Primary Care Interventions to Support Breastfeeding: A Research Review

Editor’s Note: Throughout National Breastfeeding Month, FACTS will raise awareness about breastfeeding through research reviews and interviews, including stories of several patients who benefited from using the Lactational Amenorrhea Method (LAM). This week, Dr. Nikita Satapathy summarizes evidence analyzed by Patnode et al that supported the update in the U.S. Preventive Services Task Force (USPSTF) recommendations for breastfeeding. Their systematic review [i] was published in JAMA in 2016.

Introduction

Breastfeeding has numerous benefits for both mother and baby. It fosters bonding between mother and child, promotes gastrointestinal functions in the infant, and provides immunological protection. Most medical organizations recommend breastfeeding for at least six months. Yet, CDC data from 2002-2012 reveal that although 80% of infants in the U.S. have been breastfed, only about 21.9% are breastfed exclusively until at least the 6-month mark. The primary aim of the systematic reviewⁱ conducted by Patnode et al was to examine primary care interventions to promote breastfeeding and advance maternal and child health by helping update the 2008 U.S. Preventative Services Task Force recommendations.

Methodology

The report evaluated fifty-two studies that were included in the 2008 reviews that influenced the USPSTF recommendations for breastfeeding. It also considered new relevant English-language literature published between 2008 and 2015. The studies were reviewed for effects of prenatal, peripartum, and postpartum breastfeeding interventions that were started or referred from primary care settings. They were further examined for infant health outcomes (i.e., asthma, otitis media, respiratory illnesses, gastrointestinal illnesses), maternal health outcomes (i.e., breast cancer incidence and postpartum weight loss), and adverse effects that could have occurred with breastfeeding interventions.

The report focused on three key questions:

What are the effects of prenatal, peripartum, and postpartum individual and health care system-level interventions to promote and support breastfeeding on short- and long-term child and maternal health outcomes?
What are the effects of prenatal, peripartum, and postpartum individual and health care system-level interventions to promote and support breastfeeding on initiation, duration, and exclusivity of breastfeeding?
Are there adverse events associated with interventions to promote and support breastfeeding?

The findings were separated by study, population, and intervention characteristics and outcomes based on each key question. When assessing individual-level interventions with breastfeeding, the raw number of breastfeeding events in each treatment and total number of participants were randomized, and then divided into five distinct cross-sectional time points: breastfeeding initiation (birth to 1 week postpartum), breastfeeding less than 3 months, 3 months to less than 6 months, 6 months, and 12 months.

Results

Results were compiled from 2,769 titles, 211 articles, and 52 studies reported in 57 publications, with 21 studies from the previous review being carried forward in the updated review. Six of the 52 studies reported the effects of breastfeeding interventions on infant health outcomes; 1 trial within this group found that the control group was more likely to have 1 or more diarrheal episodes compared to the intervention group during the 3-month follow up period, and this was supported by higher rates of breastfeeding. However, other trials did not report statistically significant differences in the rates of GI illness, otitis media, or healthcare visits for respiratory tract illnesses between the control and intervention groups.

Individual-level support and education interventions for breastfeeding were found to have a statistically significant higher likelihood of any exclusive breastfeeding for less than 3 months, 3-6 months, and for exclusive breastfeeding at 6 months. In 17 studies, there was a positive association between individual-level support interventions and exclusive breastfeeding at 6 months. Interventions delivered at more than one period (e.g., prenatal and postpartum) showed a statistically significant association with any type of breastfeeding for less than 3 months. However, due to variability in the types of interventions (face-to-face support, telephone support, peer support), there was no evidence of effect modification based on the type of intervention and breastfeeding status.

Nine studies showed no consistency in association between system-level changes from the Baby Friendly Hospital Initiative (BFHI)* and the rate of exclusive breastfeeding up to 16 weeks postpartum. However, a large observational study found a statistically significant higher rate of initiation of breastfeeding and exclusive breastfeeding at 4 weeks in women with lower education after starting BFHI. This did not apply to women overall or to women with higher education.

Two of the reported trials discussed adverse events related to breastfeeding intervention, with one reporting no significant difference in maternal state anxiety among women receiving postpartum care at home compared to those receiving usual care. Two women reported feeling anxious, less confident, and concerned about confidentiality in another trial conducted with a peer support intervention, while the remaining women in the group who received usual care did not experience these feelings.

Discussion

Based on the studies gathered for this review, individual-level breastfeeding support and education interventions did increase the relative likelihood of women breastfeeding up to 6 months and exclusively breastfeeding up to and at 6 months, compared to women who received usual care.

Treatment effects varied based on magnitude, precision, settings, and population characteristics. The modest effect that was seen across the trials was most likely related to the standard or usual care provided within many hospitals or healthcare settings in developed countries, with the magnitude of intervention contributing to the benefit above usual care. In addition, individual counseling and support within BFHI influenced the rate of breastfeeding more than a facility itself being BFHI accredited.

Several limitations were noted in this evidence-based review. There were no standardized breastfeeding definitions or timing of assessments; some studies referred to the World Health Organization definition for exclusive breastfeeding while others did not. Some studies had possible reporting bias, selection bias, and high attrition rates. In addition, the studies included in this review were from countries listed as “very high” on the 2014 United Nations Human Development Index, which left out a widely cited trial from Belarus about system-wide interventions on infant health outcomes and breastfeeding outcomes.

Conclusion

While the data is still limited, there is updated evidence to support that breastfeeding support interventions lead to increased rates of any and exclusive breastfeeding. More studies need to be included in the future to examine effects based on demographic data, population statistics, and maternal health. More research is also needed relating to interventions that can be provided in workplace settings to promote breastfeeding and maternal health.

* The Baby Friendly Hospital Initiative (BFHI) is a policy to provide breastfeeding support groups for breastfeeding women and pregnant mothers.

Editor’s Note: Below is an abridged list of articles previously published in the FACTS blog that address breastfeeding as well as the Lactational Amenorrhea Method:

References

[i] Patnode CD, Henninger ML, Senger CA, Perdue LA, Whitlock EP. Primary Care Interventions to Support Breastfeeding: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016;316(16):1694–1705. doi:10.1001/jama.2016.8882.

About the Author

Nikita Satapathy, DO

Nikita Satapathy, DO attended medical school at Kansas City University of Medicine and Biosciences. She completed the FACTS fertility awareness elective as a fourth-year medical student and is currently an internal medicine resident in Phoenix, Arizona. She enjoys educating her patients about women’s health and hopes to get involved with public policy to promote women’s equality in all aspects of healthcare and beyond.

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