Antenatal breastfeeding education for increasing breastfeeding duration

  • Review
  • Intervention

Authors

  • Pisake Lumbiganon,

    Corresponding author
    1. Khon Kaen University, Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen, Thailand
    • Pisake Lumbiganon, Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, 123 Mitraparb Road, Amphur Muang, Khon Kaen, 40002, Thailand. pisake@kku.ac.th.

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  • Ruth Martis,

    1. Christchurch Polytechnic Institute of Technology (CPIT), Faculty of Health, Humanities and Sciences, School of Applied Sciences and Allied Health, School of Midwifery, Christchurch, Canterbury, New Zealand
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  • Malinee Laopaiboon,

    1. Khon Kaen University, Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen, Thailand
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  • Mario R Festin,

    1. World Health Organization, Department of Reproductive Health and Research, Geneva, Switzerland
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  • Jacqueline J Ho,

    1. Penang Medical College, Department of Paediatrics, Penang, Malaysia
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  • Mohammad Hakimi

    1. Gadjah Mada University, Department of Obstetrics and Gynaecology, Faculty of Medicine, Yogyakarta, Daerah Istimewa Yogyakarta, Indonesia
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Abstract

Background

Breastfeeding (BF) is well recognised as the best food for infants. The impact of antenatal BF education on the duration of BF has not been evaluated.

Objectives

To evaluate the effectiveness of antenatal BF education for increasing BF initiation and duration.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 December 2011), CENTRAL (The Cochrane Library 2011, Issue 11), MEDLINE (1966 to 30 November 2011) and Scopus (January 1985 to 30 November 2011). We contacted experts and searched reference lists of retrieved articles.

Selection criteria

All identified published, unpublished and ongoing randomised controlled trials (RCTs) assessing the effect of formal antenatal BF education or comparing two different methods of formal antenatal BF education, on duration of BF. We excluded RCTs that also included intrapartum or postpartum BF education.

Data collection and analysis

We assessed all potential studies identified as a result of the search strategy. Two review authors extracted data from each included study using the agreed form and assessed risk of bias. We resolved discrepancies through discussion.

Main results

We included 19 studies with 8506 women in the review and 16 studies involving 8262 women contributed data to the analyses. We did not carry out any meta-analysis because there was only one study for each comparison.

Five studies compared a single method of BF education with routine care. Peer counselling significantly increased BF initiation.

Three studies compared one form of BF education versus another. No intervention was significantly more effective than another intervention in increasing initiation or duration of BF.

Seven studies compared multiple methods versus a single method of BF education. Combined BF educational interventions were not significantly better than a single intervention in initiating or increasing BF duration. However, in one trial a combined BF education significantly reduced nipple pain and trauma.

One study compared different combinations of interventions. There was a marginally significant increase in exclusive BF at six months in women receiving a booklet plus video plus lactation consultation (LC) compared with the booklet plus video only.

Two studies compared multiple methods of BF education versus routine care. The combination of BF booklet plus video plus LC was significantly better than routine care for exclusive BF at three months.

Authors' conclusions

Because there were significant methodological limitations and the observed effect sizes were small, it is not appropriate to recommend any specific antenatal BF education.There is an urgent need to conduct RCTs with adequate power to evaluate the effectiveness of antenatal BF education.

摘要

產前母乳哺育教育以增加母乳哺育期

背景

母乳哺育(BF)是廣受認可的嬰兒最佳食物。產前BF教育在BF期長短上的影響尚未被評估。

目的

想要評估產前BF教育對增加BF開始動機及持續期間的有效性。

搜尋策略

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 December 2011), CENTRAL (The Cochrane Library(2011年12月2日)、CENTRAL(考科藍資料庫2011年第11期)、MEDLINE(1966年到2011年11月30日)以及SCOPUS(1985年1月到2011年11月30日)。我們聯絡了相關的專家並搜尋找出的文章的參考文獻清單。

選擇標準

所有找出的公開、未公開與進行中的隨機對照試驗(RCTs)以BF期的長短來評估正式產前BF教育的效果或是比較兩種不同方法的正式產前BF教育。我們排除了也包含生產間或產後BF教育的RCTs。

資料收集與分析

我們評估了所有因搜尋策略而找出的可能研究。兩位審閱作者由每一個所納入的研究中使用協定的形式摘錄資料並評估偏誤風險。我們透過討論解決爭議。

主要結果

我們納入了19個研究共有8506名婦女在審閱中,其中16個研究涵蓋8262名婦女提供分析的數據。我們沒有執行任何統合分析,因為每一種比較僅有一個研究。

5個研究比較了單一方法BF教育與例行照護。同儕諮詢明顯的增加了BF的開始。

3個研究比較了一種BF教育對比另一種形式。沒有一種介入明顯的較另一個在增加BF開始或持續期間上較有效果。

7個研究比較了多種方法對比單一方法的BF教育。結合的BF教育介入沒有明顯的較單一介入在BF開始或增加BF期間上較為有效。然而,在一個試驗中,一種結合的BF教育明顯的降低了乳頭疼痛與受傷。

一個研究比較了不同的介入結合。接受到手冊加上視頻加上哺乳諮詢(LC)的婦女與僅有手冊加視頻的婦女相比,在六個月時的全母乳哺育情形有些微的顯著增加。

兩個研究比較多重BF教育方法對比例行照護,BF手冊加上視頻加上LC的結合明顯的較例行照護在三個月時的全母乳的情形較好。

作者結論

因為有顯著的方法學限制且觀察到的效果規模很小,並不適合建議任何特定的產前BF教育。對作出有適當效力的RCTS上有迫切的需要,以評估產前BF教育的有效性。

Résumé scientifique

Antenatal breastfeeding education for increasing breastfeeding duration

Contexte

L'allaitement est reconnu comme étant la meilleure alimentation pour les nourrissons. L'impact de la formation prénatale à l’allaitement sur la durée de l’allaitement n'a pas été évalué.

Objectifs

Evaluer l'efficacité de la formation prénatale à l’allaitement pour augmenter l'adoption de l'allaitement et sa durée.

Stratégie de recherche documentaire

Nous avons effectué une recherche dans le registre d'essais cliniques du groupe Cochrane sur la grossesse et l'accouchement (2 décembre 2011), CENTRAL (The Cochrane Library 2011, Numéro 11), MEDLINE (de 1966 au 30 novembre 2011) et SCOPUS (de janvier 1985 au 30 novembre 2011). Nous avons contacté des experts et avons effectué une recherche dans les références bibliographiques des articles obtenus.

Critères de sélection

Tous les essais contrôlés randomisés (ECR) publiés, non publiés et en cours identifiés évaluant l'effet d'une formation prénatale à l’allaitement reconnue ou comparant deux méthodes différentes de formation prénatale reconnues à l’allaitement , en termes de durée du BF. Nous avons exclu les ECR qui incluaient également la formation à l’allaitement pendant ou après l'accouchement.

Recueil et analyse des données

Nous avons évalué toutes les études potentielles identifiées d'après la stratégie de recherche documentaire. Deux auteurs de revue ont extrait les données de chaque étude inclue en utilisant une grille de de lecture et ont évalué le risque de biais. Nous avons résolu les divergences par la discussion.

Résultats principaux

Nous avons inclus 19 études impliquant 8506  femmes dans la revue et 16 études impliquant 8262 femmes ont servi pour les analyses . Nous n'avons réalisé aucune méta-analyse, car il n'y avait qu'une seule étude pour chaque comparaison.

Cinq études comparaient une méthode unique de formation à l’allaitement avec des soins ordinaires. Des conseils fournis par des pairs ont augmenté significativement l'adoption de l’allaitement.

Trois études comparaient un type de formation à l’allaitement avec un autyre type . Aucune intervention n'a été significativement plus efficace qu'une autre intervention pour augmenter l'adoption ou la durée du BF.

Sept études comparaient des méthodes cominées à une méthode unique de formation à l’allaitement . Les interventions de formation à l’allaitement combinées n'ont pas été significativement meilleures qu'une intervention unique pour l'adoption ou l'augmentation de la durée à l’allaitement Cependant, dans un essai, une formation à l’allaitement combinée a réduit significativement la douleur et le traumatisme du mamelon.

Une étude comparait différentes combinaisons d'interventions. Il y a eu une augmentation minime de l’allaitement exclusif à six mois chez les femmes recevant un livret, une vidéo et une consultation en lactation (CL) comparé au livret et à la vidéo seuls.

Deux études comparaient des méthodes multiples de formation BF avec des soins ordinaires. La combinaison du livret de BF, de la vidéo et de la CL a été significativement meilleure que les soins ordinaires pour allaitement exclusif à trois mois.

Conclusions des auteurs

En raison de l'existence de limites méthodologiques avérées et d’effets de taille faible il ne convient pas de recommander une formation à l’allaitement prénatale. Il est nécessaire et urgent de mener une étude des ECR avec une puissance adéquate pour évaluer l'efficacité d'une formation prénatale à l’allaitement.

アブストラクト

母乳哺育期間延長のための出産前母乳哺育教育

背景

母乳栄養(BF)は、乳児にとって最適の食物としてよく認識されている。出産前BF教育のBF期間への影響は評価されていない。

目的

BF開始例及びBF期間の増加のための出産前BF教育の有効性を評価する。

検索戦略

Cochrane Pregnancy and Childbirth Group's Trials Register(2011年12月2日)、CENTRAL(コクラン・ライブラリ2011年第11号)、MEDLINE(1966年~2011年11月30日)及びScopus(1985年1月~2011年11月30日)を検索した。 専門家と連絡を取り、検索した論文の文献リストを検索した。

選択基準

BF期間について、公式の出産前BF教育の効果を評価するか、又は2種の公式の出産前BF教育法を比較する全ての同定した、発表済み、未発表及び継続中のランダム化比較試験(RCT)。出産中又は出産後にBF教育を組み入れたRCTを除外した。

データ収集と分析

検索戦略の結果として同定した可能性のある全試験を評価した。レビューア2名が各対象試験から、合意済みの用紙を用いてデータを抽出し、バイアスのリスクを評価した。論議により不一致点を解決した。

主な結果

本レビューには8,506名の女性を含む19件の試験を組み入れ、女性8,262名を含む16件の試験のデータを解析に用いた。各比較に試験1件のみ使用可能であったため、メタアナリシスは実施しなかった。 5件の試験では、単独のBF教育方法をルーチンのケアと比較した。ピアカウンセリングは、BF開始例を有意に増加させた。 3件の試験では、1つの形態のBF教育と別の形態のBF教育を比較した。BF開始例又はBF期間の増大では他の介入より有意に有効な介入はなかった。 7件の試験では、複数のBF教育と単独のBF教育を比較した。BF教育を組み合わせた介入は、BF開始例又はBF期間の増加に対し単独の介入に勝る有意な効果を示さなかった。但し、1件の試験では、BF教育の組み合わせにより乳首の疼痛及び亀裂が有意に低減した。 1件の試験では、介入の各種組み合わせを比較した。小冊子+ビデオ+授乳相談(LC)を受けた女性の6ヵ月目の完全BFは、小冊子+ビデオのみ受けた女性よりかろうじて有意に増加した。 2件の試験では、BF教育の複数方法をルーチンのケアと比較した。BFの小冊子+ビデオ+LCの組み合わせでは、3ヵ月目の完全BFがルーチンのケアより有意に増加した。

著者の結論

方法論的に重大な限界があること、及び認められた効果サイズが小さいことから、特定の出産前BF教育を勧告するのは適切ではない。出産前BF教育の有効性を評価する十分な検出力を有するRCTを、緊急に実施する必要性がある。

บทคัดย่อ

การให้การศึกษาเรื่องการเลี้ยงลูกด้วยนมแม่ในระหว่างการตั้งครรภ์เพื่อเพิ่มระยะเวลาการเลี้ยงลูกด้วยนมแม่

บทนำ

การเลี้ยงลูกด้วยนมแม่ได้รับการยอมรับว่าเป็นอาหารที่ดีที่สุดสำหรับทารก ยังไม่มีการประเมินผลของการให้การศึกษาการเลี้ยงลูกด้วยนมแม่ในระหว่างตั้งครรภ์

วัตถุประสงค์

เพื่อประเมินประสิทธิผลของการให้การศึกษาการเลี้ยงลูกด้วยนมแม่ในระหว่างตั้งครรภ์เพื่อเพิ่มการเริ่มและระยะเวลาการเลี้ยงลูกด้วยนมแม่

วิธีการสืบค้น

เราสืบค้น Cochrane Pregnancy and Childbirth Group's Trials Register (2 December 2011), CENTRAL (The Cochrane Library 2011, Issue 11), MEDLINE(1966 to 30 November 2011) and Scopus (January 1985 to 30 November 2011). เราติดต่อผู้เชี่ยวชาญและสืบค้นเอกสารอ้างอิงของบทความที่สืบค้นได้

เกณฑ์การคัดเลือก

การทดลองแบบสุ่มที่มีกลุ่มเปรียบเทียบที่ตีพิมพ์แล้ว ยังไม่ได้ตีพิมพ์ และกำลังดำเนินการ ที่ประเมินผลของการให้การศึกษาการเลี้ยงลูกด้วยนมแม่ในระหว่างตั้งครรภ์ หรือเปรียบเทียบวิธีการให้การศึกษาการเลี้ยงลูกด้วยนมแม่ในระหว่างตั้งครรภ์ 2 แบบเพื่อเพิ่มระยะเวลาการเลี้ยงลูกด้วยนมแม่ เราไม่รวมการทดลองแบบสุ่มที่มีกลุ่มเปรียบเทียบที่มีการให้การศึกษาในระหว่างคลอดและหลังคลอดด้วย

