key: cord-0727940-444voekp
authors: Moon, Hyojeong; Woo, Kyungmi
title: An integrative review on mothers' experiences of online breastfeeding peer support: Motivations, attributes and effects
date: 2021-05-07
journal: Matern Child Nutr
DOI: 10.1111/mcn.13200
sha: 6b88526c605d651ed979191d7d586104c2a3812c
doc_id: 727940
cord_uid: 444voekp

Information on the experiences surrounding online breastfeeding peer support among breastfeeding mothers and its effects on breastfeeding outcomes is growing yet to be synthesized. The aim of this review was to synthesize the evidence of mothers' experiences of online breastfeeding peer support. An integrative review was conducted. Five electronic databases were searched. Two reviewers independently screened the articles for inclusion. The inclusion criteria were (1) involved original data focusing on mothers' experiences of online breastfeeding peer support, (2) participants who were mothers who were breastfeeding or had experiences of breastfeeding and (3) studies focusing on interaction and communication among mothers through online communities. In total, 14 publications met the inclusion criteria. Breastfeeding mothers turned to online groups when they felt isolated, lacked professional support or preferred online support over face‐to‐face support. Online breastfeeding peer support was characterized as a virtual community, with easy access, availability and a wealth of resources from actual experiences of mothers. It empowered breastfeeding mothers and resulted in changes in breastfeeding outcomes and perceptions. The positive aspects of online breastfeeding peer support have recently garnered more attention. This review provided baseline data and evidence to supplement and improve the current breastfeeding support system for breastfeeding mothers. The evidence on the effectiveness of online breastfeeding peer support for influencing breastfeeding outcomes remains inconclusive. Further empirical studies with rigorous study designs are warranted.

(2) participants who were mothers who were breastfeeding or had experiences of breastfeeding and (3) studies focusing on interaction and communication among mothers through online communities. In total, 14 publications met the inclusion criteria. Breastfeeding mothers turned to online groups when they felt isolated, lacked professional support or preferred online support over face-to-face support.

Online breastfeeding peer support was characterized as a virtual community, with easy access, availability and a wealth of resources from actual experiences of mothers. It empowered breastfeeding mothers and resulted in changes in breastfeeding outcomes and perceptions. The positive aspects of online breastfeeding peer support have recently garnered more attention. This review provided baseline data and evidence to supplement and improve the current breastfeeding support system for breastfeeding mothers. The evidence on the effectiveness of online breastfeeding peer support for influencing breastfeeding outcomes remains inconclusive. Further empirical studies with rigorous study designs are warranted.

breastfeeding, breastfeeding support, human lactation, peer support, support, support group

Breast milk is the ideal source of nutrition for newborns and young children. Breast milk, sometimes called the newborn's first vaccine, contains all the nutrients and immune substances necessary for newborns (World Health Organization, 2018) . It helps in the physical and mental development of children and reduces their risk of becoming overweight or obese (World Health Organization, 2018) . In addition, children who are breastfed have a lower risk of developing asthma, type 1 diabetes, acute otitis media and respiratory diseases (Centers for Disease Control and Prevention, 2019) . Breastfeeding is also beneficial for the health of mothers. It lowers the risk of breast cancer, ovarian cancer and metabolic diseases such as type 2 diabetes (Centers for Disease Control and Prevention, 2019; Chowdhury et al., 2015; World Health Organization, 2020) .

Despite increasing reports on its benefits over the past two decades, no notable increase in the global rates of breastfeeding has been observed (World Health Organization, 2020) . The exclusive breastfeeding rates among infants under 6 months of age have been well below 50% in most countries (World Health Organization, 2020) .

It has been reported that mothers stop breastfeeding earlier than initially planned when they fail to obtain appropriate support for various issues that occur during breastfeeding (Odom et al., 2013; Sriraman & Kellams, 2016) .

Breastfeeding support from peers is highly valued. Peer support is provided by mothers who have a wealth of empirical knowledge regarding breastfeeding and are usually of a similar level of age, socioeconomic status, race and place of residence at an appropriate time (Dennis, 2002) . The positive effects of peer support on breastfeeding attempts and duration have been reported in several previous studies (Hongo et al., 2019; Meedya et al., 2010; Raj & Plichta, 1998; Shakya et al., 2017; Sudfeld et al., 2012) .

