Nurse Education in Practice xxx (2015) 1e6

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Breastfeeding knowledge among Polish healthcare practitioners supporting breastfeeding mothers lak-Olejnik b Magdalena Nehring-Gugulska a, *, Piotr Nehring a, 1, Barbara Kro a b

The Centre for Lactation Science, Warsaw, Poland Department of Neonatology, Medical University in Wroclaw, Poland

a r t i c l e i n f o

a b s t r a c t

Article history: Accepted 25 March 2015

Introduction: The aim of the study was to evaluate the level of breastfeeding knowledge among healthcare practitioners taking care for mothers and children in the perinatal period, the training needs for such practitioners, and the forms of breastfeeding support in Poland. Research Design: The study involved a group of 361 health care practitioners, of whom 168 had followed a professional development course in breastfeeding knowledge, whilst the remaining 193 had not. A tenpoint test was used with this group to assess their 2nd level of lactation knowledge as defined by Wellstart International guidelines. Results: The study included 227 midwives, 58 medical doctors, 40 nurses, 8 educators and psychologists and 28 members of other professions. Breastfeeding support was being provided by 309 of the participants (86.3%). The highest mean test score (7.58 points) was obtained by medical doctors who had completed a professional development course in the field of breastfeeding knowledge. The probability of achieving a high score was increased by: following a professional course in breastfeeding knowledge (OR ¼ 8.73; 95% CI: 4.99e15.32), following the longest breastfeeding support skills training (OR ¼ 4.80; 95% CI: 2.83e8.14) and IBLCE certification (OR ¼ 5.07; 95% CI: 2.71e9.47). Conclusion: Specialist professional development courses are effective sources of knowledge for practitioners who provide breastfeeding support. There is a need to include breastfeeding education in curriculum for undergraduate medical training, as well as to organize professional development courses to provide evidence-based knowledge and practice to support breastfeeding mothers and babies. © 2015 Elsevier Ltd. All rights reserved.

Keywords: Breastfeeding Certificate Consultant Lactation Knowledge

Introduction For a large part of the twentieth century, health care professionals widely believed artificial feeding of infants to be at least as good as breastfeeding, possibly even better. In 1974 however, ground-breaking research by John Gerrard revealed the presence of vital immune complexes in breast milk (Gerrard, 1974). It was this work that eventually convinced WHO and UNICEF to recommend a general return to breastfeeding in all countries of the world (Cattaneo et al., 2006; UNICEF and WHO, 1989; WHO, 2002). In the years 1986e1997, against the background of a government Breastfeeding Promotion Programme in Poland, breastfeeding indicators were raised: initiation rates increased from 73.2% to 92%, exclusive breastfeeding increased from 0% to 29% at 4 months, from 0% to 9% at 6 months, and 15% of children were breastfed at 1 * Corresponding author. The Centre for Lactation Science, Herbaciana 2, 04-824 Warsaw, Poland. Tel.: þ48 605404037; fax: þ48 22 6156959. E-mail addresses: [email protected] (M. Nehring-Gugulska), piotr.nehring@ lak-Olejnik). gmail.com (P. Nehring), [email protected] (B. Kro 1 Tel.: þ48 724115359.

year of age (Mikiel-Kostyra, 1992; Mikiel-Kostyra and Mielniczuk, 1996; Mikiel-Kostyra et al., 1999). There is currently no government-financed project designed to promote breastfeeding in Poland. As a result of this, most activities involving breastfeeding promotion, staff training, certification of lactation consultants and advisors, evaluation of Hospitals as Baby Friendly, and so on, are implemented by non-governmental organizations (NGOs). Studies have shown that the situation in Poland recka et al., 97.7% of since 1997 has not improved. According to Zago mothers initiate breastfeeding after birth (n ¼ 134), but feeding of 50% of children is supplemented with artificial formulas, and most Polish mothers give up breastfeeding within 2e3 months  recka et al., 2007). In their 4th month 30% of children are (Zago exclusively breastfed, and in the 6th month the percentage drops to 14% (Bernatowicz-Łojko and Wesołowska, 2012). There is clear evidence that professional support and counselling for breastfeeding mothers raises breastfeeding rates, especially rates of exclusive breastfeeding (Sikorski et al., 2005; Britton et al., 2009). It has been shown that the education of medical staff in breastfeeding management and their participation in clinical

http://dx.doi.org/10.1016/j.nepr.2015.03.011 1471-5953/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Nehring-Gugulska, M., et al., Breastfeeding knowledge among Polish healthcare practitioners supporting breastfeeding mothers, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.03.011

