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Cer-210-Breastfeeding-Summary.Pdf Comparative Effectiveness Review Number 210 Effective Health Care Program Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries Evidence Summary Background Purpose of Review In reproductive physiology, lactation To summarize the effectiveness of follows pregnancy; a growing body community, workplace, and health care of evidence supports the association system–based programs and policies aimed between breastfeeding and better health at supporting and promoting breastfeeding, outcomes for both infants and mothers.1-3 and to determine the association between A 2007 Agency for Healthcare Research breastfeeding and maternal health. and Quality (AHRQ) review by Ip and Key Messages colleagues concluded that breastfeeding was associated with reduced maternal • Baby-Friendly Hospital Initiative (BFHI) type 2 diabetes, breast cancer and ovarian is associated with improved rates of cancer, but not fractures.2 For other breastfeeding initiation and duration. outcomes (e.g., postpartum depression), • Health care staff education combined the authors concluded that the relationship with postpartum home visits may be between breastfeeding and maternal effective for increasing breastfeeding health was unclear. Since 2007, several duration. new studies have reported on maternal outcomes not addressed in the 2007 • Health care staff education alone (with no AHRQ review, including hypertension, additional breastfeeding support services) rates of myocardial infarction, and other may not be effective for increasing cardiovascular outcomes.4-7 breastfeeding initiation rates. In 2014, an estimated 82.5 percent of • For women enrolled in the WIC Program, infants born in the United States were peer-support interventions offered by breastfed at birth, meeting Healthy People WIC agencies may improve rates of 2020 targets for the percentage of infants breastfeeding initiation and duration. who are ever breastfed (81.9%). However, • Breastfeeding is associated with reduced rates of breastfeeding duration fell short maternal risk of breast and ovarian of Healthy People 2020 targets. In 2014, cancer, hypertension, and type 2 diabetes. only 55.3 percent of women breastfed at • Workplace, school-based, and 6 months and 33.7 percent at 12 months8 community-based interventions and (falling short of the 2020 targets of underlying socioeconomic factors need 66.6 and 34.1 percent, respectively, for further research. 6 and 12 months).9 Rates of exclusive breastfeeding through 3 and 6 months e were 46.6 and 24.9 percent, respectively; these measures facilities as Baby-Friendly;13 there are likely country- are close to Health People 2020 targets (46.2 and 25.5%, specific differences in the process for determining final respectively).8 Women would prefer to breastfeed longer: accreditation (or certification) status. As a result, details of in a national survey, 45 percent of U.S. women who implementation vary from country to country. The Baby- initiated breastfeeding reported early, undesired weaning.10 Friendly USA “Ten Steps to Successful Breastfeeding” Despite rising breastfeeding initiation and duration rates for hospitals and birthing facilities are listed in Table A. in the United States, racial and ethnic differences persist. Insurance coverage for lactation support is another strategy From 2000 to 2014, the percentage of women who initiated that may enable women to achieve their breastfeeding breastfeeding went up from 47.4 to 68.0 percent for blacks, goals. Costs associated with breastfeeding support 71.8 to 85.7 percent for whites, and 77.6 to 84.8 percent (e.g., comprehensive lactation support and counseling, for Hispanics.11, 12 breastfeeding equipment) are currently covered by health In addition to setting targets for breastfeeding initiation insurance marketplace plans and private nongrandfathered health plans under the 2010 Patient Protection and rates and duration of breastfeeding, other Healthy People 14 2020 objectives related to breastfeeding include (1) Affordable Care Act. It is not clear whether certain increasing the proportion of live births that occur in lactation benefit packages (e.g., type of breastfeeding facilities that provide recommended care for lactating supplies offered, number of visits provided, or mothers and their babies and (2) increasing the proportion qualifications of intervention delivery personnel) are more of employers that have worksite lactation support or less effective than others in increasing breastfeeding programs.9 These community, workplace, and health care initiation and duration. In addition, a key program relevant system–based programs and policies may be promising to breastfeeding is the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which strategies to support initiation and increase duration of 15 breastfeeding. serves 53 percent of infants born in the United States. Because WIC reaches more than half of U.S. infants, Health care system–based interventions may include its programs have considerable influence on population maternity staff education or the Baby-Friendly Hospital health. Initiative (BFHI). The BFHI is a global program sponsored by the World Health Organization (WHO) Although there is broad appeal and interest in workplace and United Nations Children’s Fund to encourage and interventions to increase duration and exclusivity of breastfeeding, their effectiveness and harms are recognize hospitals and birth centers that create an 16 environment supporting breastfeeding. In each country, uncertain. a BFHI Coordination Group is charged with designating Table A. Baby-Friendly Hospital Initiative’s 10 steps to successful breastfeedinga 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within 1 hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants. 6. Give infants no food or drink other than breast milk, unless medically indicated. 7. Practice rooming in—allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no pacifiers or artificial nipples to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center. a Baby-Friendly USA “Ten Steps to Successful Breastfeeding”17 2 Existing Guidelines Key Questions Multiple clinical guidelines and health-related Key Question 1: organizations recommend exclusive breastfeeding up to (or around) 6 months, including the American Academy 1a. What are the effectiveness and harms of programs of Pediatrics,18 the American Congress of Obstetrics and policies on initiation, duration, and exclusivity of and Gynecology,19 the WHO,20, 21 and others.22, 23 These breastfeeding? organizations recommend continued breastfeeding through 1b. To what extent do the effectiveness and harms of the first year of life and beyond; the WHO recommends programs and policies on initiation, duration, and continued breastfeeding through the second year of life exclusivity of breastfeeding differ for subpopulations and beyond.24 of women defined by sociodemographic factors (e.g., age, race, ethnicity, socioeconomic status)? Rationale for Evidence Review 1c. To what extent do intervention-related characteristics The purpose of this review is to develop an evidence (e.g., type of breast pump provided—manual or report that summarizes the effectiveness of community, electric; delivery personnel) influence the initiation, workplace, and health care system–based programs and duration, and exclusivity of breastfeeding? policies aimed at supporting and promoting breastfeeding. Such knowledge is needed to inform allocation of Key Question 2: resources to enable more women to achieve their infant 2a. What are the comparative benefits and harms for feeding goals. The U.S. Preventive Services Task Force maternal health outcomes among women who (USPSTF) recommends providing interventions during breastfeed for different intensities and durations? pregnancy and after birth to support breastfeeding as part of routine primary care (B recommendation).25 To avoid 2b. To what extent do benefits and harms for maternal duplication, this review will not address the effectiveness health outcomes differ for subpopulations of women of individual-level primary care interventions to support defined by age, race, ethnicity, and comorbidity? breastfeeding covered in the recent systematic review to support the USPSTF recommendation.26 Analytic Framework In addition, this review will address the association between We developed an analytic framework to guide the breastfeeding and maternal health. Substantial time has systematic review process (Figure A). The analytic elapsed since the last AHRQ review on this topic in 2007, framework illustrates the population, interventions, and the body of literature focused on the maternal health outcomes, and adverse effects that guided our literature benefits of breastfeeding has grown.1, 27-29 This review will search and synthesis. conduct a partial update of the 2007 AHRQ review focused on the relationship between breastfeeding and various maternal health outcomes. This review will inform the extent to which breastfeeding may be an effective
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