This review aims to assess ways of promoting breastfeeding. Fewer resources have been spent on this than on the promotion of formula feeding. Women in most countries encounter promotion of formula feeding in various forms, a factor which has been implicated in women choosing to feed their babies on formula (WHO Data Bank 1996).
There is extensive evidence for short-term and long-term health risks of formula feeding and the World Health Organisation recommends that all infants should be fed exclusively on breast milk from birth to six months of age (WHO 2002). Babies who are not breastfed exclusively for the first three to four months are more likely to suffer health problems such as gastroenteritis (Howie 1990; Ip 2007; Kramer 2001; Quigley 2006; Quigley 2007), respiratory infection (Ip 2007; Kramer 2001; Victora 1989; Wright 1989), otitis media (Aniansson 1994; Duncan 1993; Ip 2007), urinary tract infections (Marild 1990; Pisacane 1992), necrotising enterocolitis ( Ip 2007; Lucas 1990a), atopic disease if a family history of atopy is present (Burr 1989; Lucas 1990b; Saarinen 1995) and diabetes mellitus (Karjalainen 1992; Mayer 1988; Virtanen 1991). Research also indicates a positive relationship between having been breastfed and the bone health of the child (Lucas 1990a) and with improved cognitive development (Kramer 2008). In addition, breastfeeding is beneficial to the mother's health. Women who formula feed are significantly more likely to develop epithelial ovarian cancer (Gwinn 1990; Rosenblatt 1993) and are more likely to develop breast cancer (Ip 2007; Layde 1989; Newcomb 1994; UK Study Group 1993) than women who breastfeed.
Other social and practical benefits to the breastfeeding mother include the increased likelihood she will use up the body fat deposited in pregnancy (Dewey 1993; Kramer 2002), substantive savings on the expenses associated with formula feeding (except in the case of mothers participating in welfare schemes and receiving subsidised formula milk powder), and the avoidance of effort and risks involved in preparing formula feeds (MIDIRS 1997; Bryant 1990).
Attempts have been made to quantify public cost benefits of breastfeeding. Recent National Institute for Health and Clinical Excellence (NICE), guidance on modelling the cost effectiveness of breastfeeding to the UK National Health Service (NHS) estimates that peer support which achieves an estimated 20 percentage point increase in breastfeeding initiation would save the NHS money over the long term (NICE 2007). The model suggests that such a scheme would avert 2.7 per 10,000 cases of pre-menopausal breast cancer in mothers and 285 per 10,000 cases of infections requiring hospitalisation in the first year of life. At the current NICE threshold for cost per quality-adjusted life year (QALY) gained (£20,000-£30,000), it estimates that expenditure on breastfeeding support would be justified in competition with other demands on NHS resources by an increase in initiation rates of about 15 percentage points. The authors note that evidence on other potential health benefits and savings, such as improved health of breastfed babies later in life and reduced spending on infant formula, is too complex to be accounted for by the model. Results will therefore tend to underestimate the cost-effectiveness of peer support interventions. The authors found the quality of evidence concerning the efficacy and cost of public health interventions designed to promote breastfeeding to be poor.
Despite the documented risks of formula feeding, many women choose to formula feed their babies. Given the wide variations in rates between countries and population groups (see below), the reasons for this are likely to be socio-cultural and include personal, social and structural biases against breastfeeding. These may include attitudes of family and close friends, attitudes to breastfeeding in public and employment practices (Renfrew 1998). The availability of subsidised infant formula milk through welfare food programmes, such as the UK based Healthy Start Scheme and the USA based Women, Infant and Children Supplemental Feeding Program, may be an economic factor which contributes unintentionally to women in low-income groups deciding to formula feed. The extent to which individual countries have adopted the World Health Organisation's International Code of Marketing of Breast Milk Substitutes (WHO 1981) may also be a contributing factor to the infant feeding decision, particularly for women in low- and middle-income countries. The WHO Code (WHO 1981) was adopted by the World Health Assembly in 1981 and is currently supported by over 20 countries with draft laws awaiting adoption in others. Increased support to adopt the WHO/UNICEF Code (WHO 1981) into national legislation would prohibit the provision and promotion of breast milk substitutes to pregnant women, new mothers or families.
International rates of initiation of breastfeeding are extremely variable between and within countries (see Appendix 1). Historically, breastfeeding rates have been high in many resource poor-countries despite variation in urban and rural areas. In Scandinavia and Eastern Europe, many countries have a high incidence of women starting to breastfeed. Other individual countries with breastfeeding initiation rates of over 90% include Japan, Switzerland, Luxembourg and Turkey. In central and southern Europe, initiation rates remain relatively high at around 70% to 80%, for example, in Italy, Spain and Greece.