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M. Nehring-Gugulska et al. / Nurse Education in Practice xxx (2015) 1e6

practicums in the field of lactation extend breastfeeding knowledge, initiate changing traditional practice to evidence-based, change staff attitudes, raise breastfeeding rates and improve health outcomes (Kramer et al., 2001). Content and levels of education of health professionals in the field of lactation are described by Wellstart International (WI), University of California, in their Lactation Management Curriculum Guide (Wellstart Int. 1999). The guide specifies three levels of education and three levels of support for breastfeeding mothers: 1st level e awareness e for physicians, nurses, nutritionists/ dieticians and practitioners in related disciplines who do not go on to specialize in any aspect of perinatal care and do not provide care for the breastfeeding dyad. 2nd level e generalist e for physicians, nurses, midwives, nutritionists/dieticians specializing in some aspect of perinatal care (neonatology, paediatrics, obstetrics, family medicine) and providing care for mothers and children on a regular basis. 3rd level e specialist e to be attained by those physicians, nurses, midwives, nutritionists/dieticians who intend to specialize in lactation management and spend a large portion of their practice dealing with lactation issues. They provide lactation counselling and treat mothers and their children with difficult problems and complications. This 3rd level also applies to lactation counsellors/consultants, lecturers, trainers, and authors of lactation education programs. Background During their undergraduate training, as well as in most professional development courses, neither doctors, midwives or nurses in Poland receive the WI guideline's number of hours of training in the field of lactation. The typical medical studies' curriculum in Poland provides 1e2 h of training in breastfeeding knowledge, and additional courses for medical specialization provides an average additional 1 h. There are no classes in how to assist the lactation outpatient, and educational programs rarely provide practical training that involves interacting with mothers and children. As a result, health care professionals' breastfeeding knowledge is of a limited nature and focused primarily on the birth setting (Sztyber and Dmoch-Gajzlerska, 2005). The first lactation clinic in Poland was established in Warsaw in 1987. The first Polish International Board Certified Lactation Consultant received certification in 1996. In 2003, the first training and the first International Board of Lactation Consultant Examiners (IBLCE) examination in Polish were held. Poland currently has 110 IBCLCs, 226 Certified Lactation Consultants (CDL e Polish local equivalent certificate for medical professionals), about 160 lactation outpatient clinics at hospitals and in private surgeries, against a figure of 400,000 births/year in the country as a whole. Lactation counselling is not funded by State health insurance in Poland. The aim of the study was to evaluate the level of breastfeeding knowledge among healthcare practitioners taking care of mothers and children in the perinatal period in Poland and to draw conclusions about the possible need for education in the field of lactation in this group. The objective was also to evaluate forms of professional support for breastfeeding mothers. Research design The research reported in this paper was carried out in Poland between April 2009 and January 2011. The group was composed of 361 individuals, of whom the test sample of 168 had followed professional development courses in breastfeeding knowledge, whilst a control sample of 193 had not been specifically so trained, but were serving as mothers and children support workers. All individuals in the test sample had completed professional

