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. 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. 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
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- 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
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- 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. 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
- 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. 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. 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. Poll Question #2 Have you heard of PICO(S) before? A.Yes B.No
- 14. Searchable Questions Think “PICOS” 1.Population (situation) 2.Intervention (exposure) 3.Comparison (other group) 4.Outcomes 5.Setting
- 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. 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. 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. 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. 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. 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. Breastfeeding Support Why is it needed? •Multi-faceted barriers to breastfeeding – Societal – Health system – Individual
- 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. 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. 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. 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. 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. 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. 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. 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. 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. Data Extraction • Data on study design, participants, setting, characteristics of the intervention, outcomes was extracted. • Independently checked by a second reviewer
- 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. 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. 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. Study settings and participant numbers
- 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Subgroup Analysis: When the support was offered •Compared postnatal only with antenatal +postnatal •No differences in effect size for any outcome
- 47. Subgroup Analysis: Proactive vs Reactive •All studies included at least 1 proactive contact so sub-group analysis not appropriate
- 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. 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. 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. 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. 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. 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. Poll Question #4 The information presented today was helpful A.Strongly agree B.Agree C.Neutral D.Disagree E.Strongly disagree
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- 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. Thank you! Contact us: info@healthevidence.org For a copy of the presentation please visit: http://www.healthevidence.org/webinars.aspx
Editor's Notes
- Poll question #4
- here’s a look at the team many involved in the work to keep HE current and maintained
- Health Evidence launched in 2005 comprehensive registry of reviews evaluating the effectiveness of public health and health promotion interventions provide over 90,000 visitors per year access to over 4,600 quality-rated systematic reviews links to full text, plain language summaries, and podcasts (where available) One of main goals of Health Evidence, in addition to making evidence re: effectiveness of PH interventions more accessible, is to make it easier for professionals to use evidence in decision making
- Model for Evidence-Informed decision making in PH consists of 5 components visible in this diagram Traditionally public health practitioners and decision makers do consider evidence about community health issues and local context, existing resources, and community and political climate in making decisions about programs and policies however, it has become apparent that a considering evidence about research may be more challenging As such the Health Evidence webinar series is designed to identify research evidence relevant to public health decisions
- The EIPH wheel illustrates the steps involved in evidence-informed practice The wheel is a guide for practitioners and decision makers to determine how to address a particular issue by systematically incorporating research evidence in the decision making process There are 7 steps in the EIPH process that starts with: Clearly defining the problem; Searching the research literature; Appraising the evidence you find; Synthesizing or summarizing the research on your issue; Adapting and interpreting the findings to your local context; Implementing the evidence or appropriate intervention; and Evaluating your implementation efforts. We will hear today about how (presenter) has worked through the first 4 steps, in order to help with the decision makers with the remainder of the 7 steps
- Poll question #4
- Breastfeeding has a fundamental impact on the short-, medium- and long-term health of children and has an important impact on women’s health (Victora 2016). For children, good quality evidence demonstrates that in both low-, middle- and high-income settings not breastfeeding contributes to mortality due to infectious diseases (Sankar 2015), hospitalisation for preventable disease such as gastroenteritis, and respiratory disease (Horta 2013), otitis media (Bowatte 2015), increased rates of childhood diabetes and obesity (Horta 2015a), and increased dental disease (Peres 2015; Tham 2015). For women, there is good quality evidence that not breastfeeding is associated with increased risks of breast and ovarian cancer, and diabetes (Chowdhury 2015). Lactational amenorrhoea is associated with exclusive/predominant breastfeeding and increases birth spacing when other forms of contraception are not available (Chowdhury 2015). Not being breastfed has an adverse impact on intelligence quotient (IQ), and educational and behavioural outcomes for the child (Heikkilä 2014; Heikkilä 2011; Horta 2015b; Quigley 2012). For many outcomes a dose-response relationship exists, with the greatest benefit resulting from breastfeeding exclusively, with no added food or fluids, for around six months, with breastfeeding continuing thereafter as an important component of the infant’s diet (Kramer 2012). The negative impact of not breastfeeding has been demonstrated in a range of settings and population groups, though the balance of risks and benefits varies from setting to setting; for example, gastroenteritis will result in much higher mortality in low-income countries (Horta 2013).
