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.
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.
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).
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.
Citation: Shakya P, Kunieda MK, Koyama M, Rai SS, Miyaguchi M, Dhakal S, et al. (2017) Effectiveness of community-based peer support for mothers to improve their breastfeeding practices: A systematic review and meta-analysis. PLoS ONE 12(5): e0177434. https://doi.org/10.1371/journal.pone.0177434
Editor: Robert K. Hills, Cardiff University, UNITED KINGDOM
Received: May 21, 2016; Accepted: April 27, 2017; Published: May 16, 2017
Copyright: © 2017 Shakya et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Appropriate breastfeeding practices improve child survival, health, and development . Globally, about 1.4 million child deaths are attributed to suboptimal breastfeeding . Exclusive breastfeeding (EBF) during the first 6 months of life can reduce child mortality by preventing diarrhea and pneumonia . Moreover, when breastfeeding is initiated early, it can reduce neonatal mortality [3, 4]. Therefore, the World Health Organization (WHO) recommends EBF until 6 months of age and breastfeeding initiation within the first hour of life.
Even though these recommendations were issued more than 25 years ago, breastfeeding rates still remain far below set targets in many countries . The EBF rates are well below 50% in most countries . For example, only 37% of infants living in low- and middle-income countries (LMICs), are exclusively breastfed . Infants living in high-income countries have even shorter breastfeeding duration. Globally, only about 50% of neonates are breastfed within their first hour of life . Professional health workers can help improve breastfeeding practices; however, in resource-limited settings, the lack of such health workers hinders effective breastfeeding promotion. Therefore, we have to depend on mothers themselves, as they are the primary caregivers. When mothers participate in groups for social activities or receive one-on-one counseling from another mother in the community, they can communicate with each other and exchange knowledge among themselves. Such one-on-one or group peer support for mothers allow them to support each other, helps in decision making and subsequently empowers them . Thus, these interventions have potential to improve breastfeeding practices and child wellbeing . Such interventions have therefore been considered as sustainable alternatives to counseling in primary health care settings . These are potentially lower cost interventions compared to those provided by professional health care workers .
Evidence is available on how effective peer support interventions for mothers (one-on-one or in a group) can be in improving breastfeeding practices, but the results remain inconsistent [10, 11]. We conducted this systematic review and meta-analysis to collate and summarize such evidence. We aimed 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.
We developed and followed a standard systematic review protocol (systematic review registration-PROSPERO 2015: CRD42015019105) in accordance with the PRISMA statement (S1 Table). We established four review teams, each one comprised of two researchers who worked independently to search, extract data, review, and assess the quality of the studies. We settled any disagreements among the review team via discussions until reaching a unanimous decision.
Types of participants.
We reviewed studies involving mothers of children less than five years of age.
Types of interventions.
Studies were eligible if they focused on one-on-one and/or group peer support for mothers, including peer nutrition counseling, shared decision making, grandmothers/elders-to-mother nutrition counseling. We also included studies that had nutrition-focused participatory interventions involving mothers themselves as key drivers. We excluded studies that included top-down nutrition interventions, such as the distribution of ready-to-use therapeutic foods, supplemental blanket feeding, and cash transfer.
Types of outcomes.
The primary outcome of the original study protocol was the child's nutritional status (assessed by being underweight, the presence of stunting and/or wasting), and the secondary outcome was child feeding practices (including breastfeeding and other feeding practices). However, we did not find a sufficient number of eligible studies that analyzed the role of community-based interventions on child nutritional status and feeding outcomes, such as complementary feeding, feeding frequency, and dietary diversity. Therefore, we focused on breastfeeding practices. We utilized WHO definition of EBF and defined EBF duration as the period when an infant receives only breast milk without any other liquids or solids, including water and expressed breast milk. We included breastfeeding initiation within the first hour of life and prelacteal feeding as post-hoc additional outcomes. We defined prelacteal feeding as any food or fluid provided to a newborn before initiation of breastfeeding.
