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Support for breastfeeding mothers

  1. J Sikorski,
  2. M J Renfrew Professor of Midwifery Studies*,
  3. S Pindoria,
  4. A Wade

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 21 JAN 2002

DOI: 10.1002/14651858.CD001141

How to Cite

Sikorski J, Renfrew MJ, Pindoria S, Wade A. Support for breastfeeding mothers. The Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD001141. DOI: 10.1002/14651858.CD001141.

Author Information

  1. University of Leeds, Mother and Infant Research Unit, Leeds, West Yorkshire, UK

*M J Renfrew, Professor of Midwifery Studies, Mother and Infant Research Unit, University of Leeds, 22 Hyde Terrace, Leeds, West Yorkshire, LS2 9LN, UK. m.j.renfrew@leeds.ac.uk.

Publication History

  1. Published Online: 21 JAN 2002

SEARCH

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

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

There is a large body of observational evidence for both the short-term and long-term health benefits of breastfeeding. Early benefits include reduced mortality in pre-term infants (Lucas 1990b), reduced infant morbidity from gastro-intestinal, respiratory, urinary tract and middle-ear infections and less atopic illness (Howie 1990; Victora 1989; Pisacane 1992; Aniansson 1994; Lucas 1990a).

Strong confirmation of short-term health gain has come from the recent Promotion of Breastfeeding Trial (PROBIT) (Kramer 2001) - the largest reported trial to date in the field of human lactation. This study of 17,046 mother-infant pairs confirmed significant protection from gastro-enteritis and atopic eczema from prolonged breastfeeding. The protective effect of current breastfeeding continues for long periods of time with reduced infant mortality and child mortality in the second year of life in less developed countries (WHO 2000).

Breastfeeding is also associated with significantly higher scores for cognitive development than formula feeding in a meta-analysis of 11 trials (Anderson 1999). This effect is strongest in pre-term infants.

There is also increasing evidence for a long-term cardio-protective effect of breastfeeding. Wilson et al in the Dundee infant feeding study (Wilson 1998) found systolic blood pressure at the age of seven to be significantly raised in those children who had been exclusively formula fed for the first 15 weeks of life compared to those who had received any breast milk. Taittonen et al also found that breastfeeding over three months was associated with a mean change in blood pressure of up to -6.5mm Hg (Taittonen 1996). Similar differences in blood pressure were found between two cohorts of children born prematurely and followed for between 13 and 16 years (Singhal 2001).

The optimal duration of exclusive breastfeeding has recently been reviewed by a WHO Expert/Working Group. On the basis of a systematic review of available evidence, exclusive breastfeeding until six months of age with introduction of complementary foods and continued breastfeeding thereafter, was recommended as a target for populations (WHO 2001). There are also associated health benefits for the breastfeeding woman (Heinig 1997).

Despite these established benefits and the relatively high rates of initiation of breastfeeding, exclusive breastfeeding rates even at three to four months remain remarkably low in many health care settings (UNICEF 2000). Evidence from economically advantaged countries indicates that young mothers and those in low-income groups or those who ceased full-time education at an early age are least likely to either start breastfeeding or continue for a period of time sufficient to confer health gain (Foster 1997). Paradoxically, in poorer countries, more affluent groups may have lower breastfeeding rates (Rogers 1997).

The purpose of this review was to examine interventions which provide extra support for mothers who wish to breastfeed and to assess their impact on breastfeeding duration and exclusivity and, where recorded, on health outcomes and maternal satisfaction. Specific objectives of the review were to describe the forms of support which have been evaluated in controlled studies, and the settings in which they have been used. It was also of interest to examine the effectiveness of different modes of offering similar supportive interventions (e.g. face-to-face or over the telephone) and whether interventions containing both antenatal and postnatal elements were more effective than those taking place in the postnatal period alone. The effectiveness of different care providers and training programmes and the effect of baseline breastfeeding prevalence (where known) on the effectiveness of supportive interventions were also to be examined.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

1. To describe the forms of support which have been evaluated in controlled studies, the timing of the interventions and the settings in which they have been used.

2. To examine the effectiveness of comparable interventions and to extend this to low-income groups where possible.

3. To examine the effectiveness of different modes of offering similar supportive interventions (e.g. face-to-face or over the telephone), and whether interventions containing both antenatal and postnatal elements were more effective than those taking place in the postnatal period alone.

4. To compare the effectiveness of different care providers and training.

5. To explore the effect of baseline breastfeeding prevalence (where known) on the effectiveness of supportive interventions.

 

Criteria for considering studies for this review

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support
 

Types of studies

Randomised or quasi-randomised controlled trials, with or without blinding and with a minimum of 75% follow-up.

 

Types of participants

Participants were women who intended to breastfeed, who had initiated breastfeeding or who accepted the provision of support before or after the birth of their child.

 

Types of intervention

Contact with an individual or individuals (either professional or volunteer) offering support which is supplementary to standard care (in the form of, for example, appropriate guidance and encouragement) with the purpose of facilitating continued breastfeeding. Studies were included if the intervention occurred in the postnatal period alone or also included an antenatal component. Interventions taking place in the antenatal period alone were excluded from this review as were interventions described as solely educational in nature.

 

Types of outcome measures

The main outcome measure was the effect of the interventions on duration of breastfeeding to specified points in time. Outcomes were recorded for stopping feeding before four to six weeks and two, three, four, six, nine and 12 months. Other outcomes of interest were exclusive breastfeeding, measures of neo-natal and infant morbidity (where available) and measures of maternal satisfaction with care or feeding method.

 

Search strategy for identification of studies

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

See: Cochrane Pregnancy and Childbirth Group search strategy

This review drew on the search strategy developed for the Cochrane Pregnancy and Childbirth Group as a whole. The full list of journals and conference proceedings as well as the search strategies for the electronic databases, which are searched by the Group on behalf of its
reviewers, are described in detail in the 'Search strategies for the identification of studies section' within the editorial information about the Cochrane Pregnancy and Childbirth Group. Briefly, the Group searches on a regular basis MEDLINE, the Cochrane Controlled Trials Register and reviews the Contents tables of a further 38 relevant journals received via ZETOC, an electronic current awareness service. Date of last search: October 2001.

