Interventions To Improve Breastfeeding Outcomes: A Systematic Review and Meta-Analysis

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Acta Pædiatrica ISSN 0803-5253

REVIEW ARTICLE

Interventions to improve breastfeeding outcomes: a systematic review and


meta-analysis
Bireshwar Sinha1, Ranadip Chowdhury1, M Jeeva Sankar2, Jose Martines3, Sunita Taneja1, Sarmila Mazumder1, Nigel Rollins4, Rajiv Bahl4, Nita Bhandari
([email protected])1
1.Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
2.Department of Pediatrics, Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, All India Institute of Medical Sciences, New Delhi,
India
3.Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway
4.Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland

Keywords ABSTRACT
Breastfeeding, Interventions, Meta Analysis Aim: To provide comprehensive evidence of the effect of interventions on early initiation,
Correspondence exclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health
Nita Bhandari, Centre for Health Research and systems and services (ii) Home and family environment (iii) Community environment (iv)
Development, Society for Applied Studies, 45, Kalu
Sarai, New Delhi-110016, India. Work environment (v) Policy environment or a combination of any of above.
Tel: +91 011 46043751- 55| Methods: Of 23977 titles identified through a systematic literature search in PUBMED,
Fax: +91 011 46043756|
Cochrane and CABI, 195 articles relevant to our objective, were included. We reported the
Email: [email protected]
pooled relative risk and corresponding 95% confidence intervals as our outcome estimate.
Received
In cases of high heterogeneity, we explored its causes by subgroup analysis and meta-
13 May 2015; revised 12 June 2015;
accepted 27 June 2015. regression and applied random effects model.
DOI:10.1111/apa.13127
Results: Intervention delivery in combination of settings seemed to have higher
improvements in breastfeeding rates. Greatest improvements in early initiation of
breastfeeding, exclusive breastfeeding and continued breastfeeding rates, were seen when
counselling or education were provided concurrently in home and community, health
systems and community, health systems and home settings, respectively. Baby friendly
hospital support at health system was the most effective intervention to improve rates of
any breastfeeding.
Conclusion: To promote breastfeeding, interventions should be delivered in a combination
of settings by involving health systems, home and family and the community environment
concurrently.

INTRODUCTION of deaths in children under five annually, which in 2013


Optimal breastfeeding practices are the cornerstone of child would have amounted to around 800 000 lives saved in low
survival, nutrition and early childhood development. The and middle income countries (2). Optimal breastfeeding
World Health Organization (WHO) and United Nations practices also improve mother and infant bonding, help
Children’s Fund (UNICEF) recommend initiation of breast- achieve optimum growth and development, protect against
feeding within an hour of birth, exclusive breastfeeding for non-communicable diseases and benefit maternal health
the first 6 months of life, and continued breastfeeding (3,4). However, global breastfeeding rates are still low and
beyond 6 months and at least up to 2 years of age or more
along with the introduction of nutritionally adequate and
safe complementary foods (1). These optimal breastfeeding Key notes
practices are so critical that they could prevent around 12%
 Improvements in breastfeeding rates are critical.
 Counselling by peers or health personnel, baby friendly
Abbreviations hospital support and community mobilization
BF, Breastfeeding; BFHI, Baby friendly hospital initiative; CI, approaches are the key interventions to improve
Confidence interval; HIC, High income country; IMCI, Inte- breastfeeding rates.
grated management of childhood illness; LMIC, Low and middle  Interventions should be delivered concurrently in a
income; MeSH, Medical subject heading; NICU, Neonatal combination of settings i.e. health system, home and
intensive care unit; OR, Odds ratio; RCTs, Randomized con- community to have a higher impact on optimal breast-
trolled trials; RR, Relative risk; UNICEF, United nations chil-
feeding rates.
dren’s fund; WHO, World health organization.

114 ©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
Sinha et al. Interventions to improve breastfeeding

only subtle improvements have been observed over the past feeding rates when delivered in five types of settings: (i)
decades. Only 43% of the world’s newborns are put to the Health systems and services, (ii) Home and family
breast within 1 hour of birth (5,6). UNICEF estimates that environment, (iii) Community environment, (iv) Work
globally around 40% of children under 6 months of age are environment, (v) Policy environment or (vi) Combination
exclusively breastfed (5) and 49% of children are breastfed of settings.
up to 2 years of age (7). A WHO report from 47 countries
among 75 countdown countries, showed that the median
coverage of exclusive breastfeeding has only increased from METHODS
34% in 2000–2007 to 41% in 2008–2012 (8). Improvements We searched for existing systematic reviews, particularly
in breastfeeding rates are critical to the attainment of Cochrane reviews, on the effects of interventions on
unfinished agenda of Millennium Development Goal 4 and breastfeeding outcomes. As the scope of our objective was
require urgent action (9). The Comprehensive implementa- wider than previous reviews, we planned for a new review.
tion plan for maternal, infant and young child nutrition The search strategy (Box 1) was developed and reviewed
aims to increase the rate of exclusive breastfeeding in the by all authors. Medical Subject Heading terms and key-
first 6 months of life from the current 40% to at least 50% words were used in various combinations. We searched
by the year 2025 (10).
To improve breastfeeding rates, effective breastfeeding
promotion interventions (which encompasses whole range
Box 1. Search strategy
of protection, promotion and support interventions) are
needed which can empower and enable mothers to solve
breastfeeding difficulties. Interventions such as the Baby 1 (Breastfeeding OR Breast Feeding OR (Exclusive
Friendly Hospital Initiative, peer counsellor support AND Breastfeeding [All Fields]) OR (Continued
through home visits, telephonic support, group coun- AND Breast feeding [All Fields]) OR Lactation
selling, community awareness campaigns, health pro- OR Human Milk OR Breast Milk [MeSH Majr])
gramme approaches such as Integrated Management of 2 (Counseling OR Peer OR education OR (inter-
Childhood Illness (IMCI) and policies like the WHO vention[All Fields]) OR family practice OR sup-
Code of Marketing of Breast Milk Substitutes have been port OR Groups OR health worker OR physician
found to be effective in improving breastfeeding in [MeSH terms])
different studies (11–205). Some systematic reviews have 3 (Social media OR social networking OR mass
looked at the effect on breastfeeding rates of specific media OR health campaigns OR group OR meet-
interventions like antenatal education (206), lactation ing OR health promotion OR community [MeSH
counselling by counsellors or health professionals (207), terms])
telephone support (208), peer support (209–211), and 4 (BFHI [All Fields] OR (Baby Friendly Hospital
work place support (212). Others have reviewed the effect [All Fields]) OR Rooming in OR Perinatal Care
in specific settings such as the community (213) or OR health services OR Hospital OR Facility OR
primary health care (214). Some recent reviews pooled health system OR health program[MeSH terms])
studies on educational interventions and observed that 5 ((Infant food Marketing [All Fields]) OR (Code of
exclusive breastfeeding rates can be improved significantly Marketing [All Fields]) OR (Infant milk substi-
with interventions (215,216). tutes [All Fields]) OR (Breast milk substitutes [All
Inspite of proven interventions, global improvements in Fields]) OR Policy OR Legislations OR law
breastfeeding rates have been limited. There is a lack of [MeSH terms] OR work OR Workplace)
information about which interventions delivered in clearly 6 (Addresses[ptyp] OR Autobiography[ptyp] OR
defined settings have the highest beneficial effects on Bibliography[ptyp] OR Biography[ptyp] OR pub-
breastfeeding rates. Evidence is also limited on the effect med books[filter] OR Case Reports[ptyp] OR
of interventions on all the WHO recommended breast- Congresses[ptyp] OR Consensus Development
feeding practices. In this review, we summarize the Conference[ptyp] OR Directory[ptyp] OR Dupli-
evidence on how and to what extent interventions cate Publication[ptyp] OR Editorial[ptyp] OR
delivered in various settings can improve selected breast- Festschrift[ptyp] OR Guideline[ptyp] OR In
feeding outcomes. This will help us identify the most Vitro[ptyp] OR Interview[ptyp] OR Lectures
effective interventions in each setting so that these can be [ptyp] OR Legal Cases[ptyp] OR News[ptyp] OR
prioritized. Within each setting we also examined the Newspaper Article[ptyp] OR Personal Narratives
effect of different interventions that have the highest [ptyp] OR Portraits[ptyp] OR Retracted Publica-
impact. Apart from including all studies covered in the tion[ptyp] OR Twin Study[ptyp] OR Video-Audio
most recent meta-analysis on breastfeeding interventions Media[ptyp])
(215), we have included other studies published thereafter 7 #1 AND (2 OR #3 OR #4 OR #5)
and also set our review objectives broader. The objectives 8 #7 NOT #6
of our review was to ascertain the effects of interventions
on early initiation, exclusive, continued and any breast-

©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135 115
Interventions to improve breastfeeding Sinha et al.

