Interventions for promoting the initiation of breastfeeding

  • Protocol
  • Intervention

Authors

  • L Fairbank,

  • D Lister-Sharpe,

  • MJ Renfrew,

  • MW Woolridge,

  • AJS Sowden,

  • S O'Meara


Dr Lisa Dyson, University of Leeds, Mother and Infant Research Unit, 22 Hyde Terrace, Leeds, LS2 9LN, UK.

Abstract

This is the protocol for a review and there is no abstract. The objectives are as follows:

(1) To identify and describe health promotion activity intended to increase the rate of initiation of breastfeeding.

(2) To evaluate the effectiveness of health promotion activity in terms of changing the number of women who initiate breastfeeding.

(3) To evaluate the effectiveness of interventions within the following sub-groups:
(1) public policy, eg legislation such as maternity leave;
(2) supportive environments;
(3) community action;
(4) development of personal skills;
(5) reorientation of health services.

(4) To compare the effectiveness of health promotion interventions within and between sub-groups as appropriate.

(5) To assess the impact of these interventions on secondary outcomes, namely, duration of breastfeeding, exclusive breastfeeding and other reported outcomes (beneficial or adverse).

(6) To assess the impact of these interventions on intermediate/process outcomes, for example, knowledge and attitudes, social and community support.

Background

Women in most countries encounter the promotion of bottle feeding in different forms, a factor which has been implicated in women choosing to bottle feed (WHO Data Bank 1996). Less attention has been paid to ways of promoting breastfeeding, the subject of this review.

There is extensive evidence for short-term and long-term health benefits of breastfeeding and the World Health Organisation recommends that all infants should be fed exclusively on breast milk from birth to four to six months of age (WHO/UNICEF 1989). Babies who are not fully breastfed for the first three to four months are more likely to suffer health problems such as gastroenteritis (Howie et al 1990), respiratory infection (Victora et al 1989; Wright et al 1989), otitis media (Duncan et al 1993; Aniansson et al 1994), urinary tract infections (Marild et al 1990; Pisacane et al 1992), atopic disease if a family history of atopy is present (Lucas et al 1990; Burr et al 1989; Saarinen 1995) and insulin-dependent diabetes mellitus (Mayer et al 1988; Virtanen et al 1991). Research also indicates a positive relationship between having been breastfed and the bone health of the child (Lucas and Cole 1990).

In the UK, the Department of Health has calculated that the state health system could save £10 for every extra mother who breastfed due to the reduction in child onset diabetes mellitus and £35 million each year in treating babies with gastroenteritis (Dept of Health 1995). The basis for such calculations is preliminary and rather speculative however. Further work is required to more fully clarify cost-effectiveness issues surrounding infant feeding.

In addition, breastfeeding is beneficial to the mother's health. Women who do not breastfeed are significantly more likely to develop epithelial ovarian cancer (Gwinn et al 1990; Rosenblatt 1993) and are more likely to develop pre-menopausal breast cancer (Layde et al 1989; Newcomb et al 1994; UK Study Group 1993) than women who breastfeed. One study stated that women who do not breastfeed are at greater risk of hip fractures in their old age (Cumming 1993). A more recent review of several large international studies on this issue stated however "there is no evidence that lactation, even when frequent and prolonged, has a long term influence on the bone health in later life of individual women" (Dept of Health 1998).

Other social and practical benefits to the breastfeeding mother include the increased likelihood she will use up the body fat deposited in pregnancy (Dewey et al 1993), substantive savings on the expenses associated with artificial formula feeding (except in the case of mothers participating in welfare schemes and receiving subsidised formula milk powder), and the avoidance of effort involved in preparing bottle feeds (MIDIRS 1997).

Despite the many advantages of breastfeeding, many women choose to bottle feed their babies. Many of the reasons for this are likely to be cultural and include personal, social and structural biases against breastfeeding such as attitudes of family and close friends, attitudes to breastfeeding in public and employment practices (Renfrew et al 1998). The availability of subsidised infant formula milk through the UK based Welfare Food 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 choosing to bottle feed. The extent to which individual countries have adopted the World Health Organisation's International Code of Marketing of Breastmilk Substitutes (WHO 1981) may also be a contributing factor on the infant feeding decision, particularly for women in developing countries.