Relevant trials, which are identified through the Group's search strategy, are entered into the Group's Specialised Register of Controlled Trials. Please see Review Group's details for more detailed information.

In addition, we searched MEDLINE, EMBASE and the CCTR/CENTRAL register in March 2001. Details of the search strategies can be obtained from the contact author. The Midwives Information and Resource Service (MIDIRS) quarterly Digest was hand searched from 1991. Secondary references were scanned and relevant studies obtained. Contact was made with experts in the field to identify other published or unpublished studies. However, no further data were obtained by contacting breastfeeding researchers.

The search identified one trial of lay support currently in progress in Scotland and a completed trial of trained lay breastfeeding counsellors in London from which data were not yet available (see Graffy 2001; Muirhead).

 

Methods of the review

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

Titles and abstracts of the electronic searches were screened by two reviewers (Jim Sikorski, Mary Renfrew). Articles obtained by all methods were read independently by both reviewers except for two studies in Portuguese (Barros 1994; Leite 1998), from which data were extracted jointly by the contact reviewer and a translator.

The following study characteristics were extracted and entered in the table of included studies: country, setting, demographic data on study group and controls, study design, randomisation procedure, intervention package, length and completeness of follow-up, description of withdrawals and drop-outs, blinding of assessors and outcome measures. Each study was given a quality score based on the following criteria: clear description of inclusion and exclusion criteria, adequacy of randomisation, description of withdrawals and drop-outs, description of statistical analysis, allocation concealment, blinding of outcome assessment and intention to treat analysis. The maximum score was eight. Outcome data were doubly entered by one reviewer (Jim Sikorski) and all entries were rechecked by a second reviewer (Mary Renfrew).

Data were analysed on an intention-to-treat basis whenever possible even if intention-to-treat analysis had not been used in the study report. Where cluster randomised studies reported proportions of women breastfeeding rather than cluster means, the ratio estimator procedure (Rao 1992; Donner 2001) was used to adjust proportions to an effective sample size and to calculate an effective outcome rate. For these calculations we used intraclass correlation co-efficients either reported by study authors or calculated from raw study data. Relative risk was calculated as the preferred estimate of treatment effects since events (giving up breastfeeding) were common and in this context, odds ratios are likely to exaggerate the benefits of support (Altman 1998). Random effects models were preferred to perform all meta-analyses since studies were clinically heterogeneous. Sub-group analysis was performed for the overall effect on 'any breastfeeding', to compare high and low quality studies and to compare individually randomised and cluster randomised studies.

 

Description of studies

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

PERSONNEL AND TRAINING
Studies evaluated support provided by a variety of medical, nursing and allied professionals (e.g. nutritionists) as well as lay people. Lay support was either voluntary or remunerated. Details of those involved in providing support and the interventions used are given in the table of included studies. Six studies used either the 18-hour or 40-hour WHO/UNICEF breastfeeding counselling/lactation management courses as the basis for the training of breastfeeding supporters. The studies were also subdivided into broad categories to examine aspects of the interventions as discussed in the Methods section.

COMPARISON GROUPS
In the majority of studies, the comparison group was reported to have received usual postnatal care which varies both between and within countries. The care at the time of the trials may also differ from that which is offered at the present time. In Canada, for example, many women receive one routine home visit by a public health nurse during the first month after discharge from hospital, while in the UK, at the time of the two studies contained in this review, postnatal care at home consisted of daily home visits from a midwife until 10 days after birth (and possibly until 28 days if the need arose) and a routine home visit from a health visitor (with an infant feeding advisory function) at approximately 10 days postpartum. In Brazil, no routine postnatal home visits are made and there would be no support for breastfeeding mothers routinely available from the health services, except in special programmes run by municipal secretaries of health. Wherever there were individual study details on care received by the comparison groups, these are given in the table of included studies.

OUTCOMES
Breastfeeding was usually reported as being either partial or exclusive with no further definitional refinement. Few studies reported both partial and exclusive rates at all time-points. Reporting of health outcomes was scanty and inconsistent allowing little joint analysis. The timing of outcome assessments varied considerably between studies, ranging from two weeks to one year postnatally. Several studies took repeated measurements of breastfeeding rates and some reported mean duration.

DIFFERENCES IN GROUPS STUDIED
Support was usually offered to women intending to breastfeed but in two studies (Brent 1995; Morrell 2000) intention to formula-feed was not an exclusion criterion. In the small study by Porteous (Porteous 2000), support was only offered to those breastfeeding women who identified themselves as unsupported on a self-report questionnaire. In one study (Moore 1985) only women with a personal, family or partner history of atopy were selected while two further trials (Haider 1996; Davies-Adetugbo 1997) studied the effect of support for mothers of sick infants with moderate diarrhoeal disease.

 

Methodological quality

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

Quality scores varied from two to seven (maximum score eight) with six trials scoring six or above. These quality scores are given in the table of included studies. Studies were also assigned the standard Cochrane Collaboration score for quality of allocation concealment and this information can be displayed in MetaView (via the Sort and Display menus).

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

Fourteen references not identified by previous editions of the review were identified by a search of the Cochrane Controlled Trials Register (CCTR). Searches of MEDLINE and EMBASE identified 189 references. Twenty trials from 10 countries were finally included in the review. The studies included 23,712 mother-infant pairs - a substantial increase since the previous edition of this review.