published literature from PubMed, the Cochrane Library on maternity leave, workplace support and employment
and CABI databases to identify studies examining the status of the mothers. Studies included under the category
effects of interventions to promote breastfeeding on the of policy environment examined the effect of the Breast-
following outcomes: early initiation of breast feeding, milk Substitutes Act (or the Code of Marketing of Breast
exclusive breastfeeding in the first 6 months, continued Milk Substitutes), national maternal and child health
breastfeeding between 12 and 23 months, and any breast- programmes on breastfeeding. Studies where interventions
feeding. The search was conducted in October 2014. No were delivered in multiple settings, e.g. health systems and
language or date restrictions were employed in the elec- services together with home and family environment, were
tronic searches. categorized under combination of settings.
Two review authors (BS and RC) screened the titles and Each of the five categories of interventions was further
abstracts independently to identify potentially relevant sub-grouped according to the nature of interventions. The
citations. They retrieved the full texts of all potentially Health systems and services setting was subdivided into
relevant articles and independently assessed eligibility of baby friendly hospital support, counselling or education,
the studies using pre-defined inclusion criteria. Data extrac- special training to health workers. The subgroup baby
tion was done for all the articles which were found to be friendly hospital support included studies which examined
relevant. Any disagreements or discrepancies between interventions included under the domain of ‘Ten steps of
reviewers were resolved by discussion and, if necessary, by Successful breastfeeding’ provided at hospitals or health
consulting a third review author (JSM). In addition to the systems according to the UNICEF/WHO BFHI guidelines
electronic search, we reviewed the reference lists of the (Box 2). Home and family environment was subdivided
articles identified. We used web based citation index for into counselling or education and family or social support.
citing manuscripts of these identified articles. Family or social support is the breastfeeding support that is
expected to be provided to a nursing mother by her family
Inclusion criteria members, relatives and society. Community environment
We selected studies that were either randomized controlled was subdivided into Group counselling or Education and
trials (RCTs) including cluster randomized trials or quasi- Integrated mass media-counselling-community mobiliza-
experimental trials as well as observational studies tion approach. Work environment was subdivided into
(prospective/retrospective cohort and case–control). All maternal leave policy, work place support and employment
studies on interventions to improve breastfeeding that were status. Policy environment included studies on breast milk
delivered to mothers in the antenatal or postnatal period or substitute policies and maternal and child health pro-
both, were included. Studies were also included in which grammes.
the interventions to improve breastfeeding were delivered
to families, community, health staff and other stakeholders. Outcomes and definitions
For articles in other languages, we attempted to find out We specified breastfeeding (BF) outcomes according to the
whether the abstract was available in English. If none of the categories of breastfeeding defined by the WHO (1).
key outcomes included in this review was mentioned in the Outcomes of interest were early initiation of breastfeeding,
abstract, the study was excluded. We also included articles exclusive breastfeeding, continued breastfeeding and any
which examined the effect of interventions on breastfeeding breast feeding.
outcomes in preterm infants or babies in the Neonatal Early initiation of breastfeeding was defined as initia-
Intensive Care Unit (NICU). tion of breastfeeding within 1 hour of birth irrespective of
the mode of delivery. Exclusive breastfeeding was defined
Categorization of interventions as feeding breast milk from mother or wet nurse or
We considered interventions in five categories based on the expressed breast milk and no other liquids or solids
‘Settings’ according to the place of intervention delivery, except vitamin drops or syrups, mineral supplements or
identified in a conceptual model. These were (i) Health prescribed medicines up to 6 months of age. If the
systems and services, (ii) Home and family environment, definition of breastfeeding practice assessed in a study
(iii) Community environment, (iv) Work environment (v) for a child <6 months was different from that of exclusive
Policy environment or (vi) Combination of settings. Studies breastfeeding, it was categorized under any breastfeeding.
which examined the effect of the Baby Friendly hospital A child aged more than 6 to 23 months if breastfed was
support, establishment of rooming in practices or organi- considered as receiving continued breastfeeding. If in a
zational support on breastfeeding outcomes were grouped study the breastfeeding rate was assessed in between 6 to
under health systems and services. Home and family 12 or 12 to 23 completed months it was analysed as
support included studies on peer support, one to one continued breastfeeding at 12 months and 23 months,
counselling or education by home visits or telephone, home respectively.
support by father or grandparent. Under the category of If a study examined exclusive or any breastfeeding rates
community environment we included studies which exam- at multiple time points e.g. 3, 4, 6 months, we used the
ined the effect of group counselling, group meetings, social longest time point data for pooling. Similarly, for contin-
mobilization, mass media or social media on breastfeeding ued breastfeeding we used the longest time point data
outcomes. The work environment category included studies available.

116 ©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135
Sinha et al. Interventions to improve breastfeeding

Box 2. The Baby-Friendly Hospital Initiative (BFHI): Ten pooled relative risk (RR) and corresponding 95% confi-
dence interval (CI). High heterogeneity was defined either
steps to successful breastfeeding
by a low p value (<0.05) and a large chi-squared statistic
relative to its degree of freedom or an I2 value >60%. In
 Have a written breastfeeding policy that is routinely cases of high heterogeneity, random effects model was used
communicated to all health care staff. and causes were explored by doing subgroup analysis and
 Train all health care staff in skills necessary to meta-regression.
implement this policy. Subgroup analyses were carried out based on intervention
 Inform all pregnant women about the benefits and delivery settings (Health systems and services, home and
management of breastfeeding. family environment, community environment, work envi-
 Help mothers initiate breastfeeding within one half- ronment, policy and combination of settings), study size
hour of birth. (<500, 500–1499, ≥1500), country type i.e. high income
 Show mothers how to breastfeed and maintain lacta- (HIC) vs. low and middle income (LMIC) (217), Urban or
tion, even if they should be separated from their Rural setting, study design (RCT, Observational, Quasi-
infants. experimental), control for confounding (yes, no) and quality
 Give newborn infants no food or drink other than of study (adequate, inadequate). For control of confounding
breastmilk, unless medically indicated. a judgment of ‘yes’ was assigned to a study if it had controlled
 Practice rooming in - that is, allow mothers and for maternal age, at least one among other socio-demo-
infants to remain together 24 hours a day. graphic factors viz. family type, mother’s education, working
 Encourage breastfeeding on demand. status of mother and at least one among other risk factors viz.
 Give no artificial nipples or pacifiers (soothers) to parity, mode or place of delivery. To assess quality of study,
breastfeeding infants. we used the Cochrane risk of bias tool (218). If in a study any
 Foster the establishment of breastfeeding support two or more biases e.g. selection bias, performance bias,
groups and refer mothers to them on discharge from detection bias, attrition bias, reporting bias, other bias
the hospital or clinic (confounding) were present, we labelled it as ‘inadequate’.
Research gaps We conducted subgroup analysis to examine the effect of the
different nature of interventions under each setting on
 To what extent interventions can promote optimal breastfeeding practices.
breastfeeding in premature babies and NICU infants.
 To what extent can work place interventions improve
exclusive and continued breastfeeding rates. RESULTS
 Role of educating family or society to promote We screened the 23977 titles of articles identified through
optimal breastfeeding. literature searches. Of these, after reviewing the abstracts of
 Implementation science research to better understand the 1042 articles that appeared relevant, we assessed 301 full
how to guide effective scaling up of well integrated text articles for eligibility and included 195 in our final
multisectoral breastfeeding protection, promotion database (Fig. 1) (11–205). Of these, a total of 73 studies
and support programs. examined the effect of health systems and services on
different breastfeeding outcomes, 57 studies on home and
family environment, six studies on community environment,
four studies on work environment and two studies on policy.
Abstraction, analysis and summary measures Interventions were delivered at more than one setting in 53
For the studies that met the final inclusion criteria, data studies. These were considered under combination of set-
abstraction was done by two review authors (BS and RC). tings. We could not calculate RR for 10 studies which are not
The data abstraction form (modified from the Cochrane mentioned in the tables (see Appendix). We encountered
data abstraction form) described study identifiers and studies where the effect of interventions on outcome mea-
context, study design and limitations, intervention details sures was examined in two different populations or the effects
and outcome effects. If outcomes had been assessed in two of different nature of interventions had been compared with
or more different study populations or the effects of the control group; this resulted in the number of estimates
different interventions had been compared with the control being higher than the total number of studies.
group, these outcome estimates were examined separately. Often, one study examined the effect of interventions on
We used relative risk (RR) as our outcome estimate more than one breastfeeding outcome and some studies
measure and recorded it as provided in the article. If RR examined the effect of interventions in different settings for
was not provided, we calculated it from the actual data one breastfeeding outcome. These outcomes were analysed
provided in the article. To estimate the effect of interven- separately. We estimated the effect of these interventions on
tions on breastfeeding outcomes we conducted a meta- four major breastfeeding outcomes i.e. early initiation of
analysis using ‘metan’ command in Stata 11.2 (StataCorp, breast feeding (49 estimates), exclusive breastfeeding (130
College Station, TX, USA) and pooled Hazard Ratio, estimates), continued breastfeeding up to 23 months (19
adjusted and unadjusted RR together and reported the estimates) and any breastfeeding (118 estimates).

©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135 117
Interventions to improve breastfeeding Sinha et al.

Figure 1 PRISMA flowchart.