การรวบรวมและวิเคราะห์ข้อมูล

เราประเมินการศึกษาทุกเรื่องที่ได้จากยุทธสาสตร์การสืบค้น ผู้ประพันธ์การทบทวน 2 คนคัดลอกข้อมูลจากการศึกษาที่รวบรวมเข้ามาโดยใช้แบบฟอร์มที่ตกลงกันไว้แล้ว และประเมินความเสี่ยงของการเกิดอคติ เราแก้ปัญหาความเห็นไม่ตรงกันโดยการอภิปราย

ผลการวิจัย

เรารวบรวมนำเข้าการศึกษา 19 เรื่อง สตรี 8506 คนในการทบทวนนี้และมีการศึกษา 16 เรื่อง สตรี 8262 คนที่มีข้อมูลในการวิเคราะห์ เราไม่ได้ทำการวิเคราะห์อภิมานเนื่องจากการเปรียบเทียบแต่ละอย่างมีการศึกษาเพียงการศึกษาเดียว

มีการศึกษา 5 เรื่องเปรียบเทียบการให้การศึกษาการเลี้ยงลูกด้วยนมแม่อย่างเดียวกับการดูแลที่เป็นประจำ การให้การปรึกษาแบบเพื่อนเพิ่มการเริ่มต้นการเลี้ยงลูกด้วยนมแม่อย่างมีนัยสำคัญ

มีการศึกษา 3 เรื่องเปรียบเทียบการให้การศึกษาการเลี้ยงลูกด้วยนมแม่อย่างหนึ่งกับอีกอย่างหนึ่ง ไม่มีวิธีการใดที่ดีกว่าวิธีการอื่นอย่างมีนัยสำคัญในการเพิ่มการเริ่มหรือระยะเวลาของการเลี้ยงลูกด้วยนมแม่

มีการศึกษา 7 เรื่องที่เปรียบเทียบวิธีการให้การศึกษาการเลี้ยงลูกด้วยนมแม่ที่มีกิจกรรมหลายอย่างกับอย่างเดียว วิธีการให้การศึกษาการเลี้ยงลูกด้วยนมแม่ที่มีกิจกรรมมากกว่า ๅ มากกว่า 1 อย่างไม่ดีกว่าที่มีกิจกรรมอย่างเดียวในการเพิ่มการเร่ิ่มและระยะเวลาการเลี้ยงลูกด้วยนมแม่ อย่างไรก็ดีการทดลอง 1 เรื่องพบว่าการให้การศึกษาการเลี้ยงลูกด้วยนมแม่ที่มีกิจกรรมมากกว่า 1 อย่าง สามารถลดความเจ็บปวดและแผลที่หัวนมได้ดีกว่า

การศึกษา 1 เรื่องเปรียบเทียบวิธีการแบบรวมที่แตกต่างกัน มีการเพิ่มขึ้นเล็กน้อยแต่มีนัยสำคัญของการเลี้ยงลูกด้วยนมแม่อย่างเดียวในสตรีที่ได้รับสมุดคู่มือร่วมกับวิดีโอและการให้คำปรึกษาการให้น้ำนมเปรียบเทียบกับฮที่ได้รับสมุดคู่มือร่วมกับวิดีโอ

การศึกษา 2 เรื่องเปรียบเทียบวิธีการให้การศีกษาการเลี้ยงลูกด้วยนมแม่ด้วยวิธีการหลายอย่างกับการดูแลแบบที่ใช้เป็นประจำ สตรีที่ได้รับสมุดคู่มือร่วมกับวิดีโอและการให้คำปรึกษาการให้น้ำนมมีการเลี้ยงลูกด้วยนมแม่อย่างเดียวตอน 3 เดือนหลังคลอดมากกว่าสตรีที่การดูแลแบบที่ใช้เป็นประจำ

ข้อสรุปของผู้วิจัย

เนื่องจากมีข้อจำกัดเกี่ยวกับระเบียบวิธีวิจัยที่สำคัญและผลของวิธีการมีน้อย จึงไม่เหมาะสมที่จะแนะนำการให้การศึกษาเรื่องการเลี้ยงลูกด้วยนมแม่ในระหว่าการตั้งครรภ์แบบใดแบบใดแบบหนึ่งโดยเฉพาะ มีความจำเป็นเร่งด่วนที่จะต้องมีการวิจัยการทดลองแบบสุ่มที่มีกลุ่มเปรียบเทียบที่มีอำนาจเพียงพอเพื่อประเมินประสิทธผลของการให้การศึกษาการเลียงลูกด้วยนมแม่ในระหว่างการตั้งครรภ์

หมายเหตุการแปล

เอกสารแปล CD006425.pub3

Plain language summary

Antenatal breastfeeding education for increasing breastfeeding duration

Breastfeeding is well recognised as the best food for infants and the World Health Organization recommends that all infants should have exclusive breastfeeding for at least six months after birth. Complementary foods offered before six months of age tend to displace breast milk and do not give any health advantage. Breastfeeding (BF) can improve the child's health, the mother's health and mother-infant bonding. Infants with BF have lower rates of gastrointestinal and respiratory diseases, otitis media and allergies, better visual acuity, and speech and cognitive development. The impact of educational interventions during pregnancy on breastfeeding duration has not yet been evaluated.

This review includes data from 16 randomised controlled studies involving 8262 women, mostly from developed countries including the USA, Canada, UK and Australia. Peer counselling, lactation consultation and formal BF education during pregnancy appear to increase BF duration. Peer counselling also appears to be better than routine care for initiating BF. However, because most included studies were of poor quality and the effects of BF education were quite small, it is not appropriate to recommend any specific BF educational intervention. The findings of this review are based on single studies and there is a need for well-designed clinical trials with adequate sample sizes.

淺顯易懂的口語結論

產前母乳哺育教育以增加母乳哺育的持續期間

母乳廣受認可為嬰兒的最佳食物,且世界衛生組織建議所有的嬰兒都應在出生後至少全母乳哺餵六個月。補充性食物在六個月前增加可能會取代母乳且沒有提供任何健康的優點。母乳哺育(BF)可增進兒童的健康、母親的健康以及母親與嬰兒間的特別關係。採行BF的嬰兒在腸胃不適與呼吸道疾病、中耳炎及過敏上機率較低並有較好的視覺靈敏度以及語言及認知發展。懷孕期間的教學性介入在母乳哺育持續期間上的影響尚未被評估。

此審閱包含了來自16個隨機對照研究的數據,涵蓋8262名婦女,大部分來自已開發國家,包含美國、加拿大、英國與澳大利亞。懷孕期間的同儕諮詢、哺乳諮商以及正式的BF教育似乎能增加BF持續期間。同儕諮詢也似乎較例行照護於開始BF的效果更好。然而,因為大多數所包含的研究品質不良且BF教育的效果相當小,並不適合建議任何特定BF教育介入。此審閱的發現皆是以單一研究為根據,將需要有良好設計並有適當樣本量的臨床試驗。

譯註

翻譯: East Asian Cochrane Alliance
翻譯補助: 台灣衛生福利部/台北醫學大學實證醫學研究中心

Résumé simplifié

Formation prénatale sur l'allaitement pour un allongement de la durée d'allaitement

L'allaitement est bien reconnu pour apporter la meilleure alimentation aux nourrissons et l'Organisation mondiale de la Santé recommande que tous les nourrissons soient allaités exclusivement pendant au moins six mois après la naissance. Les aliments de complément offerts avant l'âge de six mois ont tendance à remplacer le lait maternel et n'apportent aucun avantage de santé. L'allaitement (BF) peut améliorer la santé de l'enfant, la santé de la mère et le lien mère-enfant. Les nourrissons allaités ont de plus faibles taux de maladies gastro-intestinales et respiratoires, d'otites moyennes et d'allergies, une meilleure acuité visuelle et un meilleur développement du langage et de la cognition. L'impact des interventions de formation au cours de la grossesse sur la durée de l'allaitement n'a pas encore été évalué.

Cette revue inclut des données de 16 études contrôlées randomisées impliquant 8262 femmes, la plupart issues de pays développés, notamment les Etats-Unis, le Canada, le Royaume-Uni et l'Australie. Les conseils par les pairs, la consultation en lactation et la formation BF formelle au cours de la grossesse semblent augmenter la durée de l'allaitement. Les conseils par les pairs semblent également être meilleurs que les soins de routine en termes d'adoption du BF. Cependant, du fait que la plupart des études incluses étaient de qualité médiocre et que les effets de la formation à l’allaitement ont été assez faibles, il n'est pas approprié de recommander une intervention de formation à l’allaitement spécifique. Les résultats de cette revue sont basées sur les données d‘études uniques et il y a un besoin d‘essais cliniques bien conçus avec des tailles d'échantillon adéquats.

Notes de traduction

Traduit par: French Cochrane Centre 1st December, 2011
Traduction financée par: Ministère du Travail, de l'Emploi et de la Santé Français

平易な要約

母乳栄養期間延長のための出産前母乳栄養教育

母乳栄養は乳児の最適な食事として十分に認識されており、世界保健機関は、全乳児が出産後6ヵ月間以上の完全母乳哺育を受けるべきだと勧告している。6ヵ月齢前に与えられる補助食品のおかげで母乳哺育が妨げられる傾向があるが、これは健康上の利点にはならない。母乳哺育(BF)により小児の健康、母親の健康及び母子の結びつきが改善可能である。BFを受けた乳児の胃腸疾患及び呼吸疾患、中耳炎及びアレルギーの発症率は低く、視力、発話及び認知の発達もより良好である。妊娠中の教育的介入の母乳哺育期間への影響は、依然として評価されていない。 本レビューには、大半が米国、カナダ、英国及びオーストラリアなど先進国の女性8,262名を対象とする16件のランダム化比較試験のデータが含まれている。ピアカウンセリング、授乳相談及び妊娠中の公式のBF教育は、BF期間を延長させると思われる。ピアカウンセリングは、BF開始例についてもルーチンのケアより良好な効果を示すと思われる。しかし対象となる試験の大半が質が不良で、BF教育の効果がかなり低いため、特定のBF教育による介入を推奨することは適切ではない。本レビューの所見は、単独の試験に基づいており、十分なサンプル・サイズによる、適切にデザインされた臨床試験の実施が必要である。

訳注

監  訳: 江藤 宏美,2013.1.30

実施組織: 厚生労働省委託事業によりMindsが実施した。

ご注意 : この日本語訳は、臨床医、疫学研究者などによる翻訳のチェックを受けて公開していますが、訳語の間違いなどお気づきの点がございましたら、Minds事務局までご連絡ください。Mindsでは最新版の日本語訳を掲載するよう努めておりますが、編集作業に伴うタイム・ラグが生じている場合もあります。ご利用に際しては、最新版(英語版)の内容をご確認ください。

Laički sažetak

Edukacija u trudnoći za dulje trajanje dojenja

Dojenje je itekako prepoznato kao najbolja hrana za dijete i zato Svjetska zdravstvena organizacija preporučuje isključivo dojenje za svu dojenčad barem prvih šest mjeseci života. Dohrana davana prije 6. mjeseca istiskuje majčino mlijeko i pri tome ne donosi nikakve prednosti za zdravlje. Dojenje može poboljšati zdravlje djeteta, zdravlje majke i povezanost između majke i djeteta. Dojena djeca imaju manju učestalost probavnih i dišnih bolesti, upale srednjeg uha i alergija, bolji vid, i bolji kognitivni razvoj i razvoj govora. Dosada nije proučen utjecaj edukacijskih intervencija u trudnoći na duljinu dojenja.

Ovaj Cochrane sustavni pregled uključuje podatke iz 16 randomiziranih kontroliranih studija s 8262 žena iz pretežno razvijenih zemalja poput SAD-a, Kanade, Velike Britanije i Australije. Rezultati pokazuju da potpora majka-majci, potpora savjetnice za dojenje i formalna edukacija trudnica povećava trajanje dojenja. Potpora majka-majci u usporedbi sa standardnom njegom također je povećala stopu započinjanja dojenja. Nažalost, većina uključenih studija loše su kvalitete i utjecaj edukacije je prilično malen, zato u ovom trenutku nije moguće preporučiti određenu vrstu edukacije o dojenju. Dobiveni rezultati ovog sustavnog pregleda se temelje na pojedinim studijama i postoji potreba za novim, dobro osmišljenim kliničkim istraživanjima s prikladnim uzorcima.