North America and much of Western Europe have experienced lower rates of initiation of breastfeeding since the early 20th century. Significant increases have been experienced in some countries over the last decade. For example, recent UK data show that 78% of mothers initiate breastfeeding in England, 70% in Scotland, 67% in Wales and 63% in Northern Ireland (Bolling 2007) (see Appendix 2); and 85% and 74% of mothers start to breastfeed in Canada (Millar 2005) and the US (CDC 2004) respectively.
In all countries, breastfeeding initiation rates are closely related to social class, income and educational levels. In those high-income countries where breastfeeding rates are typically low, the lowest rates are found among women in low-income groups. In England and Wales, for example, only 65% of women classified as having 'never worked' or 65% of women in 'lower occupations' initiated breastfeeding in 2000 compared to 88% of women classified in 'higher occupations' (Bolling 2007). It is therefore important to examine which interventions might have an impact on rates in these groups.
The purpose of this review is to examine interventions which aim to encourage women to breastfeed, to evaluate their effectiveness in terms of changes in the number of women who initiate breastfeeding and to report any other effects (beneficial or adverse) of such interventions.
- To identify and describe health promotion activity intended to increase the rate of initiation of breastfeeding.
- To evaluate the effectiveness of different types of health promotion activity, in terms of changing the number of women who initiate breastfeeding.
- To compare the effectiveness of different types of health promotion interventions as appropriate.
- To assess the impact of these interventions on secondary outcomes, namely, duration of any or exclusive breastfeeding and any adverse outcomes as a result of the intervention.
Criteria for considering studies for this review
Types of studies
Randomised controlled trials, with or without blinding. There was no limitation of study by country of origin or language.
Types of participants
All those exposed to interventions intended to promote breastfeeding. This includes pregnant women, mothers of newborn infants and women who may decide to breastfeed in the future. We also included population subgroups of women, such as women from low-income or ethnic groups. Women and infants with a specific health problem, e.g. mothers with HIV/AIDS or infants with cleft palate, or premature babies, are excluded from this review.
Types of interventions
Any intervention aiming to promote the initiation of breastfeeding, which takes place before the first breastfeed. Evaluations of interventions taking place after the first breastfeed or whose primary purpose is to affect the duration or exclusivity of breastfeeding are excluded from this review.
Types of outcome measures
Initiation and duration of any and exclusive breastfeeding.
Search methods for identification of studies
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register by contacting the Trials Search Co-ordinator (July 2007).
The Cochrane Pregnancy and Childbirth Group's Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from:
- quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);
- weekly searches of MEDLINE;
- handsearches of 30 journals and the proceedings of major conferences;
- weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.
Details of the search strategies for CENTRAL and MEDLINE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group.
Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co-ordinator searches the register for each review using the topic list rather than keywords.
Further details of searching carried out for the initial version of this review can be found in Appendix 3.
Searching other resources
We handsearched the Journal of Human Lactation, Health Promotion International and Health Education Quarterly from inception to August 2007.
We scanned reference lists of all relevant papers retrieved.
We did not apply any language restrictions.
Data collection and analysis
Two authors independently assessed over 1400 titles and abstracts of studies, identified from all sources, for relevance. Where no clear decision could be made on the basis of the title or abstract, we considered the studies relevant. This process identified 83 potentially relevant studies for which we retrieved full reports for more detailed consideration.
One author used a prescreen form to systematically assess retrieved papers against the inclusion criteria and to classify included studies by the type of health promotion intervention. This included three papers which required translation into English before prescreening, namely, papers in Portuguese, Russian and Croatian. We contacted authors to clarify or obtain relevant details of individual studies, particularly to request details of their randomisation processes. A second author independently checked fifty papers that were classified as possible exclusions during the prescreening process. We excluded all. Two studies we previously identified as ongoing have been completed but not yet published and are awaiting assessment for this review.
One author used data extraction and quality appraisal forms to extract data from the remaining eleven studies. A second author then checked the data. Any disagreements were settled through discussion between authors. This resulted in eleven studies being included in this review, eight of which contributed data to the meta-analyses. Studies were classified by type of intervention: health education of pregnant women, health education of significant others of pregnant women, peer support, health education of pregnant women and peer support, breastfeeding promotion packs, and early mother-infant contact. One author entered data into the Review Manager software (Revman 2008).
We assessed the validity of each included study according to the criteria outlined in the Cochrane Handbook (Higgins 2008). We assessed selection bias on the basis of concealment of allocation: adequate; unclear; or inadequate. We rated performance bias, attrition bias and detection bias as: adequate; unclear or partially adequate; or inadequate.