Initiation of breastfeeding within 1 hour Study


ID ES (95% CI)
%
Weight

Initiation of breastfeeding within 1 hour increased signifi- Bartington


Buranasin
1.10
1.07
(1.05,
(1.01,
1.15)
1.14)
3.34
3.27
Dall'Oglio 1.16 (0.95, 1.43) 2.18
cantly by 25% (RR 1.25, 95% CI 1.19–1.32) as an effect of Dasgupta
Merewood
7.00
2.17
(1.63,
(1.61,
30.01)
2.92)
0.11
1.55
Ojofeitimi 1.35 (1.05, 1.73) 1.85
all interventions (Table 1, Fig. 2). In the subgroup analysis, Parker
Philipp
1.20
1.48
(1.05,
(1.23,
1.37)
1.78)
2.76
2.33
all strata showed positive associations. Pooled effect of Pincombe
Venancio
1.24
1.09
(0.84,
(1.06,
1.82)
1.11)
1.12
3.41
Ahmad 1.14 (1.00, 1.31) 2.74
studies in rural areas showed higher effect of interventions Akter MO
Artieta-Pinedo
2.14
0.98
(1.60,
(0.89,
2.86)
1.08)
1.59
3.04
Bartington 1.14 (1.11, 1.17) 3.40
on early breastfeeding initiation compared to urban areas. Bonuck Bingo
Bonuck Pairings
1.09
1.04
(1.01,
(0.98,
1.17)
1.10)
3.19
3.28
Caulfield 1.92 (1.31, 2.82) 1.14
Similar findings were observed for low and middle income Ickovics
Rosen
1.20
1.07
(1.01,
(1.01,
1.42)
1.15)
2.45
3.24
countries (LMIC) compared to high income countries Rosen
Grossman
1.02
1.10
(0.94,
(1.01,
1.11)
1.20)
3.13
3.11
Martens 1.04 (0.82, 1.29) 2.01
(HIC). Meta-regression also showed that the effects in Vittoz
Bartington
1.06
0.95
(0.83,
(0.92,
1.36)
0.97)
1.87
3.40
Vestermark 0.11 (0.05, 0.21) 0.42
country type subgroups were significantly different from the Gathwala
Watt
1.17
1.01
(0.96,
(0.93,
1.42)
1.09)
2.25
3.16
Watt 0.98 (0.87, 1.11) 2.85
overall effect. Watt
Quinlivan
0.97
1.04
(0.86,
(0.88,
1.09)
1.24)
2.88
2.44
Aksu 0.96 (0.55, 1.70) 0.64
Haider et al 4.13 (3.02, 5.72) 1.43
Caulfield 2.38 (1.65, 3.43) 1.21
According to intervention delivery setting Shaw
Baker
1.57
2.29
(1.08,
(1.51,
2.32)
3.54)
1.14
0.98
Baker 1.32 (0.92, 1.90) 1.22
Interventions delivered in the health system setting Quinn
Rossiter
1.30
1.84
(0.87,
(1.39,
1.94)
2.44)
1.07
1.64
Davies Adetugbo 5.33 (2.33, 12.19) 0.33
improved early initiation of breastfeeding rates by 11% Bruun Nielsen
Caulfield
1.54
2.00
(1.24,
(1.37,
1.90)
2.93)
2.11
1.15
whereas interventions delivered in the community envi- Labarere J
Nommsen Rivers
0.88
1.06
(0.70,
(0.65,
1.12)
1.69)
1.95
0.83
Wambach 1.25 (1.05, 1.50) 2.39
ronment showed a significant 86% increase (RR 1.86, Zimmerman
Dearden et al
1.83
1.37
(1.36,
(1.01,
2.46)
1.87)
1.55
1.49
Bhutta et al 3.14 (2.43, 4.08) 1.78
95% CI 1.33–2.59). Interventions delivered in the home Flax
Bhandari et al
1.46
2.09
(1.11,
(1.64,
1.91)
2.67)
1.70
1.89
Overall (I-squared = 90.6%, p = 0.000) 1.25 (1.19, 1.31) 100.00
and family were not statistically significant. However NOTE: Weights are from random effects analysis

interventions delivered concurrently in a combination of .0333 1 30

settings improved breastfeeding rates significantly by 57%


Figure 2 Effect of all interventions on Early Initiation of breastfeeding.
(RR 1.57, 95% CI 1.24–1.97). Interventions targeting both
home and family settings along with the community
environment (RR 1.85; 95% CI 1.08–3.17), showed the
highest effect.
Exclusive breastfeeding
According to nature of interventions Pooled results from 130 estimates showed that exclusive
Group counselling in the community (RR 1.65, 95%CI breastfeeding rates increased by 44% (RR 1.44, 95% CI
1.38–1.97) (Table 5), Baby Friendly Hospital support (RR 1.38–1.51) as an effect of all interventions (Table 2, Fig.
1.20, 95%CI 1.11–1.28), and counselling or education by 3). On subgroup analysis, it was seen that the effect of
health staff delivered in multiple settings had the largest interventions was greater for exclusive breastfeeding
effects on breastfeeding initiation in the first hour. during the 4–6 month period (RR 1.59, 95% CI 1.44–

118 ©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135
Sinha et al. Interventions to improve breastfeeding

Table 1 Effect of interventions on early initiation of breastfeeding


Subgroup analysis No. of estimates Pooled odds ratio and 95% confidence interval I2 (%) Meta-regression p value

All interventions 49 1.25 (1.19–1.32) 90.6


Intervention delivery setting
Health systems and services 29 1.11 (1.06; 1.16) 88.2 0.534
Home and family environment 5 1.74 (0.97; 3.12)* 93.8
Community environment 5 1.86 (1.33; 2.59) 69.3
Work environment – – –
Combination of settings 10 1.57 (1.24; 1.97) 86.8
Health system + Home 6 1.36 (1.07; 1.73) 79.1
Home + Community 3 1.85 (1.08; 3.17) 91.1
Health system + Community 1 2.09 (1.64; 2.67) –
Study size
<500 participants 26 1.30 (1.18; 1.44) 86.2 0.871
500–1499 participants 11 1.48 (1.24; 1.75) 92.1
≥1500 participants 12 1.10 (1.03; 1.18) 93.8
Country type
High income 31 1.13 (1.07; 1.19) 88.0 0.046
Lower mid income 18 1.66 (1.44; 1.91) 92.8
Urban/Rural‡
Urban 27 1.24 (1.13; 1.36) 87.9 0.773
Rural 8 1.72 (1.26; 2.36) 94.1
Combined 1 1.35 (1.05; 1.73) –
Study design
RCT 12 1.48 (1.23; 1.79) 94.0 0.835
Observational 15 1.20 (1.11; 1.30) 91.3
Quasi experimental 22 1.19 (1.10; 1.29) 85.7
Control for confounding
Yes 73 1.25 (1.18; 1.32) 92.8 0.930
No 57 1.26 (1.12; 1.42) 84.6
Quality of study†
Adequate 27 1.19 (1.13; 1.26) 91.4 0.283
Inadequate 22 1.36 (1.19; 1.55) 89.2
86.1% of the heterogeneity was explained by these 7 factors.

*Not significant.

Measured according to The Cochrane Collaboration’s Tool for assessing Risk of bias.

Data for all studies were not available.

1.75) compared to <4 months (RR 1.39, 95% CI 1.31– work environment were associated with an increased
1.48). The effect of interventions on exclusive breastfeed- probability of exclusive breastfeeding in the intervention
ing rates was higher in LMIC and rural areas when group but the results were not statistically significant (RR
compared with HIC and urban areas, respectively. Pooled 1.28, 95%CI 0.98–1.69). Exclusive breastfeeding rates
result from RCTs showed 61% improvement (RR 1.61, were seen to improve significantly by 79% (RR 1.79,
95% CI 1.46–1.78) in exclusive breastfeeding rates; studies 95% CI 1.45–2.21) when interventions were delivered
that had controlled for confounding showed a lower concurrently in any combination of settings. The highest
improvement (RR 1.36, 95% CI 1.28–1.46). On meta- effect i.e. 152% increase in exclusive breastfeeding was
regression, the subgroup’s country type, study design and observed when interventions were delivered together in
control for confounding showed significant differences the health systems and community environment.
from the overall effect.
According to nature of interventions
According to intervention delivery setting Pooled results showed that education or counselling had
Pooled results showed that interventions delivered in the highest impact on promoting exclusive breastfeeding
either health system and services or home and family whether delivered in health system setting (RR 1.66, 95%CI
settings increased exclusive breastfeeding by more than 1.43–1.92) or home and family environment (RR 1.58, 95%
45%. Interventions delivered only in the community CI 1.39–1.80) or in multiple settings (Table 5). Interventions
environment had a comparatively lower impact (RR such as baby friendly hospital support (RR 1.49, 95%CI
1.20, 95% CI 1.03–1.39). Interventions delivered in the 1.33–1.68) or special training of health staff in the hospitals

©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135 119
Interventions to improve breastfeeding Sinha et al.