Bilješke prijevoda

Hrvatski Cochrane ogranak
Prevela: Irena Zakarija-Grkovic

ข้้อสรุปภาษาธรรมดา

การให้การศึกษาเรื่องการเลี้ยงลูกด้วยนมแม่ในระหว่างการตั้งครรภ์เพื่อเพิ่มระยะเวลาการเลี้ยงลูกด้วยนมแม่

การเลี้ยงลูกด้วยนมแม่ได้รับการยอมรับว่าเป็นอาหารที่ดีที่สุดสำหรับทารก องค์การอนามัยโลกแนะนำว่าทารกทุกคนควรได้รับการเลี้ยงลูกด้วยนมแม่อย่างเดียวเป็นเวลาอย่างน้อย 6 เดือนหลังคลอด การให้อาหารเสริมก่อนอายุ 6 เดือนมักจะทำให้ได้รับนมแม่น้อยลงและไม่ให้ประโยชน์ต่อสุขภาพ การเลี้ยงลูกด้วยนมแม่ทำให้สุขภาพของเด็กและแม่ รวมทั้งความสัมพันธ์ระหว่างแม่และลูกดีขึ้น ทารกที่ได้รับการเลี้ยงลูกด้วยนมแม่มีอัตราการเกิดโรคระบบทางเดินอาหาร ระบบหายใจ หูอักเสบ และภูมิแพ้ น้อยลง การมองเห็น การพูด และการพัฒนาการรับรู้ ดีขึ้น ยังไม่มีการประเมินผลของการให้การศึกษาเกี่ยวกับการเลี้ยงลูกด้วยนมแม่ในระหว่างการตั้งครรภ์

การทบทวนนี้รวบรวมข้อมูลจากการศึกษาที่มีกลุ่มควบคุมแบบสุ่ม 16 เรื่อง มีสตรีเข้าร่วมโครงการ 8262 คน ส่วนใหญ่จากประเทศที่พัฒนาแล้ว รวมถึงสหรัฐอเมริกา แคนาดา สหราชอาณาจักร และออสเตรเลีย การแนะนำแบบเพื่อน การให้คำปรึกษาการให้น้ำนม และการให้การศึกษาเรื่องการเลี้ยงลูกด้วยนมแม่อย่างเป็นทางการ สามารถเพิ่มระยะเวลาการเลี้ยงลูกด้วยนมแม่ การแนะนำแบบเพื่อน สามารถทำให้การเริ่มต้นการเลี้ยงลูกด้วยนมแม่ดีกว่าการดูแลแบบธรรมดา อย่างไรก็ตาม เนื่องจากการศึกษาที่นำมาทบทวนส่วนใหญ่มีคุณภาพต่ำ และการให้การศึกษาเรื่องการเลี้ยงลูกด้วยนมแม่มีผลค่อนข้างน้อย จึงไม่เหมาะสมที่จะแนะนำการให้การศึกษาเรื่องการเลี้ยงลูกด้วยนมแม่แบบใดแบบหนึ่งโดยเฉพาะ สิ่งที่พบของการทบทวนนี้มีข้อมูลจากการวิจัยเพียงเรื่องเดียว จึงมีความจำเป็นต้องมีการทดลองทางคลินิกที่มีการเตรียมการอย่างดีและมีขนาดตัวอย่างเพียงพอ

หมายเหตุการแปล

เอกสารแปล CD006425.pub3

Ringkasan bahasa mudah

Pendidikan penyusuan susu ibu antenatal untuk memanjangkan tempoh masa penyusuan

Penyusuan susu ibu diiktiraf sebagai makanan terbaik untuk bayi dan Pertubuhan Kesihatan Sedunia (WHO) mengesyorkan bahawa semua bayi harus diberikan susu ibu secara eksklusif selama sekurang-kurangnya enam bulan selepas lahir. Makanan tambahan yang diberikan sebelum umur enam bulan biasanya mengetepikan susu ibu dan tidak memberi apa-apa faedah kesihatan. Penyusuan susu ibu boleh memperbaiki kesihatan anak, kesihatan ibu dan juga hubungan ibu-bayi. Bayi yang diberi susu ibu mempunyai kadar penyakit gastrousus, penyakit respiratori, otitis media (jangkitan kuman telinga) dan alahan yang lebih rendah serta ketajaman penglihatan, perkembangan pertuturan dan kognitif yang lebih baik. Kesan kepada tempoh penyusuan susu ibu daripada intervensi pendidikan semasa kehamilan belum lagi dinilai.

Ulasan ini termasuk data daripada 16 kajian rawak terkawal yang melibatkan 8262 wanita, kebanyakannya daripada negara-negara maju termasuk USA, Kanada, UK dan Australia. Kaunseling rakan sebaya, perundingan penyusuan dan pendidikan penyusuan susu ibu secara formal semasa kehamilan kelihatan memanjangkan tempoh masa penyusuan. Kaunseling rakan sebaya juga kelihatan lebih baik berbanding penjagaan rutin untuk memulakan penyusuan susu ibu. Namun demikian, disebabkan kebanyakan kajian yang termasuk adalah berkualiti rendah dan kesan pendidikan penyusuan adalah agak kecil, tiada intervensi pendidikan penyusuan susu ibu secara spesifik sesuai disyorkan. Hasil ulasan ini adalah berdasarkan kajian tunggal justeru kajian-kajian klinikal yang direka dengan baik dengan saiz sampel yang mencukupi diperlukan.

Catatan terjemahan

Diterjemahkan oleh Melissa de Bruyne Choon (Penang Medical College). Disunting oleh Dr Tan May Loong (Penang Medical College; mltan@pmc.edu.my) Untuk sebarang pertanyaan berkaitan terjemahan ini sila hubungi melissadebruyne@ms.pmc.edu.my

Background

Importance of breastfeeding for infants

Breastfeeding (BF) is well recognised as the best food source for infants (Simard 2005). Complementary foods offered before six months of age tend to displace breast milk and do not confer any health advantage over exclusive BF (Kramer 2002). BF has been advocated to improve child health, maternal health and mother-infant bonding (Ball 2001; Hanson 2002). BF has been associated with lower rates of gastrointestinal and respiratory diseases, otitis media and allergies, better visual acuity, and speech and cognitive development (Anderson 1999; Blaymore Bier 2002; Duffy 1997b; Innis 2001; Wold 2000). It is also cost effective (Riordan 1997). Infants who are breast fed have a lower risk of developing insulin-dependent diabetes in childhood (Fava 1994; Verge 1994), sudden infant death syndrome (Mitchell 1991) and childhood cancer (Davis 1988). Recent research indicates that the type of infant feeding may contribute to children becoming overweight and obese in early and late childhood. BF has been shown to protect against child obesity and cardiovascular risk outcomes and is dose related - the longer the infant is breast fed, the lower the risk (Arenz 2004; Harder 2005; Owen 2005). A Cochrane review by Kramer 2002 indicated that exclusive breastfeeding for six months has several advantages over exclusive breastfeeding for three to four months followed by mixed breastfeeding.

Importance of breastfeeding for mothers and families

Delay in return of fertility has been associated with frequent and long periods of exclusive BF, as well as a lower risk of developing premenopausal breast cancer (Newcomb 1994). Women who had not breast fed their babies were four times more likely to have osteoporosis than women who had breast fed (Blaauw 1994). Better emotional health has also been attributed to women who breast fed. Virden 1988 found that, at one month postpartum, women who breast fed their infants had scores indicating less anxiety than women who had bottle fed their infants. The retrospective review of medical records of 800 pregnancies by Acheson 1995 revealed an association between lack of breastfeeding and physical and sexual abuse of the women and/or her children. This was a small review, the results of which warrant further study. A recent published study found that women who breast fed for at least one year were less likely to develop Type 2 diabetes than women who did not breast feed (Stuebe 2005). Some studies have shown a benefit of BF in enhancing couple and family relationships (Cohen 2002; Falceto 2004; Jordan 1993; Li 2004; Sullivan 2004) .

Breastfeeding terminology

In 1988, the World Health Organization (WHO) and UNICEF proposed the following standard terminology for the collection and description of data on BF behaviour; these were updated in 1991 (WHO 1991), and are now widely used (Dettwyler 1992).

Exclusive breastfeeding

Defined as an infant being fed only breast milk, with the possible exception of vitamin D in certain populations and iron in infants of relatively low birthweight (Dewey 2001).

Predominant breastfeeding

When the infant receives breast milk as the predominant source of nourishment. It allows the infant to receive liquids (water and water-based drinks, fruit juice, oral dehydration solutions) and drops or syrups (vitamins, minerals, medicines) but does not allow the infant to receive anything else (in particular, non-human milk and food-based fluids).

Complementary breastfeeding

When the infant receives breast milk and solid or semi-solid foods and allows the infant to receive any food or liquid including non-human milk.

Breastfeeding

When the infant receives breast milk but allows the infant to receive any food or liquid including non-human milk.

Breastfeeding statistics and trends

Despite the many advantages and extensive promotion of BF, Susin 1999 reports that the trend towards BF in many countries is increasing slowly. However, according to the recent UNICEF report (UNICEF 2005), six million lives a year are being saved by exclusive BF and global BF initiation rates have risen by at least 15% since 1990. At the same time, women breast feed for a shorter time than they intended or wished to (Adams 2001; Wagner 2002). The World Health Organization recommends that infants should be exclusively breast fed from birth to six months and then breast fed alongside age-appropriate, complementary feeding for two years and beyond (WHO 2001).

Rationale for using educational interventions

Another Cochrane systematic review provides evidence that various forms of BF education are effective at increasing rates of BF initiation among women on low incomes in the USA and initiation will, therefore, not be the main focus in this review (Dyson 2005). The impact of antenatal BF education on the duration of BF, however, has not been widely reported. In Australia, more than 90% of mothers initiate BF; however, only 48% of mothers are BF at one month postpartum and only 23% maintain any form of BF at six months (Lund-Adams 1996). Similar BF duration rates have been reported in the USA (Raj 1998) and Britain (Griffiths 2005; Hoddinott 2000), as well as in developing countries (UNICEF 1998). A variety of BF promotion methods including educational programmes have been studied to support the trend to increase BF duration. It is generally believed that, by improving the mothers' knowledge of BF antenatally, the rates and duration of BF would increase (McLeod 2002). Lack of antenatal information and education about BF has been one factor attributed by New Zealand mothers interviewed about discontinuing BF (McLeod 2002).

Educational interventions

Antenatal BF education is defined as BF information being imparted during the pregnancy in a variety of forms. This could be on an individual or group basis, could include home visiting programmes, peer education programmes or clinic appointments specifically aimed at imparting BF knowledge and could involve prospective fathers or not. BF education is usually a formalised, defined, descriptive and goal-orientated programme with a specific purpose and target audience.

BF education differs from BF support. BF support is usually aimed at the individual person as the need arises and is defined as a person, a group or an organisation providing support in many ways. This could be psychological support (affirming and encouraging the mother), physical support (providing meals, caring for her other children, house cleaning and gardening), financial support or BF information services available to be tapped into when a BF question arises. BF support usually starts in the postnatal period, not antenatally.

Although we recognise the potential importance of interventions in the postnatal period on breastfeeding outcomes, the focus of this review is on antenatal BF education only, and we have not included trials examining interventions that also involve intrapartum or postpartum BF education. Other Cochrane reviews examine BF education and support interventions in the intrapartum and postnatal periods (Britton 2007; Dyson 2005; Sikorski 2002).

Objectives

  1. To assess the effectiveness of antenatal breastfeeding (BF) education for increasing BF initiation and duration.

  2. To compare the effectiveness of various forms of education; for example, peer support, educational programme, didactic teaching session, workshop, booklets, etc, or a combination of these interventions for increasing BF initiation and duration.

  3. To assess the effects of antenatal BF education on other maternal and infant outcomes, e.g. BF complications, maternal satisfaction and neonatal sepsis.

Methods

Criteria for considering studies for this review

Types of studies

All identified published, unpublished and ongoing randomised controlled trials (RCTs) comparing two different methods of antenatal breastfeeding (BF) education programmes, with or without formal BF education, on duration of BF. Randomised units can be clustered; for example, hospitals, communities or groups of pregnant women or individual women. We excluded quasi-RCTs. We did not include studies published only as abstracts.

Types of participants

Pregnant women.

Types of interventions

Any type of education with BF components. Antenatal BF education is defined as BF information being imparted during pregnancy in a variety of forms. This could be on an individual or group basis, include home visiting programmes; peer education programmes or clinic appointments specifically aimed at imparting BF knowledge; brochures or booklets; electronic education programmes; or a combination of these, and could involve prospective fathers or not. Formal BF education is defined as BF education that was given formally in addition to any BF education that was given as part of routine antenatal care. We excluded RCTs examining interventions that included intrapartum or postpartum BF education in addition to antenatal BF education.

Types of outcome measures

Primary outcomes
  1. Duration of any BF

  2. Duration of exclusive BF

  3. Proportion of mothers BF at three and six months

  4. Proportion of mothers exclusively BF at three and six months

  5. Initiation rate of BF

Secondary outcomes
  1. Maternal satisfaction

  2. BF complications such as mastitis and breast abscess

  3. Infant growth by weight and head circumference

  4. Neonatal sepsis

  5. Taking child to doctor

  6. Hospital admission for child

Search methods for identification of studies

Electronic searches

For this update we searched the Cochrane Pregnancy and Childbirth Group’s Trials Register by contacting the Trials Search Co-ordinator (2 December 2011).

The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from:

  1. quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);

  2. weekly searches of MEDLINE;

  3. weekly searches of EMBASE;

  4. handsearches of 30 journals and the proceedings of major conferences;

  5. 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. 

In addition, we searched CENTRAL (The Cochrane Library, 2011, Issue 11) and MEDLINE (1966 to 30 November 2011) and Scopus (January 1985 to 30 November 2011) using the search strategies detailed in Appendix 1.

Searching other resources

We contacted investigators (identified from the retrieved articles) and other content experts known to us for unpublished studies. Furthermore, we looked for relevant studies in the references of the retrieved articles.

We did not apply any language restrictions.

Data collection and analysis

Selection of studies

Six review authors (Pisake Lumbiganon (PL) Ruth Martis (RM) Malinee Laopaiboon (ML) Mario R Festin (MF) Jacqueline J Ho (JH) and Mohammad Hakimi (MH)) independently assessed for inclusion all the potential studies we identified as a result of the search strategy. We resolved any disagreement through discussion.

Data extraction and management

We designed a form to extract data. For eligible studies, PL, RM, ML and MF extracted the data using the agreed form. At least two review authors independently carried out data extraction for each included study. We resolved discrepancies through discussion. PL and ML entered data into Review Manager software (RevMan 2011) and checked for accuracy.

When information regarding any of the above was unclear, we contacted authors of the original reports (Schlickau 2005a; Schlickau 2005b; Westdahl 2008) to obtain further details.

Assessment of risk of bias in included studies

Two review authors (PL, ML) independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion.

(1) Sequence generation (checking for possible selection bias)

We described for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups.

We assessed the method as:

  • low risk of bias (any truly random process, e.g. random number table; computer random number generator);

  • high risk of bias (any non-random process, e.g. odd or even date of birth; hospital or clinic record number);

  • unclear (insufficient information to allow judgment).

 (2) Allocation concealment (checking for possible selection bias)

We described for each included study the method used to conceal the allocation sequence and determined whether the intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.

We assessed the methods as:

  • low risk of bias (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);

  • high risk of bias (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth);

  • unclear ( insufficient information to allow judgment). 