OVERALL EFFECT ON ANY BREASTFEEDING
The main summary outcome measure was breastfeeding at the time of the last study assessment up to six months. There was a beneficial effect on the duration of any breastfeeding in the meta-analysis of all forms of extra support (relative risk (RR) for stopping breastfeeding before last study assessment up to six months 0.88 [95% confidence interval (CI) 0.81,0.95]; 15 trials, 21,910 women). Sensitivity analysis without cluster randomised trials did not alter this result. Significant statistical heterogeneity was present (p = 0.0003). Excluding trials with data collection for periods shorter than six months did not alter this conclusion although the effect size was smaller (RR 0.94 [95% CI 0.89,0.99]; nine trials, 20,015 women). The main finding also persisted when higher quality trials (scoring six or more on the eight point scale) were analysed separately (RR 0.82 [95% CI 0.69,0.97]; six trials, 19,413 women). The heterogeneity present in this last analysis became non-significant on exclusion of the study by Morrell et al (Morrell 2000). This finding may reflect the fact that this trial offered support from a community postnatal support worker to any woman, irrespective of feeding method. Although the supporters in this study received some training concerning the advantages of breastfeeding and correct positioning, they reported only three percent of their time in women's homes being used in discussing breastfeeding.

In order to explore any differential effect of support conditional on the baseline prevalence of breastfeeding in the area in which the trial was conducted, the trials were divided into three categories denoted by high (> 80%), intermediate (60-80%) or low (< 40%) initiation rates. This analysis showed that clear evidence of benefit appeared to be confined to settings where there were high rates of breastfeeding initiation. (RR for stopping breastfeeding in areas of high initiation 0.84 [95% CI 0.74,0.96]; five trials, 19,223 women; in areas of intermediate initiation RR 0.91 [95% CI 0.80,1.03]; six trials, 1986 women; in areas of low initiation RR 0.88[95% CI 0.69,1.12]; three trials, 555 women.).

Analysis of results at different periods of follow-up suggested that the benefit of all forms of support was present at all time points up to nine months. Some caution needs to be exercised in interpreting these trends, however, since not all studies are represented at each of the time points at which data were analysed.

OVERALL EFFECT ON EXCLUSIVE BREASTFEEDING.
The effect of support on exclusive breastfeeding (RR for stopping breastfeeding before last study assessment 0.78 [95% CI 0.69,0.89]; 11 trials, 20,788 women) is greater than that observed on 'any breastfeeding' although there is marked heterogeneity in this group of 11 trials. Excluding trials with data collection for periods shorter than six months did not alter the this conclusion although the effect size was smaller (RR 0.96 [95% CI 0.92,0.99]; three trials, 17,825 women). This effect remained significant in a sensitivity analysis without cluster randomised trials. It does not appear that the heterogeneity can be explained by a greater effect of supportive interventions on exclusive breastfeeding in countries with higher rates of breastfeeding initiation.

PROFESSIONAL SUPPORT
Trials comparing professional support to usual care in preventing the cessation of any breastfeeding showed professional support to be effective overall (RR for stopping breastfeeding before last study assessment up to six months 0.89 [95% CI 0.81,0.97]; 10 trials, 19,692 women). As with the combined analysis of all forms of support, this benefit was present at all time points and persisted where data had been collected to nine, but not 12, months. The beneficial effect of professional support on exclusive breastfeeding at six months did not achieve statistical significance (RR for stopping breastfeeding before six months 0.90 [95% CI 0.81,1.01]; six trials, 18,258 women). There was, however, evidence for significant benefit up to two months (RR before four to six weeks 0.50 [95% CI 0.27,0.90]; RR before two months 0.76 [95% CI 0.61,0.94]).

LAY SUPPORT
Overall, trials of lay support showed a non-significant trend towards reducing breastfeeding cessation at the time of the last trial assessment (RR 0.84 [95% CI 0.69,1.02]; five trials, 2224 women). Further analysis did not reveal a statistically significant effect at any time point up to six months. However, in the studies of lay support which reported exclusive breastfeeding, there was a marked reduction in the cessation of exclusive breastfeeding (RR 0.66 [95% CI 0.49,0.89]; five trials, 2530 women).

DIFFERING MODES AND TIMING OF SUPPORT
Analysis of studies reporting a predominantly face-to-face intervention showed a statistically significant benefit (RR for giving up breastfeeding 0.86 [95% CI 0.78,0.94]; eight trials, 20,544 women) while those using mainly telephone contact failed to do so (RR 0.92 [95% CI 0.78,1.08]; five trials, 1168 women). The effect measured in studies of interventions containing an antenatal element to breastfeeding support (RR 0.85 [95% CI 0.70,1.04]; three trials, 455 women) was not significant while the effect in those studies offering only postnatal support was clearly beneficial (RR 0.88 [95% CI 0.80,0.96]: 12 trials, 21,465 women).

HEALTH OUTCOMES
There was a highly significant beneficial effect on exclusive breastfeeding two to three weeks after discharge from a health care facility in the two studies of support for mothers with sick infants (RR for stopping exclusive breastfeeding before two to three weeks after discharge 0.48 [95% CI 0.41,0.56]) (Haider 1996; Davies-Adetugbo 1997). There was also a marked short-term reduction in the recurrence of diarrhoea in these two trials (RR for recurrence before two to three weeks follow-up (RR 0.44 [95% CI 0.24,0.80]). In the study by Haider (Haider 1996) eight babies in the control group and two babies in the intervention group had died two weeks after discharge from hospital. The difference in the populations in these trials, when compared to the healthy mother-infant dyads included in other studies, led to their exclusion from the main meta-analysis.

Few trials reported health outcomes and it was not possible to combine these statistically. The PROBIT study (Kramer 2001) found a significant reduction in the risk of one or more gastrointestinal infections (9.1% versus 13.2%; adjusted odds ratio (OR), 0.60 [95% CI 0.40,0.91]) and of atopic eczema (3.3% versus 6.3%; adjusted OR 0.54 [95% CI 0.31,0.95] in the group receiving care from health professionals who had received the UNICEF/WHO Baby Friendly Initiative training. There was no significant reduction in respiratory tract infection (39.2% versus 39.4%, adjusted OR 0.87 [95% CI 0.59,1.28]). Frank et al (Frank 1987) found no difference in breastfeeding rates in those infants rehospitalised during their study while Froozani et al (Froozani 1999) observed a significant reduction in the mean number of days of gastrointestinal illness in the group receiving support (1.2 [SD 2.7] days versus 4.0 [SD 7.1] days, p < 0.004) but no significant difference in respiratory illness (3.2 [SD 5.0] days versus 3.7 [SD 8.8] days).