Breastfeeding peer support can come in a variety of forms, either in person, over the phone, or through social media on the Internet. According to a review by McFadden et al. (2017) , breastfeeding peer support had a better effect on support received face-to-face than non-face-to-face support such as over the telephone. However, in reality, obtaining peer support in-person during the postpartum period has certain limitations such as physical restraints. In addition, there has been more limit to gaining support for breastfeeding by face-to-face after childbirth because of COVID-19 (Brown & Shenker, 2021) .

Only recently has research on breastfeeding peer support through social media been conducted actively. Mothers form breastfeeding support groups through social media where they exchange support related to breastfeeding (Bridges, 2016; Clapton-Caputo et al., 2020; Jackson & Hallam, 2020; Skelton et al., 2018) . In the context of COVID-19, where in-person social networks have become increasingly restricted, online peer support provides an easy, convenient and unique opportunity to connect and communicate with the other mothers (Yamashita et al., 2020) .

Previous studies have reviewed the effects of peer support on breastfeeding (Jolly et al., 2012; Kaunonen et al., 2012; Shakya et al., 2017; Sudfeld et al., 2012) , but none, to best of our knowledge, have focused on the breastfeeding peer support through social media.

Integrative review method is the only approach that incorporates diverse methodologies such as experimental and non-experimental research and potentiates evidence-based nursing practice (Whittemore & Knafl, 2005) . Therefore, the purpose of this review is to synthesize the current evidence on mothers' experiences of online breastfeeding peer support in studies using various methodologies to provide baseline data and evidence to supplement and improve the current breastfeeding peer support system. The research questions were as follows:

1. What are the reasons that mothers seek online breastfeeding peer support?

2. What are the attributes of online breastfeeding peer support?

3. What effects have been achieved by utilizing online breastfeeding peer support? 2 | METHODS

This integrative review followed the five stages described by Whittemore and Knafl (2005) : (1) problem identification, (2) literature search, (3) data evaluation, (4) data analysis and (5) 

• Evidence regarding mothers' experiences of the utilization of online breastfeeding peer support and its effects on breastfeeding outcomes is currently limited.

• This review demonstrates that breastfeeding mothers seek online peer support when they feel isolated, lack professional support or prefer online than offline support.

Online peer support groups are virtual communities for breastfeeding mothers and are easily accessible, constantly available and provide a wealth of resources from experienced mothers.

• Online breastfeeding peer support provides some positive effects on breastfeeding duration and exclusive breastfeeding rates, but the evidence is limited due to the lack of empirical designs.

• This review provided baseline data and evidence for supplementing and improving the current breastfeeding support system. breastfeeding mobile application or a website, nonresearch articles and those whose full texts were unavailable.

The search was carried out in October 2020. Five databases (PubMed, CINAHL, Web of Science, PsycINFO and Cochrane Library) were searched using both medical subject headings (MeSH terms) and key words presented in Table 1 . Reference lists were also checked for any relevant articles. Searches were limited to studies published in English with full texts and human subjects. No limitations related to the year of publication were applied.

The two reviewers (HM and KW) independently screened the titles and abstracts to decide which articles would potentially meet the inclusion criteria. Then, full texts were reviewed independently by the reviewers, and a consensus was reached after discussion.

The quality of the selected studies was evaluated according to the Mixed Methods Appraisal Tool (MMAT) version 2018 (Hong et al., 2018) . All included studies were evaluated by two reviewers.

Both reviewers independently conducted the quality assessment, and a consensus was reached after discussion. All studies were included in the analysis to achieve a comprehensive view of the status of the research.

The contents from the studies were extracted and tabulated. This includes the authors and year of publication, study design, number of participants, characteristics of participants, the description of online breastfeeding peer support groups, interventions, methods of data collection and analysis and a summary of essential findings. The details of findings were placed in a matrix. Then, the contents were compared item by item, and similar data were categorized and grouped together according to the research questions (Whittemore & Knafl, 2005) . While constantly comparing the grouped data, the findings were coded according to emergent themes and subthemes. Constant comparison enables the identification of patterns and commonalities between studies (Whittemore & Knafl, 2005) . The data analysis process was reviewed by the authors, and agreement was reached on the identification of major themes of the study.

