What do Kramer's Baby-Friendly Hospital Initiative PROBIT studies tell us? A review of a decade of research.

BACKGROUND: Kramer et al's PROBIT (Promotion of Breastfeeding Intervention Trial) research in Belarus studied effects of the Baby-Friendly Hospital Initiative (BFHI) training on breastfeeding duration, exclusivity, and health outcomes. AIMS: To critique inclusion criteria, context, approaches to data analysis, and health outcome results.
METHOD: Twenty-two articles were retrieved from PubMed and the PROBIT Website for 2001-2010; 6 were excluded as not focusing on breastfeeding and health outcomes.
RESULTS: PROBIT data from the cluster randomized hospital comparisons included only breastfed babies since all non-breastfed babies were excluded from the research. Context may affect outcomes, knowing that Belarus has good basic health services, 3-year maternity leaves with little use of daycare, 95% breastfeeding initiation rate, and a well-educated population. PROBIT data were analyzed in 2 ways: (a) intent-to-treat analyses of breastfeeding and health differences by cluster randomized intervention and control site mother/baby pairs; and (b) as an observational cohort study of health outcomes for all mother/baby pairs, analyzed by various breastfeeding categorizations and controlling for biases. PROBIT demonstrated links between BFHI and longer breastfeeding duration (19.7% vs 11.4% at 12 months, P < .001) and exclusivity (43.3% vs 6.4% at 3 months, P < .001), reductions in gastrointestinal episodes and rashes, higher verbal IQ scores, and longer exclusive breastfeeding rates for subsequent children but no statistically significant differences in the child's body mass index, blood pressure, or dental health.
CONCLUSION: PROBIT provides foundational evidence for BFHI policy and follow-up care. Knowing that non-breastfed babies were excluded, caution must be exercised for health comparisons.