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Effective Health Care Program

Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries

Systematic Review Draft

Open for comment through Jan 26, 2018

These draft report documents are available in PDF only (Draft Report [2.4 MB], Appendixes [3.2 MB]). People using assistive technology may not be able to fully access information in these files. For additional assistance, please contact us.

Purpose of Review

To summarize the effectiveness of community, workplace and health care system-based programs and policies aimed at supporting and promoting breastfeeding, and determine the association between breastfeeding and maternal health.

Key Messages

  • Baby-Friendly Hospital Initiative (BFHI) improves rates of breastfeeding initiation and duration.
  • Healthcare staff education or training related to breastfeeding alone does not improve rates of breastfeeding initiation.
  • For women enrolled in Special Supplemental Nutrition Program for Women, Infants and Children (WIC), peer-support interventions offered by WIC agencies may improve breastfeeding outcomes.
  • Breastfeeding is associated with reduced maternal risk of breast and ovarian cancer, hypertension, and type 2 diabetes.
  • Future research should assess the benefits of workplace, school-based, and other community-based interventions for improving rates of breastfeeding and consider whether certain interventions are more effective among groups of women who differ by socioeconomic factors.

Structured Abstract

Objectives. To summarize the effectiveness of community, workplace and health care system-based programs and policies aimed at supporting and promoting breastfeeding, and determine the association between breastfeeding and maternal health.

Data sources. We searched PubMed/MEDLINE, the Cochrane Library, CINAHL from January 1, 1980, to February 8, 2017 for studies relevant to the effectiveness of health care system-based, workplace, and community breastfeeding programs and policies. For evidence on breastfeeding and maternal health, we updated the 2007 AHRQ report on this topic and searched the same databases from November 1, 2005 to February 2, 2017. For studies of breastfeeding programs and policies, eligible studies included randomized controlled trials (RCTs), nonrandomized trials, systematic reviews and observational studies with a control group; we excluded primary-care based programs delivered as part of routine care. For studies related to breastfeeding and maternal health outcomes, we included systematic reviews, case-control and cohort studies.

Review methods. Pairs of reviewers independently selected, extracted data from, and rated the risk of bias of relevant studies; they graded the strength of evidence (SOE) using established criteria. We synthesized all evidence qualitatively.

Results. We included 128 studies (119 individual studies and 9 systematic reviews). Of these, 34 individual studies were relevant to the effectiveness of breastfeeding programs or policies and the remainder were relevant to one or more maternal health outcomes. Based on evidence from one large RCT (PROBIT) enrolling mothers (N=17,046) who intended to breastfeed and 5 observational studies (62,834) we graded the SOE for Baby Friendly Hospital Initiative (BFHI) as moderate for improving rates of breastfeeding duration over 12 months postpartum. Evidence from 7 observational studies (1,156,033 women) also demonstrates improved rates of breastfeeding initiation (low SOE); however, results are imprecise and the magnitude of benefit varies across studies. Low SOE supports the benefit of BFHI combined with home visits compared with BFHI alone. For non-BFHI healthcare system-based interventions, low SOE (4 studies) supports the conclusion that healthcare education or training related to breastfeeding (without additional breastfeeding support services) does not improve rates of breastfeeding initiation. Women, Infants, and Children (WIC, a federal supplemental nutrition program) interventions that focus on in-person or telephone based peer support are effective in improving rates of breastfeeding initiation and duration (low SOE). We found limited evidence for other (community-based) interventions and no studies that focused on workplace or school-based interventions or harms associated with interventions.

For maternal health outcomes, low SOE supports the conclusion that ever breastfeeding or breastfeeding for longer durations may be associated with a reduced risk of developing (any) breast cancer, luminal breast cancer, triple-negative breast cancer, epithelial ovarian cancer, hypertension and type 2 diabetes. We rated the evidence for association between breastfeeding and fracture low for no benefit. Due to heterogeneity and inconsistent results, we found insufficient evidence on whether breastfeeding is associated with postpartum depression, cardiovascular disease, or postpartum weight change.

Conclusions. The body of evidence for breastfeeding programs and policies was diverse in terms of interventions and settings. Current evidence supports the effectiveness of BFHI for improving rates of breastfeeding initiation and duration; however, evidence from one large RCT (PROBIT) has limited applicability, and observational studies do not clearly establish the magnitude of benefit. For women enrolled in WIC, low SOE supports peer-support interventions for improving breastfeeding outcomes. Although low SOE supports the association between breastfeeding and improved health outcomes (breast cancer, ovarian cancer, hypertension, and type 2 diabetes), methodological limitations specific to observational study designs does not establish that there is a causal association between breastfeeding and maternal health.