Study
ID
Ahmad
ES (95% CI)
4.25 (2.19, 8.24)
%
Weight
0.39
breastfeeding. The study available on workplace interven-
Aidam et al. 1.13 (0.68, 1.90) 0.57
Aidam et al.
Aidam et al.
Aksu
Akter MO
1.46 (0.83, 2.60)
1.65 (0.96, 2.90)
1.86 (0.69, 5.50)
1.71 (1.28, 2.28)
0.49
0.51
0.18
1.10
tions showed that paid maternal leave from work may
Alberbaz E 2.80 (1.73, 4.71) 0.59
Albernaz E
Albernaz e
Anderson
Arifeen et al
1.31 (0.74, 2.34)
4.45 (2.28, 9.93)
1.29 (1.09, 1.91)
1.17 (0.83, 1.65)
0.48
0.33
1.13
0.93
result in significantly better continued breastfeeding prac-
Arlotti 2.83 (1.06, 8.78) 0.17
Baker et al
Baker et al
Balkam
Balkam
1.09 (0.79, 1.49)
1.06 (0.78, 1.44)
1.64 (0.98, 2.84)
1.39 (0.81, 2.48)
1.01
1.04
0.54
0.51
tices at 10 months (RR 3.33, 95%CI 1.43–10.0). A study on
Balkam 1.24 (0.60, 2.35) 0.37
Balkam
Barros
Bashour Et al
Bashour Et al
0.99 (0.60, 1.63)
2.22 (1.06, 4.64)
1.45 (0.88, 2.35)
1.50 (0.92, 2.45)
0.59
0.33
0.61
0.61
policy environment showed that use of breast milk substi-
Bhandari 10.68 (6.41, 19.07) 0.53
Bhutta et al
Bland et al.
Bonuck B
Bonuck P
1.54 (1.22, 1.95)
1.82 (1.37, 2.41)
3.00 (0.32, 28.35)
1.00 (0.14, 6.96)
1.29
1.12
0.04
0.05
tutes significantly hampered continued breastfeeding (OR
Braun ML 1.66 (1.40, 1.98) 1.51

0.16, 95% CI 0.04–0.55). Interventions delivered concur-


Buranasin 1.69 (1.22, 2.35) 0.98
Carlsen et al. 1.35 (1.05, 1.74) 1.22
Cattaneo 1.67 (1.30, 2.16) 1.22
Corriveau 1.39 (1.06, 1.84) 1.14
Coutinho et al 8.00 (2.43, 41.50) 0.10

rently in any combination of settings had a higher impact


Dearden et al 1.10 (0.79, 1.59) 0.92
Dennis et al. 1.40 (1.02, 2.06) 0.91
Duyan Camurdan 0.95 (0.79, 1.13) 1.49
Elliot R 1.12 (0.45, 2.79) 0.23
Feldens et al. 2.14 (1.37, 3.37) 0.68
Flax 1.48 (1.13, 1.95) 1.15
Forster et al
Forster et al
Frank et al
Gagnon et al.
1.14 (0.68, 1.88)
1.18 (0.72, 1.94)
1.73 (0.44, 8.05)
1.04 (0.94, 1.17)
0.58
0.60
0.10
1.73
on the continued breastfeeding rates (RR 1.97, 95% CI
Gijsbers et al. 1.79 (1.01, 3.18) 0.49
Graffy J
Grossman
Haider et al.
Haque
1.20 (0.89, 1.61)
1.04 (0.89, 1.22)
11.76 (7.16, 20.58)
1.49 (0.97, 2.27)
1.07
1.57
0.55
0.73
1.74–2.24).
Hoddinott P et al. 0.95 (0.76, 1.19) 1.32
Hoddinott et al 1.73 (0.88, 3.37) 0.38
Hopkinson 1.70 (0.82, 3.53) 0.33
Huang et al 1.33 (0.59, 3.09) 0.27
Ingram 1.46 (1.35, 1.59) 1.81
Ingram 1.15 (0.92, 1.40) 1.38
Jakobsen
Jolly K
Khresheh et al
Kistin
1.18 (1.03, 1.38)
0.91 (0.64, 1.27)
1.42 (0.64, 3.25)
2.75 (1.52, 5.22)
1.61
0.94
0.28
0.44
According to nature of interventions
Kools et al. 1.19 (0.81, 1.74) 0.83
Kramer
Kronborg et al.
Kruske et al
Kupratakul
7.16 (3.19, 19.07)
1.06 (1.01, 1.11)
2.53 (1.84, 3.48)
8.33 (2.59, 26.71)
0.24
1.88
1.01
0.15
Counselling or education when given concurrently in any
Labarere 1.17 (1.01, 1.34) 1.63

combination of settings significantly promoted continued


Langer et al 1.64 (1.01, 2.64) 0.63
Leite et al 1.09 (1.01, 1.18) 1.82
Lin et al. 1.30 (0.81, 3.30) 0.36
Lin et al. 2.17 (1.62, 2.89) 1.10
Liu 0.97 (0.96, 0.99) 1.91

breastfeeding rates (RR 1.97, 95% CI 1.74–2.24) and


Martens 1.74 (1.23, 2.45) 0.93
Mattar et al. 0.95 (0.38, 2.35) 0.23
Mattar et al. 2.37 (1.13, 4.99) 0.32
McDonald 1.04 (0.78, 1.40) 1.09
McKeever et al 1.11 (0.67, 1.84) 0.59

approached statistical significance when delivered in health


McQueen 1.12 (0.66, 1.89) 0.55
Mellin et al. 1.15 (0.78, 1.67) 0.84
Merewood 4.30 (2.21, 8.46) 0.38
Merten 1.26 (1.11, 1.42) 1.69
Morell 1.05 (0.61, 1.81) 0.53
Morrow et al._A 5.50 (1.92, 21.58) 0.14
Morrow et al._B
Muirhead et al.
Mydlilova
Mydlilova
4.12 (1.42, 16.31)
1.45 (0.73, 2.94)
1.54 (1.48, 1.61)
1.32 (1.27, 1.37)
0.13
0.36
1.89
1.89
systems alone (RR 1.15, 95% CI 0.99–1.35) (Table 5). The
Mydlilova 1.09 (1.08, 1.10) 1.92
Neyzi
Noel Weiss
Ochola
Ochola
4.25 (1.38, 17.36)
1.21 (0.70, 2.11)
4.01 (2.30, 7.01)
1.53 (0.87, 2.68)
0.13
0.52
0.51
0.50
baby friendly hospital support had no significant effect on
Ojofeitimi 2.17 (1.64, 2.89) 1.12
Olayemi
Olayemi
Olayemi
Oliveira
0.91 (0.80, 1.04)
0.89 (0.76, 1.04)
0.96 (0.84, 1.10)
1.10 (0.88, 1.45)
1.66
1.57
1.65
1.23
continued breastfeeding rates (RR 1.26, 95% CI 0.96; 1.64).
Perez 2.09 (1.52, 2.87) 1.01
Petrova et al 1.32 (0.33, 4.52) 0.12
Phillipp 6.60 (2.68, 19.21) 0.20
Pisacane 1.67 (1.02, 2.71) 0.61
Pisacane A 1.90 (1.40, 2.50) 1.10
Porteous R et al 2.35 (1.04, 5.80) 0.25
Pugh
Quinn et al
Quinn et al
Quinn et al
2.00 (1.14, 3.48)
1.48 (1.00, 2.20)
1.20 (0.83, 1.76)
1.16 (0.83, 1.63)
0.51
0.80
0.85
0.95
Any breastfeeding
Qureshi 1.40 (0.87, 2.25) 0.64

Any breastfeeding rates were seen to improve by 30% as an


Rasmussen 0.70 (0.25, 1.86) 0.19
Salonen 1.88 (1.29, 2.74) 0.85
Sandy 1.62 (1.02, 2.57) 0.66
Sciacca 2.47 (1.51, 4.03) 0.61
Simonetti et al 2.08 (1.01, 4.55) 0.32

effect of all interventions. Subgroup analysis showed greater


Sjolin 1.13 (0.59, 2.14) 0.41
Su 2.16 (1.05, 4.43) 0.34
Su 2.12 (1.03, 4.37) 0.34
Susin 1.51 (0.85, 2.77) 0.47
Suzuki 1.36 (1.07, 1.72) 1.28

improvements at <4 months (RR 1.38, 95% CI 1.28–1.50) as


Taddei 1.41 (1.17, 1.69) 1.47
Tahir et al. 1.04 (0.57, 1.87) 0.46
Taveras 0.94 (0.70, 1.25) 1.10
Turan 1.61 (0.95, 2.71) 0.56
Tylleskar(Burkina) 7.53 (4.42, 12.82) 0.54
Tylleskar(S Africa) 9.83 (1.40, 69.19) 0.05
Tylleskar(Uganda)
Valdes
Venancio
Vestermark
4.66 (3.35, 6.49)
8.83 (3.97, 19.60)
1.06 (1.01, 1.11)
0.87 (0.48, 1.57)
0.97
0.29
1.88
0.46
compared to 4–6 months (RR 1.23, 95% CI 1.13–1.35)
Vitolo 2.34 (1.37, 3.99) 0.54
Wallace
Weng
Wong et al.
Wrenn
0.97 (0.35, 2.69)
0.86 (0.43, 1.72)
1.00 (0.55, 1.81)
1.03 (0.61, 1.73)
0.19
0.36
0.46
0.56
(Table 4, Fig. 5). Similar improvements in any breastfeeding
Zakarija 1.49 (0.84, 2.72) 0.47
Overall (I-squared = 91.0%, p = 0.000)
NOTE: Weights are from random effects analysis
1.44 (1.38, 1.51) 100.00
rates were noted in urban-rural or LMIC-HIC settings.
.0145 1 69.2