(3) Blinding (checking for possible performance bias)

We described for each included study the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. We considered that studies were at low risk of bias if they were blinded, or if we judged that the lack of blinding could not have affected the results. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed the methods as:

  • low risk, high risk or unclear for participants;

  • low risk, high risk or unclear for personnel;

  • low risk, high risk or unclear for outcome assessors.

(4) Incomplete outcome data (checking for possible attrition bias through withdrawals, dropouts, protocol deviations)

We described for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and exclusions from the analysis. We stated whether attrition and exclusions were reported, the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes. We assessed methods as:

  • low risk of bias (20% or less missing data);

  • high risk of bias (more than 20% missing data);

  • unclear.

(5) Selective reporting bias

We described for each included study how we investigated the possibility of selective outcome reporting bias and what we found.

We assessed the methods as:

  • low risk of bias (where it was clear that all of the study’s pre-specified outcomes and all expected outcomes of interest to the review had been reported);

  • high risk of bias (where not all the study’s pre-specified outcomes had been reported; one or more reported primary outcomes were not pre-specified; outcomes of interest were reported incompletely and so could not be used; study fails to include results of a key outcome that would had been expected to have been reported);

  • unclear.

(6) Other sources of bias

We described for each included study any important concerns we had about other possible sources of bias.

We assessed whether each study was free of other problems that could put it at risk of bias:

  • low risk of bias;

  • high risk of bias;

  • unclear.

(7) Overall risk of bias

We made explicit judgements about whether studies were at high risk of bias, according to the criteria given in the Handbook (Higgins 2011). With reference to (1) to (6) above, we assessed the likely magnitude and direction of the bias and whether we considered it was likely to impact on the findings. We did not explore the impact of study quality using sensitivity analysis because we included a limited number of studies and did not combine studies in a meta-analysis.

Measures of treatment effect

We carried out statistical analyses using the Review Manager software (RevMan 2011). We reported BF duration and other continuous outcomes using mean difference with 95% confidence intervals (CIs) because they were measured in the same way between studies. We reported initiation rate of breastfeeding and other binary outcomes using risk ratios and 95% CIs.

We evaluated the following comparisons.

  1. An additional formal education programme versus routine care.

  2. One form of education programme versus another form of education programme.

  3. Programmes involving multiple methods of providing education compared with those using a single method.

  4. Different combinations of multiple methods of providing education.

  5. Programmes involving multiple methods of providing education versus no formal education.

Unit of analysis issues

We included studies where individual women were randomised and cluster-randomised studies where, for example, clinics were the unit of randomisation. Three included studies were cluster-randomised trials and in two of these, in the published study reports some results had already been adjusted for clustering effects. For these two trials, where adjusted data were reported (as odds ratios), we have analysed data using the generic inverse variance method in RevMan 2011 and for these results we have presented results as odds ratios. Where there was no adjustment for cluster design effect and there was insufficient information available to allow us to adjust the data ourselves (i.e. no intracluster correlation co-efficient (ICC) was provided or could be imputed), we have presented the raw data published in the study report.

In future updates, if we identify any more cluster-randomised trials we will include them in the analyses along with individually-randomised trials. If adjustment for the cluster design effect has not already been made by the trial authors, we will adjust their sample sizes using the methods described in the Handbook using an estimate of the ICC derived from the trial (if possible), from a similar trial or from a study of a similar population. If we use ICCs from other sources, we will report this and conduct sensitivity analyses to investigate the effect of variation in the ICC. If we identify both cluster-randomised trials and individually-randomised trials, we plan to synthesise the relevant information. We will consider it reasonable to combine the results from both if there is little heterogeneity between the study designs and the interaction between the effect of intervention and the choice of randomisation unit is considered to be unlikely.

Dealing with missing data

For included studies, we noted levels of attrition in the 'Risk of bias' tables.

In future updates, as more data become available, we will explore the impact of including studies with high levels of missing data in the overall assessment of treatment effect by using sensitivity analysis. For all outcomes, we will carry out analyses, as far as possible, on an intention-to-treat basis, i.e. we will attempt to include all participants randomised to each group in the analyses, and analyse all participants in the group to which they were allocated, regardless of whether or not they received the allocated intervention. The denominator for each outcome in each trial will be the number randomised minus any participants whose outcomes are known to be missing.

Assessment of heterogeneity

In this version of the review we did not assess heterogeneity because data from only one study was available for each outcome.

In the future, if we carry out meta-analysis for the updated version, we will assess statistical heterogeneity in each meta-analysis using the T², I² and Chi² statistics. We will regard heterogeneity as substantial if an I² is greater than 30% and either T² is greater than zero, or there is a low P value (< 0.10) in the Chi² test for heterogeneity.

Assessment of reporting biases

We did not formally assess reporting bias; without access to study protocols it is difficult to know whether or not there has been outcome reporting bias. We were unable to assess publication bias using funnel plots, as only one study contributed data to each analysis.

Data synthesis

We did not carry out data synthesis in this version of the review. This was because no more than one study examining a particular type of intervention addressed any of the pre-specified outcomes. Also, because postnatal care could have a possible influence on breastfeeding duration, the primary outcome of the review, and postnatal care may have varied widely across the included studies.

In future updates, if we include more studies, we will use fixed-effect meta-analysis for combining data where it is reasonable to assume that studies are estimating the same underlying treatment effect: i.e. where trials are examining the same intervention, and the trials’ populations and methods are judged sufficiently similar. If there is clinical heterogeneity sufficient to expect that the underlying treatment effects differ between trials, or if we detect substantial statistical heterogeneity, we will use random-effects meta-analysis to produce an overall summary if an average treatment effect across trials is considered clinically meaningful. We will treat the random-effects summary as the average range of possible treatment effects and we will discuss the clinical implications of treatment effects differing between trials. If the average treatment effect is not clinically meaningful, we will not combine trials.

If we use random-effects analyses, we will present the results as the average treatment effect with its 95% CI, and the estimates of  T² and I².

Subgroup analysis and investigation of heterogeneity

In future updates, if we identify substantial heterogeneity, we will investigate it using subgroup analyses.

We plan to carry out subgroup analyses according to types of interventions. We will restrict subgroup analyses to the primary outcomes. We will conduct the analyses where sufficient data are available according to the following specified factors: type of intervention, study setting, maternal education and maternal occupation.

We will assess differences between subgroups by interaction tests available in Revman (RevMan 2011).

Sensitivity analysis

We did not carry out any sensitivity analyses. However, in future updates of this review, we plan to carry out sensitivity analysis to explore the effect of study quality. This will involve analyses based on the trial quality ratings for sequence generation, allocation concealment and incomplete outcome data. We will exclude studies of poor quality in the analysis (those categorised as 'high risk of bias' or 'unclear') in order to assess for any substantive difference to the overall results.

Results

Description of studies

Results of the search

In the previous version of this review the search of the Pregnancy and Childbirth Group's Trials Register yielded 57 potential studies. Our additional search yielded one potential study. We explored the contents, and grouped together trial reports for the same study; from this we identified 17 studies (involving 7131 women) that met the inclusion criteria. We excluded 39 studies.

We subsequently updated the search of the Pregnancy and Childbirth Group's Trials Register on 2 December 2011 and in addition, we searched CENTRAL (The Cochrane Library, 2011, Issue 11) and MEDLINE (1966 to 30 November 2011) and Scopus (January 1985 to 30 November 2011) using the search strategies detailed in Appendix 1. We identified five additional potential studies, two studies (Kronborg 2011; Olenick 2010) have been included, and three excluded (Kupratakul 2010; Patel 2011; Wockel 2009). We therefore included 19 studies involving 8506 women and excluded 42 studies.

Included studies

We included 19 studies. We have provided full details of included studies in the Characteristics of included studies tables. Of these, 16 studies involving 8262 women contribute data to the analyses for primary and secondary outcomes; three included studies (Kaplowitz 1983; Noel-Weiss 2006; Ryser 2004) met our inclusion criteria but did not report data on any of our prespecified outcomes. Kaplowitz 1983 described women's attitudes towards breastfeeding (BF) before and after the intervention and we have not included results from this study in the review. Ryser 2004 and Noel-Weiss 2006 report on BF at time points which we had not prespecified, and we have included a brief description of results from these studies following results for our primary and secondary outcomes.

Interventions

Interventions included routine BF education, formal BF education, printed information, video, peer counselling and lactation consultation (LC).

There were 20 comparisons from the 19 included studies which are described below (some studies with more than two experimental arms are included in more than one comparison).

There were eight studies comparing a single method of BF education with routine care (Forster 2004; Kaplowitz 1983; Kluka 2004; Kronborg 2011; Noel-Weiss 2006; Olenick 2010; Schlickau 2005b; Wolfberg 2004). Two of these studies (Kaplowitz 1983; Noel-Weiss 2006) compared formal BF education versus routine care but did not provide any information about BF practices. Two studies (Kluka 2004; Schlickau 2005b) compared a BF education workshop versus routine care. One study with three groups (Forster 2004) compared BF practical skills education or BF attitude education versus routine care. Another study (Wolfberg 2004), compared peer counselling for expectant fathers versus routine care. Kronborg 2011 compared a training programme, and Olenick 2010 structured group education with routine care.

There were four studies comparing one form of BF education versus other forms of BF education (Forster 2004; Kistin 1990; MacArthur 2009; Schlickau 2005a). One study (Kistin 1990), compared group education versus individual education, and Schlickau 2005a compared BF education discussion versus BF handouts. One study (Forster 2004), compared BF practical skills versus BF attitude education. Another study (MacArthur 2009), compared a peer support worker service with standard antenatal care, which included usual information and advice from midwives on BF.

There were seven studies (Duffy 1997a; Finch 2002; Kools 2005; Lavender 2005; Rossiter 1994; Schlickau 2005a; Serwint 1996) that examined programmes involving multiple methods of providing education compared to those using a single method. One study (Duffy 1997a) compared formal BF education and lactation consultation versus routine BF education. Finch 2002 compared LC plus incentive plus handout with formal BF education. One study (Kools 2005) compared LC and provision of a BF booklet with the provision of a BF booklet alone. Lavender 2005 compared routine BF education plus additional formal BF education with routine BF education alone. Rossiter 1994 examined the effect of a video and formal BF educational versus a BF pamphlet. One study (Schlickau 2005a) compared formal BFeducation and baby quarantine versus routine BF education, and formal BF education and baby quarantine versus formal BF education. Finally, Serwint 1996 compared LC and routine BF education versus routine BF education alone.

There was only one study (Mattar 2007) that compared different combinations of multiple interventions; this study compared a BF booklet plus a video and LC versus a BF booklet and video only.

There were two studies (Mattar 2007; Ryser 2004) that compared programmes involving multiple methods of providing education versus no formal education. One study (Mattar 2007) compared a BF booklet, video and lactation consultation versus no formal BF education. Another study (Ryser 2004) compared a counselling session plus viewing a video plus the provision of written materials addressing common BF barriers perceived by low-income women versus no formal BF education. This study did not provide any information on our proposed outcomes and has not been included in the analyses.

In studies where BF education was compared with routine care there was considerable variation in what was offered as part of usual care in terms of BF education; in many studies routine care was not described at all, or the description was vague (e.g. provision of a leaflet or midwife advice). We have set out information about care for control groups in the Characteristics of included studies and it is important that this is taken into account in the interpretation of results. Intrapartum and postpartum care could also have an impact on BF duration and these aspects of care also varied across included studies.

Excluded studies

We excluded 42 studies. Reasons for exclusion included: the intervention was not confined to the antenatal period only or was not an educational intervention, or the paper did not report on a randomised controlled study. For further details, see the Characteristics of excluded studies tables.

We have not considered educational and support interventions to promote BF in the intrapartum and postnatal periods in this review; related Cochrane reviews (Britton 2007; Dyson 2005) examine these topics.

Risk of bias in included studies

We have provided details of the methodological quality of each study in the Characteristics of included studies tables and the methodological quality summary (Figure 1) and methodological quality graph (Figure 2).

Figure 1.

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Figure 2.

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

Allocation

Seven out of 19 included studies (Forster 2004; Kistin 1990; Kools 2005; Kronborg 2011; MacArthur 2009; Mattar 2007; Serwint 1996) had adequate sequence generation for randomisation.

Six out of 19 included studies (Forster 2004; Kluka 2004; Lavender 2005; Mattar 2007; Noel-Weiss 2006; Schlickau 2005b) had adequate allocation concealment.

Blinding

Only six included studies (Duffy 1997a; Kluka 2004; Lavender 2005; MacArthur 2009; Mattar 2007; Noel-Weiss 2006) had implemented blinding; however, this blinding was only for the outcome assessors. This is perhaps mainly due to the nature of the interventions in that it was not possible to blind both mothers and educators.

Incomplete outcome data

Twelve out of 19 included studies (Forster 2004; Kluka 2004; Kools 2005; Kronborg 2011; Lavender 2005; MacArthur 2009; Mattar 2007; Noel-Weiss 2006; Olenick 2010; Ryser 2004; Schlickau 2005b; Serwint 1996) addressed issues concerning incomplete outcome data.

Selective reporting

Since we did not have access to the protocols of all included studies, we assessed their risk of bias for selective reporting as unclear.

Other potential sources of bias

Six out of 19 included studies (Duffy 1997a; Kluka 2004; Kools 2005; Kronborg 2011; Lavender 2005; Schlickau 2005a) had unclear risk of other potential sources of biases.

We consider that one of the included studies (Mattar 2007) had low risk of bias. Two studies had high risk of bias (Finch 2002; Wolfberg 2004).

Effects of interventions

This review includes 19 studies with 8506 women. However, for our primary and secondary outcomes only 16 studies with 8262 women contributed data for analyses. The interventions for increasing BF duration differed among the studies, and due to variation in the types of interventions we were unable to combine results from studies in meta-analysis; for each different type of intervention only a single study contributed outcome data. Some studies had more than two treatment arms and are included in more than one comparison.

We have presented effects of interventions for each comparison as follows.

