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Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries
Comparative Effectiveness Review, No. 210
Investigators: Cynthia Feltner, M.D., M.P.H., Rachel Palmieri Weber, Ph.D., Alison Stuebe, M.D., M.Sc., Catherine A. Grodensky, M.P.H., Colin Orr, M.D., and Meera Viswanathan, Ph.D.
Author Information and AffiliationsStructured Abstract
Objectives:
To summarize the effectiveness of community, workplace, and health care system–based programs and policies aimed at supporting and promoting breastfeeding and determine the association between breastfeeding and maternal health.
Data sources:
We searched PubMed®/MEDLINE®, the Cochrane Library, and CINAHL® from January 1, 1980, to October 12, 2017, for studies relevant to the effectiveness of health care system–based, workplace, and community breastfeeding programs and policies. For evidence on breastfeeding and maternal health, we updated the 2007 Agency for Healthcare Research and Quality report on this topic and searched the same databases from November 1, 2005, to October 12, 2017. For studies of breastfeeding programs and policies, trials, systematic reviews, and observational studies with a control group were eligible; we excluded primary care–based programs delivered as part of routine care. For studies related to breastfeeding and maternal health, we included systematic reviews, case-control studies, and cohort studies.
Review methods:
Pairs of reviewers independently selected, extracted data from, and rated the risk of bias of relevant studies; they graded the strength of evidence (SOE) using established criteria. We synthesized all evidence qualitatively.
Results:
We included 128 studies (137 publications) and 10 systematic reviews. Of these, 40 individual studies were relevant to the effectiveness of breastfeeding programs or policies, and the remainder were relevant to one or more maternal health outcomes. Based on evidence from one large randomized controlled trial (RCT) (Promotion of Breastfeeding Intervention Trial [PROBIT], N=17,046) enrolling mothers who intended to breastfeed and nine cohort studies (1,227,182 women), we graded the SOE for the Baby-Friendly Hospital Initiative (BFHI) as moderate for improving rates of breastfeeding duration. Evidence from eight cohort studies of BFHI (135,983 women) also demonstrates improved rates of breastfeeding initiation (low SOE). Low SOE (k=4 studies; 1,532 women) supports the conclusion that health care education or training of staff alone (without additional breastfeeding support services) does not improve breastfeeding initiation rates. Women, Infants and Children (WIC, a Federal supplemental nutrition program) interventions that focus on peer support are effective in improving rates of breastfeeding initiation and duration (low SOE). We found limited evidence for other (community-based) interventions and no comparative studies on workplace or school-based interventions or harms associated with interventions.
For maternal health outcomes, low SOE supports the conclusion that ever breastfeeding or breastfeeding for longer durations may be associated with lower rates of breast cancer, epithelial ovarian cancer, hypertension, and type 2 diabetes, but not fractures. Because of heterogeneity and inconsistent results, we found insufficient evidence on whether breastfeeding is associated with postpartum depression, cardiovascular disease, or postpartum weight change.
Conclusions:
The body of evidence for breastfeeding programs and policies was diverse in terms of interventions and settings. Current evidence supports the benefit of BFHI for improving rates of breastfeeding initiation and duration; however, evidence from one large RCT (PROBIT) has limited applicability, and observational studies do not clearly establish the magnitude of benefit. For women enrolled in WIC, low SOE supports peer-support interventions for improving breastfeeding outcomes. The identified associations between breastfeeding and improved maternal health outcomes are supported by evidence from observational studies, which cannot determine cause-and-effect relationships.
Contents
- Key Messages
- Preface
- Acknowledgments
- Technical Expert Panel
- Peer Reviewers
- Evidence Summary
- Background
- Existing Guidelines
- Rationale for Evidence Review
- Key Questions
- Analytic Framework
- Methods
- Literature Search Strategy
- Risk of Bias Assessment of Individual Studies
- Risk of Bias Assessment of Systematic Reviews
- Data Synthesis
- Strength of the Body of Evidence
- Applicability
- Peer Review and Public Commentary
- Results of Literature Searches
- Discussion and Findings in Context
- Conclusions
- References
- Chapter 1. Introduction
- Chapter 2. Methods
- Chapter 3. Results
- Results of Literature Search and Screening
- Effectiveness and Harms of Breastfeeding Programs and Policies
- Effectiveness and Harms of Breastfeeding Programs and Policies for Subpopulations of Women
- Effect of Intervention Characteristics on Breastfeeding Outcomes
- Maternal Health Outcomes Associated With Breastfeeding
- Chapter 4. Discussion
- Key Findings and Strength of Evidence
- Effectiveness and Harms of Breastfeeding Programs and Policies
- Effectiveness and Harms of Breastfeeding Programs and Policies for Subpopulations of Women
- Effect of Intervention Characteristics on Breastfeeding Outcomes
- Maternal Health Outcomes Associated With Breastfeeding
- Deficiencies in Methods
- Findings in Relation to What Is Already Known
- Applicability
- Conclusions
- References
- Appendix A. Literature Search Strategies and Yields
- Appendix B. PRISMA
- Appendix C. Relevance and Risk of Bias Assessments
- Appendix D. Strength of Evidence Tables
- Appendix E. Excluded Studies
- Appendix F. Breast Cancer Evidence Tables
- Appendix G. References for All Appendixes
Suggested citation:
Feltner C, Weber RP, Stuebe A, Grodensky CA, Orr C, Viswanathan M. Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries. Comparative Effectiveness Review No. 210. (Prepared by the RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center under Contract No. 290-2015-00011-I.) AHRQ Publication No. 18-EHC014-EF. Rockville, MD: Agency for Healthcare Research and Quality; July 2018. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCCER210.
This report was funded by the Office on Women’s Health at the Office of the Assistant Secretary for Health (OASH) and the Centers for Disease Control and Prevention (CDC) through an interagency agreement with the Agency for Healthcare Research and Quality (AHRQ) and is based on research conducted by the RTI International–University of North Carolina Evidence-based Practice Center (EPC) under contract to AHRQ, Rockville, MD (Contract No. 290-2015-00011-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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