Pooled results from RCTs, adequate quality studies and


Figure 3 Effect of all interventions on Exclusive breast feeding. studies which controlled for confounding showed a more
modest effect of the interventions on any breastfeeding
rates. Meta-regression showed the effect of interventions in
all subgroups to be significantly different from the overall
(RR 1.36, 95% CI 1.14–1.63) and integrated mass media, effect.
counselling and community mobilization approach in the
community (RR 1.17, 95% CI 1.01–1.14) also had a According to intervention delivery setting
significant impact. Highest improvements in any breastfeeding rates were seen
Family or social support had no significant effect on when interventions were delivered in Health system settings
promoting exclusive breastfeeding (RR 0.95, 95% CI 0.87– (RR 1.40, 95% CI 1.30–1.52). Interventions delivered at the
1.02). work environment or combination of settings showed a
significant 30% increase in breastfeeding rates.
Continued breastfeeding up to 23 months Among combinations of settings, interventions delivered
Continued breastfeeding rates showed a significant concurrently at both health systems and home (21 estimates
improvement of 61% as a result of all interventions from 21 studies) significantly improved any breastfeeding
(Table 3, Fig. 4). All subgroup analyses showed positive rates by 23% (RR 1.23, 95%CI 1.08–1.40). The impact of
associations and meta-regression showed no significant interventions delivered at home along with community
differences between subgroups compared to the overall settings or health systems with community setting was not
estimate. During subgroup analysis it was observed that statistically significant.
the effect of interventions on continued breastfeeding
rates was more at 12 months and was lower at 12– According to nature of interventions
23 months. Interestingly, studies in HIC and urban areas Baby Friendly Hospital Support interventions in health
showed a higher effect on continued breastfeeding com- systems had the highest impact on promoting any breast-
pared to LMIC and rural areas. RCTs which controlled feeding (RR 1.66, 95% CI 1.34–2.07) (Table 5). Counselling
for confounding and adequate quality studies showed a or education given either in health systems (RR 1.47, 95%
more modest effect than the overall effect. CI 1.29; 1.68) or in the home environment (RR 1.17, 95%
CI 1.08–1.27) or in health systems together with home (RR
According to intervention delivery setting 1.23, 95% CI 1.08; 1.40) had a significant effect on
Interventions delivered either in the health system settings promoting any breastfeeding but this effect was most
or in home settings had a significant impact on continued prominent when delivered in the health systems. Special

120 ©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135
Sinha et al. Interventions to improve breastfeeding

Table 2 Effect of interventions on exclusive breastfeeding


Subgroup analysis No. of estimates Pooled odds ratio and 95% confidence interval I2 (%) Meta-regression p value

All interventions 130 1.44 (1.38–1.51) 91.0


Intervention delivery setting
Health systems and services 51 1.46 (1.37; 1.56) 94.7 0.482
Home and family environment 43 1.48 (1.32; 1.66) 22.0
Community environment 6 1.20 (1.03; 1.39) 0.0
Work environment 4 1.28 (0.98; 1.69)* 0.0
Combination of settings 26 1.79 (1.45; 2.21) 78.9
Health system + Home 16 1.63 (1.27; 2.10) 54.9
Home + Community 3 1.42 (1.21; 1.66) 23.0
Health system + Community 7 2.52 (1.39; 4.59) 92.6
Age at outcome measurement
<4 months 57 1.39 (1.31; 1.48) 93.7 0.806
4–6 months 73 1.59 (1.44; 1.75) 85.9
Study size
<500 participants 69 1.66 (1.50; 1.84) 68.2 0.548
500–1499 participants 39 1.51 (1.34; 1.70) 89.4
≥1500 participants 22 1.30 (1.21; 1.40) 97.1
Country type
High income 73 1.35 (1.26; 1.43) 87.3 0.028
Lower mid income 57 1.69 (1.54; 1.86) 92.1
Urban/Rural‡
Urban 78 1.47 (1.36; 1.59) 80.0 0.948
Rural 20 2.04 (1.52; 2.76) 94.5
Combined 8 1.51 (1.21; 1.88) 71.2
Study design
RCT 71 1.61 (1.46; 1.78) 83.3 0.009
Observational 20 1.34 (1.24; 1.46) 97.4
Quasi experimental 39 1.46 (1.31; 1.63) 81.7
Control for confounding
Yes 73 1.36 (1.28; 1.46) 84.8 <0.001
No 57 1.61(1.48; 1.75) 92.7
Quality of study†
Adequate 45 1.43 (1.30; 1.59) 77.7 0.312
Inadequate 85 1.46 (1.38; 1.54) 93.1
78.1% of the heterogeneity was explained by these 8 factors.

*Not significant.

Measured according to The Cochrane Collaboration’s Tool for assessing Risk of bias.

Data for all studies were not available.

Study %
ID ES (95% CI) Weight
training of health staff at the hospitals (RR 1.33, 95% CI
Albernaz E 2.33 (0.93, 5.82) 4.26
Buranasin 1.09 (0.80, 1.47) 6.31 1.07–1.67) also increased any breastfeeding. Pooled results
Kramer 1.82 (0.92, 3.59) 5.09
Artieta Pinedo 1.11 (0.47, 2.60) 4.47 of two estimates suggested that non-working mothers were
Bosnjak
Jakobsen
1.56 (1.02, 2.34)
1.04 (0.84, 1.29)
6.00
6.50
1.49 times (95% CI 1.12–1.98) more likely to breastfeed
Pannu et al 1.96 (1.10, 3.57) 5.42 compared to working mothers.
Zakarija 1.05 (0.77, 1.44) 6.28
Pisacane A 1.69 (0.95, 2.99) 5.48 Family or social support did not have a significant impact
Wen 1.22 (1.01, 1.47) 6.55
Cooklin et al 3.33 (1.43, 10.00) 4.08
on promoting any breastfeeding (RR 1.02, 95% CI 0.86–
Albernaz E
Jones et al
1.47 (0.91, 2.46)
0.56 (0.23, 1.24)
5.74
4.52
1.22).
Kistin 3.67 (1.90, 7.62) 5.05
Pinelli 0.86 (0.42, 1.76) 4.97
Qureshi 1.42 (1.12, 1.81) 6.45
Vitolo
Bosnjak et al
1.26 (1.02, 1.55)
10.20 (7.66, 13.74)
6.51
6.33
DISCUSSION
Overall (I-squared = 92.0%, p = 0.000) 1.61 (1.17, 2.20) 100.00 The findings of the review indicate that for all three WHO/
NOTE: Weights are from random effects analysis
UNICEF recommended breastfeeding outcomes (1), inter-
.0728 1 13.7
ventions (particularly counselling or education) delivered
Figure 4 Effect of all interventions on continued breastfeeding. concurrently in a combination of settings had a higher impact
than when delivered independently in a single setting.

©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135 121
Interventions to improve breastfeeding Sinha et al.

Table 3 Effect of interventions on continued breastfeeding


Pooled odds ratio and
Subgroup analysis No. of estimates 95% confidence interval I2 (%) Meta-regression p value

All interventions 18§ 1.61 (1.17; 2.20) 92.0


Intervention delivery setting
Health systems and services 8 1.18 (1.03; 1.35) 32.8 0.219
Home and family environment 2 1.26 (1.05; 1.50) 10.8
Community environment – – –
Work Environment 1 3.33 (1.43–10.0) –
Combination of settings 7 1.97 (1.74; 2.24) 96.4
Health system + Home 6 1.34 (1.01; 1.81) 65.2
Home + Community – – –
Health system + Community 1 10.2 (7.66; 13.74) –
Age at outcome measurement
≤12 months 14 1.67 (1.51; 1.84) 93.2 0.327
12–23 months 4 1.19 (1.03; 1.37) 49.8
Study size
<500 participants 6 1.55 (1.29; 1.86) 56.6 0.312
500–1499 participants 7 1.16 (1.05; 1.29) 26.7
≥1500 participants 5 2.37 (0.83; 6.80)* 96.7
Country type
High income 12 1.76 (1.04; 3.01) 94.0 0.368
Lower mid income 6 1.22 (1.09; 1.37) 25.7
Urban/Rural‡
Urban 8 1.53 (1.03; 2.27) 72.0 0.330
Rural 3 1.47 (1.19; 1.81) 0.0
Combined 3 2.56 (0.57; 11.4)* 98.3
Study design
RCT 8 1.22 (1.10; 1.35) 33.5 0.140
Observational 6 2.32 (0.87; 6.14)* 96.0
Quasi experimental 4 1.72 (1.04; 2.83) 74.8
Control for confounding
Yes 7 1.22 (1.08; 1.40) 84.8 0.115
No 11 1.67(1.03; 2.73) 94.6
Quality of study†
Adequate 7 1.18 (1.37; 1.61) 30.7 0.312
Inadequate 11 1.85 (1.10; 3.10) 94.3
80.9% of the heterogeneity was explained by these 8 factors.

