Interventions to Improve Breastfeeding Exclusivity in Low-And Middle-Income Countries : A Systematic Review and Meta-Analysis

Background: Exclusive breastfeeding (EBF) rates until six months in most low and middle income counties (LMICs) are well below the 90% WHO benchmark. This systematic review sought to provide evidence on effectiveness of various interventions on exclusive breastfeeding until six months in LMICs, compared with standard care. Methods: This systematic review included experimental and observational studies, with concurrent comparator, in which exclusive breastfeeding was promoted, in LMICs with high country rates of breastfeeding initiation. Studies were identified from a systematic review and PUBMED, Cochrane and CABI databases. Study selection, data abstraction, and quality assessment (using the Cochrane tools for risk of bias assessment) were carried out independently and in duplicate. Relative risks with 95% confidence intervals were calculated for individual studies and pooled. High heterogeneity was explored through pre-specified sub-group analyses for the primary outcome (exclusive breastfeeding until six months) by context and by intervention for the randomised controlled trials. Prediction intervals were calculated for each effect estimate. Findings: 67 studies with 79 comparisons from 30 LMICs were included. At six months, intervention group infants were more likely to be exclusively breastfed than controls (RR=2.19, 95%CI 1.73 to 2.77; I2 78.4%; 25 randomised controlled trials). Larger effects were obtained from interventions delivered by a combination of professional and lay persons (RR 3.90, 95%CI 1.25 to 12.21; I2 46.7%), in interventions spanning antenatal and postnatal periods (RR 2.40, 95%CI 1.70 to 3.38; I283.6%), and when the intensity was between four to eight contacts/sessions (RR 3.20, 95%CI 2.30 to 4.45; I2 53.8%). Interpretation: Almost every intervention conducted in LMICs increased exclusive breastfeeding rates. Choice of intervention should therefore be driven by feasibility of delivery in the local context to reduce infant mortality. Funding: Needs Assessment Intervention Fund of the University of Lagos, Nigeria Registration: PROSPERO International prospective register of systematic reviews of the University of York CRD42016037029 Funding: Needs Assessment Intervention Fund of the University of Lagos, Nigeria Declaration of Interest: We declare no competing interests. Ethical Approval: Ethical approval was not required for this systematic review