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Breastfeeding Promotion Interventions on Breastfeeding Rates

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Imdad A, Yakoob MY, Bhutta ZA.  Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries.  BMC Public Health. 2011; 11 (Suppl 3): S24.


  • Breast-milk has a significant positive impact on child growth and development and decreases the risk for many acute and chronic diseases (1-6), including diarrhea and respiratory tract infections during infancy (7). It also confers benefits on the mother such as reduced postpartum bleeding and early uterine involution (8).
  • The WHO recommends exclusive breastfeeding (EBF) for the first six months of life (9).  Thereafter, appropriate complementary foods should be introduced, while breastfeeding continued up to two years of age or beyond.
  • Exclusive breastfeeding (EBF) remains uncommon in most countries (both developed and developing), even in countries with high rates of breastfeeding initiation (10, 11).  EBF rates in infants less than six months of age varied from as low as 20% in central and eastern European countries to 44% in South Asia (12).
  • Breastfeeding interventions included in this review involved 1) formal or structured breastfeeding education defined as one-to-one or group education sessions; 2) professional support divided into system level support involving interventions at mass level; 3) lay support in which there was social support from peers.

Intervention Effects

Breastfeeding Interventions on EBF at 4-6 Weeks Postpartum

  • 43% increase in EBF (RR: 1.43; 95% CI 1.28-1.60) – 32 studies (high quality of evidence)
  • Sub-group analysis revealed an 89% significant increase in developing countries (RR: 1.89; 95% CI 1.50-2.37), and a 20% significant increase in developed countries
  • Sub-group analyses according to timing of intervention showed that prenatal, postnatal and combined all had statistically significant impacts, the highest impact on EBF was with prenatal counseling. 
  • Results were statistically significant at all levels of care (community, facility and both combined) as well as all modes of delivery (education, professional support and lay support)
  • Group counseling (67% increase) had a greater impact (RR: 1.67; 95% CI 1.23-2.26) than individual counseling (38% increase) on EBF

Breastfeeding Interventions on EBF at 6 Months Postpartum

  • 137% increase in EBF at 6 months postpartum- 15 studies (high quality of evidence)
  • Sub-group analysis revealed a 6 times increase in EBF in developing countries (RR: 6.32; 95% CI 3.35-11.93), and a 1.3 fold increase in developed country studies
  • Both prenatal and postnatal counseling were important for EBF at 6 months
  • Lay support had a significant impact, while education alone failed to achieve statistical significance.
  • Results were statistically significant for individual counseling (RR: 2.60; 95% CI 1.13-5.96) but not for group counseling (RR: 2.03; 95% CI 0.85-4.85)
  • No difference according to the level of care – all sub-group results were statistically insignificant

Breastfeeding Interventions on Any Breastfeeding at 4-6 Weeks Postpartum

  • 10% increase – 22 studies (high quality of evidence)
  • Prenatal and postnatal alone each had significant impacts (the combination of prenatal and postnatal counseling did not have any impact).

Breast feeding Interventions on Any Breastfeeding at 6 Months Postpartum

  • 12% increase (RR: 1.12; 95% CI: 1.01-1.24) – 20 studies (high quality of evidence)
  • The results for developing and developed countries separately showed no significant impact
  • The impact was only significant if the promotion was given in prenatal and postnatal periods combined.

Intervention Recommendation

  • Breastfeeding promotion interventions increased exclusive and any breastfeeding rates at 4-6 weeks and at 6 months.  The authors recommend estimates using the studies from developing countries:
    • 89% increase in EBF at 4-6 weeks (RR: 1.89; 95% CI 1.50-2.37) and a 6-fold increase at 6 months (RR: 6.32; 95% CI 3.35-11.93) from promotion interventions 
    • For EBF at 4-6 weeks, group counseling (RR: 1.67; 95% CI 1.23-2.26) had greater impact compared to individual counseling (RR: 1.38; 95% CI 1.22-1.56)
    • For EBF at 6 months, individual counseling (RR: 2.60; 95% CI 1.13-5.96) attained statistical significance and had a positive effect while group counseling showed no effect

References from Imdad Paper Cited Here

  1. Breastfeeding and the use of human milk. American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeed Rev. 1998;6(1):31–36.
  2. Birch E, Birch D, Hoffman D, Hale L, Everett M, Uauy R. Breast-feeding and optimal visual development. J Pediatr Ophthalmol Strabismus. 1993;30(1):33–38.
  3. Dewey KG, Heinig MJ, Nommsen-Rivers LA. Differences in morbidity between breast-fed and formula-fed infants. J Pediatr. 1995;126(5 Pt 1):696–702.
  4. Florey CD, Leech AM, Blackhall A. Infant feeding and mental and motor development at 18 months of age in first born singletons. Int J Epidemiol. 1995;24(Suppl 1):S21–26.
  5. Hanson LA, Wiedermann U, Ashraf R. Effects of breastfeeding on the baby and on its immune system. Food Nutr Bull. 1996;17:384–389.
  6. Lanting CI, Fidler V, Huisman M, Touwen BC, Boersma ER. Neurological differences between 9-year-old children fed breast-milk or formula-milk as babies. Lancet. 1994;344(8933):1319–1322. 
  7. Jalil F, Karlberg J, Hanson LA, Lindblad BS. Growth disturbance in an urban area of Lahore, Pakistan related to feeding patterns, infections and age, sex, socio-economic factors and seasons. Acta Paediatr Scand Suppl. 1989;350:44–54. 
  8. Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, Eidelman AI. Breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496–506. 
  9. Infant and young child nutrition: Global strategy on infant and young child feeding.
  10. Dimond HJ, Ashworth A. Infant feeding practices in Kenya, Mexico and Malaysia. The rarity of the exclusively breast-fed infant. Hum Nutr Appl Nutr. 1987;41(1):51–64.
  11. Perez-Escamilla R. Breastfeeding in Africa and the Latin American and Caribbean region: the potential role of urbanization. J Trop Pediatr. 1994;40(3):137–143.
  12. Infant and young child feeding (2000-2007)

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