We conducted the search process in six medical databases. These were as follows. PubMed/MEDLINE, the Cochrane Library, CINAHL, Web of Science, SocINDEX, and PsycINFO. We used the following search strategy for the PubMed/Medline database: (((((((((group, women's[MeSH Terms]) OR groups, women's[MeSH Terms]) OR club, mothers'[MeSH Terms]) OR mothers[MeSH Terms]) OR clubs, mothers[MeSH Terms]) OR mother's group) OR mother's groups)) AND (((((((((empowerment[MeSH Terms]) OR community based participatory research[MeSH Terms]) OR participatory research, community based[MeSH Terms]) OR participatory intervention) OR peer groups[MeSH Terms]) OR peer group[MeSH Terms]) OR counseling[MeSH Terms]) OR peer counseling) OR shared decision making[MeSH Terms])) AND (((((((((((nutritional status[MeSH Terms]) OR sciences, child nutritional[MeSH Terms]) OR nutritional index[MeSH Terms]) OR anthropometry[MeSH Terms]) OR nutrition) OR feeding pattern[MeSH Terms]) OR feeding behavior[MeSH Terms]) OR feeding behaviors[MeSH Terms]) OR feeding practice) OR complementary feeding[MeSH Terms]) OR breastfeeding[MeSH Terms]) AND (("1978"[Date—Publication]: "2015"[Date—Publication])). Then we used similar keywords to search in the other databases selected.
We also searched international organization databases such as the World Bank, UNICEF, and the WHO databases. We used the cited references of retrieved articles to hand search. We limited all the evidence to abstracts published in the English language between 1978 to the end of March 2015. The year 1978 was selected because the Alma Ata declaration was made in this year, and it emphasized community participation as an important primary health care component.
We allocated the searched and selected articles equally among the four review teams. Then, two researchers in each review team independently performed the eligibility assessment in a blinded standardized manner.
Assessment of risk of bias
The two researchers in each review team independently assessed the risk of bias for the studies included. We used the risk of bias assessment tool developed by Cochrane collaboration for assessing RCTs and quasi-experimental studies . For observational studies, we used "Risk of Bias Assessment Tool for Nonrandomized Studies" (RoBANS) criteria . We evaluated the risk of bias for RCTs and quasi-experimental studies based on the following criteria: sequence generation/randomization, allocation concealment, blinding of participants, blinding of outcome assessment, incomplete outcome data, and selective outcome reporting and other potential biases. For non-RCTs, risk of bias was assessed based on criteria, such as the selection of participants, consideration of confounding variables, appropriate measurement of exposure, blinding of outcome assessments, completeness of outcome data, and how outcomes were reported. We looked for an explanation for each criterion (of Cochrane tool or RoBANS) in the studies and judged them as low, unclear, or high risk of bias. Any disagreements were settled through discussion and unanimous agreement among the reviewers.
The two researchers in each review team independently extracted the data and entered it in a standardized data extraction matrix. The following information was retrieved during data extraction: study location, design, participants, type of intervention, training of the mothers, the presence of professional help, the comparison group, and reported outcomes of interest.
A meta-analysis of RCTs and quasi-experimental studies using Review Manager (Revman) 5.1 software was conducted. We used a random effect model of meta-analysis throughout and presented results as risk ratios (RRs) with their 95% confidence intervals (CI).
We conducted the meta-analyses by stratifying the studies into LMICs and high-income countries as defined by the World Bank . We also conducted subgroup analyses by EBF duration. The strategy for these analyses was planned during the data extraction stage. We estimated the percentage of variability across studies attributable to heterogeneity with the I2 statistic. We also performed sensitivity analysis, where appropriate, to evaluate whether pooled effect sizes were robust across the components of risk of bias.
We included 22 studies in the meta-analyses of different outcomes. We excluded two studies that assessed multifaceted interventions. Such multifaceted interventions make it difficult to isolate and attribute the effect of peer support for mothers [17, 18]. We also excluded one study, owing to the lack of a comparison group .
General characteristics of the selected studies
Fig 1 demonstrates the selection process and search results. Following an extensive literature search, 1,855 articles were retrieved. After removing the duplicates, 64 articles were eligible for full text review. Among them, 17 articles did not meet the inclusion criteria (S2 Table). Finally, a total of 47 articles were included in the systematic review.
Table 1 presents a summary of the descriptive characteristics and the results of 47 studies included in this review. Of them, 27 studies were conducted in high-income countries and 20 in LMICs. One study was conducted in three LMICs of sub-Saharan Africa (Burkina Faso, South Africa, and Uganda) . Of 47 studies, 20 were conducted in Northern America (USA and Canada), three in Latin America (Brazil and Mexico), three in Western Europe (UK), one in Western Asia (Turkey), nine in Southern Asia (India and Bangladesh), one in Eastern Asia (China), one in South-Eastern Asia (Philippines), three in Eastern Africa (Uganda, Malawi and Kenya), one in Western Africa (Burkina Faso), and one in Southern Africa (South Africa). In total, 22 studies were conducted in urban settings, 19 in rural settings, one in a mixed setting, and seven did not specify their settings. Of the total 47 studies, 28 were RCTs, 13 were quasi-experimental studies, and six were observational studies. Two articles presented the results of the same RCT but with different outcome variables [21, 22].