For eight studies, we considered meta-analysis appropriate to evaluate the effect of each type of intervention which measured the primary outcome of initiation of breastfeeding. The reasons for not including data from three studies (Caulfield 1998; Forster 2004; Wolfberg 2004) in the meta-analyses are given in Description of studies. Figures show calculated individual and pooled risk ratios with 95% confidence intervals for dichotomous data on initiation of breastfeeding from studies where data allow an estimation. We calculated the individual risk ratios on an intention-to-treat basis where the data from primary studies allow participants to be analysed according to the group to which they were initially allocated, regardless of whether or not they later withdrew or were lost to the study. Key differences in characteristics of participants or methods of implementation of the intervention, or both, are discussed in the interpretation of results (see Results).
We undertook subgroup analysis to compare the differential effect of interventions on initiation rates for studies within the education and education or peer support categories. This was possible due to the similarities between subgroups of interventions and low levels of statistical heterogeneity .
The nature of health promotion interventions to achieve a positive outcome in terms of an increase in the number of women starting to breastfeed warrants reversal of the traditional Cochrane Database of Systematic Reviews convention whereby a risk ratio of less than one indicates that the intervention is better than the control (Alderson 2004). For the purposes of this review therefore, a risk ratio of more than one indicates that the intervention has a more favourable effect on initiation rates than the control. This is displayed by the dot appearing to the right of the central vertical line that indicates no difference.
To summarise results, we began by using a fixed-effect approach. This approach assumes differences among study results are due solely to the play of chance (Higgins 2006). If the forest plot showed substantial statistical heterogeneity (I
No studies measuring the primary outcome of initiation rates of breastfeeding were excluded from the review and no sorting of studies for ordering of meta-analyses was considered necessary on the basis of methodological quality. Three studies included in the review did not contribute data to the meta-analyses, as detailed below.
Description of studies
See Characteristics of included studies table.
This review has a total of eleven included studies and 70 excluded studies. Two studies, completed but not published when this update went to press, are awaiting assessment.
Caulfield 1998 randomised four WIC clinics in one US city. One clinic received no intervention, one received a breastfeeding motivational video, another received a peer counselling intervention, and the fourth clinic received both the video and peer counselling interventions. The clinic populations were 90% to 96% African-American, with breastfeeding rates of 2% to 6% at one month. Outcome data are presented for 242/674 potentially eligible women (36%) for whom complete data were available. Among these 242 women, the overall breastfeeding initiation rate (defined as ever putting the infant to the breast) was 48%. In the control clinic (n = 57) 26% initiated breastfeeding; in the video clinic (n = 64) the rate was 50%; in the peer counsellor clinic (n = 55) it was 62%; and in the clinic that used both the interventions (n = 66) the breastfeeding initiation rate was 52%. We sought statistician's advice about whether we should include this study as a cluster-randomised trial. We were advised against inclusion because with only one clinic in each treatment group, it is not possible to calculate the standard error of difference. The paper reports that although clinic-level data had suggested the four clinics were comparable, characteristics of women who enrolled in the study were noted to vary by clinic. Therefore, although it appears that either intervention was better than none for promoting breastfeeding initiation, it is not possible to estimate their effects with any precision.
Forster 2004 reported a randomised controlled trial that took place in Melbourne, Australia, in a hospital that had been Baby-Friendly accredited for four years before the trial began. Women booking to have their first infant at the hospital were eligible if they were public patients, 16 to 24 weeks' pregnant at recruitment, and able to speak and write in English. In addition to Baby-Friendly standard care (n = 327), there were two interventions; practical skills (n = 327) and attitudes (n = 327) (details of the interventions appear in the Characteristics of included studies table). Breastfeeding initiation rates were high in all three groups (97% for the practical skills intervention, 95% for the attitudes intervention, and 96% for Baby-Friendly standard care). The researchers conclude that in settings where breastfeeding initiation is high, neither of the two interventions can be recommended as effective. Results from this large, well-reported trial are not included in the meta-analyses for this review. We considered the control group who received standard care compliant with the Baby-Friendly initiative had in effect received a third intervention that meant we could not compare this control group with the control groups of other studies in the review.
Wolfberg 2004 reported a randomised controlled trial with expectant fathers who were partners of women seeking prenatal care at one US hospital. Participants were predominantly black women receiving benefits under the federal Women and Infants Supplementary Feeding Program. The intervention group attended a two-hour class on infant care and breastfeeding promotion, and the control group attended a class on infant care only. Both classes were facilitated by the same person, a black father who was knowledgeable and used a non-didactic and informal method of education. Women whose partners attended the intervention class had a 74% breastfeeding initiation rate (20/27) compared with 41% (13/32) whose partners attended the control class. The authors reported significant attrition. They approached 567 pregnant women and reported data from 57 couples (10%). The numbers randomised to each group are not reported therefore results from this trial have not been included in the analyses for this review.