International rates of initation of breastfeeding are extremely variable between and within countries (see note 1 below). In Scandinavia and Eastern Europe, many countries have a high incidence of women starting to breastfeed including Russia (99% of women initiated breastfeeding in 1994), Finland (99% in 1983), Norway (98% in 1994 (Ammehjelpen 1994)), Sweden (98% in1991), Denmark (95% in 1992), Romania (91% in 1991) and Poland (90% in 1988). Other individual countries with high breastfeeding rates include Japan, Switzerland and Luxembourg at 95% (AIIKU Institute 1997), 92% and 86% respectively in 1994 and Turkey where the prevalence of women initiating breastfeeding was 95% in 1988.

In central and southern Europe, historical data indicate initiation rates were relatively high, for example, in Israel where 72% of women initiated breastfeeding in 1988, Italy (72% in 1983), Spain (78% in 1984) and Greece with a slightly lower rate of 65% in 1981.

Lower rates of initiation of breastfeeding are evident in Northern America and Western Europe where, for example, only 62% of women started to breastfeed in England and Wales (Foster et al 1997), 57% in the USA. in 1994, 59% in the Netherlands in 1985 and 55% in France in 1984 (see note 2 below). Higher incidences have been reported in Canada - 74% in 1993 and lower incidences in Scotland, Northern Ireland and Ireland where initiation rates were only 48%, 41% and 34% respectively in 1995 (Foster et al 1997).

Even in countries with high initiation rates of breastfeeding, the numbers of babies being exclusively breastfed at 3 months of age can decrease dramatically for example, from 92% to 48% in Switzerland in 1994 and from 95% to 38% in Japan in 1995. In the United Kingdom, whilst the initiation rate for breastfeeding was 66% in 1995, this figure decreases to 56% for babies still breastfed at one week with a further reduction to 27% of babies breastfed at four months of age (Foster et al 1997) (see note 3 below).

Efforts to increase initiation rates should also take account of the resources needed to support women to continue to breastfeed. One strategy to increase the duration of breastfeeding is the provision of support to women who have initiated breastfeeding, thereby assisting those women to not give up breastfeeding contrary to their wishes (Sikorski 1998). In Norway, 80% of babies are breastfeeding at three months of age (Endresen 1995) and 72% of babies are exclusively breastfed at 2 months of age in Sweden (Zetterstrom 1994).

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.

Notes:

(1) Unless otherwise stated, the source of international breastfeeding data is the WHO Global Databank on Breast-Feeding. The Databank is not comprehensive at this time and is dependent on data collected by individual countries using a variety of methods and/or indicators.
(2) Figures standardised for mother's age and age finished full-time education, factors strongly associated with the incidence of breastfeeding.
(3) These data are not standardised for mother's age and age finished full-time education and are not therefore comparable with the figures cited for breastfeeding rates in England and Wales, Scotland and Northern Ireland.

Objectives

(1) To identify and describe health promotion activity intended to increase the rate of initiation of breastfeeding.

(2) To evaluate the effectiveness of health promotion activity in terms of changing the number of women who initiate breastfeeding.

(3) To evaluate the effectiveness of interventions within the following sub-groups:
(1) public policy, eg legislation such as maternity leave;
(2) supportive environments;
(3) community action;
(4) development of personal skills;
(5) reorientation of health services.

(4) To compare the effectiveness of health promotion interventions within and between sub-groups as appropriate.

(5) To assess the impact of these interventions on secondary outcomes, namely, duration of breastfeeding, exclusive breastfeeding and other reported outcomes (beneficial or adverse).

(6) To assess the impact of these interventions on intermediate/process outcomes, for example, knowledge and attitudes, social and community support.

Criteria for considering studies for this review

Types of studies

Randomised controlled trials, with or without blinding, and with concurrent controls.

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. Population sub-groups of women, such as women from low income or ethnic groups, will also be included in the review. Women and infants with a specific health problem, eg mothers with AIDS or infants with cleft palate, are excluded from this review.

In order to examine intermediate/process outcomes, other participants exposed to such interventions, for example partners, health professionals and employers will be considered.

Types of intervention

Any intervention aiming to promote the initiation of breastfeeding, which takes place before the first breastfeed.