1. Formal BF education versus routine care

Initiation of BF

One study (Schlickau 2005b) involving 80 women compared a BF education workshop with routine care. There was no significant difference in initiation of BF (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.97 to 1.45). A study by Wolfberg 2004 involving 59 women compared peer counselling versus routine care and showed a significant increase in the initiation of BF in the intervention group (RR 1.82, 95% CI 1.13 to 2.93). One study (Forster 2004) compared BF practical skills education versus routine care and BF attitudes education versus routine care. There were no significant differences in initiation of BF (RR 1.01, 95% CI 0.98 to 1.04 and RR 0.99, 95% CI 0.95 to 1.02 respectively). One study (Kronborg 2011) with data for 1162 women compared group training programme with routine care and showed no significant difference in initiation of BF (RR 1.04, 95% CI 0.98 to 1.11). One study (Olenick 2010) with 165 women compared structured group prenatal education with routine care and also showed no significant difference in initiation of BF (RR 0.98, 95% CI 0.87 to 1.11) (Analysis 1.1).

BF and exclusive BF

Kluka 2004 compared a BF education workshop with routine care. This study reported data for 185 women and no significant increases were found either in BF at three months (RR 1.07, 95% CI 0.92 to 1.24) or in exclusive BF at three months (RR 1.08, 95% CI 0.84 to 1.38). There were 178 women remaining in the sample at six months and no significant increases were found in BF (RR 1.15, 95% CI 0.87 to 1.51) or in exclusive BF (RR 1.13, 95% CI 0.70 to 1.80). One study (Olenick 2010) with data for 168 women compared structured group prenatal education with routine care and showed no significant differences in exclusive BF at three months (RR 1.08, 95% CI 0.81 to 1.43). One study (Forster 2004) compared BF practical skills education versus routine care. There were no significant differences in BF at six months and exclusive BF at six months. The RRs and 95% CIs were 1.01 (0.87 to 1.7) and 1.19 (0.69 to 2.05) respectively. This study (Forster 2004) also compared BF attitudes education versus routine care. There were also no significant differences in BF at six months and exclusive BF at six months. The RRs and 95% CIs were 0.92 (0.79 to 1.07) and 1.16 (0.67 to 2.01) respectively.(Analysis 1.2; Analysis 1.3; Analysis 1.4; Analysis 1.5).

Duration of any BF

One study involving 165 women reported the comparison of structured group prenatal education with routine care (Olenick 2010). The mean difference (MD) in duration of any BF in the two groups was not statistically significant (MD 0.0 weeks, 95% CI --2.78 to 2.78 weeks) (Analysis 1.6).

Non-prespecified outcomes

There were two studies that reported BF practices at time points not pre-specified for this review. One study (Noel-Weiss 2006) compared a BF education workshop with routine care. It involved 92 women and no significant increases were reported for BF at eight weeks (RR 0.91, 95% CI 0.75 to 1.11) and exclusive BF at eight weeks (RR 0.82, 95% CI 0.60 to 1.12) (data not shown in data and analyses tables). Another study (Ryser 2004) compared a BF education programme with routine care. It involved 54 women and outcomes were reported at seven days; at this time point significant increases were reported in BF (RR 1.21, 95% CI 1.03 to 1.42) (data not shown in data and analyses tables).

One form of formal BF education versus another form of BF education

Initiation of BF

One cluster-randomised trial (MacArthur 2009) involving 2511 women compared an antenatal peer support worker service planned with routine care. In this study the planned intervention involved a minimum of two contacts with women to provide advice, information and support from approximately 24 weeks’ gestation within the antenatal clinic or at home. Women in the control group received standard antenatal care, which included the usual information and advice from midwives on BF, without input from community peer support workers. There was no significant difference between groups in the initiation of BF (adjusted odds ratio (OR) 1.11, 95% CI 0.86 to 1.43). Another study (Forster 2004) compared BF practical skills education versus BF attitudes education. There was no significant difference between groups in the initiation of BF (RR 1.03, 95% CI 0.99 to 1.07) (Analysis 2.1).     

BF at three months

One study (Kistin 1990) involving 74 women compared group discussion versus individual discussion and reported no significant increase in BF at three months (RR 2.84, 95% CI 0.61 to 13.18) (Analysis 2.2).

BF at six months

Forster 2004 compared BF practical skills education versus BF attitudes education. There was no significant difference between groups for this outcome (RR 1.21, 95% CI 0.87 to 1.67) (Analysis 2.3).

Exclusive BF at six months

There was no evidence of differences between groups receiving practical skills education versus BF attitudes education for exclusive BF at six months (RR 1.03, 95% CI 0.61 to 1.73) (Forster 2004) (Analysis 2.4).

Duration of any BF

One study involving 16 women reported the comparison of formal BF education with routine BF education (Schlickau 2005a). The MD in duration of any BF in the two groups was not statistically significant, (MD 6.20 months, 95% CI -10.84 to 23.24 months) (Analysis 2.5).

Programs involving multiple methods of providing BF education versus a single method  

Initiation of BF

One study involving 144 women (Serwint 1996) compared LC plus routine BF education versus routine BF education alone. There was no significant difference in the initiation of BF (RR 1.33, 95% CI 0.86 to 2.07) (Analysis 3.1).

BF at three months

A cluster-randomised trial (Kools 2005) involving 698 women comparing LC plus a BF booklet versus a BF booklet alone reported no significant difference in BF at three months (adjusted OR 0.82, 95% CI 0.59 to 1.14) (Analysis 3.2).

BF at six months

Two studies (Lavender 2005; Rossiter 1994) involving 1424 women reported this outcome. The study by Rossiter 1994 involved 175 women and compared video plus formal BF education with the provision of pamphlets. There was no significant difference in BF at six months (RR 1.59, 95% CI 0.86 to 2.94). In a cluster-randomised trial (Lavender 2005) involving 1250 women comparing routine BF education plus formal BF education with routine BF education alone, there was no significant difference in BF at six months (RR 0.97, 95% CI 0.79 to 1.19). The RR was analysed without adjusting for clustering effect because the information to carry out any adjustment for this outcome was not available in the paper (Analysis 3.3).

Exclusive BF at three months

One cluster-randomised trial (Kools 2005) involving 698 women compared lactation consultation plus a BF booklet with provision of a BF booklet alone and reported no significant differences between the two groups in exclusive BF rates at three months (RR 0.85, 95% CI 0.68 to 1.08). (We analysed the RR for this outcome without it being adjusted for cluster design effect as we did not have sufficient information to carry out the adjustments. Information on the ICC was not provided in the paper and we were unable to impute an ICC from another source as we were unable to identify any published papers reporting an ICC for a similar population (Analysis 3.4).

Duration of any BF

One study (Schlickau 2005a) involving 25 women compared formal BF education plus baby quarantine versus routine BF education. There was no significant difference in mean duration of BF (MD 14.20 days, 95% CI -2.97 to 31.37 days). This study also compared formal BF education plus baby quarantine versus formal antenatal BF education, and again reported no significant difference in the duration of any BF (MD 8.00 days, 95% CI -6.84 to 22.84 days) (Analysis 3.5).

One study (Finch 2002) involving 48 women compared LC plus incentive versus routine BF education; there were no significant differences in duration of BF between intervention and control group (median 12 versus six weeks, data not shown in the analysis).

Mastitis and other BF complications

Duffy 1997a compared formal BF education plus lactation consultation versus routine BF education. There was no significant difference in mastitis (RR 0.20, 95% CI 0.01 to 4.02); however, a significant reduction in nipple pain as measured by visual analogue scale (VAS) scores was recorded (MD -19.80, 95% CI -23.23 to -16.37). The VAS ranged from 0 to 10 with a '0' representing 'no pain' and an increase to a maximum of 10 representing 'pain as bad as it could possibly be'. Significantly less nipple trauma measured by nipple trauma index (NTI) scores was reported for the group receiving formal BF education plus lactation consultation (MD 38.65, 95% CI 32.95 to 44.35). The possible range of NTI was 0 to 34 with a higher NTI score indicating less trauma (Analysis 3.6; Analysis 3.7; Analysis 3.8).

Different combinations of multiple methods of providing BF education 

One study (Mattar 2007) compared a BF booklet plus video plus lactation consultation versus a BF booklet plus video.

Exclusive BF at three and six months

Mattar 2007 reported no significant difference in exclusive BF at three months (RR 1.29, 95% CI 0.80 to 2.06) (Analysis 4.1).

Exclusive BF at six months

At six months Mattar 2007 reported a significant increase in exclusive BF in the group receiving a booklet plus video plus lactation consultation compared with the group who received a booklet plus video only (RR 2.23, 95% CI 1.01 to 4.92) (Analysis 4.2).

Programme involving multiple methods versus no formal education

Mattar 2007 also compared a BF booklet plus video plus LC versus no formal BF education.

Exclusive BF at three months

One study (Mattar 2007) involved 159 women and reported a significant increase in exclusive BF at three months in the group who received a BF booklet plus video plus LC compared with the group who received no formal education (RR 2.02, 95% CI 1.16 to 3.49).(Analysis 5.1).

Exclusive BF at six months

Mattar 2007 involved 175 women and reported no significant difference in exclusive BF at six months (RR 2.11, 95% CI 0.99 to 4.52) (Analysis 5.2).

Discussion

Summary of main results

  • When compared with routine care, peer counselling significantly increased initiation of breastfeeding (BF).

  • We found no intervention to be significantly more effective than any other intervention in increasing BF initiation or BF duration.

  • A combined BF educational intervention was not found to be significantly better than a single intervention in initiating BF or increasing BF duration. However, in one trial a combined BF educational intervention significantly reduced nipple pain and trauma.

  • There was a marginally significant increase in exclusive BF at six months in a group receiving a booklet plus video plus lactation consultation (LC) compared with the booklet plus video group. A BF booklet plus video plus LC was significantly better than no formal BF education for exclusive BF at three months.

We would like to emphasise that all four significant results are based on findings from single studies.

Overall completeness and applicability of evidence

All studies except one were from developed countries, mainly the USA, Canada, Australia and the UK. Applying the results to low and middle-income countries should be done cautiously. Although we have 17 included studies, there were diverse interventions among these studies. There were no outcomes where we could combine data from two or more studies. The overall completeness of evidence in this review is therefore too limited to make any strong conclusions or generalisations.

Quality of the evidence

We included 19 studies but only 16 studies with 8262 women could provide data for the analysed results. However, all except one included studies (Mattar 2007) had either unclear or high risk of bias. Moreover, there were wide variations in the nature of BF educational interventions as well as in reported outcomes between studies. Therefore the internal validity of the results of this review is limited.

Potential biases in the review process

We strictly followed the review process recommended by Cochrane Pregnancy and Childbirth Review Group. We obtained all relevant studies identified from search results. We independently reviewed all potentially relevant studies and resolved disagreement by discussion. Potential bias in the review process should be minimal.

Agreements and disagreements with other studies or reviews

A systematic review of professional support interventions for breastfeeding concluded that interventions expanding from pregnancy to the intrapartum period and throughout the postnatal period were more effective than interventions concentrating on a shorter period. In addition, intervention packages using various methods of education and support from well-trained professionals are more effective than interventions concentrating on a single method (Hannula 2008). However, this review included not only educational but also support interventions and did not restrict the included studies to randomised controlled trials.

Another Cochrane review found that health education and peer support interventions can result in some improvements in the number of women beginning to breast feed (Dyson 2005). We also found that peer counselling was significantly better than formal BF education in initiation of BF.

Authors' conclusions

Implications for practice

Peer counselling alone was found to be effective in increasing initiation of breastfeeding (BF). A combination of a BF booklet, video and lactation consultation (LC) was found to be effective in increasing BF at three months when compared with routine care. A combination of BF booklet, video and LC was found to be more effective in increasing exclusive BF at six months when compared with BF booklet and video. However, because there were significant methodological limitations among included studies and the observed effect sizes were small, it is not appropriate to recommend any specific antenatal BF educational intervention.

Implications for research

There is an urgent need to conduct a high-quality, randomised controlled study with an adequate sample size and that is free from commercial influence to evaluate the effectiveness of BF education, e.g. peer counselling, LC, etc, in low- and middle-income countries where BF should have a more significant impact.

Acknowledgements

We thank staff from the Australasian Cochrane Centre for technical support. We also sincerely thank Therese Dowswell (TD) for her helpful comments and suggestions for the completion of the review. TD is supported by a grant from the National Institute for Health Research.

The Cochrane Health Promotion and Public Health Field provided a bursary to support Ruth Martis to travel to Australia to attend a review authors' meeting during the development of this review. The bursary was administered by the SEA-ORCHID project.

The World Health Organization retains copyright and all other rights in the manuscript of this Review as submitted for publication, including any revisions or updates to the manuscript which WHO may make from time to time.

As part of the pre-publication editorial process, this review has been commented on by three peers (an editor and two referees who are external to the editorial team), a member of the Pregnancy and Childbirth Group's international panel of consumers and the Group's Statistical Adviser.