Further details of these studies appear in the Characteristics of included studies table.
Among the excluded studies are four studies which were excluded due to lack of information about outcome data or method of randomisation despite efforts to contact the authors (Chapman 1986; Grossman 1988; Mattar 2007; Winterburn 2003), and one study which is ongoing but would not be included on completion due to the aims of the study being outside the focus of this review (Chong 2007). Two studies are awaiting assessment (Hoddinott 2007; Wambach 2006).
All eleven included studies evaluated the effect of the intervention in terms of the numbers of women who initiated breastfeeding (Brent 1995; Caulfield 1998; Chapman 2004; Coombs 1998; Forster 2004; Hill 1987; Howard 2000; Lindenberg 1990; Ryser 2004; Serwint 1996; Wolfberg 2004). Nine studies were conducted in the USA (Brent 1995; Caulfield 1998; Chapman 2004; Coombs 1998; Hill 1987; Howard 2000; Ryser 2004; Serwint 1996; Wolfberg 2004), one in Australia (Forster 2004) and one in Nicaragua, Central America (Lindenberg 1990). Nine of the studies have evaluated the impact of the intervention on both initiation and duration rates (Brent 1995; Caulfield 1998; Chapman 2004; Forster 2004; Hill 1987; Howard 2000; Lindenberg 1990; Serwint 1996; Wolfberg 2004). Nine studies have targeted participants on low incomes (Brent 1995; Caulfield 1998; Chapman 2004; Coombs 1998; Hill 1987; Lindenberg 1990; Ryser 2004; Serwint 1996; Wolfberg 2004). With the exception of the study conducted by Lindenberg (Lindenberg 1990) in Nicaragua, all of these interventions were implemented amongst low-income women in the US. Four of the US studies have evaluated the effect of an intervention amongst a low-income group belonging primarily to an ethnic minority group, namely African-American women (Caulfield 1998; Serwint 1996; Wolfberg 2004) and Latina women (Chapman 2004).
The following types of breastfeeding promotion intervention were evaluated by the eight trials included in the analyses for this review (see Characteristics of included studies' for details):
Health education of pregnant women - five trials
Brent 1995: white low-income women, unmarried and with an educational level of 12 years or below.
Coombs 1998: formal education programme (self-help manual) for low-income pregnant women.
Hill 1987: formal health education combined with written literature delivered by health professionals to mostly white, low-income women.
Ryser 2004: Best Start health education program (repeated one-to-one, needs-based counselling) delivered to low-income women who intended to formula feed or were undecided.
Serwint 1996: single formal health education session delivered in the antenatal period to low-income women who were mostly African-American.
(2) Peer support - one trial
Chapman 2004: home and public health facility based peer support during prenatal and perinatal period to predominantly Latina women who were considering breastfeeding.
(3) Breastfeeding promotion packs - one trial
Howard 2000: breastfeeding promotion packs in a sample of white, well-educated, women in middle- or high-income groups.
(4) Early mother-infant contact - one trial
Lindenberg 1990: hospital based early mother-infant contact combined with minimal breastfeeding education intervention delivered to primiparous women living in poor urban areas of Managua with a mean age of 20 years.
No trials of population-based programs to promote initiation of breastfeeding were found.
Risk of bias in included studies
Assessment of studies for potential sources of selection, performance, attrition and detection bias and overall risk of bias (as recommended by Higgins 2008) are detailed in Characteristics of included studies.
Seven of the eight studies were assessed as having unclear or inadequate allocation concealment (Brent 1995; Coombs 1998; Hill 1987; Howard 2000; Lindenberg 1990; Ryser 2004; Serwint 1996), raising concerns regarding the effect of selection bias on study findings. The remaining study was assessed as having achieved adequate concealment (Chapman 2004).
In regard to attrition bias, four of the eight studies included in meta-analysis reported breastfeeding initiation for all participants (Brent 1995; Chapman 2004; Hill 1987; Lindenberg 1990). The remaining four studies had losses to follow up between recruitment and breastfeeding initiation which were inadequately reported of around 8% (Ryser 2004; Serwint 1996), 19% (Howard 2000) and 25% (Coombs 1998).
