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Support for breastfeeding mothers

  1. Cathryn Britton2,
  2. Felicia M McCormick1,*,
  3. Mary J Renfrew1,
  4. Angela Wade3,
  5. Sarah E King1

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 24 JAN 2007

Assessed as up-to-date: 8 NOV 2006

DOI: 10.1002/14651858.CD001141.pub3


How to Cite

Britton C, McCormick FM, Renfrew MJ, Wade A, King SE. Support for breastfeeding mothers. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001141. DOI: 10.1002/14651858.CD001141.pub3.

Author Information

  1. 1

    University of York, Mother and Infant Research Unit, Department of Health Sciences, York, UK

  2. 2

    University of York, Department of Health Sciences, York, UK

  3. 3

    Institute of Child Health, Centre for Paediatric Epidemiology and Biostatistics, London, UK

*Felicia M McCormick, Mother and Infant Research Unit, Department of Health Sciences, University of York, Area 4, Seebohm Rowntree Building, Heslington, York, YO10 5DD, UK. fm510@york.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 24 JAN 2007

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This is not the most recent version of the article. View current version (16 MAY 2012)

 
Characteristics of included studies [ordered by study ID]
Albernaz 2003

MethodsPrimary care facilities. Recruitment over 5 months, n = 169. Follow up 95%. Outcome assessment not blinded.


Participants3 hospitals in the city of Pelotas, in southern Brazil. Ethnic composition not described. Inclusion criteria: term healthy baby, family income at least US $500 pcm (no economic constraints to baby's growth), mother intends to breastfeed and does not smoke. Baseline prevalence of breastfeeding in Brazil in the first 30 days = 88%.


InterventionsHospital visit, home visits at 5, 15, 30, 45, 90 and 120 days, and 24 hour telephone hotline for help or to arrange visits. Two members of the lactation support team had received the 40 h WHO lactation support training course.


OutcomesBreastfeeding pattern and duration up to age 4 months. Breastmilk intake for a subgroup of 68 infants at 4 months.


NotesAuthors state that children in the control group attended paediatric clinics where general advice on advantages of breastfeeding may have been offered, but specific lactation counseling was not provided.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Barros 1994

MethodsSingle-site study, n = 900. Six month follow up 93%. Stated as randomised but method not described. Reasons for drop-out recorded. Outcome assessor independent of intervention.


ParticipantsUrban setting in Brazil: in-patient maternity unit. Ethnic composition not described. Inclusion criteria: family income less than twice the minimum Brazilian wage; hospital stay less than 5 days; wanting to breastfeed: living within the city of Pelotas. Baseline prevalence in Pelotas (1993) for any breastfeeding: 85% at 1 month, 66% at 3 months and 38% at 6 months.


InterventionsThree home visits at 5, 10 and 20 days postpartum by a social assistant or nutritionist. The visitor was required to have a personal history of successfully breastfeeding a child and received training in breastfeeding physiology and common breastfeeding problems and their solutions.


OutcomesBreastfeeding at monthly intervals to 6 months and median duration of breastfeeding. Time to introduction of artificial feeds. Difficulties encountered during breastfeeding and reasons for weaning also recorded.


NotesIn usual care, a social assistant would not normally make routine home visits but would visit only when requested to do so by the hospital team.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Bhandari 2003

MethodsCluster-randomised study with 8 sites, n = 1115. 6 month follow up 86%. Communities were paired on the basis of similar scores for socio-economic, mortality and morbidity indicators. One of each pair was allocated to the intervention using a random numbers table. Reasons for dropout recorded. Outcome assessment not blinded.


Participants8 village communities located 3-5 km from the main highway in Haryana, India. Inclusion criteria: born in a study village within 9 months of start of intervention. Baseline breastfeeding prevalence stated to be high.


InterventionsHealth and nutrition workers in the intervention communities received training based on Integrated Management of Childhood Illnesses Training Manual on Breastfeeding Counseling (WHO 1997). Messages - feed only breastmilk for first 6 months of life; breastfeed the infant day and night, at least 8 times in 24 h; possible adverse effects of other foods and fluids given to breastfeeding infants - given to mothers at birth, monthly home visits, immunisation clinics and neighbourhood meetings.


OutcomesFeeding at 3 months.
Anthropometry and diarrhoea prevalence at 3 and 6 months.


NotesControl communities received routine care.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Brent 1995

MethodsSingle-site study. Duration not stated, n = 115. Follow up 94%. Randomisation partially described but allocation concealment unclear. Reasons for drop-out not recorded. Outcome assessment not independent of intervention. Potential confounders: women were excluded from intervention group following randomisation if they had received fewer than 2 prenatal lactation consultations; intention-to-treat analysis not performed (8 women in control group who met lactation consultant excluded); intervention included input to staff caring for both intervention and control groups.


ParticipantsUrban USA - ambulatory care centre and in-patient maternity unit. Inclusion criteria: English speaking; nulliparous. Exclusion criteria: separated from child at birth; preterm delivery; child in NICU longer than 72 hours. Ethnic composition: described as 71% white. 90% of participants were eligible for WIC programmes for those on low income. Baseline prevalence of breastfeeding at birth in national WIC sample = 33% (1991).


InterventionsPackage of: 2-4 prenatal sessions with lactation consultant (10-15 minutes each); telephone call 48 hours after discharge; visit to lactation clinic at 1 week postpartum (staffed by paediatrician or lactation consultant); contact with lactation consultant at each health supervision visit until weaning or 1 year; professional education of nursing and medical staff.


OutcomesRates of breastfeeding at 2 months and median duration of breastfeeding.


NotesControl group were offered optional prenatal breastfeeding classes, postpartum breastfeeding instruction by nurses and physicians and out-patient follow up by nurses and physicians in the paediatric ambulatory department.
Study population not limited to those intending to breastfeed.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Chapman 2004

MethodsRecruitment July 2000 - August 2002 at an urban US hospital with BFI accreditation. 219 women met antenatal inclusion criteria and were randomised by being entered into a data file weekly, with SPSS randomly selecting approximately 50%. These were assigned to the intervention group and the others were controls. Further inclusion criteria specified term, healthy, singleton baby, with no congenital abnormalities, no maternal history of HIV and no admission to NICU. After birth, n = 165 women remained in the study, 90 in the intervention group and 75 controls. Follow up at 3 months was 77/90 (87%) and 67/75 (89%). Reasons for postnatal loss to follow up are not reported. Blinding of outcome assessment was attempted.