Data and analyses

Download statistical data

Comparison 1. Formal BF education verus routine care
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Initiation rate of breastfeeding5 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
1.1 BF education workshop versus routine care180Risk Ratio (M-H, Fixed, 95% CI)1.19 [0.97, 1.45]
1.2 Peer counselling versus routine care159Risk Ratio (M-H, Fixed, 95% CI)1.82 [1.13, 2.93]
1.3 BF practical skills versus routine care1616Risk Ratio (M-H, Fixed, 95% CI)1.01 [0.98, 1.04]
1.4 BF attitude education versus routine care1618Risk Ratio (M-H, Fixed, 95% CI)0.99 [0.95, 1.02]
1.5 Training programme versus routine care11162Risk Ratio (M-H, Fixed, 95% CI)1.04 [0.98, 1.11]
1.6 Structured group prenatal education versus routine care1165Risk Ratio (M-H, Fixed, 95% CI)0.98 [0.87, 1.11]
2 Breastfeeding at three months1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
2.1 BF education workshop versus routine care1185Risk Ratio (M-H, Fixed, 95% CI)1.07 [0.92, 1.24]
3 Breastfeeding at six months2 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
3.1 BF education workshop versus routine care1178Risk Ratio (M-H, Fixed, 95% CI)1.15 [0.87, 1.51]
3.2 BF practical skills versus routine care1596Risk Ratio (M-H, Fixed, 95% CI)1.01 [0.87, 1.17]
3.3 BF attitude education versus routine care1592Risk Ratio (M-H, Fixed, 95% CI)0.92 [0.79, 1.07]
4 Exclusive breastfeeding at three months2 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
4.1 BF education workshop versus routine care1185Risk Ratio (M-H, Fixed, 95% CI)1.08 [0.84, 1.38]
4.2 Structured group prenatal education versus routine care1168Risk Ratio (M-H, Fixed, 95% CI)1.08 [0.81, 1.43]
5 Exclusive breastfeeding at six months2 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
5.1 BF education workshop versus routine care1178Risk Ratio (M-H, Fixed, 95% CI)1.13 [0.70, 1.80]
5.2 BF practical skills versus routine care1596Risk Ratio (M-H, Fixed, 95% CI)1.19 [0.69, 2.05]
5.3 Formal BF attitude versus routine care1592Risk Ratio (M-H, Fixed, 95% CI)1.16 [0.67, 2.01]
6 Duration of any breastfeeding (weeks)1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
6.1 Structured group prenatal education versus routine care1165Mean Difference (IV, Fixed, 95% CI)0.0 [-2.78, 2.78]
Analysis 1.1.

Comparison 1 Formal BF education verus routine care, Outcome 1 Initiation rate of breastfeeding.

Analysis 1.2.

Comparison 1 Formal BF education verus routine care, Outcome 2 Breastfeeding at three months.

Analysis 1.3.

Comparison 1 Formal BF education verus routine care, Outcome 3 Breastfeeding at six months.

Analysis 1.4.

Comparison 1 Formal BF education verus routine care, Outcome 4 Exclusive breastfeeding at three months.

Analysis 1.5.

Comparison 1 Formal BF education verus routine care, Outcome 5 Exclusive breastfeeding at six months.

Analysis 1.6.

Comparison 1 Formal BF education verus routine care, Outcome 6 Duration of any breastfeeding (weeks).

Comparison 2. One BF education versus another BF education
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Initiation of BF2 Odds Ratio (Fixed, 95% CI)Subtotals only
1.1 Peer counselling versus BF information and advice12398Odds Ratio (Fixed, 95% CI)1.11 [0.86, 1.43]
1.2 BF practical skills versus BF attitude education1614Odds Ratio (Fixed, 95% CI)1.03 [0.99, 1.07]
2 Breastfeeding at three months1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
2.1 Group education versus individual education174Risk Ratio (M-H, Fixed, 95% CI)2.84 [0.61, 13.18]
3 Breastfeeding at six months1 Odds Ratio (M-H, Fixed, 95% CI)Subtotals only
3.1 BF practical skills versus BF attitude education1590Odds Ratio (M-H, Fixed, 95% CI)1.21 [0.87, 1.67]
4 Exclusive breastfeeding at six months1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
4.1 BF practical skills versus BF attitude education1590Risk Ratio (M-H, Fixed, 95% CI)1.03 [0.61, 1.73]
5 Duration of any breastfeeding1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
5.1 BF education discussion versus handouts116Mean Difference (IV, Fixed, 95% CI)6.20 [-10.84, 23.24]
Analysis 2.1.

Comparison 2 One BF education versus another BF education, Outcome 1 Initiation of BF.

Analysis 2.2.

Comparison 2 One BF education versus another BF education, Outcome 2 Breastfeeding at three months.

Analysis 2.3.

Comparison 2 One BF education versus another BF education, Outcome 3 Breastfeeding at six months.

Analysis 2.4.

Comparison 2 One BF education versus another BF education, Outcome 4 Exclusive breastfeeding at six months.

Analysis 2.5.

Comparison 2 One BF education versus another BF education, Outcome 5 Duration of any breastfeeding.

Comparison 3. Multiple BF educational interventions versus a single BF educational interventions
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Initiation rate of breastfeeding1 Risk Ratio (M-H, Random, 95% CI)Subtotals only
1.1 LC + routine BF education versus routine BF education1144Risk Ratio (M-H, Random, 95% CI)1.33 [0.86, 2.07]
2 Breastfeeding at three months1 Odds Ratio (Fixed, 95% CI)Subtotals only
2.1 LC + BF booklet versus BF booklet1698Odds Ratio (Fixed, 95% CI)0.82 [0.59, 1.14]
3 Breastfeeding at six months2 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
3.1 Video + education session versus pamphlets1175Risk Ratio (M-H, Fixed, 95% CI)1.59 [0.86, 2.94]
3.2 Routine BF education + formal BF education versus routine BF education11249Risk Ratio (M-H, Fixed, 95% CI)0.97 [0.79, 1.19]
4 Exclusive breastfeeding at three months1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
4.1 LC + BF booklet versus BF booklet1698Risk Ratio (M-H, Fixed, 95% CI)0.85 [0.68, 1.08]
5 Duration of any breastfeeding1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
5.1 BF education discussion + baby quarantine versus BF handout116Mean Difference (IV, Fixed, 95% CI)14.20 [-2.97, 31.37]
5.2 BF education discussion+ baby quarantine versus BF education discussion118Mean Difference (IV, Fixed, 95% CI)8.0 [-6.84, 22.84]
6 Mastitis1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
6.1 Formal BF education + LC versus routine BF education170Risk Ratio (M-H, Fixed, 95% CI)0.2 [0.01, 4.02]
7 Breastfeeding complication (nipple pain)1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
7.1 Formal BF education + LC versus routine BF education170Mean Difference (IV, Fixed, 95% CI)-19.8 [-23.23, -16.37]
8 Breastfeeding complication (nipple trauma)170Mean Difference (IV, Fixed, 95% CI)38.65 [32.95, 44.35]
8.1 Formal BF education + LC versus routine BF education170Mean Difference (IV, Fixed, 95% CI)38.65 [32.95, 44.35]
Analysis 3.1.

Comparison 3 Multiple BF educational interventions versus a single BF educational interventions, Outcome 1 Initiation rate of breastfeeding.

Analysis 3.2.

Comparison 3 Multiple BF educational interventions versus a single BF educational interventions, Outcome 2 Breastfeeding at three months.

Analysis 3.3.

Comparison 3 Multiple BF educational interventions versus a single BF educational interventions, Outcome 3 Breastfeeding at six months.

Analysis 3.4.

Comparison 3 Multiple BF educational interventions versus a single BF educational interventions, Outcome 4 Exclusive breastfeeding at three months.

Analysis 3.5.

Comparison 3 Multiple BF educational interventions versus a single BF educational interventions, Outcome 5 Duration of any breastfeeding.

Analysis 3.6.

Comparison 3 Multiple BF educational interventions versus a single BF educational interventions, Outcome 6 Mastitis.

Analysis 3.7.

Comparison 3 Multiple BF educational interventions versus a single BF educational interventions, Outcome 7 Breastfeeding complication (nipple pain).

Analysis 3.8.

Comparison 3 Multiple BF educational interventions versus a single BF educational interventions, Outcome 8 Breastfeeding complication (nipple trauma).

Comparison 4. Different combinations of multiple methods of providing education
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Exclusive breastfeeding at three months1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
1.1 BF booklet + video + LC versus BF booklet + video1150Risk Ratio (M-H, Fixed, 95% CI)1.29 [0.80, 2.06]
2 Exclusive breastfeeding at six months1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
2.1 BF booklet + video + LC versus BF booklet + video1169Risk Ratio (M-H, Fixed, 95% CI)2.23 [1.01, 4.92]
Analysis 4.1.

Comparison 4 Different combinations of multiple methods of providing education, Outcome 1 Exclusive breastfeeding at three months.

Analysis 4.2.

Comparison 4 Different combinations of multiple methods of providing education, Outcome 2 Exclusive breastfeeding at six months.

Comparison 5. Multiple interventions versus no formal BF education
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Exclusive breastfeeding at three months1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
1.1 BF booklet + video + LC versus no formal BF education1159Risk Ratio (M-H, Fixed, 95% CI)2.02 [1.16, 3.49]
2 Exclusive breastfeeding at six months1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
2.1 BF booklet + video + LC versus no formal BF education1175Risk Ratio (M-H, Fixed, 95% CI)2.11 [0.99, 4.52]
Analysis 5.1.

Comparison 5 Multiple interventions versus no formal BF education, Outcome 1 Exclusive breastfeeding at three months.

Analysis 5.2.

Comparison 5 Multiple interventions versus no formal BF education, Outcome 2 Exclusive breastfeeding at six months.

Appendices

Appendix 1. Search strategies

Authors wrote and ran these searches.

CENTRAL (The Cochrane Library 2011, Issue 11)

#1 antenatal (MeSH)
#2 prenatal (MeSH)
#3 education*
#4 BF
#5 (breast next feeding)
#6 breastfeeding
#7 lactation*
#8 nursing
#9 (#1 or #2)
#10 (#4 or #5 or #6 or #7 or #8)
#11 (#9 and #3 and #10)

MEDLINE (January 1966 to 30 November 2011) and SCOPUS (January 1985 to 30 November 2011)

#1 antenatal[tiab]

#2 prenatal care[mh]

#3 (#1 or #2)

#4 breastfeeding

#5 breast feeding

#6 lactation

#7 nursing

#8(#4 or #5 or #6 or #7)

#9 randomised controlled trial[pt]

#10 controlled clinical trial[pt]

#11 randomised[tiab]

#12 placebo[tiab]

#13 groups[tiab]

#14 cluster[tiab]

#15(#9 or #10 or #11 or #12 or #13 or #14)

#16 education

#17 (#3 and #8 and #15 and #16)

What's new

Last assessed as up-to-date: 29 May 2012.

DateEventDescription
2 June 2012New search has been performedSearch updated in November 2011. Two new studies included (Kronborg 2011; Olenick 2010) and three excluded (Kupratakul 2010; Patel 2011; Wockel 2009).
2 June 2012New citation required but conclusions have not changedReview updated.

History

Protocol first published: Issue 2, 2007
Review first published: Issue 11, 2011

DateEventDescription
7 October 2011AmendedSources of support edited.
17 April 2008AmendedConverted to new review format.

Contributions of authors

P Lumbiganon (PL), R Martis (RM) and J Ho (JH) initiated the topic. PL, RM and M Laopaiboon (ML) drafted the protocol. All review authors approved the final version of the protocol. PL, RM, ML, JH, M Festin (MF) M Hakimi (MH) selected studies and extracted data. ML and PL conducted analysis and interpretation. PL and ML drafted the review.

Declarations of interest

None known.

Sources of support

Internal sources

  • Khon Kaen University, Thailand.

  • The University of Adelaide, Australia.

  • University of Philippines, Philippines.

  • Gadjah Mada University, Indonesia.

  • Royal College of Medicine Perak, Malaysia.

  • Penang Medical College, Malaysia.

External sources

  • Thailand Research Fund (Senior Research Scholar), Thailand.

  • Wellcome Trust, UK.

  • National Institute for Health Research, UK.

    NIHR Programme of centrally-managed pregnancy and childbirth systematic reviews of priority to the NHS and users of the NHS: 10/4001/02

  • Cochrane Health Promotion and Public Health (HPPH) Field, Australia.

Differences between protocol and review

We added one more comparison of 'programmes involving multiple methods of providing education versus no formal education' to our subgroup analysis. We searched SCOPUS instead of EMBASE because our university subscribed to SCOPUS but not EMBASE.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Duffy 1997a

MethodsRandomised controlled trial. Using a sealed envelope containing group allocation in blocks of 12, with 6 in the control and 6 in the experimental group. Random assignment was carried out by the lactation consultant giving the educational session.                                             
Participants

Number of women randomised: 75

Inclusion criteria
Attended antenatal classes in the study hospital, and intended to BF.
Verbal and written explanation was given.
Explained the completely voluntary and confidential nature of the study.

Exclusion criteria

Delivered less than 37 weeks.
With medical complications.

Interventions

Experimental group (n = 37)

An additional 1-hour teaching session for nulliparas more than 36 weeks' pregnant. The teaching intervention was through a lactation consultant, not involved in the data collection. The content of the teaching session was correct positioning and attachment of the baby on the breast for feeding.

Control  group (n = 38)

Standard educational program of the study hospital.

Outcomes

Outcome measures (dichotomous)

Primary

  • Incidence of BF at 6 weeks postpartum.

Secondary

  • Mastitis.

Outcome measures (continuous)  

Primary

  • LATCH score.

Secondary

  • Nipple pain (VAS).

  • Nipple trauma (NTI score).

NotesLoss of participants to follow-up: < 10%.
Blinding: outcome assessors.
This study was conducted in Western Australia.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot described.
Allocation concealment (selection bias)Unclear riskSealed envelope (not described whether it was opaque or not).
Blinding (performance bias and detection bias)
All outcomes
Low riskOnly outcome assessors.
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo details available.
Selective reporting (reporting bias)Unclear riskNo information.
Other biasUnclear riskNo other obvious biases.

Finch 2002

MethodsRandomised controlled trial.
Participants

Number of women randomised: 60

Inclusion criteria                                           

English speaking pregnant, HIV negative women.                                                              

Exclusion criteria

Not specified.

Interventions

Experimental group (n = 30)

BF education by trained LC, incentive, instruction and discussion with handout.

Control group (n = 30)

Prenatal educational regarding benefit and barriers to BF.

Outcomes
  • Duration of BF.

  • Feeding intentions.

