Welcome!Support for healthy

breastfeeding mothers with healthy term babies: What's

the evidence?

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What’s the evidence? McFadden A, Gavine A, Renfrew M, Wade A, Buchanan P, Taylor J, et al. (2017). Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews, 2017(2), CD001141.

http://www.healthevidence.org/view-article.aspx?a=support-healthy-breastfeeding-mothers-healthy-term-babies-30167

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Poll Question #1

How many people are watching today’s session with you?

A. Just me

B. 2-3

C. 4-5

D. 6-10

E. >10

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Decision Making

inform

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1. Saves you time

2. Relevant & current evidence

3. Transparent process

4. Supports for EIDM available

5. Easy to use

A Model for Evidence-Informed Decision Making

National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

Stages in the process of Evidence-Informed Public Health

National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]

Poll Question #2

Have you heard of PICO(S) before?

A.Yes

B.No

Searchable Questions Think “PICOS”

1.Population (situation)

2. Intervention (exposure)

3.Comparison (other group)

4.Outcomes

5.Setting

How often do you use Systematic Reviews to inform a program/services?

A.AlwaysB.OftenC.SometimesD.NeverE.I don’t know what a systematic review is

Poll Question #3

Alison McFadden, Senior Research Fellow, Director, Mother and Infant Research Unit, School of Nursing and Health Sciences, University of Dundee

Anna Gavine, Research Fellow, School of Nursing and Health Sciences, University of Dundee

Why breastfeeding matters

• Impact on children’s and women’s health• For children: not breastfeeding

mortality/hospitalisation due to preventable disease

rates of childhood diabetes, obesity, dental disease

has adverse impact on IQ, educational and behavioural outcomes

Why breastfeeding matters

• For women: not breastfeeding – Associated with increased risk of breast and

ovarian cancer, and diabetes

– Lactational amenorrhoea increases birth spacing in contexts where other contraceptive options are not available

Breastfeeding recommendations

The World Health Organization recommends that:•infants should be breastfed exclusively until 6 months of age•with breastfeeding continuing as an important part of the infant’s diet until at least two years of age.

Breastfeeding Rates

High income countriesIn some countries - marked decline in breastfeeding after first few weeksLow rates of exclusivity up to 6 months and continuation beyond 12 months

• Low and middle income countries

Generally higher rates of breastfeeding duration than in HICS

Variable rates of exclusive breastfeeding for 6 months

World average 37%

Breastfeeding Support

Why is it needed?

•Multi-faceted barriers to breastfeeding– Societal – Health system– Individual

Breastfeeding Support

Support - complex intervention to address multi-faceted barriers to breastfeeding

Information/education – e.g. to dispel myths

Skills to manage breastfeeding – positioning and attachment, solving problems

Confidence and esteem-building

Practical support – help with other tasks

Social support – creating supportive networks

Breastfeeding Support

• By different people: health professionals/lay people

• In different settings: hospital or community

• To groups of women or one-to-one,

• Including family members (typically fathers or grandmothers) and wider communities

• Offered proactively or reactively

• Provided face-to-face, by telephone or through social media

• Involving only one contact or regular, ongoing contact over several months

Breastfeeding Support

• Often poor and inconsistent

• Lack of recognition of policy makers and service commissioners of importance of breastfeeding

• Lack of investment

• In many health settings, health practitioners lack in-depth knowledge and skills

Global policy context

• UNICEF/WHO updating Baby-friendly hospital initiative guidance 2017– Guidelines on patient care (Ten Steps to

Successful Breastfeeding)– Implementation guidance for national

programmes (BFHI)

• Update involves 21 systematic reviews on the Ten Steps

Objectives1. To describe forms of breastfeeding support which have been evaluated in controlled studies, the timing of the interventions and the settings in which they have been used.

2. To examine the effectiveness of different modes of offering similar supportive interventions (for example, whether the support offered was proactive or reactive, face-to-face or over the telephone), and whether interventions containing both antenatal and postnatal elements were more effective than those taking place in the postnatal period alone.