MEASURES OF SATISFACTION
Satisfaction measures were, on the whole, not well reported. Jones (Jones 1985) reported satisfaction with the amount of help received both at home and in hospital and found this to be greater in the intervention group. Only Dennis (Dennis 1999) reported maternal satisfaction with infant feeding, finding no significant differences between the peer and control groups' mean scores on the Maternal Breastfeeding Evaluation Scale (mean scores 53.81 [SD 5.69] versus 52.98 [SD 5.94], p = 0.73) (Leff 1994). However, significantly more mothers in the control group reported overall dissatisfaction with their infant feeding method.

SOCIALLY DISADVANTAGED GROUPS
Only one study (Jones 1985) reported effects of the supportive intervention in different social groups. In this study the greatest difference in the proportion of women still breastfeeding at four weeks was in social classes IV and V (86% of social classes IV and V in the intervention group breastfeeding at four weeks versus 58% in social classes IV and V in the control group, p < 0.01). It was not possible to compare this finding with the three trials (Brent 1995; Frank 1987; Grossman 1990) in communities receiving assistance from the Women Infants and Children programme in the USA (which had with low rates of breastfeeding initiation) since only one of these trials reported breastfeeding rates at four to six weeks.

EFFECT OF DIFFERING TRAINING PROGRAMMES
Six trials (Kramer 2001; Leite 1998; Haider 1996; Davies-Adetugbo 1997; Froozani 1999; Haider 2000) reported using either the 18 or 40 hour WHO/UNICEF breastfeeding training courses, while one trial (Morrow 1999) used the peer counsellor programme developed by La Leche League, the international lay breastfeeding support organisation. The length of training offered to lay supporters varied from 2.5 hours (Dennis 1999) to 40 hours (Haider 2000). Meta analysis of four trials using WHO/UNICEF training showed significant benefit in prolonging exclusive breastfeeding (RR 0.70 [95% CI 0.53,0.93]) but the individual trial findings were highly heterogeneous.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

This review adds several trials to its predecessor (Sikorski 1999) and brings to 23,712 the number of women observed. The reporting of these studies was often not comprehensive - lacking, for example, in terms of details of the training and qualifications of the supporters, the definitions used of the extent of breastfeeding and in the description of adherence to the support protocol. There was also a failure to present details of the informational element of the interventions and on the background detail of the care received by the comparison groups.

Nevertheless, the newer studies included in the review (1998 onwards) were of a higher overall quality with five out of seven trials scoring six or more out of a maximum quality score of eight. These factors, together with the diversity of supportive interventions and the widely differing timing of study end-points, should urge some caution in the interpretation of the analysis of pooled data from the majority of studies to assess a measure of overall benefit.

Despite this caution, the overall benefit found from all forms of supportive intervention has been explored with sub-group analysis and is moderately robust following exclusion of the methodologically weaker trials. The apparent greater effectiveness observed in trials of support in communities with high levels of breastfeeding initiation may indicate that an early culture of breastfeeding acts synergistically with the provision of extra support.

While the effect size of support interventions on reducing the cessation of any breastfeeding is modest, there is evidence of a greater effect on the prolongation of exclusive breastfeeding. These effects are also well illustrated in the studies of sick children where the attendant short-term health benefits of exclusive breastfeeding are demonstrated.

Our attempts to determine the most helpful elements of support strategies should also be treated with some caution since they arise from qualitative judgements of the intended intervention rather than quantitative estimates of the intervention as delivered. Nevertheless, on this basis, it would appear that strategies that depend mainly on face-to-face support appear more effective than those that rely primarily on telephone contact. There also appears to be no beneficial effect on the duration of breastfeeding to be derived from including an antenatal component to the support offered.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

 

Implications for practice

Consideration should be given to providing supplementary breastfeeding support as part of routine health service provision. There is clear evidence for the effectiveness of additional professional support in prolonging any breastfeeding but the strength of its effect on exclusive feeding is less certain. WHO/UNICEF training courses appear to be an effective model for professional training. Lay support is effective in promoting exclusive breastfeeding while the strength of its effect on the duration of any breastfeeding is uncertain. Face-to-face support appears to be more effective than support by telephone but there is as yet no evidence to suggest that the duration of breastfeeding is improved by routine antenatal contact. Evidence supports the promotion of exclusive breastfeeding as central to the management of diarrhoeal illness in partially breastfed infants.

 
Implications for research

There are several areas which require further study in the light of the results of this review:

  • Further trials are required to assess the effectiveness of both lay and professional support in different settings - in particular in those communities with low rates of breastfeeding initiation.
  • Trials should test the effectiveness of different training programmes (which should be well-defined and reproducible) and should attempt to address impact on both exclusive and any breastfeeding where possible.
  • Prospective economic analyses are required to accompany trials to establish the cost-effectiveness of different interventions.
  • Implementation of the Baby Friendly Initiative should be accompanied by the continued monitoring of breastfeeding rates to explore whether its effect is similar in countries with differing rates of initiation and prevalence of breastfeeding.
  • Fundamental qualitative research should explore the different elements of breastfeeding support strategies and the mechanisms by which support operates.

 

Potential conflict of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

None declared.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

The reviewers wish to thank Dr Heloisa Bettiol and Roberto Cudell for assistance with translation and data extraction from papers in Portuguese. Julian Higgins gave early statistical advice and helpful comments on an earlier edition of the review in the Cochrane Library were made by Dr Alison Furey. Thanks are also due to Dr Allen Donner and Simon Gates. We wish to thank particularly the following study authors who were very helpful in responding to queries: Prof F Barros, Dr C-L Dennis, Dr R Haider, Dr M Kramer, Prof A Leite and Dr A Morrow. Thanks also due to Sonja Henderson, Cochrane Pregnancy and Childbirth Review Group Co-ordinator. Jim Sikorski was funded by a grant from the UK Medical Research Council.