NotesThis study was conducted in New York, USA.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNo information available.
Allocation concealment (selection bias)Unclear riskNo information available.
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNo information available.
Incomplete outcome data (attrition bias)
All outcomes
High riskLoss to follow-up in intervention group 36.7% (11/30), in control group 3.3% (1/30).
Selective reporting (reporting bias)Unclear riskNo information available.
Other biasLow riskNo other obvious biases.

Forster 2004

Methods

Randomised controlled trial.

Random allocation to a control group or 1 or 2 intervention groups, randomised by an external computerised system accessed by telephone by a research midwife.

Participants

Number of women randomised: 984

Inclusion criteria
Women booked as public patients. Women who were primiparas. Women pregnant between 16 and 24 weeks. Women able to read and write in English.        

Exclusion criteria
Women with physical problems that prevented BF. Women who chose private obstetric care. Women choosing to give birth at birth centre.

Interventions

Experimental group:

Group 1: 1.5-hour session on practical BF using teaching aids. Latch-on technique demonstrated with dolls and knitted breasts, also BF complications and management. Plus access standard care available

Group 2: 2 1-hour sessions that focused on changing attitudes to BF. Women were encouraged to bring their partners or a significant other. Session one included information about BF advantages, views and attitudes of participants, their friends and families and society. For session 2, participants were encouraged to interview their own mother or her partner’s mother about attitudes of BF, which then was reflected and discussed in this session. Access standard care available.

Control  group:

Able to access standard care, which included formal BF education sessions etc.

Outcomes

Duration of any BF at 2-4 days, excluded babies yet not feeding.

Duration of  exclusive BF at 2-4 days, excluded babies yet not feeding.

Number of mothers any BF at 6 months.

Number of mothers exclusive BF at 6 months.

Notes

Loss of participants to follow-up and reasons: < 10%.

Blinding: unclear.

Intention-to-treat analysis: used.

Each intervention group was compared only with the group of women allocated to standard care; they were not compared with each other.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"A computerized system of biased urn randomization was accessed by
telephone by the research midwife to ascertain women’s group allocation."
Allocation concealment (selection bias)Low risk"A computerized system of biased urn randomization was accessed by telephone by the research midwife to ascertain women’s group allocation."
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described.
Incomplete outcome data (attrition bias)
All outcomes
Low riskThe follow-up rate in practical skill, attitudes, standard care were 91%, 90% and 91%, respectively.
Selective reporting (reporting bias)Unclear riskNo information available.
Other biasUnclear riskNo other obvious biases.

Kaplowitz 1983

MethodsRandomised controlled trial.
Participants44 consecutive women from 2 upstate New York Women, Infants and Children (WIC) programmes, at least 18 years old, in fourth to sixth month of pregnancy, primigravida or women who had bottle-fed previous children or who previously had an unsuccessful BF experience were randomly assigned to experimental (21 women) or control (23 women) groups.
Interventions

Intervention group (21 women)

5 pamphlets providing information on the benefits of BF, basic physiology of lactation, proper nursing technique were mailed to the women's homes 1 at a time over 5 consecutive weeks.

Control group (23 women)

Did not receive pamphlets.

Outcomes
  • Women's knowledge about nursing after the intervention.

  • Attitude toward BF before and after the intervention.

These outcomes were not relevant to the review objective.

NotesThis study was conducted in New York.
No information about BF practice available.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot described.
Allocation concealment (selection bias)Unclear riskNot described.
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described.
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot described.
Selective reporting (reporting bias)Unclear riskNo information available.
Other biasUnclear riskInadequate information.

Kistin 1990

Methods

Randomised controlled trial.

Women in Monday clinic were randomised with a random number table into 2 intervention groups.

Friday clinic became control group (not randomised, therefore data can not be used, both intervention groups data can be compared, as they were randomised).

Participants

Number of women randomised: 74

Inclusion criteria                                  

Women 24 weeks' gestation or less.
Black women born in the USA.

Exclusion criteria

None mentioned.

Interventions

Describe: 2 types of prenatal education. Individual BF and antenatal BF class.

Experimental groups

Intervention group 1 (38 women): antenatal group BF class, 50-80 minutes, at least 1 session discussing myths, problems and benefits of BF.

Intervention group 2 (36 women): individual pre-counselling with a nurse practitioner or paediatrician, 1-to-1 15-30 minutes between 30-40 weeks' gestation, similar topics discussed in IG1.

Control  group

Normal antenatal care. No additional information but not randomised, therefore data excluded, and not included in our analysis.

Outcomes
  • Duration of any BF 2 weeks.

  • Duration of any BF 6 weeks.

  • Any BF at 3 months.

NotesLoss of participants to follow-up: 18.2%.
Blinding: participants; no, counsellors; not feasible, outcome assessors; not clear.
Intention-to-treat analysis: not clear.
This study was conducted in Chicago, USA.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskTable of random numbers was used.
Allocation concealment (selection bias)Unclear riskNot described.
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described.
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot enough information.
Selective reporting (reporting bias)Unclear riskInformation not available.
Other biasLow riskNo other obvious biases.

Kluka 2004

MethodsRandomised controlled trial.
Participants

Number of women randomised: 209

Inclusion criteria                                  

Primiparous women who were planning to BF their infants.

Exclusion criteria

None mentioned.

Interventions

Describe:

Experimental group: 111 women

Usual care plus a self-assessment pre-workshop guide and an interactive, educational, antenatal workshop.

Control  group: 98 women

Usual care.

Outcomes
  • BF at 3 and 6 months.

NotesThis study was conducted in Canada.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot described.
Allocation concealment (selection bias)Low riskOpaque sealed envelopes.
Blinding (performance bias and detection bias)
All outcomes
Low riskOutcome assessors.
Incomplete outcome data (attrition bias)
All outcomes
Low riskComparable loss to follow-up (< 20% at 6 months in both arms).
Selective reporting (reporting bias)Unclear riskNo information available.
Other biasLow riskNo other obvious biases.

Kools 2005

Methods

Cluster randomisation of 10 home healthcare centres. Coin flip determined which centres would receive intervention.

Clusters had comparable overall pre-randomisation rates and sizes.

Participants

Number of women randomised: 781

Inclusion criteria                                                             

Women considering BF.
All pregnant women using the identified 3 home healthcare organisations and from their 10 centres.
Women pregnant in their 7th month of pregnancy.

Exclusion criteria

Women with babies weighing < 2000 g.

Interventions

Experimental group

408 women received standard care and BF booklet, which was used and referred to by caregiver at each consultation (which included practical instructions on BF, discussion around how to cope with BF, motivational discussion to initiate and maintain BF and additional information if asked for). Opportunity to access 24-hour free lactation consultant.

Control  group

373 received standard antenatal care and BF booklet and phone number for BF questions or BF problems.

Outcomes
  • Number of mothers any BF at birth.

  • Number of mothers BF exclusively at birth.

  • Number of mothers any BF at 3 months.

  • Number of mothers exclusive BF at 3 months.

NotesLoss of participants to follow-up: < 10%.
Blinding: participants; no, others unclear.
Intention-to-treat analysis: used.
This study was conducted in Maastricht, Netherlands.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskCoin flip.
Allocation concealment (selection bias)Unclear riskCoin flip was used.
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described.
Incomplete outcome data (attrition bias)
All outcomes
Low riskMinimal loss to follow-up in experimental group and no loss to follow-up in control group.
Selective reporting (reporting bias)Unclear riskNo information available.
Other biasUnclear riskNo other obvious biases.

Kronborg 2011

MethodsRandomised controlled trial
Participants

Number of women randomised: 1193

Inclusion criteria  

1193 nulliparous women were recruited before week 21+6 days of gestation, 603 were randomised to the intervention group, and 590 to the reference group. The inclusion criteria were nullipara registered at the Aarhus Midwifery Clinic, older than 18 years of age at enrolment,with a singleton pregnancy, and the ability to speak and understand Danish.

Interventions

Experimental group

Structured antenatal training programme for 9 hours attended in mid-pregnancy.

Control group

Usual practice (no antenatal training).

Outcomes
  • Initiation of BF.

  • BF at 6 weeks and 1 year.

NotesThis study was conducted in Denmark.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskComputer generated.
Allocation concealment (selection bias)Unclear riskNot described.
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described.
Incomplete outcome data (attrition bias)
All outcomes
Low risk16 out of 603 and 15 out of 590 women in the intervention and reference groups were lost to follow-up respectively.
Selective reporting (reporting bias)Unclear riskInformation not available.
Other biasUnclear riskBaseline characteristics were quite comparable between intervention and reference groups. No other obvious biases.

Lavender 2005

Methods

Cluster-randomised controlled study.

Unit of randomisation:  8 electoral wards in 1 county, pairs were matched by according to Jarman Underprivileged area score (UPA).

Within pair randomised = 4 clusters each.

Opaque sealed envelopes.                             

Participants

Number of women randomised: 1312

Inclusion criteria                                                         
Women registered with a practice site/GP in one of the 8 wards.
Women who expressed a desire to BF.
Women with no detected fetal abnormality at 20 week ultrasound.

Exclusion criteria

Women with detected fetal abnormality.
Women who gave birth before 36 weeks' gestation.
Women who lived in potentially unsafe homes.
Women who planned to bottle feed.
Women who had previously BF for at least 6 weeks.

Interventions

Describe: 1 antenatal BF education session with the woman’s attending community midwife. Midwives were trained for this intervention. 

Experimental group (n = 633)

Normal antenatal care plus during third trimester attendance of a single antenatal BF education session. Each session involved up to 8 women and was facilitated by a qualified infant feeding co-ordinator.

Control  group (n = 679)

Received standard antenatal care that included BF advice from attending clinic midwives.

Outcomes
  • Number of mothers any BF at hospital discharge.

  • Number of mothers any BF at 2 weeks.

  • Number of mothers any BF at 4 weeks.

  • Number of mothers any BFat 6 weeks.

  • Number of mothers any BF at 4 months.

  • Number of mothers exclusive BF at 4 months.

  • Number of mothers any BF at 6 months.

  • Number of mothers any BF at 12 months.

NotesLoss of participants to follow-up: < 10%.
Blinding: participants: not feasible, counsellors: no, outcome assessors: yes.
Intention-to-treat analysis: used.
This study was conducted in Northwest UK.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot described.
Allocation concealment (selection bias)Low riskOpaque sealed envelopes were used.
Blinding (performance bias and detection bias)
All outcomes
Low riskOutcome assessors were blinded.
Incomplete outcome data (attrition bias)
All outcomes
Low riskLoss to follow-up < 10% in both arms.
Selective reporting (reporting bias)Unclear riskNo information available.
Other biasUnclear riskNo other obvious biases.

MacArthur 2009

MethodsCluster-randomised controlled trial.
Participants

66 antenatal clinics with 2511 pregnant women

33 clinics including 1140 women were randomised to receive the peer support worker service.

33 clinics including 1371 women were randomised to receive standard care.

Interventions

Intervention group (1140 women)

An antenatal peer support worker service planning a minimum of 2 contacts with women to provide advice, information, and support from approximately 24 weeks’ gestation within the antenatal clinic or at home. The trained peer support workers were of similar ethnic and socio-demographic backgrounds to their clinic population.

Control group (1371 women)

Women in the control clusters received standard antenatal care, which included usual information and advice from midwives on BF without input from community peer support workers.

OutcomesInitiation of BF obtained from computerised maternity records of the hospitals where women from the primary care trust delivered.
NotesThis study was conducted in Birmingham, UK.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskComputer generated.
Allocation concealment (selection bias)Unclear riskNot described.
Blinding (performance bias and detection bias)
All outcomes
Low riskData on outcome were supplied to the research team in an anonymous format.
Incomplete outcome data (attrition bias)
All outcomes
Low risk113 out of 2511 women (4.5%) who participated in the trial were not available for primary outcome assessment.
Selective reporting (reporting bias)Unclear riskNo information available.
Other biasLow riskNo other obvious biases.

Mattar 2007

MethodsRandomised controlled trial. A computer-generated list was used to randomise the women into the 3 groups. Each woman was allocated to the intervention group next on the list after written informed consent had been obtained.               
Participants

Number of women randomised: 401

Inclusion criteria

Singleton pregnancy, gestation of at least 36 weeks at recruitment, no uterine scar, and the absence of any obstetric complication that would contraindicate vaginal delivery, with informed consent.

Exclusion criteria

Not described. 

Interventions

Describe Intervention: multiple versus single.

Experimental group

Group A: received an information booklet describing the techniques and benefits of BF, which was written and published by the hospital’s BF support group. It contained practical advice on feeding techniques, expressing breast milk, and management of common BF problems. Patients also watched a 16-minute educational video entitled “14 Steps to Better BF” (InJoy Videos, Boulder, CO), in which the benefits of BF were introduced, correct positioning, latch-on, and breast care were demonstrated, and common concerns (such as nipple pain) discussed. In addition, each woman had one 15-minute session with a lactation counsellor who examined the woman’s nipples to assess adequacy for BF and answered questions on BF.

Group B received: the same booklet and watched the same video but did not have an individual session with the lactation counsellor.

Control  group

Received the BF booklet, did not watch the video, and did not have counselling.

Outcomes
  • Number of mothers BF at 3 months.

  • Number of mothers BF at 6 months.

NotesLoss of participants to follow-up: 10%.
Blinding: only outcome assessor.
Intention-to-treat analysis addressed: yes.
This study was conducted in Singapore.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskComputer-generated list.
Allocation concealment (selection bias)Low riskEach woman was allocated to the intervention group next on the list after written informed consent had been obtained.
Blinding (performance bias and detection bias)
All outcomes
Low riskOutcome assessors were blinded.
Incomplete outcome data (attrition bias)
All outcomes
Low riskLoss to follow-up 10%.
Selective reporting (reporting bias)Unclear riskInformation not available.
Other biasLow riskNo other obvious biases.

Noel-Weiss 2006

MethodsRandomised controlled trial.
Participants

Number of women randomised: 101

inclusion criteria

Nulliparous women expecting a single child, an uncomplicated birth, and planning to BF. The women had to read and write in English and have a telephone to complete the postpartum questionnaires. To remain in the study, a mother and her infant had to be discharged at the same time and be able to BF without restriction.

