A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding.
BACKGROUND: Human breastmilk provides complete nutrition for infants and helps protect against certain childhood diseases. Despite this, rates of initiation of breastfeeding in the UK remain low relative to other countries. In 'Our healthier nation' action report, the government has highlighted the promotion of breastfeeding in order to assist improvements in health and to reduce the health inequalities of mothers and children in the UK. OBJECTIVES: The primary aim of this systematic review was to evaluate existing evidence to identify which promotion programmes are effective at increasing the number of women who start to breastfeed. In addition, the review aimed to assess the impact of such programmes on the duration and/or exclusivity of breastfeeding and the intermediate and process outcomes. Where the strength and quality of the evidence permitted, the review aimed to identify implications for practice within the UK and priority areas for future research. METHODS DATA SOURCES: A range of electronic databases were searched from inception to November 1998, several relevant journals were hand-searched, and references of retrieved papers were examined. Relevant experts, organisations and lay groups were contacted to help identify further published or unpublished material. Additionally, an expert panel was consulted. SELECTION CRITERIA: Four types of criteria were used to select eligible studies for this review: STUDY DESIGN - randomised controlled trials (RCTs), non-RCTs with concurrent controls, and before-after studies (cohort or cross-sectional). PARTICIPANTS - pregnant women, mothers in the immediate postpartum period before the first breastfeed, any participant linked to pregnant women or new mothers, or any participant who may breastfeed in the future, or be linked to a breastfeeding woman in the future. INTERVENTIONS - any type of intervention designed to promote the uptake of breastfeeding was included; control groups could receive an alternative breastfeeding promotion programme or standard care. OUTCOMES - the primary outcome was initiation of breastfeeding; secondary outcomes (duration and exclusivity of breastfeeding) were included if initiation was reported in the same study; intermediate and process outcomes were also included, and need not necessarily be associated with reported initiation rates. DATA EXTRACTION AND VALIDITY ASSESSMENT: Data were extracted into structured tables. All included studies were checked against a comprehensive methodological checklist. Different checklists were used for RCTs, non-RCTs and before-after studies. Data extraction and validity assessment were independently checked by a second reviewer. DATA SYNTHESIS: The studies were grouped according to intervention type, and were combined using a narrative synthesis. For individual RCTs and non-RCTs reporting initiation of breastfeeding, relative risks with associated 95% confidence intervals were estimated, with calculations performed on an intention-to-treat basis where possible. Pooling of relative risks was considered inappropriate owing to the lack of similarity across the studies. RESULTS: A total of 59 studies met the selection criteria, comprising 14 RCTs, 16 non-RCTs and 29 before-after studies. Interventions were grouped into the following categories: health education, health sector initiatives (HSI) - general, HSI - Baby Friendly Hospital Initiative (BFHI), HSI - training of health professionals, HSI - US Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), HSI - social support from health professionals, peer support, media campaigns, multifaceted interventions. In many cases, studies were dissimilar in terms of the type of intervention(s), participants and the definitions of outcomes. Methodological problems of some studies also limited interpretation of findings. (ABSTRACT TRUNCATED)