The initial search yielded 941 articles. After removing duplicate citations, 506 article titles and abstracts were screened. Of those, 31 fulltext studies were assessed for eligibility based on the inclusion 3 1 AND 2 4 AB support OR MH "peer group" OR AB "peer support" OR AB "peer counseling" OR MH "social support" PsycINFO 1 AB online OR MA "social media" OR MA Internet OR AB Facebook OR AB web 2 MA "breast feeding" OR AB breastfeeding OR AB "breast milk" 3 1 AND 2 4 AB support OR MA "peer group" OR AB "peer support" OR AB "peer counseling" OR MA "social support" 5 3 AND 4

Cochrane Library 1 (online):ti,ab,kw OR ("social media"):ti,ab,kw OR ("Internet"):ti,ab,kw OR (Facebook):ti,ab,kw OR (web):ti,ab,kw 2 ("breast feeding"):ti,ab,kw OR (breastfeeding):ti,ab, kw OR ("breast milk"):ti,ab,kw 3 1 AND 2 4 (support):ti,ab,kw OR ("peer group"):ti,ab,kw OR ("peer support"):ti,ab,kw OR ("peer counseling"):ti, ab,kw OR ("social support"):ti,ab,kw 5 3 AND 4 criteria. Those not meeting the criteria were excluded, leaving 14 articles for this review (Figure 1 ).

A total of 14 publications met the criteria and were chosen for the review. Nine were qualitative (Alianmoghaddam et al., 2019; Black et al., 2020; Bridges, 2016; Clapton-Caputo et al., 2020; Jackson & Hallam, 2020; Niela-Vilén et al., 2015; Regan & Brown, 2019; Skelton et al., 2018) , and two were mixed methods (Herron et al., 2015; Skelton et al., 2020) . The remaining three were quantitative studies, of which two were randomized controlled trials (RCTs) (Cavalcanti et al., 2019; Niela-Vilén et al., 2016) and one was a cross-sectional survey . The participants in seven studies were breastfeeding mothers with no specification (Alianmoghaddam et al., 2019; Bridges, 2016; Cavalcanti et al., 2019; Herron et al., 2015; Regan & Brown, 2019; Skelton et al., 2018 Skelton et al., , 2020 . In the other seven studies, the participants were from specific groups of breastfeeding mothers, including primiparous mothers, mothers with preterm infants, primiparous African American mothers, mothers who exclusively expressed breast milk and ones who continued breastfeeding over 12 months of the child's age (Black et al., 2020; Clapton-Caputo et al., 2020; Jackson & Hallam, 2020; Niela-Vilén et al., 2015; Niela-Vilén et al., 2016; . The breastfeeding peer support groups in 10 studies were exclusively on Facebook (Black et al., 2020; Bridges, 2016; Cavalcanti et al., 2019; Clapton-Caputo et al., 2020; Niela-Vilén et al., 2015; Niela-Vilén et al., 2016; Skelton et al., 2018 Skelton et al., , 2020 . The groups in the remaining four studies were from forums in parenting websites or unspecified social media groups (Alianmoghaddam et al., 2019; Herron et al., 2015; Jackson & Hallam, 2020; Regan & Brown, 2019) . The scope of social media was diverse, from local to national and even international-level peer support groups. In most studies, that is, 10 of them, the groups were moderated by voluntary peer supporters and professionals, such as

International Board-Certified Lactation Consultants (Alianmoghaddam et al., 2019; Black et al., 2020; Bridges, 2016; Cavalcanti et al., 2019; Niela-Vilén et al., 2015 , 2016 Skelton et al., 2018 Skelton et al., , 2020 . Although the publication years were not limited, all selected studies were published after 2015. Four studies were conducted in the United States Skelton et al., 2018 Skelton et al., , 2020 , three in the United Kingdom (Herron et al., 2015;  F I G U R E 1 PRISMA flow diagram Jackson & Hallam, 2020; Regan & Brown, 2019) , two in Finland (Niela-Vilén et al., 2015 , 2016 , two in Australia (Bridges, 2016; Clapton-Caputo et al., 2020) and one each in Brazil (Cavalcanti et al., 2019) , Ireland (Black et al., 2020) and New Zealand (Alianmoghaddam et al., 2019) (Table 2) .

Study quality appraisal using the MMAT version 2018 is presented in Table 3 . Overall, the quality of qualitative studies was good. Seven out of nine qualitative studies met all five criteria for quality 3.3 | Motivations to seek online breastfeeding peer support

Breastfeeding mothers sought online support when they felt isolated.