3. To examine the effectiveness of different care providers and (where information was available) training.

4. To explore the interaction between background breastfeeding rates and effectiveness of support.

Cochrane Systematic Reviews

• A systematic review is a review of a clearly formulated question that

uses systematic and explicit methods to identify, select, and critically

appraise relevant research, and to collect and analyze data from the

studies that are included in the review. Statistical methods (meta-

analysis) may or may not be used to analyze and summarize the results

of the included studies. Meta-analysis refers to the use of statistical

techniques in a systematic review to integrate the results of included

studies (Cochrane Collaboration, Cochrane.org)

By Cochrane Collaboration (en:File:Cclogo.svg) [Public domain], via Wikimedia Commons

Methods: Inclusion Criteria• Study design:

• Randomised or quasi-randomised trials including cluster-randomised trials.

• Types of participants:• Healthy pregnant women considering/intending breastfeed or

healthy women breastfeeding healthy babies

• Types of interventions: • Support supplementary to standard care;• Offered by health professionals or lay people;• May or may not include training;• Group care or individual;• In hospital, in the community or remotely;• Proactive or reactive• Antenatal and postnatal or postnatal only

Primary Outcomes

• Stopping any breastfeeding before 4-6 weeks

• Stopping any breastfeeding before 6 months

• Stopping exclusive breastfeeding before 4-6 weeks

• Stopping exclusive breastfeeding before 6 months

Methods: Search Strategy and Study Selection

• Cochrane Pregnancy and Childbirth Group’s Trial register was searched for trials published between October 2011 and February 2016.

• No limits on language

• Two review authors independently screened the reports (n=162).

Data Extraction• Data on study design, participants, setting, characteristics of the intervention,

outcomes was extracted.• Independently checked by a second reviewer

Assessment of Risk of Bias

• Risk of bias assessed using the Higgins Risk of Bias tool (2011) which looks at following domains:

• Random sequence generation

• Allocation concealment

• Blinding of participants and personnel

• Blinding of outcome assessment

• Incomplete outcome data

• Selective Reporting

• Other bias…

GRADE

• Assessment of quality of the evidence. Looks at:

• Type of evidence

• Risk of bias

• The consistency of the effect between or within

studies

• Generalisability of the populations and outcomes

• Effect size

Results of the Search

Assessed 163 reports

Included a further 31 studies

Full review now consists of 100 studies involving more than 83,246 mother-infant pairs

73 studies contribute data

58 individually-randomised trials

15 cluster-randomised trials

Study settings and participant numbers

Characteristics of Included Studies: ParticipantsSocio-economic and health status•Women from general healthy populations•28 studies of women form low-income groups

Background rates of breastfeeding initiation

Inverse relationship between country income status and breastfeeding rates

All studies with initiation rates <80% were in HICS

All studies from LICS hade initiation rates >80%

Characteristics of Included Studies: Intervention• Level of intervention

– women (64) – education of health care practitioners (8)– policy (1)

• Characteristics of interventions

– proactive (63)/ reactive (8)

– one-to one (58)/ group (2)/ both (1)/ couples (1)– professional (49)/ lay (15/ both (9)– trained (50)– face-to-face (38)/ telephone (4)/ both (30)

Characteristics of Included Studies: Intervention• Characteristics of interventions

– postnatal only (49)/ antenatal +postnatal (25)• Intensity

– ≤3 contacts (24)/ 4-8 contacts (21)/ ≥9 (17)

Control group careBFHI accredited settings (6)

Remainder ‘standard care’/ not described

Risk of Bias in Included Studies

McFadden et al. (2017). Figure 1. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Effect of Interventions: Stopping any breastfeeding at 4-6 weeks

• Measured by a total of 33 studies including 10,776 women

• 31.3% of women intervention vs 34.8% of women in the control groups stopped any breastfeeding by 6 weeks.

• Relative Risk: 0.87, 95% CI 0.80-0.95

• GRADE: Moderate quality

Effect of Interventions: Stopping any breastfeeding up to six months

• Measured by a total of 40 studies including 14,227 women

• 52.9% of women intervention vs 56.64% of women in the control groups stopped any breastfeeding by 6 months.