Given that there are genuine pragmatic considerations when delivering and evaluating breastfeeding promotion interventions, the ability to reduce performance bias is limited and this should be recognised as an inherent weakness of this particular type of evidence base rather than of the particular studies included in this review. The only study which was considered to have adequately addressed potential sources of performance bias was the evaluation of a breastfeeding promotion pack compared to a commercial formula pack (Howard 2000), which was able to maintain blinding of both participants and providers through the use of sealed, similarly designed, packs more comparable with the use of a placebo and treatment in a therapeutic trial.
In the case of detection bias, the objective nature of the outcome being assessed, namely, whether a woman starts to breastfeed or not at a predefined timepoint, limits the scope for potential influence by the assessor, regardless of their being blind to the participant's group allocation.
Effects of interventions
Statistical analyses for the primary outcome of initiating breastfeeding are reported below for eight trials involving 1553 women (Brent 1995; Chapman 2004; Coombs 1998; Hill 1987; Howard 2000; Lindenberg 1990; Ryser 2004; Serwint 1996). Studies were analysed within four types of intervention: health education, peer support, breastfeeding promotion packs, and early mother-infant contact. Subgroup analyses have been conducted within the health education interventions to test the effect of particular types of education intervention on initiation rates.
(1) Health education interventions (comparison one)
Five studies (Brent 1995; Coombs 1998; Hill 1987; Ryser 2004; Serwint 1996) (including 582 women) evaluated the effect of health education on the initiation of breastfeeding. When all studies were combined for meta-analysis, a statistically significant increase in the number of women starting to breastfeed was demonstrated as a result of the health education interventions (risk ratio (RR) 1.57, 95% confidence interval (CI) 1.15 to 2.15). These interventions were all conducted among women on low incomes in one high-income country setting (USA). Substantial statistical heterogeneity between the six studies included in this analysis is suggested by the heterogeneity score above 50% (I
Subgroup analysis of two studies (Brent 1995; Ryser 2004; including 162 women) evaluating the effect of repeat, informal breastfeeding education which was personalised to each woman's needs demonstrated a statistically significant increase in the number of women starting to breastfeed as a result of the intervention (RR 2.40, 95% CI 1.57 to 3.66). Statistical heterogeneity between these studies was small (I
Both studies were conducted in the USA among women on low incomes from a range of ethnic groups. One intervention comprised repeat prenatal education sessions, daily perinatal input and repeat postnatal support on breastfeeding issues from a lactation counsellor based on the woman's needs and interests (Brent 1995). The other intervention comprised repeat prenatal education sessions from a breastfeeding researcher on breastfeeding issues based on the woman's concerns (Ryser 2004). Professional education was also directed at nursing and medical staff who interacted with the breastfeeding mother-infant pair. The Brent 1995 study included women regardless of feeding intention whereas the Ryser 2004 study included women who intended to formula feed or had not yet decided. Both education interventions were delivered by a breastfeeding professional or 'expert', namely, a lactation counsellor (Brent 1995) or a breastfeeding researcher (Ryser 2004).
The type of routine care received by the control group has not been specified by Ryser 2004 although care was similar between the comparison groups except for the intervention component provided to the experimental group. Brent describes routine care as optional prenatal breastfeeding classes, postpartum instruction by nurses and doctors and outpatient follow-up in the paediatric ambulatory department (Brent 1995).
The education intervention implemented in the prenatal period only (Ryser 2004) aimed to increase initiation rates and measured changes in breastfeeding at one week postpartum. The intervention which was implemented across the prenatal, perinatal and postnatal periods aimed to increase both the initiation and duration rates (Brent 1995). This study reported a significant increase in the median duration of breastfeeding as a result of this intervention (intervention: 84 days; control: 33 days).
Subgroup analysis of three studies, including 420 women, (Coombs 1998; Hill 1987; Serwint 1996) evaluating the effect of generic, formal, single breastfeeding education sessions on the initiation of breastfeeding found a positive, but non-statistically significant increase in the number of women starting to breastfeed as a result of this type of health education intervention RR 1.26, 95% CI 1.00 to 1.60). Statistical heterogeneity was not found between these studies (I
One intervention comprised generic information on parenting, including the advantages of breastfeeding, to each woman during a prenatal visit in her third trimester (Serwint 1996). Routine care was described as similar except no prenatal visit was provided. The study by Hill (Hill 1987) evaluated a one-off, generic lecture and discussion about breastfeeding with a post-test questionnaire to assess change in knowledge. Routine care comprised optional breastfeeding classes and postnatal support for mothers who wish to breastfeed (Hill 1987). A generic self-help manual was provided to each woman seven weeks before her expected date of birth during a routine prenatal breastfeeding counselling session from a nutritionist (Coombs 1998). Women in both comparison groups received a total of two prenatal interviews and two postnatal interviews.