ParticipantsUrban US hospital prenatal clinic serving a low-income, predominantly Latina population. Antenatal inclusion criteria: low-income women at least 18 years old, at 26 weeks' gestation or less, considering breastfeeding, not yet enrolled in peer counseling programme, resident in hospital area, available for telephone follow up. Postnatal inclusion criteria: healthy, full term singleton infants, no congenital abnormalities, no maternal history of HIV. Ethnic composition: 80% Hispanic (61% Puerto Rican origin), 9% African American, 3% white, 8% other. Breastfeeding prevalence low.


InterventionsPackage of: one prenatal home visit, daily visits during postpartum hospitalisation, home visit within 24 hours and at least 2 more home visits as requested, and telephone/pager contact. Package delivered by peer Counsellors who received 30 hours classroom training using combined curricula of LLLI Peer Counseling Program and Hispanic Health Council's BHP program. Peer counsellors had to score 85% in a written exam and worked for 3-6 months with experienced peer counsellors. After demonstrating competence, peer counsellors worked independently with clients. Peer counsellors had 1 hour per month continuing education and were paid for their work.


OutcomesBreastfeeding rates at birth and 1, 3 and 6 months postpartum.
Subgroups most responsive to breastfeeding peer counseling.


NotesThose in the control group received routine breastfeeding education offered by the study hospital, and the same breastfeeding services as privately paying women. A small amount of exposure to peer counselors among the control group was reported.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Davies-Adetugbo 1997

MethodsParticipants recruited from 8 public health maternity units. Duration of recruitment 6 months, n = 1003. Follow up 86%. Randomisation appropriate. Reasons for drop out not recorded. Outcome assessment blinded.


ParticipantsOsun State, rural Nigeria. Primary healthcare centre and home visits. Inclusion criteria: children presenting with uncomplicated diarrhoea to primary health care facility. Exclusions: severe diarrhoea. Baseline prevalence (UNICEF): exclusive breastfeeding at 0-3 months = 22%. Breastfeeding with complementary foods 6-9 months = 44%.


InterventionsLactation management/counseling sessions by Community Health Workers and 2 research assistants. Training: adapted WHO breastfeeding counseling and BFI courses. 18 hours duration.
Sessions on days 0, 2 and 7, lasting 30 minutes.


OutcomesExclusive and partial breastfeeding at 1 and 3 weeks postintervention. Recurrence of diarrhoea.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate





Dennis 2002

MethodsSingle-site study recruiting over 10 months, n = 258. 99% follow up. Randomisation appropriate. Outcome assessor blinded.


ParticipantsWomen at home in Toronto, Canada. Inclusion criteria: English speaking; primiparous; 16 years or over; single full-term baby. Intending to breastfeed. Predominantly educated, Caucasian and over 25 years with income over $40,000/year.
Baseline prevalence: breastfeeding initiation 79%; 35% exclusive breastfeeding at 4 months.


InterventionsTelephone support by briefly-trained volunteers (2.5 hour session) who had personal breastfeeding experience for at least 6 months. First contact within 48 hours of hospital discharge and then as required. Mean number of contacts in those completing log-books = 5.4. Mean duration of telephone contact = 16.2 min. 97% of contacts by telephone. 3% at home.


OutcomesBreastfeeding (any or exclusive) at 1, 2 and 3 months.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Di Napoli 2004

MethodsSingle-site study. Mothers recruited March 2000-December 2001, n = 605; 303 assigned to intervention group and 302 to control group by 'simple randomisation technique'. Follow-up rates for breastfeeding outcomes collected up to 180 days but after 60 days follow-up rates were less than 75% so only outcomes up to 60 days are included in this review. Reasons for drop-out reported by group. Outcome assessment not blinded.


ParticipantsUrban Italy. Inclusion criteria: mothers in public maternity ward in Rome, intending to breastfeed. Exclusion criteria: mothers who did not speak Italian, had no phone, breastfeeding medically contraindicated, baby in SCBU. Ethnic composition not defined. Baseline national breastfeeding initiation rate 70%.


InterventionsHome visit and telephone contact. Home visit, from one of the 6 midwives from the maternity ward of the study hospital, took place within 7 days of hospital discharge. Telephone breastfeeding counseling session provided by the same midwife. These midwives had attended the UNICEF 18 h intensive training course on breastfeeding techniques and management.


OutcomesAny breastfeeding up to 60 days.


NotesExtra information about reported numbers requested and received from author.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Frank 1987

MethodsSingle-site study recruiting over 17 months, n = 343. Follow up 94%. Appropriate randomisation procedures. Reasons for drop-out recorded. Independent outcome assessment.


ParticipantsUrban USA: in-patient maternity unit. Inclusion criteria: breastfed once in hospital; able to speak Spanish or English; baby needed less than 48 hours on NICU; contactable by telephone after discharge. 57% primiparous. Ethnic composition: black 65%, Hispanic 19%, white 13%, other 4%. Socio-economic status defined by: < 100% poverty level - 69%; 100%-200% poverty level - 21%; > 200% poverty level - 10%. Mean age of participants 25.7 years. No baseline data available.


Interventions(1) Postpartum research breastfeeding counseling by counsellor in hospital (20-40 minutes) and by telephone at 5, 7, 14, 21, 28, days and 6, 8 and 12 weeks. 24 hour advice by pager.
(2) Research discharge pack in English and Spanish.


OutcomesExclusive breastfeeding at 1, 2, 3 and 4 months. Any breastfeeding at 4 months. Median duration of breastfeeding. Time to introduction of formula or solids. Rehospitalisation of infants.


NotesRoutine care consisted of postpartum staff nursing contacts (including discharge teaching session on infant care), infrequent breastfeeding classes, written information on breastfeeding management and the opportunity to access a midwife-run telephone advice line.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Froozani 1999

MethodsSingle-site study recruiting over 7 months, n = 134. Follow up 90%. Assignment by day (odd or even) of baby's birth. Outcome assessment not blinded.


ParticipantsUrban Iran. Women without breastfeeding experience or chronic disease giving birth normally at term to a healthy baby 2.5 kg or over. National baseline prevalence: 96% breastfeeding with complementary foods at 6-9 months (UNICEF).


InterventionsNutritionist trained using WHO Breastfeeding Counseling training course (40 hours). Contact in hospital immediately after birth, between 10 and 15 days, after 30 days and monthly to the 4th month at home or in a lactation clinic.