*Not significant.

Measured according to The Cochrane Collaboration’s Tool for assessing Risk of bias.

Data for all studies were not available.
§
1 study on policy not pooled as they reported OR (not shown in table).

For early initiation, counselling or educational inter- counselling at health systems or community when exam-
ventions delivered at home and community were found to ined separately had a significant but lower impact on
be the most powerful intervention (85% increase) and exclusive breastfeeding rates, but the combination had a
should receive the highest priority. Counselling when synergistic effect. This finding was similar to the review by
provided as a single intervention in the community Haroon S et al. (215) where combined facility and com-
environment was also effective but had a lower impact munity based interventions resulted in greater improve-
on breastfeeding initiation. Similar to the findings of ments in breastfeeding rates. Similarly, interventions when
Ingram et al. (209), counselling by health staff only at delivered in both health systems and home settings had a
home had a non-significant effect on breastfeeding initi- greater impact on the exclusive breastfeeding rates com-
ation. This suggests that in addition to educating the pared to the effect achieved when delivered in individual
mother, increasing awareness in the whole community settings alone. Although surprising, we observed that family
may be essential. or social support had no significant effect on promoting
For promotion of exclusive breastfeeding, counselling or exclusive breastfeeding. From this finding, it seems that
education in the health system and community is likely to educating family or society regarding breastfeeding and
be the most powerful (increase by 152%) among the providing support to the mother may be useful to create a
examined interventions. The individual interventions i.e. better breastfeeding milieu.

122 ©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135
Sinha et al. Interventions to improve breastfeeding

Table 4 Effect of interventions on any breastfeeding


Subgroup analysis No. of estimates Pooled odds ratio and 95% confidence interval I2 (%) Meta-regression p value
§
All interventions 118 1.30 (1.23; 1.37) 92.1
Intervention delivery setting
Health systems and services 47 1.40 (1.30; 1.52) 94.7 0.361
Home and family environment 36 1.16 (1.07; 1.25) 63.5
Community environment – – –
Work environment 4 1.31 (1.10; 1.56) 81.1
Combination of settings 30 1.30 (1.06; 1.61) 93.6
Health system + Home 21 1.23 (1.08;l 1.40) 56.5
Home + Community 3 1.00 (0.89; 1.12) 32.7
Health system + Community 6 1.74 (0.84; 3.39) 98.3
Age at outcome measurement
<4 months 57 1.38 (1.28; 1.50) 94.5 0.218
4–6 months 61 1.23 (1.13; 1.35) 87.2
Study size
<500 participants 65 1.34 (1.25; 1.44) 72.4 0.933
500–1499 participants 29 1.14 (1.06; 1.23) 63.2
≥1500 participants 24 1.36 (1.20; 1.53) 98.0
Country type
High income 97 1.31 (1.23; 1.40) 94.0 0.418
Lower mid income 21 1.27 (1.13; 1.42) 87.2
Urban/Rural‡
Urban 83 1.30 (1.22; 1.39) 88.1 0.249
Rural 10 1.29 (1.08; 1.55) 66.0
Combined 7 1.67 (0.93; 2.99)* 98.6
Study design
RCT 48 1.07 (1.04; 1.10) 34.6 0.105
Observational 32 1.59 (1.35; 1.88) 97.3
Quasi experimental 38 1.34 (1.23; 1.45) 83.8
Control for confounding
Yes 74 1.18 (1.12; 1.24) 86.9 0.115
No 44 1.48 (1.28; 1.72) 93.9
Quality of study†
Adequate 61 1.21 (1.13; 1.30) 86.4 0.517
Inadequate 51 1.39 (1.26; 1.53) 94.0
90.4% of the heterogeneity was explained by these 8 factors.

*Not significant.

Measured according to The Cochrane Collaboration’s Tool for assessing Risk of bias.

Data for all studies were not available.
§
Includes 1 more study on policy (not shown in table).

For improvement in rates of continued breastfeeding, first 6 months of life. Baby friendly hospital support
educational interventions delivered at health systems along interventions delivered in health system settings were the
with home seemed to be the most effective (34% increase), most effective (66% increase) in improving any breastfeed-
and should be prioritized. The effect of counselling or ing rates. The reason for a higher improvement in any
education when given independently in these two settings breastfeeding rates in the health system settings alone
was significant but lower compared to the combined effect compared to health system settings and home combined,
in improving continued breastfeeding rates. Interventions may be due to the fact that many of the included studies in
delivered at home and family settings as well as in the the former group have assessed any breastfeeding rates very
community also showed a large impact on continued early i.e. at hospital discharge. Our subgroup analysis also
breastfeeding rates. It should also be noted that although shows that effect of interventions on any breastfeeding is
the available evidence is limited, workplace interventions greater at earlier ages.
and policies to restrict use of breast milk substitutes may All breastfeeding outcomes were seen to improve signifi-
significantly increase continued breastfeeding (51,175). cantly as a result of the interventions but the level of effect
We also examined the effect of interventions on any was modified by subgroup factors. Larger studies showed a
breastfeeding, although this practice falls short of recom- lower effect of interventions on breastfeeding initiation and
mended breastfeeding practices by WHO/UNICEF in the exclusive breastfeeding rates. Studies done in LMIC or rural

©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135 123
Interventions to improve breastfeeding Sinha et al.

Study
ID ES (95% CI)
%
W eight promotion interventions, others examined the effect of
Albernaz 1.19 (0.82, 1.74) 0.79
Albernaz
Artieta Pinedo
Bartington
Bartington
1.90
1.19
1.22
0.96
(1.31,
(0.78,
(1.17,
(0.84,
2.77)
1.82)
1.26)
1.09)
0.79
0.72
1.28
1.20
interventions in a particular setting (213,214). Some
Bartington 0.87 (0.84, 0.91) 1.28
Bhandari
Bonuck BINGO
Bonuck Pairings
Bosnjak
1.01
1.29
1.52
4.62
(0.88,
(0.86,
(0.99,
(3.90,
1.16)
1.97)
2.32)
5.50)
1.18
0.73
0.71
1.14
reviewed the effect of interventions on specific breastfeed-
Bosnjak 4.30 (3.79, 4.90) 1.20
Boulvain
Braun ML
Brent et al
Broadfoot
1.01
1.55
1.90
1.17
(0.73,
(1.16,
(1.55,
(1.16,
1.41)
2.07)
7.29)
1.19)
0.87
0.94
0.35
1.28
ing outcomes like exclusive breastfeeding (216) and early
Bunik 1.32 (0.88, 1.98) 0.74
Bunik
Cattaneo
Caulfield
1.34
1.14
2.72
(0.89,
(0.98,
(1.16,
2.13)
1.33)
7.10)
0.70
1.16
0.28
initiation (219). In the most recent review, Haroon S et al.
Caulfield 2.69 (1.18, 6.92) 0.29

(215) included 110 studies to examine the combined effect


Caulfield 2.23 (0.94, 5.84) 0.27
Chan-Yip 1.10 (0.64, 1.88) 0.56
Chapman 0.99 (0.79, 1.11) 1.14
Corriveau 1.08 (0.88, 1.33) 1.08
Coutinho 1.06 (0.88, 1.27) 1.12
Dabritz
Dall'Oglio
Dearden
Dennis
1.25
1.31
0.97
1.21
(1.09,
(0.91,
(0.89,
(1.04,
1.43)
1.89)
1.13)
1.41)
1.19
0.81
1.21
1.17
of interventions on exclusive breastfeeding, predominant
Elliot-Rudder 1.00 (0.86, 1.15) 1.18
Ferrara
Forster
Forster
Gagnon
1.31
0.93
1.02
0.87
(0.85,
(0.71,
(0.59,
(0.65,
2.10)
1.21)
1.31)
1.16)
0.68
0.98
0.76
0.94
breastfeeding, partial breastfeeding and no breastfeeding.
Gill SL 2.01 (1.31, 3.18) 0.69
Graffy J
Grossman
Hartley
Hauck
1.09
0.60
1.61
1.02
(0.86,
(0.33,
(0.85,
(0.67,
1.39)
1.11)
3.04)
1.56)
1.02
0.49
0.46
0.72
An increase of 90% was noted in exclusive breastfeeding as
a result of breastfeeding promotion interventions in a 1–
Hawkins 1.30 (1.17, 1.44) 1.23
Hawkins 0.99 (0.80, 1.29) 1.03
Hawkins 1.74 (1.46, 2.07) 1.13
Henderson 0.88 (0.67, 1.14) 0.98
Hoddinott 1.49 (0.92, 2.40) 0.64
Hoddinott
Hoddinott
Hoffman
Howell
1.02
1.14
1.62
1.26
(0.88,
(0.90,
(0.95,
(1.03,
1.18)
1.38)
2.82)
1.54)
1.17
1.07
0.56
1.09
5 month period. The proportion not breastfeeding at all was
Huang 1.37 (0.87, 2.18) 0.67
Ingram
Ingram
Ingram
Jenner
1.07
1.57
4.50
3.23
(0.91,
(1.45,
(1.53,
(2.16,
1.31)
1.69)
13.19)
4.84)
1.12
1.25
0.21
0.75
significantly reduced but the effect of interventions on
Jolly K 0.88 (0.71, 1.10) 1.06
Jones
Kang
Khan
Khresheh
1.37
3.00
3.26
0.46
(1.01,
(1.14,
(2.41,
(0.14,
1.84)
9.23)
4.41)
1.30)
0.92
0.22
0.92
0.20
predominant and partial breastfeeding was not significant.
Kistin 2.29 (1.44, 3.71) 0.65
Kools
Kramer
Kruske
0.84
1.39
1.58
(0.57,
(1.01,
(1.26,
1.23)
1.92)
1.98)
0.78
0.88
1.05
However, comprehensive evidence on how and where the
Labarere 1.09 (0.98, 1.22) 1.22

