Midwifery 27 (2011) 497–502

Contents lists available at ScienceDirect

Midwifery
journal homepage: www.elsevier.com/midw

Effective community-based interventions to improve exclusive breast

feeding at four to six months in low- and low–middle-income countries:
a systematic review of randomised controlled trials
Jennifer Hall, Bsc (Hons), MBChB, MSc, MFPH (Public Health Specialty Registrar)
London, Kent, Surrey and Sussex Deanery, UK

a r t i c l e in fo abstract

Article history: Background: only about 25% of babies are exclusively breast fed until six months of age in developing
Received 21 December 2009 countries and, given their greater risk of infection and infant mortality, there is a need to investigate
Received in revised form ways of increasing this. The aim of this review is to assess the effectiveness of community-based
20 March 2010
interventions to improve the rates of exclusive breast feeding at four to six months in infants in
Accepted 26 March 2010
low- and low–middle-income countries.
Methods: a systematic review of literature identified through searches of Medline, Global Health and
Keywords: CINAHL databases to identify randomised controlled trials of community-based interventions to
Systematic review improve the rate of exclusive breast feeding in low- and low–middle-income countries.
Exclusive breast feeding
Findings: four studies, from four different countries, were included in the final review. Although
Community-based intervention
they evaluated slightly different interventions, all showed a significant improvement in the rate of
Developing countries
exclusive breast feeding with a pooled odds ratio of 5.90 (95% confidence interval 1.81–18.6) on random
effects meta-analysis.
Conclusion: community-based interventions in low- and low–middle-income countries can substan-
tially increase the rates of exclusive breast feeding and are therefore a viable option. The interventions
included in the review varied, indicating that there are a number of ways in which this might be
achieved; it is recommended that these are used as a starting point for determining the most
appropriate intervention with regard to the setting. Given the importance of this issue, the lack of
research in the area is surprising. The studies in the review demonstrate that good-quality randomised
controlled trials of this area are possible and should encourage further research.
& 2010 Elsevier Ltd. All rights reserved.

Background reduced productivity, and impaired intellectual and social

On the basis of evidence from a systematic review of the
optimal duration of exclusive breast feeding (WHO, 2001), the
World Health Organization (WHO) recommends exclusive breast
feeding for the first six months of life (WHO, 2003). This
recommendation is based on evidence of the importance of good
nutrition in the early months of life and of the crucial role that
appropriate feeding practices play in achieving optimal health
outcomes:
Lack of breastfeeding – and especially lack of exclusive
breastfeeding during the first half-year of life – are important
risk factors for infant and childhood morbidity and mortality
that are only compounded by inappropriate complementary
feeding. The life-long impact includes poor school performance,
E-mail address: jenniferhall@nhs.net.
development (WHO, 2003).
Although any breast feeding is beneficial, exclusive breast
feeding, where the infant only receives breast milk with
absolutely no additional food or drink, not even water, has been
shown to have short- and long-term benefits for both mother and
child. These include reduced infant morbidity and mortality
from diarrhoea (Victora et al., 1987; Morrow et al., 1999) and
respiratory infections (Kramer et al., 2001).
Given the greater risk of infection and higher infant mortality
rates in developing countries, exclusive breast-feeding rates in
particular are considered to be too low, with only around 25% of
infants exclusively breast fed at six months (Black et al., 2008).
WHO recommends the promotion of breast feeding through
the Baby-Friendly Hospital Initiative, but in countries where
most women do not give birth in hospital, this is clearly
inappropriate; for these women, interventions must be provided
at the community level. Using both a hospital-based and a