- Cochrane collaboration founded in 1993. Have now published &gt;6000 systematic reviews many of which have informed national and international health policy.
- Healthy women and babies were considered those who did not require additional medical care (e.g. women with diabetes, women with HIV/AIDs, overweight or obese women) or surgical care (e.g. women who required a Caesarean Section). Studies which focused specifically on women with additional care needs were excluded. Very broad inclusion criteria in terms of intervention. We included any form of support to women that was supplementary to standard. Support included things such as praise, information and the opportunity for mothers to ask questions. It could also include training staff to improve supportive care given. Support could either be offered by healthcare professionals (eg midwives, obstetricians, lactation consultants) or lay people including peers We included interventions that provided one-to-one care or group care. Interventions could be delivered in hospital, primary care settings or other community locations or in the women’s home. We also included interventions where the support was delivered over the phone. Interventions could be proactive and by that we mean the person providing the intervention contacted the women. By reactive we mean that the women asked for support. The women did have to be breastfeeding in order to receive the support so we included interventions that were provided in the postnatal period. They could also have an antenatal component. However interventions delivered only in the antenatal period were excluded.
- Previous versions of the review did include stopping any or exclusive breastfeeding at other time points (two, three, four, nine and 12 months), measures of neonatal or infant morbidity, measures of maternal satisfaction of care. We had to complete this review in a very short period so we focused on these primary outcomes. A new set of core outcomes for Cochrane pregnancy and childbirth breastfeeding reviews is currently being developed and hopefully by the time we update this review we will be able to use them.
- Unlike other systematic reviews where you need to develop your own search strategy and search databases, CPG has created a database of all available reports of controlled trials related to pregnancy and childbirth. They do this through searching databases such as medline, cinahl and handsearching journals and conference proceedings. Two members of the CPG then allocate each report to a topic area. The list of all reports the topic area relevant to the review is then provided to review authors. As this review last updated in October 2011 we examined all reports published between then and Febuary 2016. 162 trials were categorised as related to lactation so we retrieved these and these were independently screened by 2 review authors. Any disagreements were resolved by discussing with a 3rd author. We did not have any restrictions on language and when non English papers were identified the CPG organised translation for us.
- First done using a data extraction form that we developed. Main challenge here was getting data into a format that we could use for the meta-analysis. What we need is just the raw data. However, often authors do not provide this so you need to work backwards from the statistics provided in the paper or contact the study author for more information. Then entered into revman
- This is the standard tool for assessing risk of bias in controlled trials. Each trial was assessed independently by 2 reviwers, Random sequence generation. Was this truly random (eg computer random number generator) or was the sequence generated by non random means (e.g. odd or even date of birth) Allocation concealment. We were looking at whether allocation could have been forseen and therefore manipulated in anyway. So looking for things like centralised randomisation procedure or the use of consecutive sealed envelopes to be classed as low ROB Blinding of participants and personnel. This refers to whether participants and staff providing the intervention or other healthcare providers knew whether they were receiving the intervention. Blinding of outcome assessment. Whether the staff collecting the outcome data knew which group the participant had been assigned to. Incomplete Outcome data. This looks at how many participants dropped out and if this varied between groups. As a rule of thumb we considered attrition of &gt;25% high ROB Selective Reporting. This involved checking that the study authors reported all the outcomes they said they would and were not omitting results. The main way we checked against this was comparison with the study protocol when available. Other bias included things like baseline imbalance, issues to do with clustering or contamination of the intervention
- Finally the quality of the evidence was assessed using GRADE. was developed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group to help make a systematic and explicit approach to making judgements about the strength of the evidence. This looks at things like the study design, risk of bias, amount of variation of the study effect sizes, generalisability of the studies and the effect size. Taking all this information into account an overall score of high, moderate, low or very low quality is made
- Studies conducted in 27 countries 4 LIC (Bangladesh, Burkina Faso, Uganda, Democratic Republic of the Congo) 4 LMIC (India, Kenya, Pakistan, Kenya) 8 UMIC (Belarus, Brazil, China, Iran, Malaysia, Mexico, Turkey, South Africa) 11 HIC (mainly UK and US) Australia, Canada, Denmark, Croatia, France, Hong Kong, Italy, Netherlands. Singapore, Sweden, UK (8), US (20)
- Lack of blinding or information about blinding of participants and personnel and outcome assessment was a big issue. Due to the nature of the intervention it was often not possible to blind women or staff providing the intervention. Also in the majority of studies data was collected in the form of self report so as the women were aware of intervention status the outcome assessors were not blinded. Another common issue was lack of a research protocol published before the study took place. This meant we were unable to compare the reported outcomes with the outcomes that were planned.