development courses in breastfeeding knowledge conducted by both of two NGOs and were working in obstetric-neonatal wards and/or in private clinics in Poland. The control group was comprised of individuals working in randomly selected obstetricneonatal units who had only undergraduate education in the field of lactation and had not taken the corresponding professional development course. The study enrolled only those individuals who consented to participate. The study, which was approved by the Bioethics Committee of the Medical University of Katowice, used a two‑part questionnaire developed by the authors. The first part related to the professional status of the respondents, the place where they were practising, their experience of breastfeeding counselling, whether they had followed a professional development course in lactation knowledge, and their motivation for undertaking training and maintaining their skills in this area (Table 1). The second part of the questionnaire consisted of a test of 10 multiple choice questions, intended to assess participants' theoretical knowledge at the WI second level. The first 5 questions were related to general knowledge about lactation concerning in examlpe the following issues: breastfeeding duration as recommended by WHO, the benefits of breastfeeding for children’s health, the lactogenesis after physiological birth and caesarean delivery. The next 5 questions were related to clinical expertise in the field of lactation concerning in example the following issues: symptoms and treatment of mastitis, differential diagnosis of postpartum breast fullness and engorgement, clinical treatment breastfeeding babies' slow gain in weight, medications and conditions that are contraindications to breastfeeding. Respondents gained 1 point for each of the 10 questions for which they chose the single correct answer from those presented; choosing more than one answer or no answer at all for a question resulted in a score of zero on that question. A test score of 7 points was graded as ‘satisfactory’, whilst scores of 8 and above were graded as ‘high’. Univariate ANOVA and linear regression were used in a statistical analysis of 12 studied qualitative predictors and quantitative test results. In order to perform a deeper analysis of the basic linear models we introduced a qualitative parameter ‘the high test score’ defined as obtaining more than 8 points per 10 possible. Quantitative assessment of the impact of different variables in obtaining a high test result was presented as the odds ratios (OR) of changes in the unit, calculated using logistic regression, together with its 95% confidence interval. In logistic regression analysis we used the Logistic Regression software developed by John C. Pezzullo (Version 05.07.20), Microsoft Excel and STATISTICA 9PL (StatSoft, Inc.). The significance level was defined with a ¼ 0.05. Results The response rate to the initial survey was 48.1%, with 361 individuals out of the 750 canvassed replying, 191 by post and 170 via the internet. The results reported express the impact of qualitative predictors on performance in the multiple choice section of the questionnaire, such performance being measured by the mean outcomes of groups in the sample defined by the individual’s occupation. The occupational categories included in the study are presented in Table 2, and it should be noted that 70% of the subjects worked in hospital maternity units. Of these individuals, 168 had followed a professional course in breastfeeding knowledge and were taken as the test sample, while the other 193, who had acquired their knowledge exclusively in various kinds of undergraduate education, formed a control sample (Fig. 1). Both samples were similar in terms of occupation, practice settings, the size of their departments, periods of employment, and their involvement in lactation counselling. There were however certain small differences

Please cite this article in press as: Nehring-Gugulska, M., et al., Breastfeeding knowledge among Polish healthcare practitioners supporting breastfeeding mothers, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.03.011

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Table 1 Questionnaire.

Table 2 Structure of occupations in the combined group. Occupation

Number

Percentage

Midwife Medical doctor Nurse Pedagogue/psychologist Other Total

227 58 40 8 28 361

62.9 16.1 11.1 2.2 7.7 100

Fig. 1. Percentage of cases n ¼ 168 and controls n ¼ 193 in the study.

between the samples: the test sample had a proportionately larger number of midwives (71.1% vs 53.3%), and of individuals with nonmedical occupations (18.0% vs 3.1%), and psychologists and educators were present only in that sample. Most individuals (86.4%) were motivated to follow professional development course in evidence-based breastfeeding knowledge

for reasons other than employer recommendation (3.6%). The main reason for seeking breastfeeding education in both groups was a need to provide professional breastfeeding support (66.8%) and a sense of lack in lactation knowledge (23.6%). A finding of significant importance is that individuals in the test sample generally had similar or even higher motivation to acquire further education in lactation as compared to those in the control sample (Fig. 2). In the test sample, 168 individuals had participated in 182 courses ranging from 20 to 80 h at the 2nd and 3rd WI levels of breastfeeding knowledge. In the combined group, 72 individuals (19.9%) were certified as IBCLC and/or CDL, but the total number of certificates was 81 e some individuals had both. Of all the individuals in Poland who had certificates in breastfeeding support skills at the time of the study, data from 46% of them are incorporated in it. Breastfeeding support was provided by 309 individuals (86.3%), mostly during professional duties in their place of work (70.1%). Providing breastfeeding support was described as being part of their job by 89.8% (n ¼ 149) of the test sample and by 83.3% (n ¼ 160) of the control sample (Fig. 3). Other individuals in the combined sample provided breastfeeding support during home visits or in private lactation clinics (19.9%), in outpatient surgeries (11.6%) and as lactation consultants employed in hospitals (7.2%). The highest test score attained was 10 points, the lowest 1 point, and the research showed significant differences in groups

Please cite this article in press as: Nehring-Gugulska, M., et al., Breastfeeding knowledge among Polish healthcare practitioners supporting breastfeeding mothers, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.03.011

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M. Nehring-Gugulska et al. / Nurse Education in Practice xxx (2015) 1e6

Fig. 2. Motivation to acquire further education in breastfeeding knowledge in the test (n ¼ 168) and control (n ¼ 193) samples.

