Interventions in Primary Care to Promote Breastfeeding: A Systematic Review

Chung M, Ip S, Yu W, Raman G, Trikalinos T, DeVine D, Lau J. Interventions in Primary Care to Promote Breastfeeding: A Systematic Review. Prepared for the Agency for Healthcare Research and Quality by the Tufts-New England Medical Center Evidence-based Practice Center, under Contract No. 290-02-0022. AHRQ Publication No. 08-05125-EF-1. Rockville, Maryland: Agency for Healthcare Research and Quality, October 2008.

Context
Breastfeeding decreases the risks of many diseases in mothers and infants. About 70 percent of US children have ever been breastfed. Thus, it is important to examine interventions that could promote and support breastfeeding in an effort to increase the breastfeeding rates and impact the public health.

Objective
To systematically review evidence for the effectiveness of primary care initiated interventions to promote and support breastfeeding.

Data Sources
We searched MEDLINE, the Cochrane Controlled Trials Registry, CINAHL, and Cochrane Database of Systematic Reviews for articles from September, 2001 to January, 2007 using the MeSH terms and keywords, such as “breastfeeding”, “breast milk feeding”, “breast milk”, “human milk”, “nursing”, “lactation”, “counseling”, and “health education”. For additional studies, we also examined the bibliographies in existing systematic reviews.

Study Selection
We identified 21 RCTs, two clustered RCTs, two quasi-RCTs, four controlled, non-randomized studies, two before-and-after experimental studies (Baby Friendly Hospital Initiative (BFHI) only), four prospective observational studies with concurrent or historical (BFHI only) control, and one Cochrane systematic review. Seventeen studies were of good or fair internal validity according to US Preventive Services Task Force (USPSTF) criteria.

Data Extraction
Data elements were abstracted on to standardized forms and included information about the setting, study design, population characteristics, types of interventions, comparators, methods of analyses, loss to followup, breastfeeding outcomes in regards to initiation, duration, and exclusivity, and maternal or infant health outcomes. In addition to assessing the internal validity of the studies, we also assessed the applicability of the studies to the US primary care population.

Data Synthesis
Comparing breastfeeding interventions to the control (usual care): prenatal breastfeeding intervention increased the rate of any short-term breastfeeding (pooled RR: 1.39; 95%CI 1.16–1.67); combination of pre- and postnatal breastfeeding interventions increased both the rate of intermediate and long-term any breastfeeding (pooled RR: 1.15; 95%CI 1.00–1.32, 1.38; 95%CI 1.33–1.43, respectively); postnatal breastfeeding interventions increased the rate of exclusive short-term breastfeeding (pooled RR: 1.21; 95%CI 1.08–1.36); structured breastfeeding education with or without other components increased the rate of any breastfeeding initiation (pooled RR: 1.15; 95%CI 1.02–1.30); individual level professional support with or without other components significantly increased the rate of any intermediate breastfeeding (pooled RR: 1.12; 95%CI 1.02–1.30); lay support with or without other components increased the rate of any short- and long-term breastfeeding (pooled RR: 1.26; 95%CI 1.07–1.48, 1.38; 95%CI 1.00–1.92, respectively) and the rate of short-term exclusive breastfeeding duration (pooled RR: 1.66; 95%CI 1.05–2.56); and BFHI increased the exclusive breastfeeding rates at 3 (43.3% vs. 6.4% (P <0.001) and 6 (7.9% vs. 0.6% (P=0.01)) months. The BFHI study from Belarus found that infants in the intervention group had a significant reduction in the risk of one or more gastrointestinal infections (9.1% vs. 13.2%; adjusted OR 0.60; 95%CI 0.40–0.91) and atopic dermatitis (3.3% vs. 6.3%; adjusted OR 0.54; 95%CI 0.31–0.95), compared to the control group. We did not identify any study that was designed to detect harms from interventions to promote and support breastfeeding.

Conclusions
The Baby Friendly Hospital Initiative is effective in promoting certain health outcomes in infants from Belarus. Whether those findings are applicable to United States primary care is unclear. Indirect evidence suggests that interventions with a component of lay support (e.g., peer support or peer counseling) are more effective than interventions with structured education or professional support in increasing both short- and long-term breastfeeding rate, compared to usual care. Prenatal combined with postnatal interventions are more effective than usual care in prolonging the duration of breastfeeding.

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