Exclusion criteria

Not described.

Interventions

Describe: workshop.

Experimental group (n = 47)

Standard care plus a 2.5-hour prenatal BF workshop designed using Bandura's theory of self-efficacy and adult learning principles. The intervention involved the use of lifelike dolls, videos, and discussion in a comfortable atmosphere.

Control  group (n = 45)

Standard care.

Outcomes
  • Maternal BF self-efficacy.

  • BF duration measured at 4 weeks and 8 weeks postpartum.

NotesThis study was conducted in Ontario, Canada.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskInformation not available.
Allocation concealment (selection bias)Low riskUsed sealed, sequentially numbered, opaque envelope containing a slip of paper stating either Control or Workshop.
Blinding (performance bias and detection bias)
All outcomes
Low riskOnly outcome evaluators.
Incomplete outcome data (attrition bias)
All outcomes
Low riskAnalysed the data with both the intention-to-treat assumption and using the actual workshop attendance. 101 randomised and 92 were available for analysis.
Selective reporting (reporting bias)Unclear riskProtocol not available.
Other biasLow riskNo other obvious biases.

Olenick 2010

MethodsRandomised controlled trial.
Participants

Number of women randomised: 182

Inclusion criteria

Pregnant women enrolled for prenatal care at 24 weeks (or beyond) who consented to participate.

Exclusion criteria

Age <18 years, stated intention to bottle-feed with formula, non-English speaking, those for whom BF is medically contraindicated, those whose newborns would be anticipated to be incapable of BF, no access to telephone for follow-up and those who are not planning to keep or raise their baby.

Interventions

Experimental group

2-hour BF self-efficacy theory based class (86 women).

Control group

No class (96 women).

Outcomes
  • BF duration.

  • BF exclusivity and confidence through 12 weeks.

NotesThis trial was conducted in Texas, USA.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot described.
Allocation concealment (selection bias)Unclear riskNot described.
Blinding (performance bias and detection bias)
All outcomes
High riskQuote "A research assistant was used for all postpartum data collection by phone. Although she did have access to the information regarding the subjects’ group assignment, she did not refer to this information when doing the phone interviews, in effect blinding her to their status. In this way, there was greater objectivity both by the interviewer and the interviewee".
Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote "The overall dropout rate was 7.7%".
Selective reporting (reporting bias)Unclear riskNo information available.
Other biasLow riskNo obvious baseline differences and other biases.

Rossiter 1994

MethodsRandomised controlled trial, did not describe how randomisation was done.
Participants

Number of women randomised: convenience sample of 194 pregnant women.

Inclusion criteria

  1. Ethnic Vietnamese or other women who were born and reared in Vietnam.

  2. Vietnamese speaking.

  3. At least 12 weeks pregnant.

  4. Gave consent to participate.

Exclusion criteria

Unforeseen circumstances (miscarriage, stillbirth, change of address).

Interventions

Describe intervention: culture and language specific educational programme.

Experimental group

A 25-minute videotape programme followed by a series of 3 x 2 hours of small-group discussion sessions conducted in Vietnamese.

Control  group

BF and childbirth pamphlets.

Outcomes
  • Number of mothers BFat birth.

  • Number of mothers BF at 4 weeks.

  • Number of mothers BF at 6 months.

Notes

Loss of participants to follow-up: < 10%.

Blinding:
Participant: not feasible.                        
Clinician: unclear.                                   
Outcome assessor: unclear.

Intention-to-treat analysis: unclear.

This study was conducted in Sydney, Australia.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot described.
Allocation concealment (selection bias)Unclear riskNot described.
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described.
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskLoss to follow-up < 10% in both arms.
Selective reporting (reporting bias)Unclear riskInformation not available.
Other biasLow riskNo other obvious biases.

Ryser 2004

MethodsRandomised controlled trial.
Participants

Total number of women randomised: 54

Pregnant women, at least 18 years old, English speaking, able to read and write, received prenatal care and could attend 4 visits before delivery, low income, having access to telephone, undecided about BF method during initial contact with researchers.

Interventions

Intervention group (26 women)

Educational program (Best Start) included:

  1. counselling session.

  2. viewing video.

  3. written materials addressing common BF barriers perceived by low-income women.

Control group (28 women)

No exposure to the program.

Outcomes
  • Attitude toward BF.

  • Social and professional support.

  • BF sense of control.

  • Intention to BF.

  • BF at 7 days delivery.

NotesThis study was conducted in Houston, Texas, USA.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot described.
Allocation concealment (selection bias)Unclear riskWomen selected a sealed envelope. No information about envelopes.
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described.
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo loss to follow-up.
Selective reporting (reporting bias)Unclear riskNo protocol was available.
Other biasLow riskNo other obvious biases.

Schlickau 2005a

MethodsRandomised controlled trial. Method of randomisation was not described.
Participants

Number of women randomised: 30

Inclusion criteria

Low-risk primigravida, Hispanic, in their third trimester, received care at Sedgwick, not planning to work outside the home for 6 months.                                                                                                      

Exclusion criteria

Not described.

Interventions

Describe intervention: prenatal BF education.

Experimental group

Level 1: the researcher approached the expectant mother. All participants confirmed that they planned to BF. Contents included benefits of BF. Charts and pictures were used to present supply-and-demand concept and prenatal breast preparation. Early and consistent BF practices were emphasised. A doll was used as a model for instruction about holding and positioning the baby and BF discreetly.

Level 2: completed first level. Participants were introduced the concept of “baby quarantine” ( nothing enters the baby’s mouth except the mother’s breast for at least 40 days after birth. The benefits of avoiding bottles, pacifier and supplementation to promote establishment of milk for successful BF were reinforced. BF commitment was encouraged through the use of checklist.  

Control group

Standard of care offered advice to BF and handouts were distributed during the initial prenatal visit.

Outcomes
  • Number of mothers BF at 45 days.

  • Duration of any BF.

Notes

Loss of participants to follow-up: 17%.

Blinding:
Participant: not feasible.                                                  
Clinician: unclear.                                                     
Outcome assessor: unclear.                                   

Intention-to-treat analysis: unclear. 

This study was conducted in Kansas, USA.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot described.
Allocation concealment (selection bias)Unclear riskNot described.
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described.
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskLoss of participants to follow-up: 17%.
Selective reporting (reporting bias)Unclear riskNo information available.
Other biasUnclear riskNot enough information.

Schlickau 2005b

MethodsRandomised controlled trial.
Participants

Number of women randomised: 86

Inclusion criteria

Primigravida, immigrant Hispanic women aged 15-45 , 32-36 weeks' gestation, stable family situation, had a work situation compatible with BF for 6 weeks, had normal nipple assessment.

Exclusion criteria

Homeless, not in a temporary agencies or shelter, high-risk pregnancies, serious illness of the newborn or mother that precluded BF, stillbirth, unforeseen family situation.

Interventions

Describe intervention: prenatal BF education.

Experimental group (44)

BF education workshop.

Control group (42)

No formal BF education.

Outcomes
  • Initiation of BF.

  • Duration of any BF.

NotesThis study was conducted in Kansas, USA.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot described.
Allocation concealment (selection bias)Low riskManila packet sealed envelopes.
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described.
Incomplete outcome data (attrition bias)
All outcomes
Low riskLoss to follow-up in intervention group (9.1%, 2/44), in control group (9.5 %, 4/42).
Selective reporting (reporting bias)Unclear riskProtocol not available.
Other biasLow riskNo other obvious biases.

Serwint 1996

MethodsRandomised controlled trial. Random number table was used. Method of randomisation was not described.
Participants

Number of women randomised: 156

Nulliparous women, 18 years or older, with a fetus of gestational age of 28 weeks or less, who had not yet selected a paediatrician or wanted their infants to receive paediatric care at the hospital-based paediatric clinic.

InterventionsLC plus routine BF education (81 women) versus routine BF education (75 women).
Outcomes
  • Number of mothers who initiated BF at birth.

  • Number of mothers BF at 30 days.

  • Number of mothers BF at  60 days.

NotesThis study was conducted in Baltimore, USA.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskRandom number table was used.
Allocation concealment (selection bias)Unclear riskNot described.
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described.
Incomplete outcome data (attrition bias)
All outcomes
Low riskLoss to follow-up 7.7%.
Selective reporting (reporting bias)Unclear riskNo information available.
Other biasLow riskNo other obvious biases.

Wolfberg 2004

  1. a

    BF: breastfeeding
    LC: lactation consultation
    NTI: nipple trauma index
    VAS: visual analogue scale

MethodsRandomised controlled trial. Method of randomisation was not described.
Participants

Number randomised: not clear (59 couples completed study)

567 expectant mothers were approached during 1st and 2nd trimester, refused to participate 24%; lost during prenatal period 36%; lack of involvement with father 8%; fathers refusal to participate 11%; fathers’ failure after enrolling 9%, completed the study with 59 couples.

Inclusion criteria

Women who sought prenatal care in the resident and faculty practices at Johns Hopkins Hospital.

Exclusion criteria

Not described.

Interventions

Describe intervention: classroom discussion on infant care and BF for expectant fathers.

Experimental group (27 fathers)

Groups of 4-12 expectant fathers attending the classroom with open discussion about BF and support each other to be advocates for BF among fathers in the groups, facilitated by a man who was himself a father. 2- hour classes used a variety of teaching media were held approximately every 2 weeks.

Control group (32 fathers)

The class covered topics related to infant care and safety only using the same facilitator, and methods of interactive and informal education as of those the intervention group. These subjects did not receive the intervention class that contained the BF content.

Outcomes
  • Number of mothers for initiated BF.

  • Number of mothers BF at  4 weeks.

  • Number of mothers BF at  6 weeks.

  • Number of mothers BF at  8 weeks.

Notes

Loss of participants to follow-up: 36%.

Blinding:
Participant: not feasible.                                                     
Clinician: unclear.                                                                    
Outcome assessor: unclear.                                

Intention-to-treat analysis: not used.

This study was conducted in Baltimore, USA.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot described.
Allocation concealment (selection bias)Unclear riskNot described.
Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described.
Incomplete outcome data (attrition bias)
All outcomes
High riskLoss to follow-up 36%.
Selective reporting (reporting bias)Unclear riskNo information available.
Other biasLow riskNo other obvious biases.

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
  1. a

    BF: breastfeeding
    RCT: randomised controlled trial

Aidam 2005Not only antenatal BF education. 9 home visits were provided in the 6-month postpartum period.
Anderson 2005Not only antenatal BF education. Peer counsellors also gave postpartum visits.
Barlow 2006Not only antenatal BF education. Home visits extended to 6 months postpartum.
Bonuck 2005Not only antenatal BF education. Lactation consultants also made postpartum hospital or home visits.
Brent 1995Not only antenatal BF education. Lactation consultants provided support in the postpartum period and until infants up to 1 year of age.
Caulfield 1998Not only antenatal BF education. Peer counsellors followed up women in the postpartum period as long as they continued to breast feed.
Chapman 2004Not only antenatal BF education. Peer counselling extended to postpartum period.
Ekstrom 2006Not only antenatal BF education. Support was also provided at 3-day, 3-month and 9-month postpartum.
Eneroth 2007Not RCT, objective not relevant.
Gijsbers 2006Not only antenatal BF education; a home visit was also provided postnatally.
Graffy 2004Not only antenatal BF education. Lactation counsellors provided postnatal support by telephone or home visits.
Grossman 1988Not RCT (Letter to editor commenting on non-RCT papers).
Hall 2007Not RCT.
Isselmann 2006Intervention was not antepartum BF education.
Jenner 1988Not RCT.
Johnston 2001Not RCT.
Kafatos 1991Not only antenatal BF education. Home visits continued after delivery until the infant was 12 months.
Kupratakul 2010Not only antenatal BF education. Document on breastfeeding was provided, that affects breastfeeding behaviour of postpartum mothers.
Loh 1997Not RCT.
Mattar 2003Not RCT (Letter to editor with comments on non-RCT papers).
Memmott 2006Not RCT.
Moore 2007Not RCT, did not evaluate antenatal BF education.
Morrow 1999Not only prenatal BF education intervention. Peer counsellors also visited mothers at 1st, 2nd, 4th and 8th week postpartum.
Muirhead 2006Not only prenatal BF education intervention. Peer supporters provided support up to 16 week postpartum.
Patel 2011Not only prenatal BF education intervention. Counseling during the antenatal period, at delivery and during the immunisation visits.
Petrova 2009Not only prenatal BF education intervention. Lactation consultant also provided support postnatally.
Rea 1999Participants were not pregnant women.
Redman 1995Not only antenatal BF educational intervention. Lactation counsellors also visited women after delivery.
Reeve 2004Not RCT.
Reifsnider 1997Not RCT (systematic assignment).
Ross 1983Not RCT.
Sandy 2009Not only antenatal BF education. Following the birth of a prenatally enrolled target child, the Family Support Workers (FSW) typically made a visit to the newborn’s mother in the hospital. During this visit, the FSW assisted program group mothers with any problems initiating breastfeeding. After hospital discharge, FSWs continued to offer program group mothers information and support in the home on a weekly basis.
Sciacca 1995Not only antenatal BF education. BF incentives were given pre- and post-natally.
Su 2007Not only antenatal BF education. Lactation support was also provided in the postpartum period.
Taddei 2000Participants were not pregnant women. They were health professionals.
Walkup 2009Not only antenatal BF education. Paraprofessional delivered home visit education during the postpartum period.
Waller 1946Not RCT.
Wambach 2009Not only antenatal BF education. Lactation consultant and peer counselling extended through 4 weeks postpartum.
Westdahl 2008Intervention was not antenatal BF education.
Westphal 1995Participants were not pregnant women.
Wiles 1984Not RCT.
Wockel 2009Participants were not pregnant women.

Ancillary