The efficacy and the safety of antenatal breastmilk expression on breastfeeding outcomes: a systematic review and meta-analysis

Antenatal breastmilk expression (ABE) has gained attention as a potential intervention to improve breastfeeding success, particularly among women at risk of delayed lactogenesis or breastfeeding difficulties. Breastfeeding is highly beneficial for maternal and infant health, yet global exclusive breastfeeding rates remain below WHO targets. Although emerging evidence suggests potential benefits, a comprehensive synthesis of recent randomized controlled trials (RCTs) is lacking. This systematic review aimed to evaluate the effectiveness and safety of ABE on breastfeeding outcomes. This systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Statement. PubMed, Web of Science, Scopus, Embase, CINAHL (via EBSCOhost), The Cochrane Library, WanFang Data, China National Knowledge Infrastructure (CNKI) were searched from the inception of the data bases to September 2024. Two authors independently reviewed the studies. Studies were included if they used randomized controlled trials to evaluate the effect of ABE on breastfeeding related outcomes. The Cochrane Risk of Bias Tool was used to assess quality. Meta-analyses were performed using RevMan version 5.4. Heterogeneity was assessed using the I² statistic, and certainty of evidence was assessed using the GRADE approach. This systematic review included 10 randomized controlled trials involving 1672 participants. ABE significantly improved the initiation of lactation (MD = -6.23; 95% CI: -7.77 to -4.69; moderate certainty evidence. at < 72 h: OR = 4.06; 95% CI: 2.15–7.67; high certainty evidence), and the breastfeeding self-efficacy (MD = 8.51; 95% CI: 7.69–9.33; moderate certainty evidence), both statistically significant. Exclusive breastfeeding rates were significantly higher within 3 months postpartum (OR = 4.95; 95% CI: 2.65–9.25, I2 = 85%; moderate certainty evidence), but no significant difference was observed at ≥ 3 months (OR = 1.09; 95% CI: 0.83–1.44, P = 0.54; moderate certainty evidence). There was no difference in the risk of admission to Neonatal Intensive Care Unit (OR = 1.08; 95% CI: 0.74–1.57, P = 0.69), gestational age at birth (MD = -0.15; 95% CI: -0.29 to 0.00, P = 0.05), birthweight (MD = -0.04; 95% CI: -0.14 to 0.05, P = 0.35), and cesarean section delivery (OR = 1.10; 95% CI: 0.87–1.40, P = 0.42) among mothers with ABE compared to those who did not. The existing evidence supports the efficacy and safety of ABE interventions on promoting breastfeeding. ABE programs can be incorporated into antenatal breastfeeding education. This review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42024534064).