An absent or inadequate in-person social support network was identi- Regan & Brown, 2019; Skelton et al., 2020) . Primiparous mothers who did not know anyone or knew only a few others with experiences of breastfeeding had a limited resource to seek breastfeeding support (Herron et al., 2015) . Breastfeeding mothers who did not know anyone with experiences within the immediate social network felt isolated and desired to find the support online (Regan & Brown, 2019; Skelton et al., 2020) . For mothers, whose breastfeeding practices were uncommon, such as mothers who practiced exclusive expression of breast milk, unmet needs of in-person breastfeeding support were observed (Clapton-Caputo et al., 2020) . Mothers turned to online platforms when they received no support (Skelton et al., 2018) or unsatisfactory support from significant others, family members and/or friends (Herron et al., 2015; Regan & Brown, 2019) . Unmet informational needs, a lack of skill (Alianmoghaddam et al., 2019; Clapton-Caputo et al., 2020; Herron et al., 2015; Niela-Vilén et al., 2015) and stigmatization regarding breastfeeding in public, exclusive pumping and continued breastfeeding beyond infancy (Alianmoghaddam et al., 2019; Skelton et al., 2018) were reported as motivations of seeking online breastfeeding peer support (Table 4 ).

Mothers reported that inadequate breastfeeding support from health care professionals (HCPs) led them to turn to online support.

In a study by Regan and Brown (2019) , mothers stated that the support on breastfeeding was insufficiently provided after childbirth. In addition, mothers reported that the support from their HCPs diminished and was insufficient as they continued breastfeeding beyond 12 months of their child in a study by Jackson and Hallam (2020) .

Mothers' negative experiences with HCPs who had a lacked knowledge and/or specific training on breastfeeding were also addressed 

Breastfeeding mothers who preferred online support mentioned that they had difficulty accessing local face-to-face breastfeeding support due to physical exhaustion (Bridges, 2016; Regan & Brown, 2019) and pressure in terms of time and resource (Bridges, 2016; Herron et al., 2015; Regan & Brown, 2019) . In addition, mothers preferred online breastfeeding support due to its convenience (Herron et al., 2015) and flexibility (Bridges, 2016) .

Online breastfeeding peer support took place in a virtual community for breastfeeding mothers. There were four factors describing an online breastfeeding community: shared experiences in breastfeeding, breastfeeding, asked questions on issues related to breastfeeding and received tailored solutions. By sharing common experiences, motherto-mother support alleviated isolation and provided emotional support. In addition, shared experiences among breastfeeding mothers enabled mothers to feel a sense of bond, belonging, comfort and empowerment (Clapton-Caputo et al., 2020; Regan & Brown, 2019; Skelton et al., 2018 Skelton et al., , 2020 .

Breastfeeding peer support groups in social media provided reassurance and normalized breastfeeding practices. Mothers were reassured by reading others' challenges and from advice by peers (Alianmoghaddam et al., 2019; Regan & Brown, 2019) . For those who fed their children with expressed breast milk or breastfed beyond infancy, online support offered reassurance that their feeding practices were also valuable and beneficial to their children (Clapton-Caputo et al., 2020; Jackson & Hallam, 2020) . In addition, online breastfeeding peer support disproved misconceptions (Black et al., 2020; Bridges, 2016; Herron et al., 2015; Jackson & Hallam, 2020; Regan & Brown, 2019; Skelton et al., 2018 Skelton et al., , 2020 .

Indirect reciprocity was also dominant among the studies reviewed. Mothers who received support from the community were willing to help others; mothers who had previously gained support returned to or stayed in the groups to provide support to other novice mothers who were assumed to be experiencing similar trial-and-errors in their breastfeeding journey (Alianmoghaddam et al., 2019; Black et al., 2020; Bridges, 2016; Clapton-Caputo et al., 2020; Herron et al., 2015; Jackson & Hallam, 2020; Niela-Vilén et al., 2015; Regan & Brown, 2019; Skelton et al., 2018 Skelton et al., , 2020 . Bridges (2016) noted that this act of offering support to other breastfeeding mothers is particularly important to sustain an online community in a healthy and productive way.

Mothers in the groups reported they felt a strong sense of confidentiality within the groups despite online breastfeeding support groups were composed mainly of strangers (Bridges, 2016; Skelton et al., 2018 Skelton et al., , 2020 . The online breastfeeding community was a comfortable place to ask questions (Black et al., 2020) , and the nature of anonymity in an online environment made it possible for mothers to freely discuss matters online (Herron et al., 2015; Skelton et al., 2018) .