OutcomesExclusive breastfeeding at 1, 2, 3 and 4 months. Mean number of days illness with diarrhoea.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate





Gagnon 2002

MethodsStudy conducted at a University teaching hospital and affiliated community health centres. Recruitment January 1997-September 1998, n = 586, 292 assigned to intervention group and 294 to control group by stratifying women by parity into blocks of 8 using computer-generated table of random numbers. Numbers, but not reasons for dropout reported. Outcome assessment was blinded.


ParticipantsUrban Quebec, Canada. Inclusion criteria: mothers participating in hospital short-stay programme. Ethnic and socio-economic composition of sample not reported. Baseline prevalence of breastfeeding initiation in Canada (excluding territories) 1994-5 = 73%.


InterventionsHome visit from community nurse 3-4 days postpartum. Nurses were Baccalaureate prepared, had minimum 3 years clinical experience in maternal-child health, and had attended training to ensure assessment skills of maternal-newborn and breastfeeding support. Nurse contact continued if felt it was required.


OutcomesBreastfeeding frequency and infant weight gain assessed at 2 weeks postpartum.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Graffy 2004

MethodsStudy conducted in 32 general practices in the UK. Recruitment April 1995-August 1998, n = 720, 363 assigned to intervention group and 357 to control group by numbered sealed envelopes prepared from random permuted blocks. Reasons for drop-out recorded. Outcome assessment blinded.


ParticipantsUrban South-East England. Inclusion criteria: mothers considering breastfeeding who had not breastfed a previous child for 6 weeks. Exclusion criteria: planning to contact a breastfeeding counsellor, address considered unsafe to visit, baby born before 36 weeks' gestation. Ethnic composition of sample: 59% white (UK) participants, 11% white (other) participants, 16% African or Caribbean, 8% Indian subcontinent, 6% other. Socioeconomic status on RG classification: 10% I, 26% II, 19% IIINM, 26% IIIM, 12% IV, 3% V, 5% other. First baby: 74%. National baseline prevalence 66% breastfeeding at birth.


InterventionsIntervention group were allocated to receive one antenatal visit from a National Childbirth Trust trained breastfeeding counsellor, who offered postnatal support by telephone or further visits if the mother requested this after the birth.


OutcomesPrevalence of any breastfeeding to 6 weeks; duration of any breastfeeding to 4 months; time to introduction of formula feeds; maternal satisfaction and common feeding problems; mothers' perspectives on support from counsellors; association between counseling uptake and feeding behaviour.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Grossman 1990

MethodsSingle-site study recruiting over 10 months, n = 97. Follow up 90%. Quasi-randomised (coin toss with women sharing same room allocated by the same toss). Drop-out reasons not recorded. Outcome assessment not independent.


ParticipantsUrban USA - in-patient maternity unit. Inclusion criteria: women eligible for WIC programme services for those on low incomes; women intending to breastfeed. Approximately one-third were primiparous. Ethnic composition described as 54% black. Mean age 25.4 years. WIC breastfeeding prevalence at birth 1991 = 33%.


InterventionsPackage of: face-to-face meeting in hospital with lactation counsellor (a registered nurse) after birth lasting 30-45 minutes - educational booklet given; telephone contacts on days 2, 4, 7, 10 and 21; a telephone helpline staffed by a nurse or paediatrician; back up support for those with problems from a lactation clinic.


OutcomesRates of breastfeeding at 6 weeks and 3 and 6 months. Median duration of breastfeeding.


NotesControl group received routinely available postnatal teaching regarding infant care and feeding by obstetrical nursing staff.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate





Haider 1996

MethodsSingle-site study. Duration of recruitment not stated, n = 250 mother-infant pairs. Follow up 83%. Randomisation procedures appropriate. Reasons for drop-out recorded. Outcome assessment not independent. Potential confounders: control group received a postdischarge home visit by a lactation counsellor without 'intervening for breastfeeding management'; intervention group members were encouraged to stay in hospital until diarrhoea had resolved; significant difference in percentage of primiparous women in the control and intervention groups (44% vs 65%; P = 0.007).


ParticipantsMothers with infants admitted to a diarrhoeal disease hospital in Bangladesh. Inclusion criteria: infants less than 12 weeks old; diarrhoea for less than 5 days; living within 15 km of Dhaka. Exclusion criteria: severe infection; mothers unable to stay with infants. 44% were primiparous. Baseline prevalence for hospital attenders in Dhaka 1993-94 = 63% partial breastfeeding; 28% non-breastfed.


InterventionsPackage of: counseling in hospital by a lactation counsellor or research physician (trained using the UNICEF/WHO course) on days 1 and 2 and the day of discharge (1st for 5-7 minutes, 2nd and 3rd for 30-40 minutes); home visit by lactation counsellor lasting 2-4 hours; encouraged to stay in hospital until the diarrhoea had resolved.


OutcomesExclusive and predominant breastfeeding on discharge and exclusive breastfeeding at 2 weeks follow up. Episodes of diarrhoea between discharge and follow up.


NotesControl group mothers attended daily health education sessions, which included advice on exclusive breastfeeding for 5 months.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Haider 2000

MethodsCommunity-based cluster-randomised study. Recruitment over 10 months, n = 726. Follow up 79%. Randomisation appropriate. Reasons for drop-out recorded. Outcome assessment not blinded.


ParticipantsDakka, Bangladesh. Mainly lower-middle and low socio-economic status.
Women aged 16-35 with 3 children or fewer (or 5 or less pregnancies) and no serious illness. Multiple births; children with congenital abnormalities, and those weighing less than 1800 g were excluded. National baseline prevalence reported in paper to be similar to control group rates. UNICEF quotes higher rates - 53% exclusive breastfeeding at 0-3 months.


InterventionsPeer counseling by women with personal breastfeeding experience trained over 40 hours with the WHO/UNICEF Breastfeeding Counseling course. Paid honorarium. Supervised caseload of 12-25 mothers. 15 home visits: 2 in last trimester/4 in month 1/2-weekly in months 2-5. Duration of visits 20-40 minutes.


OutcomesExclusive breastfeeding at birth, 4 days, 4 weeks, 2, 3, 4 and 5 months.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Jenner 1988

MethodsRecruitment location/duration not stated, n = 38. 100% follow up. Alternate assignment. Outcome assessment not blinded.


ParticipantsWhite, working-class women 19-32 years, living with partner and intending to breastfeed. Prevalence breastfeeding 1985 = 64% at birth and 26% at 4 months.