0266-6138/$ - see front matter & 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.midw.2010.03.011
498 J. Hall / Midwifery 27 (2011) 497–502
community-based approach will maximise the chances of
increasing the rates of exclusive breast feeding. Community-
based interventions have the potential to reach more women, and
have been shown to be effective in other contexts such as
maternal mortality (Kidney et al., 2009), but their efficacy with
regards to breast feeding is currently uncertain.
Aim
This review seeks to assess the effectiveness of community-
based interventions to improve the rates of exclusive breast
feeding at four to six months in infants in low- and low–middle-
income countries compared with standard care.
Exclusive breast feeding at four to six months was chosen as
the outcome because this is the recommendation of WHO. This is
not to suggest that interventions that do not focus on exclusive
breast feeding or that operate on a shorter time scale are not
worthwhile, but the aim was to identify evidence that would
support the implementation of this recommendation. In addition,
interventions that focus on exclusive breast feeding have the
potential to increase breast-feeding levels in general.
The World Bank classification was used to determine which
countries are low- and low–middle-income countries. Using
the gross national income (GNI) per capita, low-income countries
have a GNI per capita of US$975 or less, and low–middle-income
countries have a GNI per capita of US$976–$3855.
No previous review exists. One Cochrane review, updated in
2009, looked at support for breast-feeding women; however, only
four of 34 included studies were from low- or low–middle-
income countries, and it considered any type of intervention
(Britton et al., 2009). Other reviews have focused on low-income
women in high-income countries (Dyson and Renfrew, 2005) and
on interventions in the workplace (Abdulwadud, 2007).
Methods
Search strategy
The search was conducted in March 2010 and three databases
were searched. Medline was included because of its wide
coverage of medical journals, the Global Health/Global Health
Archive for its international perspective and coverage of public
health issues, and CINAHL Plus for its comprehensive, interna-
tional coverage of nursing and midwifery topics.
In Medline, MeSH terms of community health services,
community health aides, maternal health services (exploded)
and health promotion were searched, as were keywords ‘commu-
nity’, ‘participat$ adj4 interven$’ and ‘education$ adj4 interven$’.
Breastfeeding was searched as a MeSH term and as keywords
‘breastfeeding’, ‘breast feeding’, ‘breast-feeding’ or ‘breast adj4
feed$’ and these were combined with ‘or’. The setting/intervention
search and the breast-feeding search were combined and limited
to randomised controlled trials published in the English language.
The same MeSH headings did not apply in the Global Health
database, and the randomised controlled trial limit was
not applied as it is not as reliable. Instead, ‘randomised’ or
‘randomized’ were searched as keywords. In CINAHL, the keyword
‘breast feeding’ and the heading ‘breast feeding promotion’
were combined with ‘or’. This was combined with keywords
‘community’, ‘randomised’ or ‘randomized’ and limited to studies
published in the English language.
Criteria for selecting studies for the review
In order to be included in the review, studies had to be
randomised controlled trials where at least 75% of participants
completed full follow-up, and therefore had data available on the
outcome, and where the control group received ‘usual care’. Only
randomised controlled trials were included as, when conducted
correctly, they are the ‘gold standard’ because the process of
randomisation should ensure groups that are balanced on all
known and unknown confounders, thereby reducing the risk of
bias. Any type of community-based intervention that was in
addition to usual care and that was aimed at increasing rates of
breast feeding was included in the review. A ‘community-based’
intervention was defined as: accessible locally to the woman,
whether in her own home or a local building such as a clinic
or school; delivered by any trained person, either a health
professional or a lay person; and provided either one to one or
in a group. The intervention could be provided antenatally,
postnatally or both. ‘Usual care’ was defined as the service that
women would normally receive, and included no care if that was
the usual situation.
Participants in the studies had to be women who were
either pregnant or currently breast feeding an infant aged less
than six months in a low- or low–middle-income country.
Interventions that were targeted at women or babies with specific
problems, such as human immunodeficiency virus or premature
birth, rather than potentially being available to the whole
community were excluded. This was because the external
pressures on this group because of their health problems may
have increased or decreased their breast-feeding rates and
could have inappropriately influenced the results of the review.
In order to be included, studies had to report the rate of exclusive
breast feeding, as previously defined, in the intervention group
compared with controls at four to six months.
Description of studies
The searches yielded a total of 255 citations (including
duplications); it proved impossible to further limit the search
