4Conclusion and Discussion

Publication Details

Key Question 1

The PROBIT trial in Belarus provided good evidence that a system wide intervention to promote breastfeeding could affect certain health outcomes in infants (lower risk of gastrointestinal infections and atopic dermatitis). The study also found that infants in the intervention group (modeled Baby-Friendly Initiative) were more likely to be exclusively breastfed at 3 and 6 months, compared to the control. Whether the findings in Belarus are applicable to the United States are unclear, because the social milieu in Belarus is much more conducive (3-years obligatory maternity leave, no day care, expensive formula) to prolonged breastfeeding.

The two fair quality studies conducted in the United States focused on families from low income stratum, an important target of the interventions to promote breastfeeding because families from this stratum had lower breastfeeding rates compared with families from higher income stratum. 3 These studies focused on postnatal home support by trained peer counselors or lactation consultants. One study reported an increased exclusive breastfeeding rate at 3 months and a lower risk of diarrheal diseases in the intervention arm compared to control. The other study conducted in Bronx did not detect a significant difference in the exclusive breastfeeding rate at 3 months and also did not detect a difference in certain infant health outcomes between the intervention and control groups. One may surmise from the above studies that exclusive breastfeeding rate is an important determinant of certain health outcomes in infants. Studies that reported an increase in exclusive breastfeeding rate also reported a reduced risk of gastrointestinal infections or atopic dermatitis.

Whether possible differences in definitions of exclusive breastfeeding, health outcomes, and unknown factors that could interact with the intervention may also explain some of the different findings are unclear. Findings from one study stressed the need to further examine the role of postnatal home support for breastfeeding from trained professionals or peer counselors in affecting maternal mental health outcomes.

Key Question 2

Studies comparing the effects of primary care initiated breastfeeding interventions to usual care on the rate of any or exclusive breastfeeding initiation, short-, intermediate, and long-breastfeeding are heterogeneous in many respects. Comparing the intervention to control, our meta-analyses showed a consistently increased rate of any or exclusive breastfeeding initiation, short-, intermediate, and long-term breastfeeding, although most of these findings were not statistically significant.

In our subgroup analyses, we found that breastfeeding interventions with a component of lay support (e.g., peer support or peer counseling) were more effective in increasing both short- and long-term breastfeeding, than interventions without lay support.

We examined possible sources of heterogeneity by conducting subgroup analyses on exclusivity of breastfeeding (any versus exclusive), quality of study (good or fair versus poor), and timing of intervention (prenatal, postpartum, or combined prenatal and postpartum). Comparing breastfeeding interventions to usual care, the sensitivity analyses showed that:

  • The pooled rate ratios of exclusive short- and intermediate breastfeeding were larger than that of any short-, and intermediate breastfeeding, respectively.
  • The impacts of study quality on the pooled rate ratios of breastfeeding initiation and durations were inconsistent.
  • Timing of interventions had impacts on the pooled rate ratios of any or exclusive breastfeeding initiation and duration. Prenatal breastfeeding intervention significantly increased the rate of any short-term breastfeeding compared to usual care. In addition, combination of pre- and postnatal breastfeeding interventions significantly increased both the rate of any intermediate and long-term breastfeeding. Postnatal breastfeeding interventions significantly increased the rate of exclusive short-term breastfeeding.

Subgroup analyses were performed to examine the effects of different components of breastfeeding interventions on breastfeeding initiation, duration, and exclusivity. The interventions of interest were classified into the following categories: formal/structured breastfeeding education, professional support, lay support, and Baby Friendly Hospital Initiative (BFHI).

Formal/structured breastfeeding education

Compare to usual care, breastfeeding education (with or without other components) significantly increased the rate of any breastfeeding initiation (pooled RR: 1.15; 95%CI 1.02–1.30). There were no significant differences in the rate of exclusive breastfeeding initiation or durations between the breastfeeding education and usual care group.

Professional support

Four of the five trials comparing system level professional support to usual care did not find significant effects on breastfeeding initiation or durations. The fifth trial reported that BFHI significantly increased both short- and long-term exclusive breastfeeding comparing to usual care.

Individual level professional support with or without other components significantly increased the rate of any intermediate breastfeeding compared to usual care (pooled RR: 1.12; 95%CI 1.02–1.30).

Lay support

Lay support with or without other components significantly increased the rate of any short- and long-term breastfeeding compared to usual care (pooled RR: 1.26; 95%CI 1.07–1.48, 1.38; 95%CI 1.00–1.92, respectively). The effects of lay support also increased with breastfeeding durations (P=0.008). For outcomes of exclusive breastfeeding initiation and durations, the result showed that lay support with or without other components significantly increased short-term exclusive breastfeeding duration (pooled RR: 1.66; 95%CI 1.05–2.56), compared to usual care.

Baby Friendly Hospital Initiative

Both the PROBIT trial and the study in Brazil provided good evidence that BFHI is effective in increasing the exclusive breastfeeding rates, at least up to 6 months postpartum. The former study was conducted on a well-educated sample in a country with wide availability of basic health services and uncontaminated water supply, while the latter was conducted on a sample with widespread poverty, female illiteracy rate of around 33 percent, and an infant mortality rate of 76.5 per 1000 live births. Despite these differences, both studies reported increasing breastfeeding rates with BFHI. Furthermore, the study in Brazil illustrates the importance of postnatal home visits to sustain the increased rates. This is especially important in a country where the typical postpartum stay was only 24 to 36 hours for women who had a normal vaginal delivery and 48 hours for those who had a caesarian section. Regardless of the applicability of these findings to a developed country like the United States, it should be noted that the first nine of the ten Baby Friendly steps take place in a hospital setting, but the tenth step concerning breastfeeding support during the post discharge period (i.e., foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic) is essential in ensuring long-term breastfeeding success.

Interventions Involving Family Members

One fair quality study showed the importance of fathers in breastfeeding success. More women whose husbands received breastfeeding education concerning management of breastfeeding difficulties were fully (exclusive and predominant) breastfeeding at 6 months than women whose husbands did not receive the education. The strengths of the study include the fact that all eligible married fathers were enrolled and there was no loss to followup at 12 months. However, the experimental and the control intervention did not take place during the same time periods. Also, the findings are applicable only to married couples as unmarried ones were excluded from the study. Nevertheless, this study points out the importance of involving fathers in ensuring the long-term success of breastfeeding.