InterventionsFace-to-face and telephone support by single lay supporter (mother/previous breastfeeding experience). No indication of training. Control group received 1 antenatal home visit and one postnatal hospital visit. Intervention group received 3 antenatal home visits/1 hospital visit/1 'immediate' home visit and 1 or 2 further home visits 'in the early weeks'.


OutcomesBreastfeeding at 3 months. Partial breastfeeding grouped with formula feeding as 'breastfeeding failure'.


NotesModerate-to-high risk of bias.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate





Jones 1985

MethodsSingle-site study. Recruitment period 18 months, n = 678. Follow up 96%. Quasi-randomisation using alternating two-week periods. Reasons for drop-out recorded. Independent outcome assessment. Potential confounder: Late exclusion of 66 women because of overlap of recruitment periods.


ParticipantsUK - maternity department of district general hospital. Inclusion criteria: all women who attempted at least one breastfeed. Exclusion criteria: birth of child overlapped intervention and control periods. 55% of the sample were primiparous. Ethnic composition not stated. Socio-economic status defined by UK census categories (I and II 22%, III 46%, IV and V 13%). Baseline prevalence see Jenner 1988.


InterventionsIndividual support and problem solving by lactation nurse in hospital and at home. Duration of the intervention not specified.


OutcomesBreastfeeding rates at 4 weeks, 3, 6 and 12 months. Satisfaction with care and intention to breastfeed next pregnancy.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate





Kools 2005

MethodsCluster-randomised study with 10 sites, divided into 2 groups, which had similar numbers of births and breastfeeding rates. Allocation by coin flip. Recruitment December 2000-December 2002, n = 781, 408 women in sites assigned to the intervention and 373 in sites assigned to the control group. Reasons for drop-out reported. Blinding of outcome assessment unclear.


ParticipantsChild healthcare centres in Limbourg province, Netherlands. Inclusion criteria: mothers applying for maternity care at any of the 10 centres. Exclusion criteria: birthweight < 2000 g. Ethnic composition not defined. Baseline prevalence of breastfeeding initiation 80% in the Netherlands in 2002.


InterventionsProgramme with three elements: structured health counseling by maternity and child healthcare nurses and physicians; booklet to transfer information between caregivers and between mother and caregivers and used at each consultation; lactation consultancy available via caregiver faxing consultant with details of problem (consultant would then contact the caregiver or mother within 24 hours of receiving the fax).


OutcomesExclusive and complementary breastfeeding rates at 3 months; determinants of breastfeeding at 3 months.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Kramer 2001

MethodsMulti-site cluster-randomised study. Recruitment period 19 months, n = 17,046. Follow up 96.7%. Randomisation appropriate. Outcome assessment not blinded.


ParticipantsUrban and rural sites within Belarus. Inclusion criteria: intention to breastfeed, healthy mother, child 2500 g or more at term, Apgar 5 or more at 5 mins. Baseline breastfeeding prevalence 50% at 3 months.


InterventionsWHO/UNICEF Baby Friendly Initiative training for all staff dealing with mothers and babies in hospitals and community polyclinics. Infants seen monthly for polyclinic well-child visits and whenever ill.


OutcomesAny breastfeeding at 3, 6, 9 and 12 months. Incidence of respiratory, gastro-intestinal and atopic eczema in first year.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Leite 1998

MethodsParticipants recruited from 8 public health maternity units. Duration of recruitment 6 months, n = 1003. Follow up 86%. Randomisation appropriate. Reasons for drop-out not recorded. Outcome assessment blinded.


ParticipantsUrban Brazil. Inclusion criteria: healthy babies, weighing < 3000 g, discharged at < 5 days. Exclusion criteria: twins, important health problems in mother or child. Rate of exclusive + predominant breastfeeding in North-East Brazil in 1994 = 50%.


InterventionsPeer counsellor home visits lasting 30-40 minutes at 5, 15, 30, 60, 90 and 120 days. Counsellors from same social group as women they supported, had personal experience of breastfeeding and had been associated with maternity unit milk bank for a minimum of 5 years. Trained with adapted WHO breastfeeding counseling course (20 hours). Paid $4 per visit. Each counsellor supported 25 mothers.


OutcomesRates of exclusive, predominant, partial and artificial feeding at 4 months.


NotesStudy targeted babies with birthweights below 3000 g.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Lynch 1986

MethodsSingle site study. Duration of recruitment not stated, n = 270. 100% follow up. Randomisation procedure not described. Outcome assessment independent. Possible confounders: significant differences in baseline characteristics were present for parity (P = 0.02) and intention to return to work (P = 0.05).


ParticipantsUrban Canada - maternity unit of regional general hospital. Inclusion criteria: intending to breastfeed; English speaking. Exclusion criteria: multiple births; birthweight < 2500 gm; birth before 37 weeks. 41% were primiparous. Ethnic composition not described. Socio-economic status defined by Blishen scale for husband's occupation (62% groups 2-3).
Baseline prevalence (1984) = 69% breastfeeding initiation (75% stopping by 6 months).


InterventionsCombination of home visit by breastfeeding consultant within 5 days of hospital discharge (duration 2 hours) and telephone calls by the consultant weekly for 1 month and monthly from 2-6 months.


OutcomesDuration of breastfeeding.


NotesRoutine care group received postpartum home visit by public health nurse who gave breastfeeding advice determined largely by the questions and concerns of the mother.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





McDonald 2003

MethodsInformation from published abstract. Randomised controlled trial stratified by tertiary education and parity. Randomisation to two groups. Intervention: Extended Midwifery care (EM) n = 425, and Control - Standard Midwifery care (SM) n = 424, within strata of tertiary education. Recruitment March 2000-October 2001. Abstract does not include details of allocation concealment, outcome assessment or loss to follow up. Outcomes included in the abstract are reported by intention-to-treat.


ParticipantsResearcher based at La Trobe University, Victoria, Australia. Participants were women intending to breastfeed their term infants. Baseline prevalence of breastfeeding in Australia = 83% at hospital discharge.


InterventionsThe intervention group received an in-hospital postnatal education session. Post-discharge, they were offered home support visits with a research midwife once per week and telephone contact at least twice per week for 6 weeks. The control group received routine midwifery support and information as per the hospital protocol.


OutcomesAbstract reports any breastfeeding and exclusive breastfeeding at 6 months.


NotesFurther details not available at preparation of this update (June 2005).