proven interventions should be delivered to improve


Labarere 1.01 (0.83, 1.23) 1.10
Lamotagne 2.37 (1.06, 6.00) 0.30
Leite 1.64 (1.33, 2.01) 1.08
Long DG 0.67 (0.24, 1.65) 0.25
Lovera 1.16 (0.92, 1.46) 1.04
McDonald
McInnes
McQueen
Merewood
0.96
1.56
1.07
2.35
(0.87,
(0.92,
(0.69,
(1.67,
1.04)
2.71)
1.65)
3.32)
1.24
0.56
0.70
0.84
breastfeeding practices was lacking. We did a unique
Merten 1.35 (1.12, 1.64) 1.11
Morrow
Muirhead
Pannu et al
Pannu et al
1.14
1.31
1.50
2.27
(1.00,
(0.70,
(1.01,
(1.25,
1.31)
2.48)
2.22)
4.17)
1.19
0.46
0.76
0.49
setting-wise analysis which showed how and to what extent
Perez 1.15 (1.02, 1.31) 1.20
Pinelli
Pisacane
Pisacane
Porteous
1.30
2.01
0.98
1.97
(0.85,
(1.30,
(0.68,
(0.77,
2.01)
3.01)
1.39)
2.89)
0.71
0.72
0.82
0.44
interventions delivered in different settings affected breast-
feeding rates. Thus, based on the evidence, we identified the
Pugh 1.28 (0.91, 1.81) 0.84
Pugh 1.04 (0.68, 1.59) 0.72
Quinlivan 1.01 (0.55, 1.82) 0.50
Rasmussen 0.76 (0.34, 1.64) 0.34
Redman 1.04 (0.67, 1.63) 0.69
Rosen
Rosen
Russell
Russell
1.54
1.38
7.59
2.29
(1.19,
(1.05,
(5.59,
(1.58,
2.01)
1.81)
10.55)
3.37)
0.99
0.97
0.89
0.79
most effective interventions in each setting that can be
Ryan 0.48 (0.31, 0.76) 0.68
Schafer
Shaw
Shinwell
Sjolin
4.86
1.97
1.81
1.23
(1.25,
(1.11,
(1.50,
(0.89,
41.71)
3.64)
2.19)
1.71)
0.09
0.50
1.11
0.87
prioritized for scaling up to improve the WHO/UNICEF
Steel O'Conner 1.03 (0.82, 1.31) 1.03
Su
Susin et al
Taddei
Tahir
1.25
0.83
0.99
1.05
(0.83,
(0.63,
(0.82,
(0.97,
1.87)
1.09)
1.20)
1.14)
0.74
0.96
1.11
1.25
recommended breastfeeding indicators.
Valdes 1.41 (1.18, 1.69) 1.12
Valdes 2.91 (1.98, 4.27) 0.78
Victora 0.86 (0.74, 1.01) 1.16
Victora 1.13 (0.93, 1.38) 1.10
Vittoz 1.42 (1.09, 1.85) 0.98

Limitations
W allace 1.18 (0.82, 1.71) 0.81
W att 0.99 (0.90, 1.10) 1.23
W att 0.98 (0.86, 1.12) 1.19
W en 1.31 (0.91, 1.89) 0.81
W eng 1.15 (0.93, 1.42) 1.07
W ilhelm
W olfberg et al
W ong
W renn
1.28
1.79
1.00
1.06
(0.82,
(0.57,
(0.48,
(0.71,
1.99)
6.11)
2.08)
1.57)
0.69
0.18
0.38
0.76
Our review had some important limitations. There were
Zakarija 1.05 (0.89, 1.25) 1.14
Zimmerman
ingram J
Overall (I-squared = 92.1%, p = 0.000)
1.62
1.39
1.30
(1.18,
(0.94,
(1.23,
2.23)
2.08)
1.37)
0.89
0.76
100.00 only a few studies in the categories of work environment or
NOTE: W eights are from random effects analysis

.024 1 41.7 policy environment for which a quantitative measure was


available and therefore the pooled estimate for these groups
Figure 5 Effect of all interventions on any breastfeeding
may not represent the true effect. For some categories e.g.
interventions in community environment to promote con-
tinued or any breastfeeding, we did not find any studies.
areas showed a higher effect of interventions on early There were insufficient studies examining the effect of mass
initiation and exclusive breastfeeding rates than in HIC or media or social media so these were obviously grouped with
urban areas. This could be because there are more gaps in community environment which may have masked their
mothers’ knowledge about breastfeeding in the less devel- effect as an independent intervention that could possibly
oped regions because of poorly developed health systems and have a large impact. Though we included breastfeeding
low education levels as compared to developed countries and intervention studies among premature babies and in NICU,
therefore these mothers are likely to benefit more from any we have not done any subgroup analysis for these groups.
educational intervention. Breastfeeding is also a socially We have converted studies which provided only OR to RR
acceptable norm in less developed regions which may make (from the data provided in study) and have pooled hazard
these mothers more amenable to breastfeed their child post ratios, unadjusted and adjusted RRs together to get the
counselling. In developed regions the increases in breast- pooled estimate. As it was not possible to get adjusted
feeding rates were less, perhaps due to the easy availability of estimates for all studies, we judged that this was the best
formula and other factors that hinder breastfeeding such as approach to still get a single pooled estimate closest to true
work constraints. Educational interventions seemed to have effect, instead of excluding the study.
a lower effect on continued breastfeeding rates in LMIC or Apart from methodological heterogeneity due to differ-
rural areas as the average duration of breastfeeding is usually ence in study designs, heterogeneity was also observed due
longer in these settings than in urban areas. to the variations in the nature of interventions and their
Study design was also an important effect modifier. RCTs duration, different health personnel delivering the inter-
showed a higher effect of interventions on early initiation ventions, periodicity of the interventions, differences in
and exclusive breastfeeding rates but a lower effect on study population (income, place of residence i.e. rural or
continued and any breastfeeding rates. Studies of adequate urban, socioeconomic status and education), outcome
quality or studies which controlled for potential con- definitions (full breastfeeding interpreted as exclusive
founders uniformly showed, when pooled, a more modest breastfeeding but possibly including predominant breast-
effect of interventions on all breastfeeding outcomes. feeding in some cases) and different time intervals for
Previous systematic reviews showed that interventions follow-up. There was also variability in the recall period of
can improve breastfeeding rates (215,216). Some reviews infant feeding practices by mothers. Exclusive breastfeeding
examined the individual effects of specific breastfeeding data were sometimes collected from birth whereas in most

124 ©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135
Sinha et al.

Table 5 Effect of nature of interventions on breastfeeding outcomes according to settings


Early Initiation of BF Exclusive BF Continued BF Any BF

Nature of Interventions No. of estimates RR (95% CI) No. of estimates RR (95% CI) No. of estimates RR (95% CI) No. of estimates RR (95% CI)

1. Health systems and services


Baby friendly support 10 1.20 (1.11; 1.28) 15 1.49 (1.33; 1.68) 3 1.26 (0.96; 1.64) 13 1.66 (1.34; 2.07)
Counseling or education 10 1.12 (1.05; 1.19) 28 1.66 (1.43; 1.92) 5 1.15 (0.99; 1.35) 24 1.47 (1.29; 1.68)
Special training of health staff 3 1.09 (1.01; 1.18) 5 1.36 (1.14; 1.63) – 5 1.33 (1.07; 1.67)
2. Home and family environment
Counseling or Education 5 1.74 (0.97; 3.12) 38 1.58 (1.39; 1.80) 1 1.22 (1.01; 1.47) 33 1.17 (1.08; 1.27)
Family or Social Support – – 5 0.95 (0.87; 1.02) 1 1.69 (0.95; 2.99) 3 1.02 (0.86; 1.22)
3. Community environment
Group counseling or education 4 1.65 (1.38; 1.97) 1 1.61 (0.95; 2.71) – –
Integrated mass media, counseling 1 5.33 (2.33;12.19) 5 1.17 (1.01; 1.36) – –
and community mobilization approach
4. Work environment
Maternal leave policy – 2 1.52 (1.03; 2.23) – 1 0.99 (0.80; 1.29)
Workplace support – 2 1.08 (0.74; 1.60) – 1 1.25 (1.09; 1.43)
Employment status – – 1 3.33 (1.43; 10.0) 2 1.49 (1.12; 1.98)
5. Policy environment
WIC federal program (US) – – – – – 1 0.48(0.31; 0.76)
Breast milk substitutes – – – – – –

*Studies for which RR could not be calculated are not mentioned.