The five areas of health promotion action identified in the Ottawa Charter for Health Promotion (WHO 1987) will be used as a framework within which to investigate initiatives to promote breastfeeding. These are:
(a) public policy such as legislation, fiscal measures, taxation and organisational change, eg maternity leave;
(b) supportive environments which generate healthy living and working conditions, eg public attitude and infrastructure to support breastfeeding out of the home and in the place of employment;
(c) community action which uses existing human and material resources to enhance self help and social support, eg La Leche League, National Childbirth Trust;
(d) development of personal skills through the provision of information, education for health and enhancing life skills, eg media campaigns and education programmes;
(e) reorientation of health services to promote health, eg the Baby Friendly Hospital Initiative.

This framework may be adapted to reflect the studies included in this review, for example, a further category may be required for interventions which include several components from more than one of these five areas.

Evaluations of interventions taking place after the first breastfeed or whose primary purpose is to affect the duration of breastfeeding are excluded from this review.

There will be no limitation of study by country of origin or language.

Types of outcome measures

The primary outcome measure is the rate of initiation of breastfeeding.

Secondary outcome measures are the rate of women breastfeeding exclusively and increased duration of breastfeeding as a result of the health promotion intervention. Measures of other beneficial or adverse outcomes as a result of the intervention will also be reported.

Intermediate/process outcomes relating to women, health professionals and other relevant participants, have been classified into three groups of 'health promotion outcomes' (Nutbeam 1998) as follows:
(a) Health literacy outcome group (examples include knowledge, attitude, intentions, motivation);
(b) Social influence and action outcome group (examples include social support, public opinion, community competency, peer and community norms); and
(c) Public policy and organisational practice outcome group (examples include change to health and social policies such as policy statements, change to organisational practice such as procedures, rules and administration.)

Search strategy for identification of studies

See: Unavailable search strategy

This review will draw on the search strategy developed for the Cochrane Pregnancy and Childbirth Group.

Relevant trials will be identified in the Group's Specialised Register of Controlled Trials. See Review Group's details for more information.

In addition:

(1) A search will be systematically applied to the following databases: CINAHL, ERIC, applied social sciences, psychLIT, EMBASE, British Nursing Index, BIDS and EPI-centre in June 1998. Details of the search strategy can be obtained from the reviewers.

The following databases were searched for 'grey literature': SIGLE; DHSS Data; and Dissertation Abstracts in June 1998.

(2) The Cochrane Controlled Trials Register/Central was searched in October 1998. Details of the search strategy can be obtained from the reviewers (CCTR 1998)
Relevant journals not incorporated in the Cochrane Controlled Trials Register will be hand searched, for example, Journal of Human Lactation, Health Promotion International and Health Education Quarterly in October 1998. Reference lists of all relevant retrieved papers will be examined to identify further studies.

An international advisory panel of breastfeeding and health promotion experts has been established and nearly three hundred letters have been sent to professional and voluntary organisations with an interest or involvement in breastfeeding and health promotion to identify other published or unpublished studies and to assist with the dissemination of the final review.

Methods of the review

Titles and abstracts of studies identified from all sources will be independently assessed for relevance by two reviewers. All obtained papers will be read independently by at least two reviewers. Papers will be classified by the type of health promotion intervention (public policy, supportive environments, community action, development of personal skills, reorientation of health services) and the type of study (randomised controlled trial, quasi randomised study). The validity of studies will be assessed by investigating the potential sources of bias including selection, performance, attrition and detection bias. Any disagreements will be settled through discussion and if necessary, by recourse to a third reviewer.

Data will be extracted by one reviewer using a data extraction form and checked by a second reviewer. Data will be entered into the RevMan software by one reviewer (Review Manager 1998). The results from the primary studies will be synthesised as appropriate to provide a summary of the evidence of interventions to promote breastfeeding. Where appropriate, a quantitative meta-analysis will be carried out using Metaview. Odds ratios with 95% confidence intervals for initiation rates will be calculated. Tests of heterogeneity will be carried out and sources of heterogeneity examined. Sensitivity analyses will be conducted to see whether the inclusion of quasi randomised controlled studies alter the finding. Subgroup analysis to compare the differential effect of interventions on initiation rates and both initiation and duration where possible, will be carried out.

Potential conflict of interest

None known.

Acknowledgements

None.

Sources of support

External sources of support

  • NHS Centre for Reviews and Dissemination, University of York UK

  • Health Technology Assessment Programme, Research and Development Programme, NHS UK

Internal sources of support

  • Mother and Infant Research Unit, University of Leeds UK

Ancillary