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Mongeon 1995

MethodsSingle-site study. Duration of recruitment not stated, n = 200. Follow up 97%. Quasi-randomised (drawing numbered tickets). Reasons for drop-out recorded. Independent outcome assessment.


ParticipantsUrban Canada - antenatal meetings in a community health district. Inclusion criteria: women who wish to breastfeed and who have not previously breastfed. 97% of subjects were primiparous. Ethnic composition not stated. 57% had received education to college or university level. No specific socio-economic classification used. Baseline prevalence data - see Dennis 1999.


InterventionsHome visit by volunteer during last month of pregnancy followed by telephone contacts weekly for 6 weeks and then 2 weekly to 5 months or until weaning. Volunteers were women who had breastfed themselves and had received 3 training sessions of 3 hours duration followed by on-going monthly supervision sessions. Average caseload 1-3 cases at any one time.


OutcomesBreastfeeding rates at 1, 2, 3, 4 and 6 months.


NotesControl group received home visit from public health nurse during the first month after birth followed by other contacts (face-to-face or by telephone) as determined by the mother.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate





Moore 1985

MethodsSingle-site study. 19 months recruitment, n = 525. Follow up 90%. Randomisation procedure not stated. Reasons for drop-out recorded. Outcome assessment not independent. Possible confounder: inclusion criterion and racial exclusion criterion designed for trial of atopic allergy prevention.


ParticipantsUrban UK - antenatal clinic of city maternity hospital. Inclusion criterion: personal or partner history of atopy. Exclusion criteria: non-white women; unsure EDD; multiple pregnancy. Socio-economic status not described. Baseline prevalence 1980 = 65% at birth and 25% at 4 months.


InterventionsPackage of: daily visits as hospital in patient by health visitor or clinical medial officer followed by home visit 4-6 weeks postnatally and the support of a 24 hour telephone advice line. Subsequent follow up at home or in hospital at 3, 6 and 12 months.


OutcomesExclusive breastfeeding at 3 months.


NotesThis study was designed as a trial to prevent the development of atopic allergy by promoting exclusive breastfeeding. Sample size requirements for such a trial were not met. Control group received standard hospital infant feeding advice.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Morrell 2000

MethodsSingle-site study recruiting over 14 months, n = 632. Follow up 78%. Randomisation appropriate.


ParticipantsUrban UK. All English-speaking women 17 years or over giving birth at the study hospital unless their baby spent more than 48 hours on the SCBU. National baseline prevalence 66% breastfeeding at birth and 42% at 4 months. Exclusive breastfeeding 21% at 4 months.


InterventionsCommunity postnatal support worker. 8 week training. Home-based support of up to 10 visits in the first 28 days. Maximum 3 hours per visit.


OutcomesExclusive or any breastfeeding at 6 weeks and 6 months.


NotesStudy population not limited to those intending to breastfeed.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Morrow 1999

MethodsCommunity-based cluster-randomised study. Recruitment over 18 months, n = 130. Follow up 96% to 3 months, 80% to 6 months. Randomisation appropriate.


ParticipantsPeri-urban Mexican community. All pregnant or postnatal women in 39 geographical clusters. Perinatal death only clinical exclusion criterion. Baseline breastfeeding prevalence: 92% initiation; 4% exclusivity at 2 weeks and 3 months; 50% cessation by 6 months.


InterventionsHome visits by peer-counsellors trained by La Leche League.
(7 days theoretical teaching/2 months in lactation clinics and with mother to mother support groups.) Personal breastfeeding experience not essential. 2 intervention groups 1. 6 visits (mid and late pregnancy and 1, 2, 4 and 8 weeks) 2. 3 visits (late pregnancy and 1 and 2 weeks). 30% secondary education.


OutcomesBreastfeeding at 3 and 6 months. Incidence of diarrhoea in infants 0-3 months.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Pinelli 2001

MethodsSingle-site study of VLBW babies (birthweight 1500 g or less). Duration of recruitment not stated, n = 128, 64 assigned to the intervention and 64 to control group by use of random number tables and sealed, opaque envelopes. Reasons for drop-out not reported. Blinding of outcome assessment unclear.


ParticipantsNICU in teaching hospital in Ontario, Canada. Inclusion criteria: VLBW babies born at and admitted to NICU of study hospital, or transferred in with mother within 72 hours of birth: fed mother's milk by parental choice. Exclusion criteria: multiple births, infants with severe congenital, surgical or chromosomal abnormalities, parents who did not speak English. Ethnic composition "generally white". Baseline prevalence of breastfeeding initiation in Canada (excluding territories) 1994-5 = 73%.


InterventionsSSBC programme with four elements: video on breastfeeding premature infants; individual counseling by research lactation consultant (who was not a member of hospital staff); weekly in-hospital contact; post-discharge contact through first year of life or until breastfeeding discontinued.


OutcomesDuration of breastfeeding to 12 months; per cent human milk intake of total fluid intake to 12 months; breastfeeding problems, resources for advice and reasons for discontinuation; factors influencing breastfeeding duration.


NotesFathers were included in this study. Participants were parents of infants with birthweight 1500 g or less. Mean gestational age of these infants at birth was 29 weeks.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Porteous 2000

MethodsSingle-site study recruiting over 3 months, n = 52. Follow up 98%. Recruitment limited by availability of investigator. Randomisation appropriate. Outcome assessment not blinded.


ParticipantsUrban Canada. Inclusion criteria: singleton pregnancy, healthy mother and child, vaginal delivery, self-identified on breastfeeding questionnaire as unsupported. Baseline breastfeeding prevalence approximately 33% at 4 months.


InterventionsSupport by community midwife: daily visits in hospital; telephone call within 72 hours of discharge; minimum of 1 home visit (in first week). Home visits 60-90 mins.


OutcomesExclusive and partial breastfeeding at 4 weeks.


NotesStudy population specifically limited to those identifying themselves as unsupported.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Pugh 2002

MethodsSingle-site study. Recruitment April 1999-February 2000, n = 41; 21 assigned to intervention and 20 to control group by sealed envelope. 100% follow up at 6 months with no drop-outs recorded. Blinding of outcome assessment unclear.


ParticipantsCommunity intervention in urban USA. Inclusion criteria: low-income women receiving financial medical assistance. Exclusion criteria not stated. Ethnic composition: 95.2% African American.


InterventionsBreastfeeding support visits by community health nurse/peer counsellor team. Support offered daily when in hospital, and at home during weeks 1, 2 and 4 and at the team's discretion. Telephone support from peer counsellor twice weekly through week 8 and monthly through month 6.


