Health Technology Assessment 2000; Vol. 4: No. 25
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1 Mother and Infant Research Unit, Faculty of Medicine, Dentistry, Psychology and Health, University of Leeds, UK
2 NHS Centre for Reviews and Dissemination, University of York, UK
* Corresponding author
Human breastmilk provides complete nutrition for infants and helps protect against certain childhood diseases. Despite this, rates of initiation of breastfeeding in the UK remain low relative to other countries. In ‘Our healthier nation’ action report, the government has highlighted the promotion of breastfeeding in order to assist improvements in health and to reduce the health inequalities of mothers and children in the UK.
The primary aim of this systematic review was to evaluate existing evidence to identify which promotion programmes are effective at increasing the number of women who start to breastfeed. In addition, the review aimed to assess the impact of such programmes on the duration and/or exclusivity of breastfeeding and the intermediate and process outcomes. Where the strength and quality of the evidence permitted, the review aimed to identify implications for practice within the UK and priority areas for future research.
A range of electronic databases were searched from inception to November 1998, several relevant journals were hand-searched, and references of retrieved papers were examined. Relevant experts, organisations and lay groups were contacted to help identify further published or unpublished material. Additionally, an expert panel was consulted.
Four types of criteria were used to select eligible studies for this review:
Data were extracted into structured tables. All included studies were checked against a comprehensive methodological checklist. Different checklists were used for RCTs, non-RCTs and beforeafter studies. Data extraction and validity assessment were independently checked by a second reviewer.
The studies were grouped according to intervention type, and were combined using a narrative synthesis. For individual RCTs and non-RCTs reporting initiation of breastfeeding, relative risks with associated 95% confidence intervals were estimated, with calculations performed on an intention-to-treat basis where possible. Pooling of relative risks was considered inappropriate owing to the lack of similarity across the studies.
A total of 59 studies met the selection criteria, comprising 14 RCTs, 16 non-RCTs and 29 beforeafter studies.
Interventions were grouped into the following categories:
In many cases, studies were dissimilar in terms of the type of intervention(s), participants and the definitions of outcomes. Methodological problems of some studies also limited interpretation of findings. Whilst the results from beforeafter studies should be viewed with some caution, inclusion of these studies provided a useful evidence base for evaluation of more complex interventions.
Breastfeeding literature alone, or combined with a more formal, non-interactive method of health education, appears to have limited impact on initiation rates. Small, informal, group health education classes, delivered in the antenatal period, can be an effective intervention to increase initiation rates, and in some cases the duration of breastfeeding, among women from different income or ethnic groups.
HSI: general, and based on the BFHI (two RCTs, three non-RCTs, four beforeafter studies)
Institutional changes in hospital practices to promote breastfeeding, either as part of, or independent to, the BFHI, can be effective at increasing both the initiation and duration of breastfeeding, particularly in developing countries. These may include stand-alone interventions such as rooming-in, or a package of interventions, such as rooming-in, early contact and health education.
In most studies, WIC programs were effective at increasing both the initiation and duration of breastfeeding among women of low-income groups in the USA. Effective WIC interventions included one-to-one health education in the antenatal period, peer counselling in the ante- and postnatal periods, or a combination of one-to-one health education and peer counselling in the ante- and postnatal periods.
The limited evidence available suggests that these programmes may be useful in improving the knowledge of midwives and nurses; however, favourable results were not shown in terms of changes in attitudes of health professionals, or changes in breastfeeding rates.
The social support intervention did not produce significantly increased rates of initiation compared with standard care.
Both studies showed peer support programmes, when delivered as a stand-alone intervention to women in low-income groups, to be an effective intervention at increasing initiation rates (and duration) among women who had expressed a wish to breastfeed.
The limited evidence available suggests that a media campaign as a stand-alone intervention, and particularly television commercials, may improve attitudes towards, and increase initiation rates of, breastfeeding.
Several studies found multifaceted interventions to be effective in increasing initiation rates (and duration and exclusivity of breastfeeding). Most of the multifaceted interventions that were found to be effective comprised a media campaign and/or a peer support programme combined with structural changes to the health sector (HSI) or, in fewer cases, combined with health education activities.
Three types of intervention have been shown to be useful in the promotion of breastfeeding when delivered as a stand-alone intervention in developed countries. Informal, small group health education, delivered during the antenatal period, appears to be effective at increasing initiation rates among women from different income groups and from some minority ethnic groups. There is also some evidence to show that one-to-one health education can be effective at increasing initiation rates among women on low incomes. Peer support programmes, delivered in the ante- and postnatal periods, have also been shown to be effective at increasing both initiation and duration rates of breastfeeding among women on low incomes, and particularly among women who have expressed a wish to breastfeed.
Packages of interventions have also been shown to be effective at increasing the initiation and, in most cases, the duration of breastfeeding in developed countries. Effective packages appear to include a peer support programme and/or a media campaign combined with structural changes to the health sector and/or health education activities.
Structural changes in hospital practices to promote breastfeeding (HSI) have been shown to be effective at increasing both initiation and duration of breastfeeding in developing countries. Rooming-in, as either a stand-alone intervention or as one component of a package of interventions, is a key example of an effective HSI.
The authors’ judgement is that there is sufficient evidence of effectiveness for practitioners and policy-makers to consider the following:
Priorities for further research, not in order of importance, are:
Fairbank L, O’Meara S, Renfrew MJ, Woolridge M, Sowden AJ, Lister-Sharp D. A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding. Health Technol Assess 2000;4(25).
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