Online breastfeeding peer support was easily accessible by anyone, anytime and anywhere, via mobile devices, such as mobile phones, tablets and/or laptops (Alianmoghaddam et al., 2019; Black et al., 2020; Bridges, 2016; Herron et al., 2015; Niela-Vilén et al., 2015; . In addition, mothers were able to access help and receive timely support from the groups whenever the support was needed, all day and all night. There was no limitation in terms of time or geographical distance. Immediacy of online breastfeeding peer support was emphasized; there was always someone online to help mothers, offering support the mothers needed (Alianmoghaddam et al., 2019; Black et al., 2020; Bridges, 2016; Clapton-Caputo et al., 2020; Herron et al., 2015; Jackson & Hallam, 2020; Niela-Vilén et al., 2015; Regan & Brown, 2019; Skelton et al., 2018) .

Being such a real-time resource, online breastfeeding peer support (Skelton et al., 2018) , and mothers felt that they were not alone in their breastfeeding journey with the help of online peer support (Jackson & Hallam, 2020) .

Mothers appreciated factual or evidence-based information and advice from a variety of peers and professionals with extensive experience in breastfeeding, either directly or indirectly. (Bridges, 2016; Jackson & Hallam, 2020; Regan & Brown, 2019; Skelton et al., 2018) and considered the information and advice to be more beneficial than those from the HCPs with less experience (Clapton-Caputo et al., 2020; Jackson & Hallam, 2020) .

Mothers expressed their trust over the information and advice provided by their peers (Alianmoghaddam et al., 2019; Clapton-Caputo et al., 2020; Skelton et al., 2018 Skelton et al., , 2020 . Online breastfeeding peer support was tailored to mothers with specific circumstances. Peer supporters provided relevant and specific information with references (Black et al., 2020; Clapton-Caputo et al., 2020; Herron et al., 2015; Regan & Brown, 2019) . In addition, online breastfeeding peer support enabled mothers to access advice from peers and professionals for free (Black et al., 2020) .

3.5 | Effects of online breastfeeding peer support

One of the effects of online breastfeeding peer support was empowerment of self and others. Mothers gained self-confidence and became empowered as they involved themselves in online breastfeeding support communities, through the activities of reading others' experiences, asking questions, receiving support and commenting on others' posts (Alianmoghaddam et al., 2019; Black et al., 2020; Bridges, 2016; Clapton-Caputo et al., 2020; Jackson & Hallam, 2020; Niela-Vilén et al., 2015; Skelton et al., 2018) . In addition, mothers who were empowered enough were willing to make others empowered in their breastfeeding journey, giving advice and supporting them to continue breastfeeding (Alianmoghaddam et al., 2019; Jackson & Hallam, 2020; .

Online breastfeeding peer support brought changes in breastfeeding outcomes and perceptions among breastfeeding mothers. Seven studies addressed that the breastfeeding goals were extended or achieved (Black et al., 2020; Clapton-Caputo et al., 2020; Herron et al., 2015; Skelton et al., 2018 Skelton et al., , 2020 . However, the effect of online breastfeeding peer support on the duration of breastfeeding was inconsistent. Four studies specifically mentioned the duration of breastfeeding as the outcome; the breastfeeding duration was reported to be extended in an RCT by Cavalcanti et al. (2019) and two qualitative studies by and Skelton et al. (2018) in the study by Cavalcanti et al. (2019) also increased after participating in an online breastfeeding peer support group.

Online breastfeeding peer support brought a change in breastfeeding perceptions in mothers as well. Mothers perceived breastfeeding as something to be proud of (Jackson & Hallam, 2020) and public breastfeeding into something to be comfortable with Skelton et al., 2018) .

This review presents an overview of the evidence regarding mothers' online breastfeeding peer support experiences using the methodology of integrative review, which enabled a more comprehensive understanding by synthesizing various studies with different study designs and populations.