OutcomesDuration of breastfeeding to 6 months; healthcare services use by infants; costs.


NotesLow-income women (receiving financial medical assistance).


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Quinlivan 2003

MethodsSingle-site study. Recruitment July 1998-December 2000, n = 136; 65 assigned to the intervention and 71 to the control group by computer-generated randomised allocation schedule concealed in numbered, sealed opaque envelopes. Reasons for drop-out recorded. Outcome assessment not blinded.


ParticipantsUrban Australia. Inclusion criteria: teenagers aged less than 18 years attending first antenatal appointment at public-care teenage pregnancy clinic for first time mothers; English speaking; intending to continue with the pregnancy and not relinquish the infant. Exclusion criteria: residence > 150 km from the study hospital; known fetal abnormality. Ethnic composition of sample: 24% indigenous Australian. Socioeconomic status: 86.5% of sample scored low or destitute on score derived from educational level of participant and her parents, and family income. Baseline prevalence of breastfeeding in Australia = 83% at hospital discharge.


InterventionsStructured home visits in weeks 1 and 2 by certified nurse-midwives to teach feeding and maternal-infant bonding skills. Further visits at months 1, 2, 3 and 4 to provide advice and support.


OutcomesAdverse neonatal outcomes (infant death, severe non-accidental injury and non-voluntary foster care); knowledge and practice of contraception, vaccination schedules and breastfeeding.


NotesParticipants were recruited at a teenage pregnancy clinic serving mostly disadvantaged women. The intervention was offered regardless of feeding intention or practice.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate





Santiago 2003

MethodsSingle-site study. Recruitment: August 2000-July 2002, n = 101; 35 assigned to control group, 33 to intervention group 1 and 33 to intervention group 2 by 'a simple lots procedure'. Follow up rates 100% at 4 months with no drop-outs reported. Blinding of outcome assessment unclear.


ParticipantsUrban setting in Minas Gerais, Brazil. Inclusion criteria: mother breastfeeding her well, term baby when appointment for paediatric clinic made; first clinic consultation took place, at 30 days or less. Exclusion criteria: mothers who expressed a preference to see a particular paediatrician; babies no longer breastfed at the first appointment. Ethnic composition: 62% of babies white. Baseline prevalence of breastfeeding in Brazil in the first 30 days = 88%.


InterventionsIntervention group 1: babies were monitored by a trained paediatrician working with a multidisciplinary breastfeeding team. Intervention group 2: babies were monitored by the same paediatrician, in individual consultations. The paediatrician and team had all received training in promoting exclusive breastfeeding (MB training).


OutcomesExclusive breastfeeding to 4 months.


NotesControl group babies were monitored by a paediatrician who did not have formal MB lactation training.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Sjolin 1979

MethodsSingle-site study. Duration 12 months, n = 146. Follow up 100%. Quasi-randomised (births before and after midnight). No drop-out reported. Outcome assessment not independent.


ParticipantsUrban Sweden - maternity ward of University Hospital. Inclusion criteria; resident in Uppsala; normal birth; healthy babies weighing > 3 kg. Ethnic composition not stated. 28% of mothers had completed college or university education. Baseline prevalence (1972): 4% breastfeeding at 24 weeks.


Interventions'Interview' with paediatrician in hospital on days 1 and 4 and at home at 2 and 6 weeks and 3 months; telephone contact weekly while breastfeeding followed by home visit if problem noted.


OutcomesPartial and exclusive breastfeeding at 2, 4, 8, 12, 16, 20 and 24 weeks.


NotesPrimarily designed as a study of the reasons for breastfeeding difficulties and the cessation of breastfeeding. Recruitment halted during holidays.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate





Winterburn 2003

MethodsSingle-site study. Duration of recruitment not reported, n = 72, 30 allocated to the intervention and 42 to the control group. Method of allocation not reported. 100% follow up at 3 months with no drop-outs reported. Blinding of outcome assessment unclear.


ParticipantsCommunity study in North Trent, England, UK. Inclusion criteria: mothers attending for antenatal care on one area. Other details not reported. National baseline prevalence 66% breastfeeding at birth.


InterventionsThe midwife asked mothers during their pregnancy to identify a close female confidante who could support them to breastfeed, and visited the mother and confidante together during the third trimester to discuss breastfeeding.


OutcomesDuration of breastfeeding to 3 months; women's satisfaction with the intervention; midwives' assessments of the intervention.


NotesNumerical outcome data provided by the researcher.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Wrenn 1997

MethodsSingle-site, two-group quasi-randomised study (even numbers to intervention and odd numbers to control group). Recruitment April 1999-February 2000, n = 186, with 79 assigned to the intervention and 107 to the control group. Information on drop-outs incomplete. Blinding of outcome assessment unclear.


ParticipantsUrban USA - military hospital in Texas. All participants were members of the armed forces or their dependents. Inclusion criteria: mothers on postpartum ward of study hospital; aged 18+; primiparous; uncomplicated delivery and postpartum; healthy baby; mother planned to breastfeed for at least 6 weeks. Exclusion criteria: hospitalisation of mother or baby for > 4 days; mothers who did not speak English. Ethnic composition of sample: 63% white, 11% black, 20% Hispanic, 2% Asian, 3% other. Baseline breastfeeding rate in Texas at hospital discharge = 67% in 1999.


InterventionsBreastfeeding support in hospital visit lasting approximately 30 minutes, home visit 2-4 days after discharge lasting 45-60 minutes, and phone call 10-14 days after the home visit.


OutcomesBreastfeeding attrition to 6 weeks.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

 BFI: Baby Friendly Initiative (UNICEF)
EDD: expected date of delivery
h: hour(s)
HIV: Human Immunodeficiency Virus
LLLI: La Leche League International
MB training: maternal breastfeeding training
min: minute(s)
NICU: Neonatal Intensive Care Unit
pcm: per calendar month
RG: Registrar General
SCBU: Special Care Baby Unit
SPSS: Statistical Package for the Social Sciences
SSBC: supplementary structured breastfeeding counselling
VLBW: very low birthweight
WHO: World Health Organization
WIC: Special Supplemental Nutrition Programme for Women, Infants and Children (US Department of Agriculture, Food and Nutrition Service)
vs: versus


 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Barnet 2002Intervention did not have the purpose of facilitating continued breastfeeding.

Black 2001Intervention did not have the purpose of facilitating continued breastfeeding.

