Interventions promoting exclusive breastfeeding up to six months after birth: A systematic review and meta-analysis of randomized controlled trials

https://doi.org/10.1016/j.ijnurstu.2018.01.004Get rights and content

Abstract

Background

The World Health Organization (WHO) recommends that mothers practice exclusive breastfeeding (EBF) of their infants for 6 months. Various breastfeeding support interventions have been developed to encourage mothers to maintain breastfeeding practices. Research aim: This study aims to review how effectively breastfeeding support interventions enable mothers to practice EBF for 6 months and to suggest the best intervention strategies.

Methods

Six databases were searched, including MEDLINE, EMBASE, Cochrane, CINAHL, PsycINFO, and KoreaMed. The authors independently extracted data from journals written in English or Korean and published between January 2000 and August 2017. Randomized controlled trials (RCTs) reporting EBF until 6 months were screened.

Results

A total of 27 RCTs were reviewed, and 36,051 mothers were included. The effectiveness of breastfeeding support interventions to promote EBF for 6 months was significant (odds ratio [OR] = 2.77; 95% confidence interval [CI]: 1.81–3.76). A further subgroup analysis of intervention effects shows that a baby friendly hospital initiative (BFHI) intervention (OR = 5.21; 95% CI: 2.15–12.61), a combined intervention (OR = 3.56; 95% CI: 1.74–7.26), a professional provider led intervention (OR = 2.76; 95% CI: 1.76–4.33), having a protocol available for the provider training program (OR = 2.87; 95% CI: 1.89–4.37) and implementation during both the prenatal and postnatal periods (OR = 3.32; 95% CI: 1.83–6.03) increased the rate of EBF for 6 months.

Conclusion

We suggest considering a multicomponent intervention as the primary strategy and implementing BFHI interventions within hospitals. Evidence indicates that intervention effectiveness increases when a protocol is available for provider training, when interventions are conducted from the pre- to postnatal period, when the hospital and community are connected, and when healthcare professionals are involved.

Section snippets

What is already known about this topic?

  • Previously, there was no evidence regarding the efficacy of breastfeeding promotion interventions to promote 6 months of EBF and no reviews regarding the intervention strategies used to enhance compliance.

What this paper adds

  • Through systematic review and meta-analysis of RCTs, mothers who received breastfeeding promotion interventions were 2.77 times more likely to continue EBF 6 months after birth. Five strategies were identified to improve the effectiveness of interventions: multicomponent intervention, professional involvement, having a precise protocol for provider training, interventions persisting from the prenatal to postnatal period and interventions incorporating both hospital and community settings.

Background

Breastmilk is an optimal nutritional source for the growth and development of infants. Compared with breastfeeding in general, exclusive breastfeeding (EBF) has been associated with better health outcomes. EBF offers numerous benefits: reduced rates of infant morbidity resulting from allergic and gastrointestinal disease, reduced pneumonia rates, greater prevention of non-communicable disease and a long-term reduction in obesity rates (Kramer and Kakuma, 2002; Kramer and Kakuma, 2004; Lamberti

Search strategy

This study was conducted in accordance with the recommended guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis (Moher et al., 2015). Two authors conducted the literature searches. Keywords used in the searches include: breastfeeding; lactation; psychological; psycho-social; counselling; education; support/supportive; peer support; mutual support; and self-help. The full search strategies used for individual data are provided in Table S1. Five databases were

Characteristics of the included studies

Table 1 shows the characteristics of the 27 included RCTs. The total number of participants from all studies was 36,051. The studies were published between 2000 and August 2017, and the majority were published after 2010 (59.3%). Most of the studies ended follow-up at 6 months after birth; however, four studies lasted longer: up to 12 months (Bonuck et al., 2006; Kramer et al., 2001; Wen et al., 2011) and 18 months (Aksu et al., 2011) after delivery. Four assessed the effectiveness of BFHI. The

Discussion

This review synthesized the studies regarding the effect of breastfeeding promotion interventions on 6-month EBF rates. Twenty-seven RCTs involving breastfeeding promotion interventions met the inclusion criteria. Using a random-effect model, the results of the meta-analysis showed beneficial effects of interventions; mothers who received interventions were more likely to continue EBF at 6 months after birth. Overall, studies were of a moderate quality due to failure to use or lack of reporting

Conclusion

This systematic review and meta-analysis of 27 RCTs provides moderate evidence for the beneficial effects of breastfeeding promotion interventions. The results of a subgroup analysis showed the beneficial effects of BFHI. Thus, BFHI should be preferred over other interventions when feasible. In addition, the findings showed the critical need for multicomponent and long-term interventions that cover both the pre- and postnatal periods. Having a precise protocol for provider training may enhance

Declaration of conflicting interests

None.

Funding

This study was supported by National Research Foundation of Korea (NRF No. 2017R1A2B4002488).

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