Some caution is required in interpretation of these findings due to variation between studies; for example, definitions of routine care, the methods, content and duration of the health education interventions. However, all studies were conducted among low-income women in the USA with a range of ethnic backgrounds and feeding intentions and the type of formal, generic, one-off education session was consistent across all three studies.
(2) Peer support for women considering breastfeeding (comparison two)
A single study evaluating the effect of prenatal, perinatal and postnatal peer support services among a total of 165 participants (Chapman 2004) was shown to be effective at increasing initiation rates among predominantly Latina women who were considering breastfeeding in the USA (RR 4.02, 95% CI 2.63 to 6.14, P<0.00001). Authors describe many of the study population as feeling socially uncomfortable with breastfeeding in the USA. The personalised, problem-solving approach of the intervention had been developed for 10 years in collaboration with the study hospital.
Peer counsellors were community women who have completed high school, breastfed for six months and received 30 hours of internationally recognised classroom training in breastfeeding management. Counsellors served as observers for three to six months with experienced peer counsellors, received a payment (US$12) and the potential for health benefits if working at least 20 hours per week. Counselling services included at least one prenatal home visit, daily postpartum visits during hospitalisation and at least three home visits following return from hospital.
Routine care was patient-led comprising breastfeeding information in response to participant's questions and written materials available at the prenatal clinic. Perinatal care included hands-on assistance and education from maternity ward nurses. Written breastfeeding materials and access to a Lactation Consultant for breastfeeding problems were also available if requested as was a 'warm line' where nurses answer postpartum breastfeeding questions.
A significant increase in duration rates of breastfeeding was not demonstrated at one or three months postpartum. Failure to adhere to protocol, particularly the delivery of half of postnatal home visits in the first month, was a study limitation due to staffing problems.
(3) Breastfeeding promotion packs (comparison three)
A single study (Howard 2000) involving 547 women reported on the outcome of initiation of breastfeeding. The provision of a non-commercial breastfeeding promotion pack compared to a formula company produced pack has been shown to have no effect (RR 0.93, 95% CI 0.80 to 1.08, P=0.34) on increasing initiation rates among women of middle- or higher-income groups in a high-income country setting (USA).The authors also reported no effect on rates of stopping breastfeeding up to two weeks (RR 1.58, 95% CI 0.97 to 2.56).
(4) Early mother-infant contact followed by separation (comparison four)
A single study (Lindenberg 1990) (including 259 women and their babies) reported on the outcome of initiation of breastfeeding. It must be noted that whilst this intervention evaluated early mother-infant contact immediately after birth, women and their babies were then separated for the rest of their stay. This minimal contact intervention was shown to have no effect (RR 1.05, 95% CI 0.94 to 1.17, P = 0.39) on increasing initiation rates among women living in poor urban areas in Nicaragua.
The meta-analysis of the five studies evaluating the effectiveness of health education interventions for increasing initiation rates of breastfeeding showed the interventions were effective overall (risk ratio (RR) 1.57, 95% confidence interval (CI) 1.15 to 2.15). The studies were small, with the largest having 200 participants. All five evaluated programmes were delivered in the USA to low-income women with a range of feeding intentions and where baseline breastfeeding rates are typically low. Programme components varied; however, all forms of health education included in this review seem to have increased breastfeeding rates.
Subgroup analyses of different types of health education intervention showed that both one-to-one, needs-based, informal repeat sessions and generic, formal antenatal sessions favour the intervention in terms of an increase in breastfeeding rates among women on low incomes regardless of ethnicity and feeding intention. Findings from these studies do suggest however that larger increases in the numbers of women are likely to result from needs-based, informal repeat education sessions than more generic, formal antenatal sessions. These findings are based only on studies conducted in the USA, however, raising some questions regarding generalisability to other settings.
The single study evaluating needs-based, informal peer support in the antenatal and perinatal periods was shown to be effective at increasing initiation rates among predominantly Latina women who were considering breastfeeding in the USA (RR 4.02, 95% CI 2.63 to 6.14). These findings are consistent with those reported above for needs-based, informal health education sessions from a health professional.
The evaluation of hospital breastfeeding promotion packs compared to formula-company produced materials about infant feeding (Howard 2000) showed this intervention to be ineffective at increasing initiation rates of breastfeeding. This trial was of high quality with sample size sufficient to provide 80% power to detect a 15% difference in breastfeeding initiation between the groups. However, approximately 40% of women in both groups reported receipt of formula company promotion items from sources other than their obstetric provider. These findings suggest that this form of breastfeeding promotion intervention is not the most effective use of breastfeeding promotion resources in a context of widespread use of formula company promotion items. Future research to evaluate the effect of full implementation of the WHO Code (WHO 1981) and the use of breastfeeding promotion packs in an environment free of formula-company produced materials would provide a useful contribution to the evidence base for the promotion of breastfeeding.