• Relative Risk: 0.91, 95% CI 0.88-0.95

• GRADE: Moderate quality

Effect of Interventions: Stopping exclusive breastfeeding at 4-6 weeks

• Measured by a total of 32 studies including 10,960 women

• 57.2% of women intervention vs 65.0% of women in the control groups stopped exclusive breastfeeding by 6 weeks.

• Relative Risk: 0.79, 95% CI 0.71-0.81

• GRADE: Moderate quality

Effect of Interventions: Stopping exclusive breastfeeding up to six months

•Measured by a total of 46 studies including 18,591 women

•74.9% of women intervention vs 83.4% of women in the control groups stopped exclusive breastfeeding by 6 months.

•Relative Risk: 0.88, 95% CI 0.85-0.92

•GRADE: Moderate quality

Subgroup Analysis: Who delivered the support

•Majority of studies the intervention was delivered by professionals

•For cessation of exclusive breastfeeding up to 6 months, greater treatment effects were associated with interventions delivered by non-professionals

•For cessation of any breastfeeding up to 6 months and exclusive breastfeeding at 6 weeks there was a possible treatment effect

•For cessation of any breastfeeding at 4-6 weeks there was no evidence of any difference

Subgroup Analysis: Type of Support

•Compared face-to-face, with telephone and telephone + face-to-face

•For cessation of exclusive breastfeeding at 6 weeks and 6 months there was some evidence in favour of interventions delivered face-to-face

•For cessation of any breastfeeding at 6 weeks and 6 months there was no evidence to favour a particular type of support

Subgroup Analysis: When the support was offered

•Compared postnatal only with antenatal +postnatal

•No differences in effect size for any outcome

Subgroup Analysis: Proactive vs Reactive

•All studies included at least 1 proactive contact so sub-group analysis not appropriate

Subgroup Analysis: Background Breastfeeding Initiation Rates

•Compared high background rates (>80%) with intermediate rates (60-80%) with low (<60%).

•For cessation of exclusive breastfeeding at 6 weeks and 6 months, the intervention effect was greater in areas with high background rates

•For cessation of any breastfeeding at 6 weeks and 6 months there was no evidence of a difference in intervention effect

Subgroup Analysis: Intensity of Intervention

•Compared < 4 contacts; 4-8 contacts; >8 contacts; and unspecified number of contacts

•For cessation of exclusive breastfeeding at 6 weeks and 6 months, the intervention effect was greatest for women receiving 4-8 contacts

•For cessation of any breastfeeding at 6 weeks and 6 months there was no evidence of a difference in intervention effect

Strengths and Limitations

• Large number of trials and participants across all country income settings

• Rigorous review methods to minimise bias in the review process

• Reporting of studies not always clear• Possible publication bias• Very diverse interventions

• Wide variation in study endpoints

• Overall risk of bias in studies mixed

Implications for Practice

• When breastfeeding support is offered to women, the duration and exclusivity of breastfeeding is increased

• Characteristics of effective support – offered as standard by trained personnel during antenatal or

postnatal care– includes ongoing scheduled visits so that women can predict

when support will be available, – tailored to the setting and the needs of the population group– offered by professional or lay/peer supporters, or a combination

of both– strategies that rely mainly on face-to-face support are more likely

to succeed with women breastfeeding exclusively

Implications for Research

• Large number of trials• Future research could focus on identifying how

such support can best be provided consistently, for all women, in all countries– scaling-up– implementation and quality improvement

approaches

Implications for ResearchFurther research needed on:

•training programmes (which should be well-defined and reproducible) •develop the theoretical basis for •analyse elements have impact

– training, timing, intensity

– differential impact on different population subgroups

•establish the cost-effectiveness of different interventions;•investigate strategies for supporting women who wish to breastfeed for longer than six months;

Poll Question #4

The information presented today was helpful

A.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

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Poll Question #5What are your next steps? [Check all

that apply]

A.Access the full text systematic reviewB.Access the quality assessment for the

review on www.healthevidence.org C.Consider using the evidence D.Tell a colleague about the evidence

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