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Chung M, Ip S, Yu W, et al. Interventions in Primary Care to Promote Breastfeeding: A Systematic Review [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Oct. (Evidence Syntheses, No. 66.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

1Background

Human milk is the natural nutrition for all infants. According to the American Academy of Pediatrics (AAP), it is the preferred choice of feeding for all infants. 1 The goals of Healthy People 2010 for breastfeeding are initiation rate of 75% and continuation of breastfeeding of 50% at 6 months and 25% at 12 months postpartum. 2 A survey of US children in 2002 indicated that 71% had ever been breastfed. The percentage of infants who continued to breastfeed to some extent are 35% at 6 months and 16% at 12 months. 3 Although the breastfeeding initiation rate from this survey is close to the goal of 75%, the breastfeeding continuation rates at 6 and 12 months are short of the goals set by that of Healthy People 2010.

Tufts-New England Medical Center Evidence-based Practice Center (Tufts-NEMC EPC) completed a review in 2006 examining the effects of breastfeeding on infant and maternal health outcomes in developed countries. 4 The Center on Primary Care, Prevention and Clinical Partnerships at the Agency for Healthcare Quality and Research (AHRQ), on behalf of the US Preventive Services Task Force (USPSTF), requested an additional related evidence report on the effectiveness of interventions to promote breastfeeding.

The topic, effectiveness of interventions to encourage and support breastfeeding, was last considered in 2003 by the USPSTF. The Task Force issued a B recommendation (fair evidence that the service improves important health outcomes) for structured education and behavioral counseling programs to promote breastfeeding, and an I recommendation (insufficient evidence to recommend for or against routinely providing the service) for other interventions. The present report will be used by the USPSTF to update its 2003 recommendation.

According to AAP, some of the obstacles to initiation and continuation of breastfeeding include insufficient prenatal education about breastfeeding, disruptive maternity care practices, and lack of family and broad societal support. 5 Effective interventions reported to date include changes in maternity care practices, like those implemented in pursuit of the Baby Friendly Hospital Initiative 6 designation, 7 and worksite lactation programs. 8 Some of the other interventions implemented include peer to peer support, maternal education and media marketing. 9

This review focuses only on interventions that were initiated in a primary care setting. Any counseling or behavioral intervention initiated from a clinician's practice (office or hospital) to improve breastfeeding initiation, duration, or both will be considered. Interventions could be conducted by a variety of providers (lactation consultants, nurses, peer counselors, midwives or physicians) in a variety of settings (hospital, home, clinic, or elsewhere) as long as they originated from a health care setting. Health care system interventions, such as staff training, will also be included. However, community or peer initiated interventions is not part of this review.

To expand on the background behind the present review, the following is a brief summary of the 2003 evidence review 10 that supported the formulation of the 2003 recommendations. 11

Brief Summary the 2003 Evidence Review

Effectiveness of structured breastfeeding education and behavioral counseling programs

Structured breastfeeding education and behavioral counseling programs improve the rates of breastfeeding initiation, breastfeeding duration, or both. The most effective interventions used brief, relatively directive health education combined with behaviorally-oriented skills training and problem-solving counseling.

Effectiveness of support from providers and peers

  • The independent effect of support alone on breastfeeding was modest.
  • The combined effects of education and support significantly increased breastfeeding.

However, the effects of combined education and support on breastfeeding initiation and its continuation were not higher than the estimated effect of education alone.

No studies had evaluated whether advice by the women's primary obstetric provider or by the infant's primary pediatric provider in the course on in-hospital care or routine preventive visits was effective on its own in increasing breastfeeding rates.

Effectiveness of other breastfeeding education and support measures

  • Peer counselors are potentially a useful source of support and motivation for breastfeeding, though studies initiated from the clinical practice setting were judged to be of either poor quality or of limited generalizability due to the use of financial incentives.
  • Written materials alone do not appear effective in increasing breastfeeding rates.
  • Commercial discharge packs, in one good-quality Cochrane review of 9 randomized trials, were found to reduce exclusive breastfeeding.

Adequacy of previous literature

The 2003 review found that overall studies of breastfeeding interventions lacked scientific rigor. Intervention studies often lacked detail to assess similarity among similar interventions. The adequacy of reporting of information on educational interventions varied in the areas of:

  • content of the session
  • method of communicating the content,
  • training of the individual to deliver the content
  • total time spent in the educational session.

Across studies, it was difficult to assess the variability of routine care, which was the most common control group. For example, in certain communities it might be a standard practice to receive one home visitation and in others it might not.

Studies rated as poor quality by the USPSTF quality-rating system had results similar to those rated as good or fair. Many of these were non-randomized controlled trials that were rated poor due to baseline differences in the comparison groups, or randomized studies with inadequate randomization methods or lack of intention to treat analyses. Such flaws have been shown to be correlated with effect sizes in studies of obstetric interventions. 12 However, their impact in studies of clinic-based behavioral counseling is uncertain. Due to such uncertainty and the lack of statistically significant difference with and without poor-quality studies, all the studies were combined to display the mean differences and confidence boundaries. The 2003 review also noted that the lack of scientific rigor in the individual studies was a limitation for the strength of the findings in the meta-analysis.

Evidence gaps

There was insufficient evidence to recommend for or against the following interventions to promote breastfeeding:

  • brief education and counseling by primary care providers
  • peer counseling used alone and initiated in the clinical setting
  • written materials, used alone or in combination with other interventions.

The 2003 review reported that breastfeeding intervention studies often combined interventions. None of the individual studies compared the combined intervention against each component separately. The meta-analysis also suggested that, in light of the results of the meta-regression to estimate the effects of education and support alone (results indicated that the combination of education plus support may be more effective than support alone for initiation and short-term duration of breastfeeding), there is a rationale for future intervention studies that compare combined education and support with education and support alone.

USPSTF Recommendations (2003)

The USPSTF recommends structured breastfeeding education and behavioral counseling programs to promote breastfeeding 11 . B recommendation.

  • The USPSTF found fair evidence that programs combining breastfeeding education with behaviorally oriented counseling are associated with increased rates of breastfeeding initiation and its continuation for up to 3 months, although effects beyond 3 months are uncertain. Effective programs generally involved at least 1 extended session, followed structured protocols, and included practical, behavioral skills training and problem-solving in addition to didactic instruction.
  • The USPSTF found fair evidence that providing ongoing support for patients, through in-person visits or telephone contacts with providers or counselors, increased the proportion of women continuing breastfeeding for up to 6 months. Such support, however, had a much smaller effect than educational programs on the initiation of breastfeeding and its continuation for up to 3 months. Too few studies have been conducted to determine whether the combination of education and support is more effective than education alone.

The USPSTF found insufficient evidence to recommend for or against the following interventions to promote breastfeeding: brief education and counseling by primary care providers; peer counseling used alone and initiated in the clinical setting; and written materials, used alone or in combination with other interventions. I recommendation.

  • The USPSTF found no evidence for the effectiveness of counseling by primary care providers during routine visits and generally poor evidence to assess the effectiveness of peer counseling initiated from the clinical setting when used alone to promote breastfeeding in industrialized countries. The evidence for the effectiveness of written materials suggests no significant benefit when written materials are used alone and mixed evidence of incremental benefit when written materials are used in combination with other interventions.
Cover of Interventions in Primary Care to Promote Breastfeeding
Interventions in Primary Care to Promote Breastfeeding: A Systematic Review [Internet].
Evidence Syntheses, No. 66.
Chung M, Ip S, Yu W, et al.

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