The evaluation of early mother-infant contact immediately after birth prior to complete separation until discharge on breastfeeding initiation rates (Lindenberg 1990), which was the only study included in this review that was conducted in a low- to middle-income country setting (Nicaragua), found no effect. In this study the overall breastfeeding initiation rate was 87%, higher than in the other included studies. Standard care was complete separation of mother and infant throughout hospitalisation (normally 12 to 24 hours). No sample-size calculation is reported. This finding suggests that early mother-infant contact followed by complete separation did not increase or decrease breastfeeding initiation rates in a population of women with relatively high breastfeeding rates and living in poor urban areas in a low- to middle-income country. Generalisation of the result of this evaluation is not recommended due to the moderate quality and size of the study and to fundamental concerns regarding the practice of routine separation of mother and infant prior to hospital discharge. The World Health Organisation recommends mothers and infants should not be separated after birth unless there is an unavoidable medical reason (WHO 1998). In addition, the literature on the promotion of the duration of breastfeeding provides clear evidence of the benefits of ongoing mother and infant contact during the hospital stay to support the mother's ability to breastfeed (Bonnin 1989; Inch 1989; Perez-Escamilla 1994; Renfrew 2000).
The Australian study (Forster 2004) conducted in a hospital which had been accredited with Baby Friendly status (WHO 1998) for four years prior to trial implementation was also conducted among a population with high breastfeeding rates (96% for control group receiving routine Baby Friendly Initiative care). Whilst the authors of this good quality study conclude that the high breastfeeding rates may have been a factor affecting the lack of effectiveness of the education interventions (Forster 2004), the 'intervention' of Baby Friendly Initiative implemented in this hospital as routine care is also noteworthy. In the absence of a formal trial evaluating the effectiveness of the Baby Friendly Initiative intervention in this hospital or hospital baseline data on breastfeeding initiation rates prior to implementation of Baby Friendly Initiative, it is not possible to attribute the current high breastfeeding rates across the study population to the Baby Friendly Initiative (Forster 2004). Other good quality non-randomised evidence on the effectiveness of the Baby Friendly Initiative does, however, demonstrate significant increases in initiation rates among all women attending maternity services with the Baby Friendly Initiative Full Accreditation Award (Bartington 2005; Kramer 2001; Philipp 2001; Radford 2001; Tappin 2001). Indeed, the routine implementation of the UNICEF Baby Friendly Initiative to full accreditation level, or an externally evaluated structured programme using the Baby Friendly Initiative as a minimum standard, has been recommended as clinical guidance and effective action for UK maternity and community services by the National Centre for Health and Clinical Excellence (Demott 2006; Dyson 2006). This is consistent with UNICEF/WHO adoption of the Baby Friendly Hospital Initiative as a global programme to support successful breastfeeding for all mothers and babies (WHO/UNICEF 1989).
Implications for practice
Health education and peer support interventions included in this review are likely to result in some improvements in initiation rates among low-income women in the USA where baseline breastfeeding rates are typically low. The small number of trials and participants, all of which were conducted in the USA, warrant caution for generalisability of findings to other country settings, particularly those where breastfeeding rates are typically high.
The type of education or support intervention which may be most likely to increase initiation rates among low-income women appears to be needs-based, one-to-one, informal sessions delivered in the antenatal or antenatal or perinatal period by a trained breastfeeding professional or peer counsellor. As above, generalisability of findings into practice to settings other than the USA warrants some caution.
Early mother-infant contact followed by complete separation until hospital discharge was not effective when targeting women with high breastfeeding rates living in poor urban areas in a low- and middle-income country setting. Enabling mothers and infants to remain together for 24 hours a day, 'rooming-in', is one of the Ten Steps of the UNICEF/WHO Baby Friendly Hospital Initiative adopted as a global programme to support successful breastfeeding and demonstrated to increase initiation rates for all women in all settings.
Breastfeeding promotion packs, in contexts where formula feeding packs are widely distributed, may be an inappropriate use of valuable breastfeeding promotion resources that could be more effectively used for population-appropriate breastfeeding education. However, increased support to adopt the WHO/UNICEF Code (WHO 1981) into national legislation would prohibit the provision and promotion of breastmilk substitutes to pregnant women, new mothers or families, potentially increasing the impact of breastfeeding promotion.
Implications for research
The effectiveness of interventions reviewed here needs to be assessed in diverse countries and settings, particularly outside the USA, in studies that are adequately powered, have adequate methods of randomisation, adequate reporting of losses to follow-up and utilise intention-to-treat analysis.
