Recommendation grades [A, B, C, D, E, I] and levels of evidence [I, II-1, II-2, II-3, III; good, fair, poor] are indicated after each recommendation. Definitions for these grades and levels are provided following the recommendations.
Education programs and post-partum support to promote breast-feeding*: There is good evidence to recommend provision of structured antepartum educational programs and postpartum support (Canadian Task Force on Preventive Health Care, 1994) to promote breast-feeding initiation and duration. [A recommendation]
- Education. Structured antepartum breast-feeding education improves both initiation and continuation of short-term breast-feeding rates post-partum, compared with usual care.* (Duffy, Percival, & Kershaw, 1997; Pugh & Milligan, 1998; Hill, 1987; Kistin, Benton, & Rao, 1990; Brent et al., 1995; Redman et al., 1995) [Level of Evidence: I-fair]; (Sciacca et al., 1995; McEnery & Rao, 1986; Rossiter, 1994; Wiles, 1984; Reifsnider & Eckhart, 1997); [Level of Evidence: I-poor]
- Education + support. In-person or telephone support strengthens the effect of education, leading to an additional 5 to 10% increase in breast-feeding initiation and short-term duration. In-person or telephone support by itself may increase both short- and long-term breast-feeding rates. (Pugh & Milligan, 1998; Brent et al., 1995; Redman et al., 1995; Oakley, Rajan & Grant, 1990; Frank et al., 1987; Serafino-Cross & Donovan, 1992) [Level of Evidence: I-fair]; (Sciacca et al., 1995; Jones & West, 1985) [Level of Evidence: I-poor]
Peer counseling to promote breast-feeding: There is fair evidence to recommend peer counseling to promote initiation and maintenance of breast-feeding. [B recommendation]
- Peer counselors had a significant effect on breast–feeding rates and duration. (Dennis et al., 2002) [Level of Evidence: I-fair]; (Sciacca et al., 1995) [Level of Evidence: I-poor]; (Caulfield et al., 1998; Schafer et al., 1998; Kistin, Abramson, & Dublin, 1994; McInnes, Love, & Stone, 2000) [Level of Evidence: II-1-poor]
Provision of written materials to new mothers to promote breast-feeding: There is good evidence to recommend against providing written materials alone to promote breast-feeding. [D recommendation]
- There is no benefit when written materials are used alone. (Curro et al., 1997) [Level of Evidence: I-good]; (Hill, 1987; Redman et al., 1995; Frank et al., 1987) [Level of Evidence: I-fair]; (Rossiter, 1994; Kaplowitz & Olson, 1983; Loh et al., 1997; Grossman et al., 1990) [Level of Evidence: I-poor]
Primary health care provider (physician or midwife) advice to expectant or new mothers to promote breast-feeding: There is insufficient evidence to make a recommendation regarding advice by primary health care providers to promote breast-feeding. [I recommendation]
- Effectiveness is unknown [no studies found]
Provision of commercial discharge packages to new mothers: There is good evidence to recommend against providing commercial discharge packages to new mothers. [E recommendation]
- Women receiving commercial discharge packages had lower breast-feeding rates than patients not receiving packages. (Donnelly et al., 2001) [Level of Evidence: I (systematic review)-good]
Rooming-in and early maternal contact to promote breast-feeding: There is good evidence to recommend rooming-in and early maternal contact to promote breast-feeding (The 1994 recommendations of the task force reviewed "good" level I evidence. Those recommendations, which were classified as grade A, are not overturned by the evidence reviewed here.) [A recommendation]
- Rooming-in. The sole new study of rooming-in included multiple interventions, and conclusions could not be drawn. (Winikoff et al., 1987) [Level of Evidence: I-fair]
- Early maternal contact. New data regarding early maternal contact are insufficient. (De Chateau & Wiberg, 1977; Salariya, Easton ,& Cater, 1978; Thomson, Hartsock, & Larson, 1979; Taylor, Maloni, & Taylor, 1985) [Level of Evidence: I (individual studies and meta-analysis)-good)]
*In the studies reviewed, these interventions were usually provided in the clinical setting by lactation specialists or nurses, and consisted of individual or group instruction about breast-feeding knowledge, practical skills, and problem-solving techniques.
Definitions:
Recommendations Grades
A: The Canadian Task Force (CTF) concludes that there is good evidence to recommend the clinical preventive action.
B: The CTF concludes that there is fair evidence to recommend the clinical preventive action.
C: The CTF concludes that the existing evidence is conflicting and does not allow making a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.
D: The CTF concludes that there is fair evidence to recommend against the clinical preventive action.
E: The CTF concludes that there is good evidence to recommend against the clinical preventive action.
I: The CTF concludes that there is insufficient evidence (in quantity and/or quality) to make a recommendation; however, other factors may influence decision-making.
Levels of Evidence
I: Evidence from randomized controlled trial(s)
II-1: Evidence from controlled trial(s) without randomization
II-2: Evidence from cohort or case–control analytic studies, preferably from more than one centre or research group
II-3: Evidence from comparisons between times or places with or without the intervention; dramatic results from uncontrolled studies could be included here
III: Opinions of respected authorities, based on clinical experience; descriptive studies or reports of expert committees
Quality (Internal Validity) Rating
Good: A study that meets all design- specific criteria* well.
Fair: A study that does not meet (or it is not clear that it meets) at least one design-specific criterion* but has no known "fatal flaw."
Poor: A study that has at least one design-specific* "fatal flaw," or an accumulation of lesser flaws to the extent that the results of the study are not deemed able to inform recommendations.
