Research Article: A multi-component intervention to support breastfeeding in Lebanon: A randomized clinical trial

Date Published: June 14, 2019

Publisher: Public Library of Science

Author(s): Mona Nabulsi, Hani Tamim, Lama Shamsedine, Lama Charafeddine, Nadine Yehya, Tamar Kabakian-Khasholian, Saadieh Masri, Fatima Nasser, Soumaya Ayash, Diane Ghanem, Seth Adu-Afarwuah.


Effective evidence-based breastfeeding support interventions can bolster breastfeeding practices. This study investigated the effect of a multi-component breastfeeding support intervention delivered in hospital and home settings on six-month exclusive breastfeeding (EBF) relative to standard care.

This is a parallel group, randomized clinical trial, in which 362 healthy pregnant women with singleton pregnancy were randomly allocated to a multi-component intervention that included antenatal breastfeeding education, professional, and peer support, delivered in hospital and home settings for six months (experimental, n = 174), or to standard care (control, n = 188). The primary outcome was six-month EBF rate. Secondary outcomes were exclusive and any breastfeeding rates at one and three months, maternal breastfeeding knowledge, attitude, and behavior at six months, and satisfaction with the intervention.

The crude six-month EBF rate was similar in both groups (35.2% vs. 28.1% in the experimental and control groups, respectively, p = 0·16). In adjusted analysis, six-month exclusivity was twice as likely in the experimental group relative to standard care (OR = 2.02; 95%CI: 1.20 to 3.39); whereas the odds for any breastfeeding were similar. Participants compliant with all three components were six times more likely to practice EBF for six months relative to standard care (OR = 6.63; 95% CI: 3.03 to 14.51). Breastfeeding knowledge of the experimental group, at six months, was significantly improved compared to the control. No changes were observed in breastfeeding attitude or behavior.

Combining education with peer and professional breastfeeding support improved six-month breastfeeding exclusivity and knowledge.

Partial Text

Breastfeeding is an important public health measure that impacts short-, and long-term outcomes of children and their mothers [1]. Evidence from systematic reviews reveals that breastfeeding is associated with reduced child under-five mortality, infections, and dental malocclusion; and with higher child intelligence quotient. Moreover, it reduces maternal risks of breast and ovarian cancers, and type 2 diabetes. It is estimated that scaling up of breastfeeding prevents 823,000 child deaths, and 20,000 maternal deaths from breast cancer each year [1]. Despite this overwhelming evidence in support of breastfeeding practice, breastfeeding rates of developing, as well as developed countries are disappointingly low. In low- and middle-income countries, only 37% of infants are exclusively breastfed until six months of age, with much lower rates reported from high-income countries. The prevalence of any breastfeeding at twelve months in low-income countries is less than 90%, and is less than 20% in high-income countries, with middle-income countries having in between rates [1]. The effectiveness of antenatal breastfeeding education, peer support, or professional lactation support has been demonstrated in several systematic reviews [2–8]. For example, peer support reduced the risk of not breastfeeding by 30% in low- or middle-income countries, and by 7% in high-income countries [2], and all forms of extra support, analysed together, increased the duration of exclusive breastfeeding (EBF) until six months [3,4]. Breastfeeding education increased initiation rates in low-income USA women, as compared to standard care [4], and breastfeeding promotion interventions improved six-month EBF rates of developing countries by six fold [5].

This was a randomized, parallel-group, clinical trial, conducted between December 2013 and January 2016 in the obstetrics clinics of two academic tertiary care centers in Beirut, Lebanon. Trained research assistants reviewed the schedule of appointments of the prenatal clinics at both participating sites on daily basis, and identified eligible women. Eligible women were then directly approached for enrolment in the trial upon presentation to the clinic, and inclusion and exclusion criteria were validated by asking the pregnant women about each criterion. Inclusion criteria were healthy pregnancy in the first or second trimester, as determined by date of the last menstrual period, and intention to attempt breastfeeding after delivery. Exclusion criteria were pregnancy beyond the second trimester, maternal chronic medical condition such as hypertension or diabetes, abnormal fetal screen at 20–22 weeks, determined not to breastfeed, twin pregnancy, not residing in Lebanon for at least six months after delivery, or delivery before 37 weeks of gestation.

Between December 2013 and January 2016, 446 women were enrolled and assigned to the control (n = 224), or to the experimental (n = 222) group. Of 446 participants, 362 (81.2%) received the allocated intervention, and 340 (93.9%) provided outcome assessment at six months. Reasons for drop out from the study are detailed in the flow diagram (Fig 1).

This study builds on the existing literature, and provides further evidence on the additive positive effect of combining antenatal breastfeeding education with peer and professional lactation support on exclusive breastfeeding, when delivered as a continuum that starts in the hospital, and extends to the home setting. The multi-component intervention doubled six-month EBF as opposed to standard of care. There was a positive association between the number of intervention components received by the participants in the experimental group and EBF at six months. Moreover, the combined intervention improved BF knowledge of the intervention group significantly more than that of the control group, but did not affect their attitude or behaviour. The improvement in breastfeeding knowledge noted in the control group could be attributed to the “placebo effect”. The lack of effect on attitude and behavior may be explained by the fact that intent to breastfeed was one of the trial’s inclusion criteria. Hence the intervention may fail to have a significant impact on the attitude or behavior of an already motivated mother. This is further supported by the relatively high six-month EBF rate in the control group (28.1%), which is much higher than what has been previously reported from Lebanon (2%-15%) [10,24].