without losing some of the key studies, so the titles and abstracts
of these results were reviewed according to the inclusion criteria.
On this basis, the search results were reduced to 11 studies as
shown in Fig. 1.
Full-text articles of the 11 studies were obtained and were
then scrutinised on the basis of the inclusion criteria. Five were
excluded for not reporting breast feeding at four to six months,
one was excluded as it was reporting the same data as another
included study, and one was excluded because the first contact
was hospital based, leaving four studies (Haider et al., 2000;
Bhandari et al., 2003; Bashour et al., 2008; Bhutta et al., 2008). The
references of these studies were examined but no additional
studies meeting the inclusion criteria were found.
A description of the included studies is given in Table 1. The
interventions were all slightly different. Bashour et al. (2008)
evaluated the impact of registered midwives with special training
making one or a series of postpartum home visits to support
women in rural and urban areas of Syria. Bhandari et al.’s (2003)
study in rural communities in India assessed the effect of a range
of lay and professional health workers incorporating information
about breast feeding into routine community-based services as
well as providing community education sessions. In the study by
Bhutta et al. (2008), female health workers and traditional birth
attendants were given extra training on perinatal care, and
provided seven home visits and quarterly community education
sessions to women in rural communities in Pakistan. Finally,
 J. Hall / Midwifery 27 (2011) 497–502
255 citations identified on all
searches
194 studies
44 studies
19 studies
Full text obtained
of 11 studies
4 studies included
in final review
Fig. 1. Flow chart describing the study selection process. RCT, randomised controlled trial.
Haider et al. (2000) trained peer counsellors in Dhaka, Bangladesh
to support women to breast feed exclusively through a series of
15 antenatal and postnatal visits.
Methodological quality of included studies
All studies were reviewed for quality according to the
CASP framework for randomised controlled trials; a recognised
tool to assist the critical appraisal of randomised controlled
trials. They were then graded low, medium or high quality on
the basis of the presence or absence of: selection bias, as assessed
by the process of randomisation and allocation concealment;
performance bias, as indicated by the equal treatment of
both groups; measurement bias, by blinding the outcome
assessors or objective verification of the outcome; and loss
to follow-up. Studies that had taken steps to reduce these
potential sources of bias were rated the highest quality, as shown
in Table 2. As selection bias was considered to be the most
important potential source of bias in these studies, greater
weighting was given to this. None of the studies did an
intention-to-treat analysis, but the data were available enabling
this to be done in the review so this was not included in the
quality criteria. Equally, as blinding of the participants and
providers is not possible for this sort of intervention, it was not
penalised; however, credit was given for blinding of the outcome
assessors. No study was excluded on the grounds of quality,
although the results of Bhutta et al. (2008) could be considered
less robust than the others.
499
61 duplicates
110 excluded - not conducted in low-or
low _ middle-income country
40 excluded - not an intervention relating
to exclusive breast feeding
12 excluded - hospital-based
intervention
13 excluded - disease specific
8 excluded
Not an RCT
4 excluded – not reporting
breast feeding rates at 4-6 months
2 excluded as first contact was
hospital based
1 excluded as reporting the same
data as another study
Data analysis
Data were extracted using a data extraction form designed for
this review. The data were analysed using STATA10 to calculate
odds ratios (OR) and 95% confidence intervals (CI) for the outcome
measure: exclusive breast feeding at four to six months in the
intervention group compared with the control group. It was also
used to perform a sensitivity analysis of the effect of an intention-
to-treat analysis on the main outcome measure, fixed and random
effects meta-analyses and w2 tests for heterogeneity.
Findings
Table 3 shows the results for exclusive breast feeding in the
intervention group compared with the control group for the four
studies. As not all the studies reported at six months, the lowest
common denominator of four months was taken; however, Haider
et al. (2000) only reported at five months so this was used for that
study. As breast feeding declines with time, this should result in an
underestimate of the true effect as the rate of exclusive breast feeding
at four months would have been higher than that at five months.
This shows that all the studies found that their intervention
significantly improved the rates of exclusive breast feeding at
four to five months. These results were not intention-to-treat
analyses where the outcome is analysed according to how people
were originally randomised rather than only analysing the
data available. Not including the people who have dropped out
of the study can lead to an overestimation of the effect of the
intervention. Therefore, a sensitivity analysis was performed to
500 J. Hall / Midwifery 27 (2011) 497–502