A large proportion of the included studies were targeted at certain groups of mothers, such as those who were exclusively expressing, breastfeeding beyond their child's infancy and breastfeeding preterm infants. The reason these groups of mothers sought online support was mainly due to a lack of understanding from their social network, including their family members and HCPs. These Mothers turned online for support when support from HCPs was unsatisfactory. HCPs, who work in maternity care in particular, need to develop in-depth knowledge and skills related to breastfeeding management (McGuire, 2014) . HCPs, despite their theoretical expertise, often lacked the latest knowledge and experience in breastfeeding and were not ready to address the needs of breastfeeding mothers (de Almeida et al., 2015; Radzyminski & Callister, 2015) . Several studies have found that mothers appreciated support from non-HCPs who had experiences in breastfeeding (Balogun et al., 2016; McFadden et al., 2017; O'Connor et al., 2011; Pate, 2009) . Resources from HCPs, such as information and allocated time, have been reported to be limited. They often provide evidence-based information but tend to provide information that does not take into account the mother's individual circumstances (Blixt et al., 2019) . Training targeting HCPs should be implemented to ensure that evidence-based and sensible breastfeeding support is delivered to mothers.

Independence from limitations surrounding geography and time is a major characteristic of online breastfeeding support. Mothers can give or receive breastfeeding support regardless of time and where they resided. Mothers in a similar situation developed a close network with others and shared their experiences from anywhere without leaving their home (Bartholomew et al., 2012) . In addition, peer support can be expanded to diverse population groups regardless of age, education, race, ethnicity or locality (Moorhead et al., 2013) , which is also a beneficial characteristic of online breastfeeding support. Due to the COVID-19 pandemic, local breastfeeding support group meetings have been cancelled or are being moved online.

Mothers, according to a recent study by Brown and Shenker (2021) , have struggled to get support and had many barriers with breastfeeding. Overcoming the difficulties of the current situation with the advantage of online breastfeeding peer support seems to be an alternative.

Online breastfeeding peer support groups are highly valued with many benefits; however, negative aspects still exist. Further research is necessary to explore the roles of moderators and the effectiveness of moderation or facilitation from professionals or laypeople within online peer support groups (Coulson & Greenwood, 2012; Eysenbach et al., 2004) .

Effects associated with breastfeeding peer support in social media were predominantly positive in this review. However, its effectiveness remains inconclusive because of the limited number of empirical studies, such as RCTs in the area reviewed. RCTs are considered the gold standard for determining the effectiveness of health care interventions (Grove et al., 2012) . Thus, there is a need for high-quality research in online breastfeeding peer support with this methodology.

In five out of 11 qualitative studies, experiences surrounding online breastfeeding peer support were analysed based on theories from sociology and psychology. Of the two RCTs included, none of the interventions were based on theories. As theoretical knowledge can be used to guide the development of an intervention and provide direction in the design of the study and testing procedures (Grove et al., 2012) , a systemic intervention needs to be developed and tested based on appropriate theories (Craig et al., 2008) to ensure that evidence-based breastfeeding peer support is provided in social media.

First, there is a generalizability issue related to participants. Women who participated in the studies may have high online competence, which may indicate that women with less online competence may be excluded. Second, representativeness of the samples in each study is limited. Most studies recruited participants through social media except a few. Therefore, in the case of mothers who had already experienced negative aspects of online breastfeeding peer support, it is highly likely that they had removed themselves from the group, which might limit the scope of experiences of online breastfeeding peer support. There is also a possibility that the findings of this review might be further improved by including non-English publications.

It is significant that this review has provided baseline data and evidence for supplementing and improving the current breastfeeding peer support system for breastfeeding mothers. However, the evidence is still insufficient due to a lack of empirical research designs of the included studies. More rigorous research is warranted not only in Asia but also in non-North American and non-Northwestern European countries. If theory-based interventions using RCTs are conducted, more evidence-based research and practice would be possible.

This review synthesized the evidence of mothers' experiences of online breastfeeding peer support to provide baseline data and evidence to supplement and improve the current breastfeeding peer support system. Breastfeeding mothers sought online peer support when they felt isolated, lacked professional support or preferred online than offline support. Online breastfeeding peer support was characterized as a virtual community, with easy access, availability and a wealth of resources from actual experiences of mothers. It empowered breastfeeding mothers and resulted in changes in breastfeeding outcomes and perceptions.

Considering that breastfeeding is a critical piece of optimal maternal and child health, we believe this paper would contribute to enhancing breastfeeding practice by providing insights into the mother's online breastfeeding peer support experience. There is no doubt that online breastfeeding peer support is an increasing phenomenon that provides a unique form of support supplementing other methods of support, and it should be further developed and tested through research. More empirical studies on the effectiveness of online breastfeeding peer support with a rigorous design are necessary.

This review received no specific grant from any agency.

