Breastfeeding Intervention Design Study
EXECUTIVE
SUMMARY
Background
WIC encourages breastfeeding as the best source of infant
nutrition and currently earmarks funds for breastfeeding promotion and
support activities. However, while a great deal of breastfeeding promotion
and support is happening in WIC at both the state and local levels, there
has been no systematic effort to evaluate what might work best in the WIC
setting. Within this context, the Food and Nutrition Service contracted
with Abt Associates Inc. for a breastfeeding intervention design study
with the following goals:
-
Identify interventions to increase the incidence,
duration and intensity of breastfeeding among women participating in
WIC; and
-
Design an evaluation plan to examine the
implementation and effectiveness of these interventions.
After a review of the literature, and in consultation with
outside experts and FNS staff, peer counseling was recommended as a
promising breastfeeding promotion intervention for implementation in WIC.
An experimental design was chosen to provide clear evidence of the
intervention’s effectiveness. The design would involve randomly
assigning pregnant WIC participants in selected sites to one of three
groups: high-cost peer counseling, low-cost peer counseling, or a control
group, which would receive postpartum support services currently offered
by the WIC sites. Each phase of the design study is described below.
Literature Review
A thorough review of English-language breastfeeding
promotion and support intervention efforts described in articles and
reports written since 1990 was conducted. The interventions varied across
a number of characteristics including the nature of the intervention, the
target group, time period in which intervention was implemented (e.g.,
prenatal, postpartum), the delivery person or persons, and where the
intervention took place. Although the review suggested interventions that
have improved breastfeeding outcomes, there were gaps in research
evidence, as well as methodological and implementation issues.
Most of the studies that focused on WIC participants were
based on two types of interventions: peer counseling and various
multifaceted interventions (i.e., interventions with three or more
intervention strategies). Twelve peer counseling studies focused on WIC
participants, although none of these studies used a methodologically
strong design. Eleven of these 12 peer-counseling studies suggested a
positive benefit on breastfeeding outcomes, including initiation and
duration. Most of the multifaceted interventions with WIC participants
were not designed to test the effects of the intervention on
breastfeeding. The three multifaceted interventions that included
evaluations used designs with methodological weaknesses, and only two of
these reported positive intervention effects. Aside from these common
intervention types, there were three prenatal education interventions of
WIC participants. The two of these prenatal education interventions that had
valid research designs found no significant effects of the interventions
on breastfeeding outcomes. One with a weak design found an effect on
breastfeeding duration. Two postpartum support interventions involving WIC
participants included evaluations with weak designs. One reported
increases in breastfeeding initiation, while the other reported an
increase in breastfeeding duration. No reports on hospital-based
breastfeeding interventions with WIC populations were identified. Thus,
there are only a small number of WIC-based studies that provide a basis
for selecting the intervention(s) to be evaluated, and even fewer that
used valid evaluation methods.
Peer Counseling Intervention
Proposed for Testing in WIC
Based on findings from the literature review, four
interventions were selected for consideration by FNS and expert
consultants with expertise in breastfeeding promotion and support in WIC,
extensive research in maternal and child health issues, and research on
breastfeeding interventions with low-income and minority groups. The
proposed interventions were those that had some evidence of success based
on statistically significant increases in breastfeeding initiation and/or
duration, appeared feasible for the WIC setting, had potential to be
evaluated using an experimental design, and appeared sensitive to cultural
differences or were shown effective with different racial or ethnic
groups. Peer counseling was selected as the breastfeeding promotion and
support intervention to be
tested in WIC.
Evaluation Design for Peer
Counseling Intervention
A draft evaluation design and analysis plan for peer
counseling interventions was proposed and developed to assess 1) how well
the interventions have been implemented and 2) their
effectiveness in improving breastfeeding outcomes. The draft evaluation
plan was provided to a panel of experts who strongly recommended an
experimental design in which sites are selected from among those that
volunteer and in which WIC study participants within each site are
randomly assigned to one of three groups:
-
high-cost peer counseling which might include, for
example, one prenatal one-on-one counseling visit, one individual
counseling in the hospital, four home visits and weekly phone calls;
-
low-cost peer counseling which might include no
one-on-one prenatal counseling, but one hospital visit, one home visit
and a phone call every two weeks; or
-
control group, which would receive existing postpartum
support services currently offered by the WIC clinic.
Last modified: 12/04/2008
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