Table 1
Characteristics of included studies.

Bashour et al. (2008) Bhandari et al. (2003) Bhutta et al. (2008) Haider et al. (2000)

Country Syria India Pakistan Bangladesh

Setting Mixed urban and rural Rural communities Rural communities Urban

Study design RCT RCT Pilot study of RCT RCT

Randomisation Block randomisation, Cluster randomisation, allocation Insufficient description of method of Cluster randomisation, no comment
allocation concealed concealed randomisation on allocation but well-balanced
groups
Intervention Follow-up, educate, Incorporate education about exclusive A package of interventions to Home-based peer counselling as a
support and counsel breast feeding into routine, community- improve perinatal and newborn care breast-feeding promotion strategy
women who had recently based services
given birth

Provided by Trained midwives Traditional birth attendants; local Female health workers (women from Trained peer counsellors
village-based workers; auxiliary nurse the community given 6/12 training)
midwives; other health-care providers and traditional birth attendants
Location Home visits Home at birth then at all health clinics Home visits and community Home visits
(immunisation, weighing, any health education sessions
care) and community education sessions
Number of Group A had four visits, Impossible to determine but multiple; Seven home visits plus quarterly 15 visits ante- and postnatal
visits Group B one and Group C likely to be in excess of 20 in the first community education
were control year

Number of 876 1025 800 726

women

Exclusions Premature, low birth No individual exclusion criteria given No individual exclusion criteria Women with more than three children
weight or congenital given or chronic illness. Premature, low
anomalies birth weight or congenital
abnormalities
Length of Four months Nine months Survey 18–24 months after Five months
follow-up introduction of intervention

Completeness 86.3% 85.6% High completion rate for survey 79%

of follow-up

Description of Stated to be similar Stated to be similar None given Stated to be similar

withdrawals

Blinding Outcome assessors but Outcome assessors Not mentioned Women unaware of study hypothesis
compromised
Outcome Exclusive breast feeding at Exclusive breast feeding at three Exclusive breast feeding at four Exclusive breast feeding at five
measure four months to six months months months

Intention to Not done Not done Not done Not done

treat analysis

Overall High High Low Medium

assessment
of quality

RCT, randomised controlled trial.

Table 2
Quality assessment of the included studies.

Study

Bashour et al. (2008) Bhandari et al. (2003) Bhutta et al. (2008) Haider et al. (2000)

Selection bias High quality. 2 High quality. 2 Low quality. 0 Medium quality. 1
Randomised and concealed Randomised and concealed Insufficient detail on process Randomised. Allocation unclear
of randomisation but balanced groups
Performance High quality. 1 Medium quality. ½ Low quality. 0 High quality. 1
bias Equal treatment of groups Cannot be sure of treatment of controls Unequal treatment of groups Equal treatment of groups

Measurement High quality. 1 High quality. 1 High quality. 1 High quality. 1

bias Equal assessment of outcome, attempt to Equal assessment of outcome, attempt to Outcome assessed equally in Equal assessment of outcome.
blind outcome assessors blind outcome assessors both groups Objective verification
Loss to follow- High quality. 1 High quality. 1 High quality. 1 Medium quality. ½
up Minimal loss to follow-up Small loss to follow-up High completion rates of 20% lost to follow-up
survey
5/5 High quality 4.5/5 High quality 2/5 Low quality 3.5/5 Medium quality
 J. Hall / Midwifery 27 (2011) 497–502 501

Table 3
Results of included studies – exclusive breast feeding at four to five months.