 

Characteristics of included studies

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support


StudyBarros 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. Quality score 5/8.

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.

Allocation concealmentB






StudyBrent 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 two 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. Quality score 4/8.

ParticipantsUrban USA - ambulatory care centre and inpatient 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 (Women, Infants and Children) 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.

Allocation concealmentB






StudyDavies-Adetugbo 1997

MethodsPrimary care facilities. Recruitment over 5 months. n = 169. Follow-up 95%. Outcome assessment not blinded. Quality score 4/8.

ParticipantsOsun State, rural Nigeria. Primary health care 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/ counselling sessions by Community Health Workers and 2 research assistants. Training: adapted WHO breastfeeding counselling 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 post-intervention. Recurrence of diarrhoea.

Notes

Allocation concealmentC






StudyDennis 1999

MethodsSingle site study recruiting over 10 months. n = 258 99% follow-up. Randomisation appropriate. Outcome assessor blinded. Quality score 6/8.

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 mins. 97% of contacts by telephone. 3% at home.

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

Notes

Allocation concealmentA






StudyFrank 1987

MethodsSingle site study recruiting over 17 months. n = 343. Follow-up 94%. Appropriate randomisation procedures. Reasons for drop-out recorded. Independent outcome assessment. Quality score 7/8.

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.

Interventions1. Postpartum research breastfeeding counselling 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.

Allocation concealmentA






StudyFroozani 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. Quality score 3/8.

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 Counselling 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

Allocation concealmentC






StudyGrossman 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. Quality score 3/8.

ParticipantsUrban USA - in patient maternity unit. Inclusion criteria: women eligible for WIC (Women, Infants and Children) 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 beastfeeding 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.

Allocation concealmentC






StudyHaider 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 post-discharge 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). Quality score 6/8.

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: counselling 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.

Allocation concealmentA






StudyHaider 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. Quality score 5/8.

ParticipantsDakka, Bangladesh. Mainly lower-middle and low socioeconomic 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 1800g 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 counselling by women with personal breastfeeding experience trained over 40 hours with the WHO/Unicef Breastfeeding Counselling 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

Allocation concealmentB






StudyJenner 1988

MethodsRecruitment location/duration not stated. n = 38
100% follow-up. Alternate assignment. Outcome assessment not blinded. Quality score 4/8.

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.

Allocation concealmentC






StudyJones 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. Quality score 5/8.

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

Allocation concealmentC






StudyKramer 2001

MethodsMulti-site cluster randomised study. Recruitment period 19 months. n = 17,046. Follow - up 96.7%. Randomisation appropriate. Outcome assessment not blinded. Quality score 6/8.

ParticipantsUrban and rural sites within Belarus. Inclusion criteria: intention to breastfeed, healthy mother, child 2500g 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

Allocation concealmentA






StudyLeite 1998

MethodsSubjects 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. Quality score 6/8.

ParticipantsUrban Brazil. Inclusion criteria: Healthy babies, weighing < 3000g, 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 counselling 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 birth weights below 3000g.

Allocation concealmentA






StudyLynch 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). Quality score 3/8.

ParticipantsUrban Canada - maternity unit of regional general hospital. Inclusion criteria: intending to breastfeed; English speaking. Exclusion criteria: multiple births; birth weight < 2500gm; 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.

Allocation concealmentB






StudyMongeon 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. Quality score 3/8.

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 primparous. 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.

Allocation concealmentC






StudyMoore 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. Quality score 4/8.

ParticipantsUrban UK - antenatal clinic of city maternity hospital. Inclusion criterion: personal or partner history of atopy. Exclusion criteria: non-white; 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.

Allocation concealmentB






StudyMorrell 2000

MethodsSingle site study recruiting over 14 months. n = 632 Follow-up 78%. Randomisation appropriate. Quality score 7/8.

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 Special Care Baby Unit. National baseline prevalence 66% breastfeeding at birth and 42% at 4 months. Exclusive breastfeeding 21% at 4 months.

InterventionsCommunity posnatal 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.

Allocation concealmentA






StudyMorrow 1999

MethodsCommunity based cluster randomised study. Recruitment over 18 months. n = 130 Follow-up 96% to 3 months, 80% to 6 months. Randomisation appropriate. Quality score 6/8.

ParticipantsPeri-urban Mexican community. All pregnant or postnatal women in 39 geographical clusters. Peri-natal 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. Two 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

Allocation concealmentA






StudyPorteous 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. Quality score 4/8.

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.

Allocation concealmentB






StudySjolin 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. Quality score 2/8.

ParticipantsUrban Sweden - maternity ward of University Hospital. Inclusion criteria; resident in Uppsala; normal birth; healthy babies weighing > 3kg. 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.

Allocation concealmentC



NICU = neonatal intensive care unit
EDD = expected date of delivery
BFI = Baby Friendly Initiative.
WIC= Women, Infants and Children.

 

Characteristics of excluded studies

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support


StudyReason for exclusion

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

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

Ellis 198432% loss to follow-up.

Gagnon 199744% post-randomisation exclusions.

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

Kistin 1994Non-randomised observational study.

Neyzi 1991Only 66% follow-up in intervention group.

Redman 199534% loss to follow-up.

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.

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



 

Characteristics of ongoing studies

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support


StudyMuirhead

Trial name or titleOngoing trial of peer-counsellor support in Ayrshire, Scotland.

Participants

Interventions

Outcomes

Starting date

Contact informationOxenward.Surgery@dial.pipex.com.

Notes



 

Graphs

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support

 
Comparison 01. All forms of support versus usual care

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Stopping any breastfeeding before last study assessment up to 6 months
 FigureFigure 1. 01 Stopping any breastfeeding before last study assessment up to 6 months
Relative Risk (Random) 95% CISubtotals only

 
Comparison 02. All forms of support versus usual care.

