of the IPT participants and 100% of the PEP participants received this breastfeeding intervention.

Breastfeeding was not defined as exclusive. In addition, the sample was small, and counselling was less than 100%. Given that this was a depression intervention study, the desire for treatment may have biased the outcomes. A benefit of this study is that prospective data on breastfeeding were not subject to recall bias.

 Kao 2015, [38] RCT

yes

Four 60-min group sessions over a 4-week period and a 50-min individual booster session after delivery. The sessions provided a review of the symptoms of PPD, addressed stress management skills, identified conflicts around childbirth and techniques for resolving them.

Group leaders were two nurses who received two hours of training and supervision in the delivery of the intervention.

Women were randomized to group sessions plus standard antenatal care or to standard antenatal care alone. Standard antenatal care included no groups for mental health issues, but offered classes on breastfeeding, infant safety, and parenting.

Duration of breastfeeding was only assessed in the three months postpartum period. Variables such as improved self-care and self-efficacy in the postpartum period, were not measured and therefore could not be examined. These findings may not generalize to women at low risk for PPD.

 Shariat 2017, [39] Cluster-RCT

no

Pregnant women in the intervention group took part in three supportive psychotherapy group sessions. The mothers were allotted to ask questions at the end of each session. They were also given an instructional package associated with mother-infant attachment behaviors aside from the group sessions.

Clinical psychologist

Women visiting a maternity clinic were randomly assigned to intervention and control groups. The control group was only provided with the routine pregnancy care.

Breastfeeding persistence in the intervention group increased significantly compared to the control group. This increase could be due to the influence of supportive psychotherapy, instructions, interactions, visualization, or more communication with the fetus in the intervention group.

 Werner 2013, [37] RCT

no

The intervention group attended three 1-h classes on self-hypnosis held over three consecutive weeks with additional audio-recordings to ease childbirth.

Women have been trained to guide themselves through a hypnotic procedure by two midwives trained in hypnosis.

A relaxation group receiving lessons in various relaxation methods and mindfulness, and a group receiving only the usual antenatal care were compared with the intervention group.

The intensity of the intervention may have been too limited, which may have reduced the effect. The generalizability of the results of this trial may be limited as the participants scored high on wellbeing and were well-educated.

 Mitchell 2018, [55] Pre-post assessment

no

Online resources comprised two videos and a tip sheet. The first video and the tip sheet explained the concept of self-compassion during the transition to motherhood, and the second video was a guided self-compassion visualisation exercise. Participants could access the videos as many times as they wished during the course of the study.

The online package included practicing self-compassion visualisation exercises.

There was no control group. This longitudinal study used a within-group repeated-measures design (pre-intervention, 1-month post-intervention).

Given the brevity of the intervention and short-duration follow-up, changes from pre- to post-intervention must be interpreted with caution.

 Patel 2013, [45] Quasi-experimental

no

The first back massage was given within two hours of delivery and continued for four times a day at regular intervals for three days. After proper exposure and comfortable position, gentle pressure with both thumbs was given on the back, in circulatory motion. This was applied for 15 min at each sitting.

Orientation about the protocol was given by nursing staff taking care of the postnatal wards. Acupressure, also called shiatsu, is a simple, and friendly method of back massage.

The study was conducted over a period of 16 months. Group A was the study group of subjects to whom back massage was given and group B, the control group of subjects to whom routine care was provided.

Other studies have shown similar effects, though the site of massage/acupressure was different. This study assessed the effect of back massage on lactation indirectly.

 Mohammadpour 2018, [44] Pre-post assessment

no

In the reflexology group, massage was done in six sessions. Each session lasted about one hour.

The mother first was placed in a comfortable position. Subsequently, the researcher applied continuous pressure to feet and kidneys.

Only routine interventions were performed in the control group, including regular breastfeeding training.

The authors comment that they cannot be sure about the level of interest of the participants when performing the intervention. In addition, participants may have used other milk-enhancing methods.

 Procelli 2005, [53] RCT

no

New mothers who intend to breastfeed received music therapy and relaxation. A minimum duration of 10 min of music therapy was required for the study. When the mother verbalized her readiness to breastfeed the music ceased and observation began.