We noted differences in the inclusion criteria of the study populations. The enrollment period for mothers varied among the studies, from any time during the antenatal period, either the first, second or third trimester of pregnancy to the postpartum period. Two studies exclusively included mothers who had low birth-weight infants [23, 24].
We also noted differences in the type of interventions, which included either one-on-one counseling or mothers' group meetings. Of 47 studies, 38 focused on one-on-one counseling with the remaining nine focusing on mothers' group meetings [6, 7, 17–19, 25–28]. One-on-one counseling was conducted by peer counselors during home visits, telephonic interactions, when the mother visited the antenatal clinic/hospital, or a combination of the above. Both, one-to-one counseling and mothers’ group meetings were conducted during antenatal, postpartum or both antenatal and postpartum periods. The number of contacts made by peer counselor or mothers' group meetings ranged from one to more than 10 visits. We noted differences in training periods for peer counselors and local facilitators of mothers’ group meetings. They ranged from a 4-hour session to over 6 months of classroom training and practice [9, 26]. We also noted that some peer counselors were paid employees [29–31], some received honorarium or payment per visit [24, 33].We also found differences in the methods, frequency, and recall period in measuring EBF duration. Overall, the studies were heterogeneous and the sample sizes varied largely.
Risk of bias in the selected studies
We noted differences in the risk of bias among the studies (S3 and S4 Tables). Of 41 RCTs and quasi-experimental studies, 22 were at high risk for the blinding of participants and personnel criteria, and 20 were classified as high risk due to the lack of outcome assessment blinding. Of six observational studies, two were assessed as high risk in terms of measurement of exposure [34, 35], two were assessed as high risk for blinding of outcome assessments [34, 36], three were assessed as high risk for incomplete outcome data [36–38], and two were assessed as high risk for selective outcome reporting [37, 38].
a. Exclusive breastfeeding duration in low- and middle-income countries.
We included14 studies in the meta-analysis to measure the effect of community-based peer support for mothers on EBF duration in LMICs (Fig 2). Among them, two were quasi-experimental studies [6, 25] and the rest were RCTs. Furthermore, we conducted subgroup analyses by dividing all of these studies by different EBF duration.
Until 1 month.
We included two studies in this subgroup analysis [28, 39] which comprised of 15,128 mothers. The pooled relative risk of continuing EBF until 1 month was 1.11 (95% CI: 0.98–1.25) for the intervention group versus the control (Fig 2). This estimate was characterized by substantial heterogeneity (I2 = 68%).
Until 3 months.
We included four studies in this subgroup analysis [9, 20, 21, 39] which comprised of 3,777 mothers. The pooled relative risk of continuing EBF until 3 months was 1.90 (95% CI: 1.62–2.22) for the intervention group versus the control (Fig 2). This estimate was characterized by substantial heterogeneity (I2 = 71%).
Until 4 months.
We included three studies in this subgroup analysis [22, 24, 40] which comprised of 3,690 mothers. The pooled relative risk of continuing EBF until 4 months was 2.20 (95% CI: 0.99–4.88) for the intervention group versus the control (Fig 2). The estimate was characterized by substantial heterogeneity (I2 = 98%).
Until 5 months.
We included two studies in this subgroup analysis [22, 32] which comprised of 1,448 mothers. The pooled relative risk of continuing EBF until 5 months was 9.55 (95% CI: 6.65–13.70) for the intervention group versus the control (Fig 2). The estimate was characterized by low heterogeneity (I2 = 30%).
Until 6 months.
We included 10 studies in this analysis [6, 7, 20, 22, 23, 25, 27, 39–41] which comprised of 24,490 mothers. The pooled relative risk of continuing EBF until 6 months was 3.53 (95% CI: 2.49–5.00) for the intervention group versus the control (Fig 2). This estimate had substantial heterogeneity (I2 = 94%).
b. Exclusive breastfeeding duration in high-income countries.
We included eight studies in this analysis to measure the effect of community-based peer support for mothers on EBF duration in high-income countries (Fig 3). Among them, two were quasi-experimental studies [42, 43] and the rest were RCTs. Furthermore, we conducted subgroup analyses by dividing all of these studies by EBF duration.
Until 1 month.
