Question

• In mothers of healthy infants, do low-quantity intervention sessions, as compared to no intervention, increase the rate of exclusive breastfeeding?

Clinical Bottom Lines

1. Data from this study show significant increases in exclusive breastfeeding rates, both at individual times and on a consistent basis, with small numbers of education- and support-oriented home visits, with 6 being significantly superior to 3 across outcomes.
2. The surrounding literature on the topic shows that educational programs significantly increase rates of breastfeeding initiation and short-term (up to 3mo) continuation, where support-oriented interventions significantly increase short- and long (up to 6 mo) term breastfeeding rates. Baby-friendly hospitals, which incorporate both techniques, generate significantly better breastfeeding rates on follow-up than those without the designation do. Written materials and early mother-child contact do not significantly affect breastfeeding rates.

Summary of Key Evidence

1. 170 expectant mothers in San Pedro Martir, Mexico were screened, with 130 randomized, to a) no intervention, b) 3 home counseling sessions (1 prepartum), or c) 6 sessions (2 prepartum). All known pregnancies during the enrollment period were approached; only mothers who refused, moved out/were nonresident, or had fetal/neonatal death were excluded.
2. 50% of the six-visit group, 33% of the 3-visit group, and 12% of controls remained consistent exclusive breastfeeders throughout the 3-mo follow-up period. The 6-visit mothers remained significantly ahead at every individual data collection time since birth, but their lead widened at the six-week point (after a visit that only their group received).
3. Infants in the control group had a relative risk of at least one diarrhea episode in 1st 3 months of life that was 2.1 times that of infants in the collapsed intervention groups.

Additional Comments

• The initial and persistent lead of 6-visit mothers suggests that their extra pre-partum (mid-pregnancy) visit was the single most important variable in distinguishing them from the 3-visit mothers. 2 prepartum interventions bundled into regular prenatal care visits, and then one done in-hospital post-partum, might combine the economy of the three-visit group with much of the efficacy of 6 visits without requiring additional points of contact with the health care system beyond those already involved in standard obstetric care.
• Similarly, the additional marginal efficacy of the 6-week postpartum visit may be worth investigating further.
• The sample size of 170 pregnancies detected over 1.5 years in a population of 30,000 is equivalent to a crude birth rate of 3.7/1000 population/year, where Mexico's true crude birth rate is over 20. This suggests over 3/4 of births in that time period may not have been detected for inclusion.
• The non-milk food substances used in this population do vary significantly from those likely to be prevalent in the US population.
  

Citation

1. Morrow AL, Guerrero ML, Shults J, et al. Efficacy of home-based peer counseling to promote exclusive breastfeeding: a randomized controlled trial. Lancet 1999;353:1226-31.
2. Guise JM, Palda V, Westhoff C, et al. The Effectiveness of Primary Care-Based Interventions to Promote Breastfeeding: Systematic Evidence Review and Meta-Analysis for the US Preventive Services Task Force. Annals of Family Medicine.2003;1:70-8.
3. Merten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics. 2005;116:e702-8.
   

CAT Author: Stephanie Davis, MD

CAT Appraisers: Amanda Dempsey , MD

Date appraised: October 18, 2006