Live music was sung by the researcher and played on a classical guitar. Mothers were asked their music preference according to favourite songs. During the music therapy intervention, subjects engaged in relaxation techniques and counselling techniques.

Two-group study, experiment and control, post-test design with random assignment of subjects. The intervention was music therapy paired with relaxation techniques.

Prior research indicated that performing a routine before each breastfeeding experience can enhance her milk production. Music therapy allowed the mother to have at least ten minutes of time exclusively for her and her baby. In this case, music therapy itself cannot be disentangled from setting a routine to prepare the mother.

 Keith 2012, [50] RCT

no

The three experimental groups received mp3 players with a recording of approximately 12 min in duration. All recordings consisted of a spoken progressive muscle relaxation protocol, followed by a guided imagery protocol.

Each mother was asked to listen to the mp3 player on headphones as often as possible while using the breast pump

Mothers who chose to participate were randomized into 3 experimental groups and the control group. Each group received standard medical, nursing, lactation education, and support in initiating and maintaining breast milk production. Generally, mothers were encouraged to pump 8 times daily for about 10 min.

The results suggest that mothers who heard the verbal-only protocol produced more milk than those who heard both verbal and music. This brings up one question: did the simultaneous presentation of two audio stimuli represent a distraction for the participants?

 Ak 2015, [51] Quasi-experimental

no

Music therapy was given to mothers of preterm babies when they went to the NICU to express breast milk in a randomized manner, without an accompanying verbal protocol, when they were seated comfortably in a quiet room, at a comfortable level of volume of their choice.

Study subjects were trained to use the breast milk pump. A total of 30 min rendition of the raga Malkauns and Yaman played on the flute was used for music therapy. Mothers heard the music with earphones.

Cross-over trial. Each subject was assessed for 4 sessions on Music Therapy and 4 sessions on No Music Therapy.

In the absence of any literature providing the yield of breast milk with and without music therapy, a sample size of 30 was fixed. Salivary cortisol was used as an indirect measure of stress. As it was a nonparametric data, Wilcoxon rank test was applied.

 Feher 1989, [54] RCT

no

Mothers in the treatment group received a cassette tape. The tape consisted of a progressive relaxation exercise followed by a guided imagery section. Progressive relaxation involves alternately tensing and relaxing muscle groups while taking deep breaths. The guided images included descriptions of pleasant surroundings, and the baby’s warm skin against the mother.

The treatment tape was made by the senior author, who was a man. It is possible that a female voice could increase the effectiveness of the tape.

After the initial interview, the women were randomly assigned to the intervention or comparison groups. All mothers received routine supportive care from the nursing staff, including verbal and written instructions concerning the use of the electric breast pump.

More clear-cut differences in creamatocrits might have been observed in this study if the time of day of sample collection had been standardized. Compared with the mothers in the intervention group, the group of control mothers were more likely to be primiparous, and were less likely to be affluent.

 Vidas 2011, [40] RCT

no

Mothers from the experimental group were taught autogenic training for 12 weeks. Autogenic training is a suggestion-supportive psychotherapy technique. Experienced physical changes lead to psychological relaxation.

Mothers in the intervention group were learning autogenic training with the trainer. Every two weeks they were practicing a new exercise. The six basic exercises of autogenic training were taught in small groups to 10 members.

Mothers from experimental and control groups were advised for successful breastfeeding up to six months of age. Both groups were equally satisfied with the health care in order to protect breastfeeding.

Despite the high satisfaction with counselling, mothers were more satisfied when they used autogenic training. According to the authors, this could mean that autogenic training plays a critical role in their success at breastfeeding.

 Mohd Shukri 2019, [52] RCT

no

After each home visit, mothers in the intervention group were asked to listen to the therapy daily while breastfeeding for at least 2 wk. They were also encouraged to listen beyond 2 wk. as frequently as they found useful throughout the trial and to record in a diary when it was used; the duration of the intervention was 12 wk.

The relaxation therapy audiorecording was a modified audio-guided imagery protocol designed for breastfeeding mothers.

