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Support for healthy breastfeeding mothers with healthy term babies: What's the evidence?

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Health Evidence hosted a 60 minute webinar examining breastfeeding support interventions for healthy breastfeeding mothers with healthy term babies. Click here for access to the audio recording for this webinar: https://youtu.be/fxDY-Q87xaY

Alison McFadden, Senior Research Fellow, Director, Mother and Infant Research Unit, School of Nursing and Health Sciences, University of Dundee and Anna Gavine, Research Fellow School of Nursing and Health Sciences, University of Dundee will be leading the session and presenting findings from their recent Cochrane review:

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.

Evidence suggests that not breastfeeding negatively impacts the health of both infants and mothers. Additionally, data demonstrates an inadequate uptake of the World Health Organization’s recommendations regarding type and duration of breastfeeding in many countries. This review examines the impact of breastfeeding support interventions on breastfeeding duration and exclusivity in healthy breastfeeding mothers with healthy term babies, compared to usual care. One-hundred trials with over 83,246 mother-infant pairs were included in this review. Seventy-three of the one-hundred trials were involved in the data analyses. Findings suggest that breastfeeding support interventions reduce cessation of ‘any breastfeeding’ before 4 to 6 weeks and 6 months, and cessation of ‘exclusive breastfeeding’ at 4 to 6 weeks and at 6 months. This webinar will provide an overview of the impact of support on breastfeeding duration and exclusivity in healthy breastfeeding mothers with healthy term babies.

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Support for healthy breastfeeding mothers with healthy term babies: What's the evidence?

  1. 1. Welcome! Support for healthy breastfeeding mothers with healthy term babies: What's the evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
  2. 2. Poll Questions: Consent • Participation in the webinar poll questions is voluntary • Names are not recorded and persons will not be identified in any way • Participation in the anonymous polling questions is accepted as an indication of your consent to participate Benefits: • Results inform improvement of the current and future webinars • Enable engagement; stimulate discussion. This session is intended for professional development. Some data may be used for program evaluation and research purposes (e.g., exploring opinion change) • Results may also be used to inform the production of systematic reviews and overviews Risks: None beyond day-to-day living
  3. 3. After Today • The PowerPoint presentation and audio recording will be made available • These resources are available at: – PowerPoint: http:// www.slideshare.net/HealthEvidence – Audio Recording: https://www.youtube.com/user/healthevidence/vide 3
  4. 4. 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
  5. 5. • Use CHAT to post comments / questions during the webinar – ‘Send’ questions to All (not privately to ‘Host’) • Connection issues – Recommend using a wired Internet connection (vs. wireless) • WebEx 24/7 help line – 1-866-229-3239 Participant Side Panel in WebEx Housekeeping
  6. 6. Housekeeping (cont’d) • Audio – Listen through your speakers – Go to ‘Communicate > Audio Broadcast’ • WebEx 24/7 help line – 1-866-229-3239
  7. 7. 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
  8. 8. The Health Evidence™ Team Maureen Dobbins Scientific Director Heather Husson Manager Susannah Watson Project Coordinator Students: Emily Belita (PhD candidate) Jennifer Yost Assistant Professor Olivia Marquez Research Coordinator Emily Sully Research Assistant Liz Kamler Research Assistant Zhi (Vivian) Chen Research Assistant Research Assistants: Claire Howarth Rawan Farran Kristin Read Research Coordinator
  9. 9. What is www.healthevidence.org? Evidence Decision Making inform
  10. 10. Why use www.healthevidence.org? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
  11. 11. 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]
  12. 12. 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]
  13. 13. Poll Question #2 Have you heard of PICO(S) before? A.Yes B.No
  14. 14. Searchable Questions Think “PICOS” 1.Population (situation) 2.Intervention (exposure) 3.Comparison (other group) 4.Outcomes 5.Setting
  15. 15. How often do you use Systematic Reviews to inform a program/services? A.Always B.Often C.Sometimes D.Never E.I don’t know what a systematic review is Poll Question #3
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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.
  20. 20. Breastfeeding Rates High income countries In some countries - marked decline in breastfeeding after first few weeks Low 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%
  21. 21. Breastfeeding Support Why is it needed? •Multi-faceted barriers to breastfeeding – Societal – Health system – Individual
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. Objectives 1. 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.
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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).
  31. 31. Data Extraction • Data on study design, participants, setting, characteristics of the intervention, outcomes was extracted. • Independently checked by a second reviewer
  32. 32. 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…
  33. 33. 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
  34. 34. 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
  35. 35. Study settings and participant numbers
  36. 36. Characteristics of Included Studies: Participants Socio-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%
  37. 37. 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)
  38. 38. 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 care BFHI accredited settings (6) Remainder ‘standard care’/ not described
  39. 39. 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.
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. Subgroup Analysis: When the support was offered •Compared postnatal only with antenatal +postnatal •No differences in effect size for any outcome
  47. 47. Subgroup Analysis: Proactive vs Reactive •All studies included at least 1 proactive contact so sub-group analysis not appropriate
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. 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
  53. 53. Implications for Research Further 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;
  54. 54. Poll Question #4 The information presented today was helpful A.Strongly agree B.Agree C.Neutral D.Disagree E.Strongly disagree
  55. 55. What can I do now? Visit the website; a repository of over 5,000+ quality-rated systematic reviews related to the effectiveness of public health interventions. Health Evidence™ is FREE to use. Register to receive monthly tailored registry updates AND monthly newsletter to keep you up to date on upcoming events and public health news. Tell your colleagues about Health Evidence™: helping you use best evidence to inform public health practice, program planning, and policy decisions! Follow us @HealthEvidence on Twitter and receive daily public health review- related Tweets, receive information about our monthly webinars, as well as announcements and events relevant to public health. Encourage your organization to use Health Evidence™ to search for and apply quality-rated review level evidence to inform program planning and policy decisions. Contact us to suggest topics or provide feedback. info@healthevidence.org
  56. 56. Poll Question #5 What are your next steps? [Check all that apply] A.Access the full text systematic review B.Access the quality assessment for the review on www.healthevidence.org C.Consider using the evidence D.Tell a colleague about the evidence
  57. 57. Thank you! Contact us: info@healthevidence.org For a copy of the presentation please visit: http://www.healthevidence.org/webinars.aspx

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