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Stopping exclusive breastfeeding before last study assessment
 FigureFigure 2. 01 Stopping exclusive breastfeeding before last study assessment
114080Relative Risk (Random) 95% CI0.78 [0.69, 0.89]

 
Comparison 03. All forms of support versus usual care

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Stopping any breastfeeding at different times
 FigureFigure 3. 01 Stopping any breastfeeding at different times
Relative Risk (Random) 95% CISubtotals only

02 Stopping exclusive breastfeeding at different times.
 FigureFigure 4. 02 Stopping exclusive breastfeeding at different times.
Relative Risk (Random) 95% CISubtotals only

 
Comparison 04. Professional support versus usual care.

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Stopping any breastfeeding before last study assessment up to 6 months
 FigureFigure 5. 01 Stopping any breastfeeding before last study assessment up to 6 months
103210Relative Risk (Random) 95% CI0.89 [0.81, 0.97]

02 Stopping exclusive breastfeeding before last study assessment
 FigureFigure 6. 02 Stopping exclusive breastfeeding before last study assessment
61716Relative Risk (Random) 95% CI0.90 [0.81, 1.01]

 
Comparison 05. Lay support versus usual care.

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Stopping any breastfeeding before last study assessment.
 FigureFigure 7. 01 Stopping any breastfeeding before last study assessment.
52194Relative Risk (Random) 95% CI0.84 [0.69, 1.02]

02 Stopping exclusive breastfeeding before last study assessment.
 FigureFigure 8. 02 Stopping exclusive breastfeeding before last study assessment.
52364Relative Risk (Random) 95% CI0.66 [0.49, 0.89]

 
Comparison 06. Professional support versus usual care

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Stopping any breastfeeding at different times.
 FigureFigure 9. 01 Stopping any breastfeeding at different times.
Relative Risk (Random) 95% CISubtotals only

02 Stopping exclusive breastfeeding at different times.
 FigureFigure 10. 02 Stopping exclusive breastfeeding at different times.
Relative Risk (Random) 95% CISubtotals only

 
Comparison 07. Lay support versus usual care

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Stopping any breastfeeding at different times
 FigureFigure 11. 01 Stopping any breastfeeding at different times
Relative Risk (Random) 95% CISubtotals only

02 Stopping exclusive breastfeeding at different times.
 FigureFigure 12. 02 Stopping exclusive breastfeeding at different times.
Relative Risk (Random) 95% CISubtotals only

 
Comparison 08. Differing modes of support versus usual care

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Stopping any breastfeeding before last study assessment up to 6 months
 FigureFigure 13. 01 Stopping any breastfeeding before last study assessment up to 6 months
155404Relative Risk (Random) 95% CI0.88 [0.81, 0.95]

 
Comparison 09. Differing timings of support versus usual care

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Stopping any breastfeeding at last study assessment up to 6 months
 FigureFigure 14. 01 Stopping any breastfeeding at last study assessment up to 6 months
155404Relative Risk (Random) 95% CI0.88 [0.81, 0.95]

 
Comparison 10. Differing training versus usual care.

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Stopping exclusive breastfeeding before last study assessment
 FigureFigure 15. 01 Stopping exclusive breastfeeding before last study assessment
Relative Risk (Random) 95% CISubtotals only

 
Comparison 11. Support of mothers with sick children.

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Exclusive breastfeeding 2-3 weeks after discharge from health care facility.
 FigureFigure 16. 01 Exclusive breastfeeding 2-3 weeks after discharge from health care facility.
2419Relative Risk (Fixed) 95% CI0.48 [0.41, 0.56]

02 Recurrence of diarrhoea 2-3 weeks after discharge from health care facility.
 FigureFigure 17. 02 Recurrence of diarrhoea 2-3 weeks after discharge from health care facility.
2419Relative Risk (Fixed) 95% CI0.44 [0.24, 0.80]

 
Comparison 12. Lay support versus usual care

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Maternal satisfaction with infant feeding.
 FigureFigure 18. 01 Maternal satisfaction with infant feeding.
1251Weighted Mean Difference (Fixed) 95% CI0.83 [-0.61, 2.27]

 
Comparison 13. Lactation nurse versus usual care.

Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size

01 Sufficient help received with breastfeeding problems.
 FigureFigure 19. 01 Sufficient help received with breastfeeding problems.
Relative Risk (Fixed) 95% CISubtotals only

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Criteria for considering studies for this review
  5. Search strategy for identification of studies
  6. Methods of the review
  7. Description of studies
  8. Methodological quality
  9. Results
  10. Discussion
  11. Authors' conclusions
  12. Potential conflict of interest
  13. Acknowledgements
  14. Characteristics of included studies
  15. Characteristics of excluded studies
  16. Characteristics of ongoing studies
  17. Graphs
  18. Sources of support
 

External sources of support

  • UK Medical Research Council UK

 