Fig. 3. Percentage of individuals who are providing/not providing breastfeeding support in the test (n ¼ 168) and control (n ¼ 193) samples.

according to occupation. Only individuals from the test sample obtained satisfactory mean test results (>7 points) across all occupations.In the control group, satisfactory test scores were obtained neither by medical doctors (mean 5.22 points), midwives (mean 4.97 points), nurses in maternity departments (mean 4.70 points) and in other departments (mean 5.50 points), nor by individuals with other occupations (mean 5.50 points) (Table 3). The relationship between quantitative test results and other qualitative predictors was a consequence of relation with participating in professional development course in breastfeeding knowledge variable. Having followed a specific professional education programme in lactation had the most significant impact on the test result (mean 7.36 vs 5.00 points in test and control samples, respectively). Having followed a professional development course in breastfeeding knowledge increased 8.7-fold the probability of obtaining a high score in the theoretical test (analyzing according to the qualitative variable defined by test score  8 points) (Table 4). The highest mean score was obtained in the test sample by medical doctors and by representatives of ‘other’ professions. The lowest mean score was obtained by nurses working in perinatal departments and midwives who had only undergraduate education. Logistic regression analysis showed that the impact on achieving a high score had the following variables: working in large cities/at university (OR ¼ 1.80; 95% CI: 1.10e2.95), working in an outpatient surgery (OR ¼ 4.65; 95% CI: 1.64e13.16) and providing

Table 3 Test scores for the combined group divided according to occupation and whether or not a course in lactation has been followed. Group

Course followed

Number

Mean

Median

Minimum

Maximum

Lower quartile

Upper quartile

SD

All

Yes þ no Yes No Yes No Yes No Yes No Yes No Yes Yes No

361 168 193 31 27 89 138 13 29 5 2 8 22 6

6.10 7.36 5.00 7.58 5.22 7.24 4.97 7.23 4.70 7.20 5.50 7.25 7.68 5.50

6 7 5 8 5 8 5 7 5 7 5.5 7 8 5

1 2 1 4 2 2 1 4 2 7 3 6 5 3

10 10 9 10 9 10 9 9 8 8 8 10 10 8

5 7 4 7 4 6 4 7 3.5 7 3 6.5 7 4

8 8 6 8 7 8 6 8 6 7 8 7.5 9 8

2.08 1.52 1.88 1.39 2.01 1.69 1.88 1.42 1.63 0.45 3.54 1.28 1.25 2.07

Medical doctor Midwives Nurses in maternity department Nurses in other department Educator, psychologist Other professions

Please cite this article in press as: Nehring-Gugulska, M., et al., Breastfeeding knowledge among Polish healthcare practitioners supporting breastfeeding mothers, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.03.011

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Table 4 Results of logistic regression determining the odds of achieving a high test result for the participants. Variables

OR

95% CI

p value

Having followed a course in lactation IBCLC Certificate Lengths of courses 20 h 45 h 65e80 h Workplace Working in maternity hospital or delivery department Working in outpatient surgery Working in other place Size of department Working in large cities/at university Profession Other Seniority 6e15 years Over 15 years Breastfeeding support In private lactation clinic or during home visits Via Internet

8.73 5.07 2.27 3.31 4.80 0.47 4.65 1.85 1.80 2.83 1.91 0.77 2.96 3.76

4.98e15.32 2.71e9.47 1.21e4.23 1.55e7.06 2.83e8.14 0.29e0.76 1.64e13.16 1.06e3.23 1.10e2.95 1.29e6.17 1.17e3.12 0.66e0.91 1.73e5.07 1.53e9.23

0.00001 0.00001

Breastfeeding knowledge among Polish healthcare practitioners supporting breastfeeding mothers.

The aim of the study was to evaluate the level of breastfeeding knowledge among healthcare practitioners taking care for mothers and children in the p...
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