Exclusive breast feeding at four to five months Bashour et al. (2008)a Bhandari et al. (2003) Bhutta et al. (2008) Haider et al. (2000)b

Intervention n (%) 146/498 (29) 319/464 (69) 190/395 (48) 202/288 (70)
Control n (%) 52/258 (20) 49/411 (12) 117/375 (31) 17/285 (6)
Odds ratio (95%CI) 1.64 (1.13, 2.40) 16.3 (11.2–23.7) 2.04 (1.51, 2.77) 37.0 (20.9, 68.1)

a
The two intervention groups have been combined for this analysis.
b
Data on exclusive breast feeding at five months.

Table 4
Results of the intention-to-treat analysis.

Exclusive breast feeding at four to five months Bashour et al. (2008)a Bhandari et al. (2003) Bhutta et al. (2008) Haider et al. (2000)b

Intervention n (%) 146/579 (25) 319/552 (58) 190/400 (47.5) 202/363 (56)
Control n (%) 52/297 (18) 49/473 (10) 117/400 (29.3) 17/363 (5)
Odds ratio (95%CI) 1.59 (1.10, 2.31) 11.8 (8.34, 17.0) 2.19 (1.62, 2.96) 25.5 (14.9, 46.0)

a
The two intervention groups have been combined for this analysis.
b
Data on exclusive breast feeding at five months.