We included two studies in this subgroup analysis [44, 45] which comprised of 391 mothers. The pooled relative risk of continuing EBF until 1 month was 2.10 (95% CI: 0.55–8.04) for the intervention group versus the control (Fig 3). This estimate was characterized by substantial heterogeneity (I2 = 90%).
We included five studies in this subgroup analysis [29, 33, 42, 43, 46] which comprised of 2,488 mothers. The pooled relative risk of continuing EBF until 1.5 months was 1.25 (95% CI: 0.96–1.64) for the intervention group versus the control (Fig 3). This estimate was characterized by substantial heterogeneity (I2 = 63%).
Until 2 months.
We included three studies in this subgroup analysis [33, 44, 45] which comprised of 616mothers.The pooled relative risk of continuing EBF until 2 months was 1.82 (95% CI: 0.85–3.91) for the intervention group versus the control (Fig 3). This estimate was characterized by substantial heterogeneity (I2 = 81%).
Until 3 months.
We included four studies in this subgroup analysis [43–45, 47] which comprised of 534 mothers. The pooled relative risk of continuing EBF until 3 months was 2.61 (95% CI: 1.15–5.95) for the intervention group versus the control (Fig 3). This estimate was characterized by substantial heterogeneity (I2 = 73%).
Until 6 months.
We included two studies in this subgroup analysis [29, 47] which comprised of 292 mothers and the pooled relative risk of continuing EBF until 6 months was 1.02 (95% CI: 0.59–1.76) for the intervention group versus the control (Fig 3). This estimate had low heterogeneity (I2 = 22%).
c. Breastfeeding initiation within the first hour of life.
We included four studies in this analysis to measure the effect of community-based peer support for mothers on breastfeeding initiation within the first hour of life [7, 27, 32, 41]. All of the studies were conducted in LMICs. They included a total of 18,540 mothers and the pooled relative risk breastfeeding initiation was 1.51 (95% CI: 1.04–2.21) for the intervention group versus the control (Fig 4). This estimate had substantial heterogeneity (I2 = 98%).
d. Prelacteal feeding.
We included two studies in this analysis to measure the effect of community-based peer support for mothers on prelacteal feeding of infants [22, 32]. Both studies were conducted in LMICs. The analysis included a total of 1,548 participants and the pooled relative risk of prelacteal feeding was 0.38 (95% CI: 0.33–0.45) for the intervention group versus the control (Fig 5). The estimate was characterized by moderate heterogeneity (I2 = 56%).
e. Exclusive breastfeeding until 6 months (subgroup analysis by the type of interventions).
We conducted subgroup analyses by the type of intervention (one-on-one or group peer support) for the outcome of EBF until 6 months. We included 12 studies in this analysis. Among them, two were quasi-experimental studies [6, 25] and the rest were RCTs. Two studies were conducted in high-income countries [29, 47] and the rest in LMICs. We included eight studies in the subgroup one-on-one peer support [20, 22, 23, 29, 39–41, 47]. We included only four of the nine available studies for the subgroup of group peer support [6, 7, 25, 27]. Of the five excluded studies, two assessed a multifaceted intervention [17, 18], two did not report EBF at 6 months [26, 28], and one lacked a comparison group .
Interventions for one-on-one peer support for mothers.
The eight studies in this subgroup included 6,254 mothers. The pooled relative risk of continuing EBF until 6 months was 3.24 (95% CI: 2.04–5.14) for the intervention group versus the control (Fig 6). This estimate had substantial heterogeneity (I2 = 90%).
Interventions for group peer support for mothers.
The four studies in this subgroup included 18,849 mothers. The pooled relative risk of continuing EBF until 6 months was 2.77 (95% CI: 1.71–4.51) for the intervention group versus the control (Fig 6). This estimate had substantial heterogeneity (I2 = 96%).
This systematic review highlighted four major findings on the effectiveness of community-based peer support for mothers on their breastfeeding practices. First, community-based peer support for mothers can improve EBF duration. Moreover, mothers in LMICs continued EBF for a longer period than mothers in high-income countries. Second, such interventions can improve breastfeeding initiation within the first hour of life in LMICs. Finally, community-based peer support can reduce prelacteal feeding in LMICs.
Community-based peer support for mothers significantly increased EBF duration among mothers in both LMICs and high-income countries. In LMICs, mothers who received such support exclusively breastfed their infants until 3, 5 or 6 months compared to those who did not have such support. They even continued EBF until later months as suggested by the higher risk ratios in meta-analyses results at 5 and 6 months. In high-income countries, mothers who received such support exclusively breastfed their infants until 3 months compared to those without such support. We did not find any significant results proving effectiveness of peer support for EBF until the fifth and sixth months in high-income countries.