Bloom 1982No numerical outcomes. Author could not be contacted.

Bolam 1998Evaluates an educational intervention.

Cattaneo 2001Intervention was training, and participants were hospitals.

Chen 1993Author unable to provide data in form suitable for analysis.

Davies-Adetugbo 1996Controlled study of breastfeeding counseling intervention without randomisation.

Ellis 198432% loss to follow up.

Forster 2004Evaluates an educational intervention.

Gagnon 199744% post-randomisation exclusions.

Gross 1998Cluster study without design effect. 38% loss to follow up.

Grossman 1987Abstract with no numerical outcomes. Author could not be contacted.

Guise 2003Paper is a review.

Hall 197830% loss to follow up in control group.

Hauck 1994Intervention was a booklet and did not involve contact with an individual.

Henderson 2001Evaluates an educational intervention.

Kistin 1994Non-randomised observational study.

Labarere 2003Evaluates an educational intervention.

Lavender 2004Evaluates an educational intervention.

Lieu 2000Support was not supplementary to standard care.

MacArthur 2002Intervention was not breastfeeding support. No breastfeeding outcomes reported.

Mattar 2003Evaluates an educational intervention.

McInnes 2000Geographical controls.

McKeever 200230% loss to follow up in control group.

Neyzi 1991Only 66% follow up in intervention group.

Pascali-Bonaro 2004Paper is not about a trial.

Perez-Escamilla 1992Study controlled but not randomised.

Ratner 1999Intervention did not have the purpose of facilitating continued breastfeeding.

Rea 1999Training intervention with no data on breastfeeding women.

Redman 199534% loss to follow up.

Reeve 2004Evaluated an antenatal education intervention.

Rowe 1990Abstract only available. No information on intervention used.

Rush 1991Trial of hospital telephone helpline. No suitable outcome data available.

Schy 1996Evaluates a purely educational intervention.

Sciacca 1995Support intervention available to all women in the trial.

Segura-Millan 1994Study controlled but not randomised.

Serafino-Cross 1992Approximately 50% loss to follow up in control group (exact figure not published).

Steel O'Connor 2003Support was not supplementary to standard care.

Valdes 2000Study controlled but not randomised.

Westphal 1995Intervention was training, and participants were hospitals.

Wiggins 2005Evaluates a social support intervention.

Wolfberg 2004Follow up rates were 14%.



 
Comparison 1. All forms of support versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stopping any breastfeeding before last study assessment up to 6 months28Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 All trials
289997Risk Ratio (M-H, Random, 95% CI)0.91 [0.86, 0.96]

    1.2 Studies with adequate allocation concealment
145632Risk Ratio (M-H, Random, 95% CI)0.90 [0.83, 0.98]

    1.3 Trials in settings with low breastfeeding initiation
3555Risk Ratio (M-H, Random, 95% CI)0.88 [0.69, 1.12]

    1.4 Trials in settings with intermediate breastfeeding initiation
144489Risk Ratio (M-H, Random, 95% CI)0.92 [0.85, 0.98]

    1.5 Trials in settings with high breastfeeding initiation
104797Risk Ratio (M-H, Random, 95% CI)0.91 [0.81, 1.01]

 
Comparison 2. All forms of support versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stopping exclusive breastfeeding before last study assessment207668Risk Ratio (M-H, Random, 95% CI)0.81 [0.74, 0.89]

 
Comparison 3. All forms of support versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stopping any breastfeeding at different times27Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Before 4 to 6 weeks
144728Risk Ratio (M-H, Random, 95% CI)0.88 [0.78, 1.00]

    1.2 Before 2 months
82372Risk Ratio (M-H, Random, 95% CI)0.83 [0.69, 0.99]

    1.3 Before 3 months
144635Risk Ratio (M-H, Random, 95% CI)0.88 [0.80, 0.98]

    1.4 Before 4 months
93780Risk Ratio (M-H, Random, 95% CI)0.86 [0.77, 0.96]

    1.5 Before 6 months
123804Risk Ratio (M-H, Random, 95% CI)0.94 [0.90, 0.99]

    1.6 Before 9 months
2688Risk Ratio (M-H, Random, 95% CI)0.90 [0.81, 0.99]

    1.7 Before 12 months
31640Risk Ratio (M-H, Random, 95% CI)0.99 [0.90, 1.08]

 2 Stopping exclusive breastfeeding at different times20Risk Ratio (M-H, Random, 95% CI)Subtotals only

    2.1 Before 4 to 6 weeks
103475Risk Ratio (M-H, Random, 95% CI)0.67 [0.54, 0.84]

    2.2 Before 2 months
51308Risk Ratio (M-H, Random, 95% CI)0.59 [0.38, 0.92]

    2.3 Before 3 months
112993Risk Ratio (M-H, Random, 95% CI)0.67 [0.53, 0.84]

    2.4 Before 4 months
82900Risk Ratio (M-H, Random, 95% CI)0.64 [0.48, 0.86]

    2.5 Before 5 months
1590Risk Ratio (M-H, Random, 95% CI)0.47 [0.40, 0.54]

    2.6 Before 6 months
62583Risk Ratio (M-H, Random, 95% CI)0.90 [0.81, 1.00]

 
Comparison 4. Professional support versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stopping any breastfeeding before last study assessment up to 6 months165380Risk Ratio (M-H, Random, 95% CI)0.94 [0.87, 1.01]

 2 Stopping exclusive breastfeeding before last study assessment124133Risk Ratio (M-H, Random, 95% CI)0.91 [0.84, 0.98]

 
Comparison 5. Lay support versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stopping any breastfeeding before last study assessment73079Risk Ratio (M-H, Random, 95% CI)0.86 [0.76, 0.98]

 2 Stopping exclusive breastfeeding before last study assessment63084Risk Ratio (M-H, Random, 95% CI)0.72 [0.57, 0.90]

 
Comparison 6. Professional support versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stopping any breastfeeding at different times16Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Before 4 to 6 weeks
92529Risk Ratio (M-H, Random, 95% CI)0.85 [0.70, 1.02]