Mothers in both groups received standard breastfeeding support during the trial (standard breastfeeding education materials such as a breastfeeding guidance booklet, as well as a list providing contact details of health practitioners in health clinics, breastfeeding support groups, and lactation counsellors in their area).

First, no adjustment of sample size was performed for the primary outcomes. Thus, the possibility of a type 1 error should be considered when interpreting the findings. Second, due to the nature of the therapy tool, it was not possible to blind mothers or researchers to the intervention.

 O’Connor 1998, [48] Quasi-experimental

no

Women in group 1 were encouraged to practice the relaxation once or twice a day for two weeks, and a second visit was made to all mothers with repeated breast milk collections; women who were still breast-feeding at 6 weeks after study end had a final breast milk sample collected. Women in group 2 had a conversation with similar breast milk sample collection. And women in group 3 had 1 breast milk sample collected.

Participants varied in their mental imagery preferences. Some described excellent visual imagery, whereas others preferred auditory or olfactory imagery.

Study groups: relaxation intervention, attention control, and no intervention.

This study explores relaxation success: recent mothers rated from very good to poor at relaxation. Inasmuch as the authors attempted to use the same relaxation coaching for each subject, they did not allow sufficiently for individual differences.

 Yu 2019, [47] Quasi-experimental, within-subject study

no

Primiparous mothers attended relaxation meditation tape, music tape, relaxation lighting, or combined relaxations sessions. The tape was recorded by a certified yoga therapist. Participants could choose their preferred music to enhance stress reduction. Participants could choose either the orange light (“Relax” setting) or the blue light (“Energize” setting) to meet their preference.

To control for circadian rhythm, all sessions were performed in the afternoon between 2:00 PM and 4:00 PM. The duration of each treatment was 10 min, with additional 10-min pre- and post- test measurements.

A within-subject study on mothers allocated in randomised order to different relaxation sessions and control sessions, with a washout period of 1–3 days between sessions.

Only 20 participants from one community were enrolled, so the population may not be representative. A potential disadvantage of the within-subjects design is that there might be “carryover effects” of one intervention on the next.

 Cowley 2005, [49] Case series, Pharmacotherapy and active mental imaging relaxation techniques

no

After learning how to recognize the signs of milk ejection, paraplegic mothers of five neonates used a process of relaxation and imaging to mentally elicit a let-down reflex. In the immediate postnatal period, one mother used an oxytocin nasal spray to enhance let-down.

Mothers watch their infants’ suckling behaviour, and as soon as their milk flow is starting to decrease, they begin the mental process to elicit a second let-down, through a series of thoughts that involved images of nurturing their infants.

There is no control group. However, the initial failure of the mother in case 1 to thrive her twins without relaxation techniques suggests that imaging techniques foster breastfeeding.

In this series, no measurements were made with which to correlate the mothers’ perceptions of let-down with increased intramammillary pressure. Therefore, it is possible that these mothers were able to achieve let-down without active mental relaxation techniques

 Tipping 2000, [46] Case series, Manual relaxation

no

In all cases, a reflexologist was asked to see a mother who was having difficulty with the initiation of lactation. At this time a reflexology treatment to activate the whole body of the mother is offered.

Teaching reflexology techniques to parents to empower them to have control over at least one part of their baby’s care.

Reflexology cannot take all the credit for the increase in lactation. There is no control group. Many women report self-esteem or confidence increase when supported in comprehensive ways.

The numbers involved were too small to substantiate that reflexology could reduce the particular stress involved with lactating mothers of a neonate.

 Hauck 2008, [43] Case series, Environmental sensory stimulations

no

A relaxation room has soft earthy colours and provides a chaise where a mother can lie and relax. The relaxing environment includes a fish tank, music and aromatherapy.

Information about the relaxation room and its aim to promote relaxation is provided during hospital tours and antenatal classes. Midwives encourage use of the room for relaxation for breastfeeding women, women in early labour, and anxious women.

A qualitative exploratory design was employed to obtain a rich description of the experience of using the relaxation room. No control group.

The researchers are aware that a Snoezelen room is just one example that may be considered to assist breastfeeding mothers to achieve relaxation, and anticipate that the description of these findings will enable the reader to determine the transferability of the findings to their own context.