The authors declare no conflict of interest.

HM conceived the research question. HM and KW created the search strategy. HM conducted the search. HM and KW conducted the study selection and data extraction. HM and KW contributed to data interpretation and involved in writing and editing. KW approved the final article.

Data in this study were a reanalysis of existing data, which are openly available at locations cited in the reference section.

Hyojeong Moon https://orcid.org/0000-0002-8424-3960

Kyungmi Woo https://orcid.org/0000-0002-8710-2696

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Infant and young child feeding

How to cite this article: Moon H, Woo K. An integrative review on mothers' experiences of online breastfeeding peer support: Motivations, attributes and effects

seek online breastfeeding support Isolation as a breastfeeding mother -Lack of in-person social support network (Clapton-Caputo et al., 2020; Herron et al., 2015; Regan & Brown, 2019; Skelton et al., 2020 ) -Lack of understanding (Clapton-Caputo et al., 2020) -Lack of support or unsatisfactory support from partners, family members, friends or others (Herron et al., 2015; Regan & Brown, 2019; Skelton et al., 2018 ) -Unmet informational needs (Alianmoghaddam et al., 2019; Clapton-Caputo et al., 2020; Herron et al., 2015; Niela-Vilén et al., 2015 ) -Lack of skill (Niela-Vilén et al., 2015) -Stigmatization (Alianmoghaddam et al., 2019; Skelton et al., 2018) Unmet support needs from health care professionals -Lack of breastfeeding support (Jackson & Hallam, 2020; Regan & Brown, 2019 ) -Lack of knowledge (Clapton-Caputo et al., 2020; Herron et al., 2015 ) -Lack of specific training (Herron et al., 2015;  Regan & Brown, 2019) -Contradictory advice (Herron et al., 2015; Niela-Vilén et al., 2015; Regan & Brown, 2019) -Discouragement to breastfeed premature babies (Herron et al., 2015; Niela-Vilén et al., 2015) Preference for online breastfeeding support -Difficulty accessing face-to-face breastfeeding support ✓ Physically exhausted (Regan & Brown, (Bridges, 2016; Skelton et al., 2018 Skelton et al., , 2020 Easy access and round-the-clock availability -Easy access via mobile devices regardless of time and location (Alianmoghaddam et al., 2019; Black et al., 2020; Bridges, 2016; Herron et al., 2015; Niela-Vilén et al., 2015; ) -Access to help and timely support, unlimited by time and geographical distance (Alianmoghaddam et al., 2019; Black et al., 2020; Bridges, 2016; Clapton-Caputo et al., 2020; Herron et al., 2015; Jackson & Hallam, 2020; Niela-Vilén et al., 2015; Regan & Brown, 2019; Skelton et al., 2018) Resource from lived experience -From a variety of people (Jackson & Hallam, 2020; Regan & Brown, 2019; Skelton et al., 2018 ) -Factual/evidence based and experiential (Bridges, 2016; Jackson & Hallam, 2020; ) -Beneficial than health care professionals (Clapton-Caputo et al., 2020; Jackson & Hallam, 2020 ) -Reliable (Alianmoghaddam et al., 2019; Clapton-Caputo et al., 2020; Skelton et al., 2018 Skelton et al., , 2020 ) -Tailored (Black et al., 2020; Clapton-Caputo., 2020; Herron et al., 2015; Regan & Brown, 2019 ) -Costless (Black et al., 2020) Effects of online breastfeeding support Empowerment of self and others Alianmoghaddam et al., 2019; Black et al., 2020; Bridges, 2016; Clapton-Caputo et al., 2020; Jackson & Hallam, 2020; Niela-Vilén et al., 2015; Skelton et al., 2018 Changes in breastfeeding outcomes and perceptions -Changes in breastfeeding outcomes Breastfeeding goals ✓ Extended or achieved (Black et al., 2020; Clapton-Caputo et al., 2020; Herron et al., 2015; Skelton et al., 2018 Skelton et al., , 2020 Breastfeeding duration ✓ Extended (Cavalcanti et al., 2019; Skelton et al., 2018 ) ✓ No effect (Niela-Vilén et al., 2016 Exclusive breastfeeding rates ✓ Increased (Cavalcanti et al., 2019) -Changes in breastfeeding perception Breastfeeding as something to be proud of (Jackson & Hallam, 2020 ) Comfort with public breastfeeding Skelton et al., 2018)