Publication of evaluations of effectiveness should detail the content and method of the intervention delivered, the people (e.g. peer or professional) who delivered it, the training and experience these people had, baseline breastfeeding rates for the study-site population and feeding intention for participants within each comparison group.
Future research should aim to evaluate the effectiveness of the intervention to improve both the initiation and duration of any and/or exclusive breastfeeding at least up to six months to enable appropriate planning and implementation of interventions during pregnancy and the postnatal period.
Further research to evaluate interventions that combine health education or support before the birth with support during the days immediately after the birth should be evaluated and compared with those that offer education alone.
Research to evaluate the impact of adopting and/or implementing the WHO Code on Marketing of Breast-milk Substitutes is urgently needed as well as the use of breastfeeding promotion packs in an environment free of formula-company produced materials.
Further research into early mother-infant contact followed by rooming-in until hospital discharge may be effective at increasing breastfeeding initiation rates among various population groups.
Good quality research to evaluate the effectiveness of breastfeeding promotion and support on breastfeeding rates among maternity and community services who achieve fully accredited Baby Friendly status would further inform policy and practice.
Developmental work for this review (development of the conceptual framework for identification and classification of health promotion interventions and the search strategy) was conducted for the purposes of 'A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding', funded by and produced for the NHS Research and Development Health Technology Assessment Programme, UK (Fairbank 2000). Co-authors of this review, not involved in the adaptation and update of this review for the Cochrane Collaboration, were: S O'Meara, Dr AJ Sowden, D Lister-Sharp (NHS Centre for Reviews and Dissemination, University of York, UK) and Dr M Woolridge (Mother and Infant Research Unit, Faculty of Medicine, University of Leeds, UK). An international Advisory Panel of breastfeeding and health promotion experts also provided guidance on the classification of studies and interpretation of findings for the HTA 2000 review. Members of the Advisory Panel were: Rosamund Bryar, Petra Clarke, Leslie Davidson, Elisabeth Helsing, Stuart Logan, Miranda Mugford, Patricia Muirhead, Felicity Savage, Jim Sikorski and Mary Smale.
Searches for studies relevant to this substantive update of this Cochrane review were conducted by Lynn Hampson (Trials Search Co-ordinator, Cochrane Pregnancy and Childbirth Group, Liverpool Women's Hospital Foundation Trust). Professor Martin Bland, University of York, provided statistical advice for this update.
Data and analyses
- Top of page
- Authors' conclusions
- Data and analyses
- What's new
- Contributions of authors
- Declarations of interest
- Sources of support
- Index terms
Appendix 1. Note 1
Unless otherwise stated, the sources of international breastfeeding data are the WHO Global Strategy for Infant and Yound Child Feeding (WHO 2003) or the WHO Global Databank on Breast-Feeding (WHO Data Bank 1996) . The Databank is not comprehensive at this time and is dependent on data collected by individual countries using a variety of methods or indicators, or both.
Appendix 2. Note 2
Figures presented are not standardised for mother's age and age at which she completed full-time education, factors strongly associated with the incidence of breastfeeding. Standardised figures were not available for individual countries. Available data for changes in breastfeeding rates for England and Wales between 2000 and 2005, when standardised for mother's age and education, report a real increase in breastfeeding rates which was not simply due to changes in the sample composition (Bolling 2007).
Appendix 3. Searching information
For the initial version of this review, we also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2003, Issue 1) and the following databases from inception to October 2002: MEDLINE, CINAHL, ERIC, Applied Social Sciences, PsychLIT, EMBASE, British Nursing Index, BIDS, EPI-centre.
We searched the following in October 2002 for 'grey literature': SIGLE, DHSS Data, and Dissertation Abstracts. Details of the search strategies for all these databases can be obtained from the review authors.
Last assessed as up-to-date: 30 July 2007.
Protocol first published: Issue 3, 1999
Review first published: Issue 2, 2005
Contributions of authors
L Dyson: primary review author for independent prescreening, data extraction, quality appraisal, analysis and synthesis of findings.
F McCormick: second author for final review preparation, third author for data extraction. Administrative support for retrieval and translation of papers.
Professor MJ Renfrew: second author for independent trawling of titles and abstracts and checking of prescreening, data extraction, quality appraisal, analysis and synthesis of findings.
Declarations of interest
Sources of support
- Mother and Infant Research Unit, University of Leeds, UK.
- Canadian Cochrane Child Health Field Bursary Award, Canada.
- York Centre for Reviews and Dissemination, UK.
Medical Subject Headings (MeSH)
MeSH check words
* Indicates the major publication for the study