exclusive breast feeding at four to five months: pooled OR 5.80

Random Effects Meta-Analysis
Study ID OR (95% CI)
Bashour 2008 1.59 (1.12, 2.26)
Bhandari 2003 11.85 (8.43, 16.65)
Bhutta 2008 2.19 (1.64, 2.93)
Haider2000 25.54 (15.04, 43.34) 24.45
Overall (I-squared = 97.7%, p = 0.000) 5.63 (1.71, 18.59)
NOTE: Weights are from random
effects analysis
1 2 10 2030
Fig. 2. Forest plot of random effects meta-analysis of included studies.
determine how the worst-case scenario affected the results
(i.e. that all those that were lost to follow-up were not exclusively
breast feeding at four to five months) and is shown in Table 4.
As expected, the ORs were reduced, except in the study by
Bhutta et al. (2008) in which the OR increased slightly, possibly
due to larger losses in the control group, but all remained
significant. The finding that the worst case scenario still finds a
significant benefit is reassuring evidence that there is a true effect.
Using STATA10, a meta-analysis was performed with the figures
for the intention-to-treat analyses. A fixed effects model was used
first, but the w2 test confirmed the presence of heterogeneity
(po0.001) so a random effects model was used instead. This gave a
pooled OR of 5.80 (95%CI 1.81–18.6) as shown in Fig. 2. This can be
interpreted as showing that community-based interventions were
associated with an almost six-fold increase in the rates of exclusive
breast feeding at four months compared with usual care. The CIs
are very wide however, meaning that the true effect may be as
low as about a two-fold increase up to as much as an 18 times
increase. How this translates to an absolute increase will be
dependent on the baseline prevalence of exclusive breast feeding.
Discussion and interpretation
This review has demonstrated that in low- and low–middle-
income countries, community-based interventions can improve
(95%CI 1.81–18.6). As this was calculated on an intention-to-treat
basis, this is likely to be an underestimate. These findings are
%
consistent with the Cochrane review which also found that
Weight support increased the rates of exclusive breast feeding (Dyson and
Renfrew, 2005).
25.11
Given the differences between the studies, it is not surprising
that a large amount of heterogeneity was found. The studies were
25.15
conducted in different populations (rural and urban and in
25.29
different countries) and compared interventions that, although
they were all aimed at promoting breast feeding and were
100.00 community-based, differed in important ways such as who
delivered them and the frequency of the contacts.
The appraisal of the quality of the study did not appear to
directly relate to the size of the effect observed by the study. This
could be because any bias introduced due to the lower quality was
more than outweighed by differences in setting, e.g. the baseline
prevalence of breast feeding, or intervention, e.g. the timing or
number of contacts.
Limitations of the review
The review only considered randomised controlled trials and
could be criticised for this; including other trial designs may have
enriched the review. However, the risk of selection bias or of
factors outside the intervention covertly influencing the findings
was considered too high in this situation to make this a viable
option. Limiting the studies to those published in the English
language could have eliminated relevant studies, particularly as
the countries of interest were low- and low–middle-income
countries and may not publish in English.
Although the aim of this review was to assess the evidence for
the effect of community-based interventions on exclusive breast
feeding at four to six months, it should be borne in mind that any
breast feeding is beneficial. Of the 11 potentially relevant studies,
four were excluded for not reporting exclusive breast feeding at
four to six months. Of these, one provided no data at all (Mannan
et al., 2008), one reported at 12, 18 and 24 months (Jakobsen et al.,
1999), one only mentioned colostrum (Omer et al., 2008) and the
last only presented the percentage breast feeding in the first hour
(Kumar et al., 2008). Jakobsen et al. (1999) found no evidence that
their interventions improved the duration of breast feeding;
however, this was in the context of near 100% breast-feeding
initiation and a median duration of breast feeding of almost
502 J. Hall / Midwifery 27 (2011) 497–502
two years. Omer et al. (2008) and Kumar et al. (2008) both found
that their interventions were beneficial (OR 1.60, 95%CI 1.17–
2.18; rate ratio 4.57, 95%CI 3.38–6.15, respectively); due to
differences in the way data was presented in these studies
meaningful statistical analysis of their results was not possible
although there may be useful lessons to be learnt from them.
Given the importance of this issue, the paucity of research in
low- and low–middle-income countries is surprising. Equally
surprising is the relative abundance of research on improving
breast-feeding rates in high-income countries where, while breast
feeding is still ‘best for baby’, the infant morbidity and mortality
from infections is much less common. A strength of this review,
therefore, is in highlighting this lack of research and in showing
that good-quality randomised controlled trials have, can and
should be done to improve our knowledge and ability to
implement community-based interventions to improve the rates
of exclusive breast feeding in low- and low–middle-income
countries.
Conclusions
Implications for practice
The findings of this review show the positive effect that
community-based interventions can have on improving the levels
of exclusive breast feeding at four to five months in low- and low–
middle-income countries. Community-based interventions can
therefore be seen as a viable way of improving exclusive breast
feeding in settings where hospital births are less common. This
benefit was found despite the variation in settings and interven-
tions, which would seem to suggest that there are a number of
ways in which breast-feeding rates may be improved through
community interventions. The finding that peer support from
non-health-care professionals was found to improve breast-
feeding rates is good news for low- and low–middle-income
countries which may not have the resources to train more formal
health workers. The same is true for adding the message to
already existing services, as in resource-poor settings, workers
dedicated to a single intervention are unlikely to be sustainable.
Due to the heterogeneity of the studies included in this review,
it is not possible to state with any certainty exactly which aspects
of the interventions were most important in improving the levels
of breast feeding. This makes it difficult to identify a ‘one size fits
all’ approach to community-based interventions. Instead, the
interventions included in this review, and described in Table 1,
should be used as a starting point from which to design country-
and context-specific interventions.
Implications for research
Further research should be done to elucidate which compo-
nents of community-based interventions are related to improved
rates of breast feeding. This could include comparing trained
health workers with trained peer supporters to see if the person
delivering the intervention has an impact, or looking at different
numbers and schedules of visits to determine the optimal number
and timing. The important factors may vary according to the
baseline prevalence of breast feeding in the country, and whether
the setting is urban or rural; therefore, these should also be
considered. A complementary search of the literature to identify
qualitative research on users’ views of these services might
further our understanding of why some interventions are more
effective than others.
Improving rates of exclusive breast feeding in itself is not the
aim of the interventions; it is primarily to reduce morbidity and
mortality of the child. It should therefore be seen as a surrogate
measure, and future research should aim to link the improved
rates of breast feeding to lower rates of morbidity and mortality.
Cost–benefit analyses could then be done to assess the overall
value of such interventions.
Competing interests
None.
Author’s contributions
Sole author.
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