©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135
Interventions to improve breastfeeding

125
Interventions to improve breastfeeding Sinha et al.

studies it was defined ascertaining feeding practices in the DISCLAIMER


last 24 hours. In case of significant heterogeneity we have The authors alone are responsible for the views expressed in
done post-hoc subgroup analysis and meta-regression and this article and they do not necessarily represent the views,
have used the random effects model. But even within the decisions or policies of the institutions with which they are
subgroups there was significant heterogeneity which sug- affiliated.
gests some unidentified factors. Although the meta-regres-
sion seemed to explain around 80% of the heterogeneity for
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132 ©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135
Sinha et al. Interventions to improve breastfeeding

Appendix 1 Summary of studies included in early initiation of breastfeeding


Estimates Studies Ref. No. Design Country Quality

Health systems and services (1)


Overall 29 23 12, 15, 23, 28, 33, 44, 47, 56, RCT 4 HIC 22 AQ 17
57, 72, 78, 92, 123, 131, 141, Obs 10 LMIC 7 IQ 12
145, 148, 149, 161, 189, 190, Quas 15
193, 198
Home and family environment (2)
Overall 5 5 14, 47, 79, 156, 171 RCT 3 HIC 4 AQ 2
Obs 1 LMIC 1 IQ 3
Quasi 1
Community environment (3)
Overall 5 4 25, 58, 157, 162 RCT 0 HIC AQ 0
Obs 0 LMIC 5 IQ 5
Quasi 5
Work environment (4)
No studies
Policy environment (5)
No studies
Combination of Setting (6)
Setting 1+2 6 6 40, 47, 110, 139, 197, 205 RCT 2 HIC 5 AQ 5
Obs 2 LMIC 1 IQ 1
Quasi 2
Setting 2+3 3 3 31, 60, 67 RCT 2 HIC 0 AQ 2
Obs LMIC 3 IQ 1
Quasi 1
Setting 1+3 1 1 30 RCT 1 HIC AQ 1
Obs 0 LMIC 1 IQ 0
Quasi 0

RR, relative risk; 95% CI, 95% confidence interval; RCT, randomized controlled trial; Obs., observational study; Quas, quasiexperimental design; HIC, high income
country; LIC, low income country; AQ, adequate quality; IQ, inadequate quality.

Appendix 2 Summary of studies included for exclusive breastfeeding


Estimates Studies Reference Nos. Design Country Quality

Health systems and services (1)


Overall 51 46 16, 12, 15, 27, 33,34, 44, 46, 52, 63, 64, 78, RCT 18 HIC 30 AQ 19
80, 89, 91, 93, 96, 106, 108, 110, 113, 117, Obs 16 LMIC 21 IQ 32
118, 119, 123, 124, 129, 131, 132, 136, 138, Quas 17
140, 141, 143, 146, 148, 152, 177, 179, 180,
187, 189, 190, 196, 200, 204
Home and family environment (2)
Overall 43 36 14, 19, 21, 22, 29, 32, 45, 61, 65, 68, 71, 73, 75, RCT 31 HIC 24 AQ 16
79, 86, 105, 107, 115, 125, 133, 134, 135, 140, Obs 0 LMIC 19 IQ 26
142, 151, 158, 159, 165, 166, 167, 173, 174, Quas 12
178, 181, 185, 203
Community environment (3)
Overall 6 3 25, 157, 184 RCT 0 HIC 1 AQ 0
Obs 0 LMIC 5 IQ 6
Quas 6
Work environment (4)
Overall 4 1 26 RCT 0 HIC 4 AQ 0
Obs 0 LMIC 0 IQ 4
Quas 4
Policy environment (5)
No studies

©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135 133
Interventions to improve breastfeeding Sinha et al.

Appendix 2 (Continued)

Estimates Studies Reference Nos. Design Country Quality

Combination of setting (6)


Setting 1+2 16 14 13, 17, 18, 53, 69, 86, 98,102, 103, RCT 13 HIC 10 AQ 5
127, 128, 131, 147, 153 Obs 0 LMIC 6 IQ 11
Quas 3 0
Setting 2+3 3 3 31, 60, 67 RCT 2 HIC 0 AQ 2
Obs 0 LMIC 3 IQ 1
Quas 1
Setting 1+3 7 7 30, 94, 109, 154, 170, 183, 192 RCT 4 HIC 4 AQ 2
Obs 0 LMIC 3 IQ 5
Quas 3

RR, relative risk; 95% CI, 95% confidence interval; RCT, randomized controlled trial; Obs., observational study; Quas, quasiexperimental design; HIC, high income
country; LIC, low income country; AQ, adequate quality; IQ, inadequate quality.

Appendix 3 Summary of studies included in continued breastfeeding


Estimates Studies Ref. No. Design Country Quality

Health systems and services (1)


Overall 8 8 16, 23, 35, 44, 96, 106, 144, 204 RCT 2 HIC 5 AQ 4
Obs 4 LMIC 3 IQ 4
Quasi 2
Home and family environment (2)
Overall 2 2 151, 199 RCT 2 HIC 2 AQ 2
Obs 0 LMIC 0 IQ 0
Quasi 0
Community environment (3)
No studies
Work environment (4)
Overall 1 1 51 RCT 0 HIC 1 AQ 0
Obs 1 LMIC 0 IQ 1
Quasi 0
Policy environment (5)
Overall 1 1 175 Obs 1 LMIC 1 IQ 1
Combination of setting (6)
Setting 1+2 6 6 17, 99, 103, 150, 158, 192 RCT 4 HIC 3 AQ 5
Obs 0 LMIC 3 IQ 1
Quasi 2
Setting 2+3 No studies
Setting 1+3 1 1 35 RCT 0 HIC 1 AQ 0
Obs 1 LMIC 0 IQ 1
Quasi 0

RR, relative risk; 95% CI, 95% confidence interval; RCT, randomized controlled trial; Obs., observational study; Quas, quasiexperimental design; HIC, high income
country; LIC, low income country; AQ, adequate quality; IQ, inadequate quality.

134 ©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135
Sinha et al. Interventions to improve breastfeeding

Appendix 4 Summary of studies included in any breastfeeding


Estimates Studies Ref. No. Design Country Quality

Health systems and services (1)


Overall 47 39 23, 28, 33, 35, 37, 38, 39, 46, 47, 52, 56, 64, 85, 91, RCT 11 HIC 36 AQ 30
93, 101, 106, 108, 110, 112, 131, 132, 144, 146, Obs 20 LMIC 11 IQ 17
151, 161, 163, 172, 177, 180, 186, 187, 191, 196, Quas 16
198, 200, 201, 204
Home and family environment (2)
Overall 36 34 41, 43, 47, 49, 54, 61, 68, 71, 74, 83, 87, 86, 95, 97, RCT 22 HIC 30 AQ 19
100, 105, 115, 121, 125, 134, 135, 151, 156, 159, Obs 5 LMIC 6 IQ 17
165, 168, 171, 174, 176, 178, 181, 199, 202, 203 Quas 9
Community environment (3)
Overall No studies
Work environment (4)
Overall 4 2 55, 84 RCT 0 HIC 4 AQ 0
Obs 4 LMIC 0 IQ 4
Quas 0
Policy environment (5)
Overall 1 1 164 Obs 1 HIC 1 AQ 0
LMIC 0 IQ 1
Combination of setting (6)
Setting 1+2 21 21 17, 18, 36, 46, 66, 78, 81, 90, 98, 99, 102, 103, 111, RCT 13 HIC 19 AQ 8
120, 128, 150, 153, 154, 155, 160, 205 Obs 1 LMIC 2 IQ 13
Quas 7
Setting 2+3 3 3 48, 60, 126 RCT 0 HIC 1 AQ 0
Obs 1 LMIC 2 IQ 3
Quas 2
Setting 1+3 6 5 30, 35, 75, 88, 94 RCT 2 HIC 5 AQ 4
Obs 1 LMIC 1 IQ 2
Quas 3

RR, relative risk; 95% CI, 95% confidence interval; RCT, randomized controlled trial; Obs., observational study; Quas, quasiexperimental design; HIC, high income
country; LIC, Low income country; AQ, adequate quality; IQ, inadequate quality.

Appendix 5 Studies for which RR could not be calculated


Author Name Year Ref. No.

Agrasada 2005 11
Anderson 1984 20
Baghurst 2007 24
Bonuck 2005 34
Chapman 2011 50
Lavender 2005 114
Lucchini 2013 122
Merewood 2006 130
Ryan 2006 164
Tarrant 2011 182

©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 114–135 135

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