Effectiveness of community-based peer support for mothers to improve their breastfeeding practices: A systematic review and meta-analysis

Breastfeeding is associated with reduced mortality in children aged less than 5 years. We conducted a systematic review and meta-analysis (registered as PROSPERO 2015: CRD42015019105) to examine the effectiveness of community-based peer support for mothers on their breastfeeding practices as compared to mothers who have not received such a support. Methods We searched for evidence regarding community-based peer support for mothers in databases, such as PubMed/MEDLINE, the Cochrane Library, CINAHL, Web of Science, SocINDEX, and PsycINFO. We selected three outcome variables for breastfeeding practices, namely, exclusive breastfeeding duration, breastfeeding within the first hour of life, and prelacteal feeding. We conducted meta-analyses of the included randomized controlled trials and quasi-experimental studies. Results For our review, we selected 47 articles for synthesis out of 1,855 retrieved articles. In low- and middle-income countries, compared to usual care, community-based peer support increased exclusive breastfeeding at 3 months (RR: 1.90, 95% CI: 1.62–2.22), at 5 months (RR: 9.55, 95% CI: 6.65–13.70) and at 6 months (RR: 3.53, 95% CI: 2.49–5.00). In high-income countries, compared to usual care, peer support increased exclusive breastfeeding at 3 months (RR: 2.61, 95% CI: 1.15–5.95). In low- and middle-income countries, compared to usual care, peer support increased the initiation of breastfeeding within the first hour of life (RR: 1.51, 95% CI: 1.04–2.21) and decreased the risk of prelacteal feeding (RR: 0.38, 95% CI: 0.33–0.45). Conclusions Community-based peer support for mothers is effective in increasing the duration of exclusive breastfeeding, particularly for infants aged 3–6 months in low- and middle-income countries. Such support also encourages mothers to initiate breastfeeding early and prevents newborn prelacteal feeding.


Review question(s)
How effective are participatory mothers' group interventions in improving their feeding practices for children and their nutritional status?

Searches
We will search the following databases: PubMed/MEDLINE, Cochrane Library, CINAHL, Web of Science, SocIndex, PsycINFO. We will also hand search international organization databases and PhD thesis databases using the references of certain papers of interest. Searches will be limited to abstracts published in the English language and will be limited by year of publication from 1978 (Alma Ata declaration year, when community participation was first described as an important component of primary health care) to the end of March 2015.
Types of study to be included Randomized controlled trial (RCT), nonrandomized trials, cohort, quasiexperimental, observational, crosssectional studies, and other comparative observational studies as well as multiple case studies and evaluation reports. We will not include single case studies, letters, editorials, reviews, and books.

Condition or domain being studied
Child undernutrition contributes to about 45% of the 6.3 million child deaths every year (Liu et al., 2012, UNICEF, 2014. Undernutrition is caused by myriad of factors including poor feeding practices, childhood illnesses, and socio demographic disadvantages (Black et al., 2008). Ensuring optimal infant and young child feeding (IYCF) practices is the key to improve nutritional status and thus promote the survival, growth and development of the child (Kushwaha et al., 2014). Mothers are the primary caregivers of children in most communities. When mothers participate in group social activities, they are able to communicate with each other and exchange knowledge among themselves. Participatory mothers' group interventions have potential to improve IYCF practices and child's wellbeing (Lewycka et al., 2013). These interventions empower mothers through peer counseling and shared decision making (Younes et al., 2015). Evidence is scarce and inconsistent on the effectiveness of participatory mothers' group interventions on feeding practices and child's nutritional status. No systematic review has been conducted to examine such effectiveness and their effect on policy and practice. This systematic review aims to collate and summarize evidence on the effectiveness of mothers' groups in improving the feeding practices and nutritional status.

Participants/ population
Mothers of children under 5 years old Intervention(s), exposure(s) Inclusion criteria 1. Participatory interventions including peer nutrition counseling, shared decision making, grandmothers/elders to mother nutrition counseling OR 2. Nutrition focused participatory interventions involving mothers' groups with mothers themselves as key drivers. Exclusion criteria 1. Topdown nutrition interventions e.g. distribution of readytouse therapeutic foods (RUTF), blanket supplemental feeding programs, and cash transfer.

Comparator(s)/ control
We will include studies with and without control groups. If applicable, comparator will be comparable mothers' groups who have children under 5 years old and did not receive the interventions. We will also compare outcomes between pre and post intervention, where applicable. Data extraction, (selection and coding) Paired researchers will conduct the literature search and review the articles for eligibility. We will discuss disagreements on eligibility of study until a consensus is reached. If required, we will consult the supervisor for final decision.

Risk of bias (quality) assessment
We will assess each selected study for selection bias, performance bias, detection bias, attrition bias and reporting bias using GRADE criteria.

Strategy for data synthesis
We will conduct a descriptive analysis of individual studies according to the type of intervention, duration, outcome, quality and risk of bias. We will analyze the effectiveness of intervention, based on the nature of reported outcomes. If we find enough studies with quality data, we will conduct a metaanalysis to examine the effectiveness of mothers' groupbased empowerment interventions