Interventions for promoting the initiation of breastfeeding
Information, education and communication (IEC) activities can help promote the initiation and successful continuation of breastfeeding. Information packs provided by commercial companies to pregnant mothers to encourage breastfeeding appear to have no benefit. There is a need to conduct large trials on this subject in under-resourced settings.
RHL Commentary by Jana AK
1. EVIDENCE SUMMARY
This review aimed to evaluate the effectiveness of interventions to increase the rate of initiation of breastfeeding. Three types health education interventions designed to increase the rate of initiation of breastfeeding were evaluated in the seven trials (1388 women) included in the review: breastfeeding promotion packs, early mother–infant contact, and population-based programmes. Six of the seven trials had been conducted among low-income women in the USA and one in Nicaragua. Pooled together, five small trial (involving 582 women) showed a significant beneficial effect on breastfeeding initiation rates with the use of breastfeeding promotion packs, irrespective of the type of package used (relative risk [RR] 1.53; 95% confidence interval [CI] 1.25 to 1.88). In another trial, postnatal support provided by specialists in addition to prenatal health education had additional benefits of increasing initiation rates (RR 2.18; CI 1.40 to 3.40) and the median duration of breastfeeding (Intervention: 84 days, Control: 33 days). Finally, the seventh was a study of 547 women that compared breastfeeding initiation rates using promotion packages prepared by noncommercial bodies with that produced by a formula milk company. The trial included a third intervention group which evaluated early rooming-in of 259 mother–infant pairs followed by prolonged separation during the rest of their hospital stay. These two interventions had no effect on improving breastfeeding initiation rates.
The trials were identified and retrieved using the Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Central Register of Controlled Trials and a comprehensive search up to October 2002 of databases such as MEDLINE, EMBASE, ERIC and CINAHL, the “grey literature” and relevant journals. Trials that focused on promotion of exclusive breastfeeding or prolonging its duration were excluded.
The quality and validity of the trials was evaluated independently and cross-checked. The effect of each type of intervention was calculated using individual and pooled relative risk estimates with 95% confidence intervals. Contrary to the convention of Cochrane reviews, in this review a relative risk of more than one indicates that the intervention has a more favorable effect on initiation rates than controls. Subgroup analysis was not possible because of paucity of studies and differences in the types of interventions.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
The definition of initiation of breast feeding, relating to the time at which the first breastfeed is given to the newborn infant, varies widely between studies. This is ill-defined in this review as some studies have defined initiation of breastfeeding as breastfeeding commenced in the hospital. Although initiation of breast feeding is a strong predictor of exclusive breastfeeding at four months of age (1), in many developing countries the rate has been found to be very low
In India, the overall rate of initiation of breastfeeding within 1 hr of birth is 15.8% with a national goal to increase the rate to 50% by 2007 (6). In developing countries in general, in addition to the influence of educational status and parity of mothers, initiation of breastfeeding is delayed for several days because of various social, cultural and religious beliefs (7).
2.2. Applicability of the results
In this review, six of the seven studies were conducted in the USA where socio-economic and cultural practices are far different from those in the developing world. In some under-resourced settings, more than two-thirds of all babies are delivered at home and more than half of them are assisted by a semi-skilled or an unskilled person (6). Pregnant mothers in these communities receive limited or no antenatal care. Thus there is little opportunity to counsel and educate mothers about breastfeeding prior to delivery. There is also very little scope to identify a lactation consultant or physician to assist these mothers. Therefore, alternative strategies are required that can be used in these circumstances.
A study in Bangladesh (5) showed that women with personal breastfeeding experience and little education could be trained over a period of 10 days to work as peer counsellors in the community. With home-based counselling, improvements were seen in breastfeeding practices—e.g. prevalence of exclusive breastfeeding and initiation of breastfeeding.
Providing commercial promotional packs to pregnant mothers to encourage breastfeeding is particularly common in urban areas. However, they appear to have no benefit and resources could be more effectively used for breastfeeding education.
Early mother–infant contact is essential to initiate and sustain breastfeeding as infants are most alert in the first hour of life and this is best time to initiate bonding
9). The lack of beneficial effect of early mother–infant contact in the study included in this review could be due to the brief period of rooming-in followed by prolonged separation. The World Health Organization recommends that mothers and infants should not be separated after birth unless there is an unavoidable medical reason (10).
2.3. Implementation of the intervention
Studies in India have shown that implementation of the Baby-Friendly Hospital Initiative improved the rates of initiation of breastfeeding. Training of health workers in lactation and breastfeeding management seemed to be the key factors in this success (11). Breastfeeding behavior can be promoted by a team of grassroots workers (trained birth attendants and midwives) through ongoing counselling during all possible contacts with mothers, including during home visits (12).
This review reiterates that information, education and communication (IEC) plays a crucial role in the initiation (and successful continuation of) breastfeeding. Population-specific interventions are necessary to educate and motivate pregnant mothers to initiate breastfeeding. Postnatal counselling in addition to prenatal education is important to achieve maximum benefits. Counsellors also need to refresh their skills and information in order to sustain their knowledge and enthusiasm (13). In developing countries, decisions regarding breastfeeding are often made by elders in the household. Decision-makers in the community and family need to be identified and counselling should include these individuals. The involvement and coordination of non-governmental organizations and governmental agencies in advocacy, information-sharing and training of health workers would help in achieving the targets for improvement in the initiation of breastfeeding.
In this review most trials on initiation of breastfeeding were conducted in the developed world with a small numbers of participants. There are no trials from developing countries that have evaluated initiation of breastfeeding as their primary objective. There is a need to conduct large, well-planned, randomized trials with uniform methodology that is especially applicable to under-resourced settings, keeping in mind the diverse social and cultural practices in different parts of the developing world. In settings where antenatal care attendance is low and home delivery is common the interventions tested should be community-based.
Sources of support: None
Acknowledgment: Dr. Kurien Anil Kuruvilla, Neonatology Unit, Christian Medical College, Vellore, Tamil Nadu, India
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This document should be cited as: Jana AK. Interventions for promoting the initiation of breastfeeding: RHL commentary (last revised: 20 February 2006). The WHO Reproductive Health Library; Geneva: World Health Organization.