- This was a significant difference between the groups with women not receiving support being 13% less likely to be doing any breastfeeding at 6 weeks. When we took out the studies at risk of bias for allocation concealment the difference was still significance although the effect size very slightly reduced to 0.88 The quality was downgraded to moderate because of statistical heterogeneity suggesting varience in effect estimates. We didn’t downgrade because of risk of bias in any outcome because the sensitivity analysis was robust
- This was a significant difference between the groups with women not receiving support being 9% less likely to be doing any breastfeeding at 6 months When we took out the studies at risk of bias for allocation concealment the difference was still significance although again the effect size rediced to 0.93. Quality was downgraded because of statistical heterogeneity suggesting varience in effect estimates
- This outcome demonstrated the largest effect sizes. This was a significant difference between the groups with women not receiving support being 21% less likely to be exclusive breastfeeding at 6 weeks When we took out the studies at risk of bias for allocation concealment the difference was still significance although the effect size rediced to 0.8 in the studies at low rob. The study was downgraded to moderate quality because of statistical heterogeneity suggesting varience in effect estimates
- This was a significant difference between the groups with women not receiving support being 12% less likely to be exclusive breastfeeding at 6 months When we took out the studies at risk of bias for allocation concealment the difference was still significance although again the effect size rediced to 0.93 in the studies at low ROB The study was downgraded to moderate quality because of statistical heterogeneity suggesting varience in effect estimates
- The imbalance in sub-groups makes comparisons difficult. What we can say is that for exclusive breastfeeding at 6 months there was a statistical difference which supported interventions delivered by lay people. For cessation of any breastfeeding up to 6 months and exclusive breastfeeding at 6 weeks there was suggestion that larger intervention effects were associated with studies delivered by lay people. However we are not confident in these results as the number of trials with interventions delivered by lay people is much smaller than those delivered by professionals.
- Advise caution in interpreting results due to high levels of statistical heterogeneity (ie variance within the groups)
- This was a planned analysis that we did not undertake.
- the four studies from low-/low-middle income countries had the highest rates and All the studies with intermediate or low background rates of breastfeeding initiation were undertaken in high-income countries. The intervention effect was strongest for Exclusive breastfeeding at 6 weeks and 6 months in studies with initation rates showing the importance of interventions that also promote breastfeeding initation. There was no difference in intervention effect for any breastfeeding at 6 weeks or 6 months according to background initiation rates.
- Again we do advise caution in interpreting this result. Differences in the sub groups could also be explained by differences in risk of bias between studies with the studies with more pronounced treatment effects at greater risk of bias. There was also differences in the settings of visits with the studies offering more visits tending to be carried out face to face which may confound the results
- Reporting deficits - description of the components of the support intervention, details of the training and qualifications of the supporters, the definitions used of the extent of breastfeeding and in the description of adherence to the support protocol. failure to present details of the interventions and of the standard care available to both intervention and comparison groups. Very few of the trials described a theoretical basis for the intervention tested, with the result that the findings are difficult to explain or to replicate. Publication bias: Smaller studies showing a less beneficial effect of the intervention may be missing.
- This should be a check-box answer (i.e. select all that apply)