Mothers who received peer support in LMICs tended to exclusively breastfeed their infants for a longer period than such mothers in high-income countries. A separate systematic review also found that peer support had greater effect on EBF in LMICs than in high-income countries . One possible explanation may be the higher social preferences for infant formula feeding in high-income countries. Community-based peer support for mothers alone may be less effective in overcoming social barriers in those countries. In Scotland, social preferences for bottle feeding and aversion to public breastfeeding were likely factors responsible for the no-effect of peer support on EBF duration . On the other hand, several factors create a favorable environment for EBF in LMICs, such as negative social attitudes towards infant formula, the high cost of infant formula, and the low prevalence of its commercial marketing [10, 49]. Therefore, support alone can be effective in increasing EBF duration in LMICs. In addition, mothers in high-income countries are likely to receive more advice and breastfeeding support from professional health workers. Therefore, the definition of ‘usual care’ in high-income countries may be different from ‘usual care’ received in LMICs. This may be another reason for greater effectiveness of peer support in LMICs compared to that of high-income countries.
Mothers who received peer support in LMICs were more likely to initiate breastfeeding within the first hour of life than those who did not have such support. Moreover, peer support also decreased the risk of prelacteal feeding of newborns in LMICs. A separate systematic review also reported peer support as an effective intervention to promote breastfeeding initiation among low-income group mothers .
Strengths and limitations
Our findings should be interpreted in line with the following limitations. First, we found differences in study populations, type of interventions, training methods, and outcome measurement methods, all of which may modify the effect of the interventions. This may also explain the source of substantial heterogeneity in some of our meta-analysis results. We addressed this by conducting subgroup analyses based on EBF duration and type of interventions (one-on-one or group peer support). Some of the subgroup analyses at different EBF follow-up time points were based on relatively smaller samples and may not have had the power to identify significant effects. We included quasi-experimental studies in the meta-analysis, which may have increased the risk of bias.
We were not able to assess the effect of community-based peer support for mothers when it was integrated into a multifaceted intervention. Only two studies included a multifaceted intervention. In the first study, the packaged intervention was the Integrated Management of Childhood Illness (IMCI) that significantly increased EBF duration . The second study included peer support promotion as a part of its multifaceted intervention along with professional support . However, we could not synthesize these results because packaged intervention components and the study area settings were different between these two studies. We did not analyze the effect of factors, such as health conditions of the mothers and their babies, and insufficiency of breast milk. These factors may have prevented mothers to exclusively breastfeed or to initiate breastfeeding within the first hour of delivery, even if they received peer support. We did not analyze the effect of alternative modes of breastfeeding such as breast milk expression by hand or pump. Lastly, we did not include any non-English language studies in this review.
Despite these limitations, this study is the first systematic review and meta-analysis to report the effectiveness of community-based peer support for mothers for different EBF durations ranging from 1 month to 6 months. Our findings may help policy makers to design low-cost and sustainable strategies to improve breastfeeding practices in locations where effective programming is lacking.
Community-based peer support is effective in increasing EBF duration among mothers. Therefore, the mothers in LMICs continue EBF for much longer periods than the mothers in high-income countries. Such community-based peer support also enabled mothers to initiate breastfeeding early and avoid prelacteal feeding of newborns in LMICs. Moreover, mothers are more likely to exclusively breastfeed when they receive peer support one-on-one or through a mother’s group. Future studies are needed to explore sources of heterogeneity in such estimates and also examine the effect of a multifaceted intervention on breastfeeding practices.
S3 Table. Risk of bias assessments of RCTs and quasi-experimental studies.
S4 Table. Risk of bias assessments of observational studies.
We would like to thank Ms. Hiroko Makino and Ms. Ayumi Toda for their precious help during protocol writing and initial screening process. We would also like to thank Editage (www.editage.jp) for English language editing.
- Conceptualization: PS MKK BFS.
- Data curation: PS MKK MJ.
- Formal analysis: PS MKK MK.
- Investigation: PS MKK MK SSR MM SD SS BFS.
- Methodology: PS MKK MK.
- Project administration: MJ.
- Resources: MJ.
- Supervision: MJ.
- Validation: PS MKK.
- Writing – original draft: PS.
- Writing – review & editing: PS MKK BFS MJ.
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