Internal sources of support

  • No sources of support supplied

References

References to studies included in this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Criteria for considering studies for this review
  6. Search strategy for identification of studies
  7. Methods of the review
  8. Description of studies
  9. Methodological quality
  10. Results
  11. Discussion
  12. Authors' conclusions
  13. Potential conflict of interest
  14. Acknowledgements
  15. Characteristics of included studies
  16. Characteristics of excluded studies
  17. Characteristics of ongoing studies
  18. Graphs
  19. Sources of support
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
  25. References to other published versions of this review
Barros 1994{published data only}
  • Barros FC, Halpern R, Victora CG, Teixera AM, Beria J. A randomised intervention study to increase breastfeeding prevalence in southern Brazil. Revista de Saude Publica 1994;28(4):277-83.
Brent 1995{published data only}
  • Brent NB, Redd B, Dworetz A, D'Amico FD, Greenberg J. Breastfeeding in a low-income population. Archives of Pediatric and Adolescent Medicine 1995;149:798-803.
Davies-Adetugbo 1997{published data only}
  • Davies-Adetugbo AA, Adetugbo K, Orewole Y, Fabiyi AK. Breast-feeding promotion in a diarrhoea programme in rural communities. Journal of Diarrhoel Diseases Research 1997;15(3):161-6.
Dennis 1999{published data only}
  • Dennis C-L. A randomized controlled trial evaluating the effect of peer (mother-to-mother) support on breastfeeding duration among primiparous women. [PhD dissertation] Toronto, Ontario, Canada: University of Toronto 1999.
Frank 1987{published data only}
  • Frank DA, Wirtz SJ, Sorensen JR, Heeren T. Commercial hospital discharge packs and breastfeeding counselling: effects on infant feeding practices in a randomized trial. Paediatrics 1987;80:845-54.
Froozani 1999{published data only}
  • Froozani MD, Permehzadeh K, Motlagh AR, Golestan B. Effect of breastfeeding education on the feeding pattern and health of infants in their first 4 months in the Islamic Republic of Iran. Bulletin of World Health Organisation 1999;77(5):381-5.
Grossman 1990{published data only}
  • Grossman LK, Harter C, Kay A. The effect of postpartum lactation counseling on the duration of breastfeeding in low-income women. American Journal of Diseases in Childhood 1990;144:471-4.
Haider 1996{published data only}
  • Haider R, Islam A, Hamadani J, Amin NJ, Kabir I, Malek MA, et al. Breastfeeding counselling in a diarrhoeal disease hospital. Bulletin of the World Health Organization 1996;74(2):173-9.
Haider 2000{published data only}
  • Haider R, Ashworth A, Kabir I, Huttly S. Effects of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. Lancet 2000;356:1643-7.
Jenner 1988{published data only}
  • Jenner S. The influence of additional information, advice and support on the success of breast feeding in working class primiparas. Childcare: Health and Development 1988;14:319-28.
Jones 1985{published data only}
  • Jones DA, West RR. Lactation nurse increases duration of breastfeeding. Archives of Diseases in Childhood 1985;60:772-4.
Kramer 2001{published and unpublished data}
  • Kramer MS, Chalmers B, Hodnett E, Sevkovskaya Z, Dzikovich I, Shapiro S for the PROBIT Study Group. Promotion of Breastfeeding Intervention Trial (PROBIT) A randomized trial in the Republic of Belarus. JAMA 2001;285:413-20.
Leite 1998{published data only}
  • Leite AJM, Puccini R, Atallah A, Cunha A, Machado M, Capiberibe A, et al. Impact on breastfeeding practices promoted by lay counselors: a randomized and controlled clinical trial. Clinical Epidemiology 1998;51 (Suppl):10S.
Lynch 1986{published data only}
  • Lynch SA, Koch AM, Hislop TG, Coldman AJ. Evaluating the effect of a breastfeeding consultant on the duration of breastfeeding. Canadian Journal of Public Health 1986;77:190-5.
Mongeon 1995{published data only}
  • Mongeon M, Allard R. [Essai controle d'un soutien telephonique regulier donne par une benevole sur le deroulment et l'issus de l'allaitment]. Revue Canadienne de Sante Publique 1995;86(2):124-7.
Moore 1985{published data only}
  • Moore WJ, Midwinter, Morris AF, Colley JRT, Soothill JF. Infant feeding and subsequent risk of atopic eczema. Archives of Disease in Childhood 1985;60:722-6.
Morrell 2000{published data only}
  • Morrell CJ, Spiby H, Stewart P, Walters S, Morgan A. Costs and effectiveness of community postnatal support workers: randomised controlled trial. BMJ 2000;321:593-8.
Morrow 1999{published data only}
  • Morrow AL, Lourdes Guerrero M, Shults J, Calva JJ, Lutter C, Bravo J, et al. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet 1999;353:1226-31.
Porteous 2000{published data only}
  • Porteous R, Kaufman K, Rush J. The effect of individualized professional support on duration of breastfeeding: a randomized controlled trial. Journal of Human Lactation 2000;16(4):303-8.
Sjolin 1979{published data only}
  • Sjolin S, Hofvander Y, Hillervik C. A prospective study of individual courses of breastfeeding. Acta Paediatrica Scandinavica 1979;68:521-9.

References to studies excluded from this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Criteria for considering studies for this review
  6. Search strategy for identification of studies
  7. Methods of the review
  8. Description of studies
  9. Methodological quality
  10. Results
  11. Discussion
  12. Authors' conclusions
  13. Potential conflict of interest
  14. Acknowledgements
  15. Characteristics of included studies
  16. Characteristics of excluded studies
  17. Characteristics of ongoing studies
  18. Graphs
  19. Sources of support
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
  25. References to other published versions of this review
Chen 1993
  • Chen C-H. Effects of home visits and telephone contacts on breastfeeding compliance in Taiwan. Maternal-Child Nursing Journal 1993;21(3):82-90.
Davies-Adetugbo 1996
  • Davies-Adetugbo AA. Promotion of breastfeeding in the community: impact of health education programme in rural communities in Nigeria. Journal of Diarrhoeal Disease Research 1996;14(1):5-11.
Ellis 1984
  • Ellis DJ, Hewat RJ. Factors related to breastfeeding duration. Canadian Family Physician 1984;30:1479-84.
Gagnon 1997
  • Gagnon AJ, Edgar L, Kramer MS, Papageorgiou A, Waghorn K, Klein MC. A randomized trial of a program of early postpartum discharge with nurse visitation. American Journal of Obstetrics and Gynecology 1997;176:205-11.
Gross 1998
  • Gross SM, Caulfield LE, Bentley ME, Bronner Y, Kessler L, Jensen J, et al. Counseling and motivational videotapes increase duration of breast-feeding in African-American WIC participants who initiate breast-feeding. Journal of the American Dietetic Association 1998;98:143-8.
Kistin 1994
  • Kistin N, Abramson R, Dublin P. Effect of peer-counsellors on breastfeeding initiation, exclusivity and duration among low-income women. Journal of Human Lactation 1994;10(1):11-5.
Neyzi 1991
  • Neyzi O, Gulecyuz M, Dincer Z, Olgun P, Kutluay T, Uzel N, et al. An educational intervention on promotion of breast feeding complemented by continuing support. Paediatric and Perinatal Epidemiology 1991;5:299-303.
Redman 1995
  • Redman S, Watkins J, Evans L, Lloyd D. Evaluation of an Australian intervention to encourage breast feeding in primiparous women. Health Promotion International 1995;10(2):101-13.
Rowe 1990
  • Rowe L, Hartmann PE. Comparison of two methods of breast feeding management. Proceedings of 6th Congress of the Federation of the Asia-Oceania Perinatal Societies; 1990; Perth, Western Australia, 1990:236.
Rush 1991
  • Rush JP, Kitch TL. A randomized, controlled trial to measure the frequency of use of a hospital telephone line for new parents. Birth 1991;18:193-7.
Schy 1996
  • Schy DS, Folker Maglaya C, Mendelson SG, Race KEH, Ludwig-Beymer P. The effects of in-hospital lactation education on breastfeeding practice. Journal of Human Lactation 1996;12(2):117-22.
Sciacca 1995
  • Sciacca JP, Phipps B, Dube D, Ratliff MI. Influences on breast-feeding by lower-income women: an incentive, partner-supported educational program. Journal of the American Dietetic Association 1995;95(3):323-8.
Serafino-Cross 1992
  • Serafino-Cross P, Donovan P. Effectiveness of professional breastfeeding home-support. Society for Nutrition Education 1992;24(3):117-22.

Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Criteria for considering studies for this review
  6. Search strategy for identification of studies
  7. Methods of the review
  8. Description of studies
  9. Methodological quality
  10. Results
  11. Discussion
  12. Authors' conclusions
  13. Potential conflict of interest
  14. Acknowledgements
  15. Characteristics of included studies
  16. Characteristics of excluded studies
  17. Characteristics of ongoing studies
  18. Graphs
  19. Sources of support
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
  25. References to other published versions of this review
Altman 1998
  • Altman DG, Deeks JJ, Sackett DL. Odds ratios should be avoided when events are common. BMJ 1998.
Anderson 1999
  • Anderson JW, Johnstone BM, Remley DT. Breast-feeding and cognitive development: a meta-analysis. American Journal of Clinical Nutrition 1999;70:525-35.
Aniansson 1994
  • Aniansson G, Alm B, Andersson B, Hakansson A, Larsson P, Nylen O, et al. A prospective cohort study on breast-feeding and otitis media in Swedish infants. Pediatric Infectious Disease Journal 1994;13:183-8.
Donner 2001
  • Donner A, Klar N. Issues in the meta-analysis of cluster randomized trials. Statistics in Medicine (in press)
Foster 1997
  • Foster K, Lader D, Cheesebrough S. Infant feeding. London: The Stationery Office, 1995.
Heinig 1997
  • Heinig MJ, Dewey KG. Health effects of breast feeding for mothers: a critical review. Nutrition Research Reviews 1997;10:35-56.
Howie 1990
  • Howie PW, Forsyth S, Ogston SA, Clark A, Florey C du V. Protective effect of breastfeeding against infection. BMJ 1990;300:11-6.
Leff 1994
  • Leff EW, Jefferis C, Gagne MP. The development of the Maternal Breastfeeding Evaluation Scale. Journal of Human Lactation 1994;10(2):105-11.
Lucas 1990a
  • Lucas A, Brooke OG, Morley R, Cole TJ, Bamford MF. Early diet of preterm infants and development of allergies or atopic disease: randomised prospective study. BMJ 1990;300:837-40.
Lucas 1990b
  • Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet 1990;336:1519-23.
Pisacane 1992
  • Pisacane A, Graziano L, Mazzarella G, Scarpellino B, Zona G. Breastfeeding and urinary tract infection. Journal of Pediatrics 1992;120(1):331-2.
Rao 1992
  • Rao JNK, Scott AJ. A simple method for the analysis of clustered binary data. Biometrics 1992;48:577-85.
Rogers 1997
  • Rogers IS, Emmett PM, Golding J. The incidence and duration of breast feeding. Early Human Development 1997;49 Suppl:S45-74.
Singhal 2001
  • Singhal A, Cole TJ, Lucas A. Early nutrition in preterm infants and later blood pressure: two cohorts after randomised trials. Lancet 2001;357:413-9.
Taittonen 1996
  • Taittonen L, Nuutinen M, Turtinen J, Uhari M. Prenatal and postnatal factors in predicting later blood pressure among children: cardiovascular risk in young Finns. Pediatric Research 1996;41(4):627-32.
UNICEF 2000
  • UNICEF 2000. The State of the World's Children. www.unicef.org/sowc00/stat4.htm (accessed 2000)
Victora 1989
  • Victora CG, Smith PG, Barros FC, Vaughan JP, Fuchs SC. Risk factors for deaths due to respiratory infections among Brazilian infants. International Journal of Epidemiology 1989;18:918-25.
WHO 2000
  • WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious disease in less developed countries: a pooled analysis. 2000;355:451-5.
WHO 2001
  • WHO Note for the Press. The Optimal Duration of Exclusive Breastfeeding. Results of a WHO systematic review. http://www.who.int/inf-pr-2001/en/note2001-07.html (accessed 2001)
Wilson 1998
  • Wilson AC, Stewart Forsyth J, Greene SA, Irvine L, Au C, Howie PW. Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study. BMJ 1998;316:21-5.

References to other published versions of this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Criteria for considering studies for this review
  6. Search strategy for identification of studies
  7. Methods of the review
  8. Description of studies
  9. Methodological quality
  10. Results
  11. Discussion
  12. Authors' conclusions
  13. Potential conflict of interest
  14. Acknowledgements
  15. Characteristics of included studies
  16. Characteristics of excluded studies
  17. Characteristics of ongoing studies
  18. Graphs
  19. Sources of support
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
  25. References to other published versions of this review
Renfrew 1995
  • Renfrew MJ. Postnatal support for breastfeeding mothers. [revised May 1994] In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.
Sikorski 1999
  • Sikorski J, Renfrew MJ. Support for breastfeeding mothers (Cochrane Review). In: The Cochrane Library, Issue 1, 1999. Oxford: Update Software.