    1.2 Before 2 months
3897Risk Ratio (M-H, Random, 95% CI)0.89 [0.67, 1.19]

    1.3 Before 3 months
82690Risk Ratio (M-H, Random, 95% CI)0.90 [0.77, 1.04]

    1.4 Before 4 months
5957Risk Ratio (M-H, Random, 95% CI)0.78 [0.67, 0.91]

    1.6 Before 6 months
82779Risk Ratio (M-H, Random, 95% CI)0.94 [0.86, 1.03]

    1.7 Before 9 months
1552Risk Ratio (M-H, Random, 95% CI)0.87 [0.78, 0.97]

    1.8 Before 12 months
31640Risk Ratio (M-H, Random, 95% CI)0.99 [0.90, 1.08]

 2 Stopping exclusive breastfeeding at different times12Risk Ratio (M-H, Random, 95% CI)Subtotals only

    2.1 Before 4 to 6 weeks
61457Risk Ratio (M-H, Random, 95% CI)0.69 [0.51, 0.92]

    2.2 Before 2 months
3633Risk Ratio (M-H, Random, 95% CI)0.76 [0.61, 0.94]

    2.3 Before 3 months
61829Risk Ratio (M-H, Random, 95% CI)0.84 [0.72, 0.99]

    2.4 Before 4 months
5922Risk Ratio (M-H, Random, 95% CI)0.69 [0.47, 1.02]

    2.6 Before 6 months
31509Risk Ratio (M-H, Random, 95% CI)0.95 [0.91, 0.98]

 
Comparison 7. Lay support versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stopping any breastfeeding at different times7Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Before 4 to 6 weeks
51966Risk Ratio (M-H, Random, 95% CI)0.91 [0.73, 1.14]

    1.2 Before 2 months
2458Risk Ratio (M-H, Random, 95% CI)0.86 [0.41, 1.78]

    1.3 Before 3 months
4733Risk Ratio (M-H, Random, 95% CI)0.76 [0.54, 1.09]

    1.4 Before 4 months
31923Risk Ratio (M-H, Random, 95% CI)0.92 [0.74, 1.14]

    1.6 Before 6 months
3933Risk Ratio (M-H, Random, 95% CI)0.98 [0.92, 1.04]

 2 Stopping exclusive breastfeeding at different times6Risk Ratio (M-H, Random, 95% CI)Subtotals only

    2.1 Before 4 to 6 weeks
42018Risk Ratio (M-H, Random, 95% CI)0.66 [0.46, 0.96]

    2.2 Before 2 months
2675Risk Ratio (M-H, Random, 95% CI)0.44 [0.26, 0.73]

    2.3 Before 3 months
3713Risk Ratio (M-H, Random, 95% CI)0.42 [0.31, 0.57]

    2.4 Before 4 months
21568Risk Ratio (M-H, Random, 95% CI)0.62 [0.25, 1.53]

    2.5 Before 5 months
1590Risk Ratio (M-H, Random, 95% CI)0.47 [0.40, 0.54]

    2.6 Before 6 months
1623Risk Ratio (M-H, Random, 95% CI)0.98 [0.93, 1.03]

 
Comparison 8. Differing modes of support versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stopping any breastfeeding before last study assessment up to 6 months289997Risk Ratio (M-H, Random, 95% CI)0.91 [0.86, 0.96]

    1.1 Predominant telephone support
51168Risk Ratio (M-H, Random, 95% CI)0.92 [0.78, 1.08]

    1.2 Predominant face-to-face contact
145127Risk Ratio (M-H, Random, 95% CI)0.85 [0.79, 0.92]

    1.3 Balanced telephone and face-to-face support
93702Risk Ratio (M-H, Random, 95% CI)1.00 [0.91, 1.09]

 
Comparison 9. Differing timings of support versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stopping any breastfeeding at last study assessment up to 6 months289997Risk Ratio (M-H, Random, 95% CI)0.91 [0.86, 0.96]

    1.1 Postnatal support alone
207259Risk Ratio (M-H, Random, 95% CI)0.89 [0.84, 0.96]

    1.2 Antenatal component to support
82738Risk Ratio (M-H, Random, 95% CI)0.92 [0.83, 1.02]

 
Comparison 10. Differing training versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stopping exclusive breastfeeding before last study assessment7Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 WHO/UNICEF courses versus usual care
62829Risk Ratio (M-H, Random, 95% CI)0.69 [0.52, 0.91]

    1.2 La Leche League training versus usual care
1110Risk Ratio (M-H, Random, 95% CI)0.52 [0.39, 0.69]

 
Comparison 11. Support of mothers with sick children

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Exclusive breastfeeding 2 to 3 weeks after discharge from healthcare facility2419Risk Ratio (M-H, Fixed, 95% CI)8.32 [4.94, 14.01]

 2 Recurrence of diarrhoea 2 to 3 weeks after discharge from healthcare facility3829Risk Ratio (M-H, Fixed, 95% CI)0.70 [0.54, 0.90]

 
Comparison 12. Lay support versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Maternal satisfaction with infant feeding1251Mean Difference (IV, Fixed, 95% CI)0.83 [-0.61, 2.27]

 
Comparison 13. Lactation nurse versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Sufficient help received with breastfeeding problems1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 In hospital
1583Risk Ratio (M-H, Fixed, 95% CI)2.05 [1.52, 2.77]

    1.2 At home
1583Risk Ratio (M-H, Fixed, 95% CI)1.83 [1.39, 2.42]

 
Comparison 14. Combination of lay and professional support versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stopping any breastfeeding at different times55210Risk Ratio (M-H, Random, 95% CI)0.84 [0.77, 0.92]

    1.1 Before 4 to 6 weeks
1900Risk Ratio (M-H, Random, 95% CI)0.65 [0.51, 0.82]

    1.2 Before 2 months
31087Risk Ratio (M-H, Random, 95% CI)0.74 [0.66, 0.83]

    1.3 Before 3 months
31382Risk Ratio (M-H, Random, 95% CI)0.90 [0.80, 1.00]

    1.4 Before 4 months
1900Risk Ratio (M-H, Random, 95% CI)0.95 [0.85, 1.06]

    1.6 Before 6 months
2941Risk Ratio (M-H, Random, 95% CI)0.95 [0.86, 1.05]

 2 Stopping exclusive breastfeeding at different times21312Risk Ratio (M-H, Random, 95% CI)0.62 [0.50, 0.77]

    2.1 Before 3 months
2451Risk Ratio (M-H, Random, 95% CI)0.60 [0.43, 0.86]

    2.2 Before 4 months
1410Risk Ratio (M-H, Random, 95% CI)0.47 [0.40, 0.55]

    2.3 Before 6 months
2451Risk Ratio (M-H, Random, 95% CI)0.71 [0.59, 0.86]