BREASTFEEDING MEDICINE Volume 10, Number 2, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2014.0034

Public Health and Policy

Incorporating Breastfeeding Education into Prenatal Care Adrienne Pitts, Mary Ann Faucher, and Rebecca Spencer

Abstract

Introduction: Prenatal breastfeeding education increases breastfeeding initiation, exclusivity, and duration. Current research regarding antenatal breastfeeding education suggests that recurrent, individual, and technology-based education programs are effective in providing women with evidence-based breastfeeding information and guidance. Materials and Methods: This project was implemented at an obstetrical practice in the northeast United States. Pregnant women between 32 weeks of gestation and birth, receiving care from certified nurse-midwives, were the targeted population. Three breastfeeding modules were created and offered to women at the 32-, 34-, and 36-week prenatal visit via computer tablets. Women answered questionnaires at the end of each module, serving as a measure for participation and content learning. Women also completed a questionnaire at the 6-week postpartum visit to assess summative perceptions. Results: Twenty-three women participated, and 21 women completed questionnaires at 6 weeks postpartum. All women answered the content questions at the end of the modules correctly. Sixty-seven percent reported prior breastfeeding experience, 95% initiated breastfeeding, 86% were exclusively breastfeeding at 6 weeks postpartum, and 71% of the women planned to exclusively breastfeed for 6 months. Sixty-seven percent reported the modules promoted or affirmed their decision to breastfeed, whereas 5% would have preferred group-based education. Providers documented breastfeeding education 52% of the time. Conclusions: The results of this project indicate that women successfully learned breastfeeding content via the tablet methodology. The results confirm that prenatal breastfeeding education, in the office setting, is well accepted by women. In order to assess the impact of the program on breastfeeding success, further study is needed.

Introduction

T

he American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life, followed by the addition of solid foods and continued breastfeeding to 1 year or beyond.1 However, many women choose to formula feed or to discontinue exclusive breastfeeding before the recommended 6 months. Women often discontinue breastfeeding when they feel unprepared or encounter problems.2–4 The top five reasons women discontinue breastfeeding are (1) feeling that the baby is too hungry, (2) perceiving an inadequate milk supply, (3) difficulty in latching, (4) painful breasts or nipples, and (5) returning to work.2,3 The literature provides evidence that prenatal breastfeeding education can address these problems and prevent early discontinuation.3,5,6 Prenatal breastfeeding education increases the rate of breastfeeding initiation,5,6 exclusivity,7–11 and duration.2,5,6,8–13 Women receiving prenatal breastfeeding education were 1.5 times more likely to initiate breastfeeding,5 increase breastfeeding duration by up to 3 months,5,6 increase exclusivity and

the number of nighttime feedings,7 and decrease the amount of supplementation given to infants than women who did not receive prenatal education.7 When compared with group education, individual education was more effective at increasing initiation and duration.5,6 The best results were achieved when sessions were interactive and personalized.5,6 Mixed-methodology education, or using multiple teaching strategies, maximizes the benefits of breastfeeding education.6,9,12,14 Furthermore, greatest success comes from recurrent education.5,6,13 Technology-based education is a valuable alternative to provider-based education. Pate11 reported that technologybased education was twice as likely to produce favorable breastfeeding outcomes as provider-based education. Similarly, Huang et al.10 found that Web-based, compared with provider-based, education increased breastfeeding exclusivity, duration, knowledge, and self-efficacy. Computer-based breastfeeding education has been perceived positively, with participants being satisfied with the education modality; this was especially true when the computer-based program included graphics and text.15

Baylor University Louise Herrington School of Nursing, Dallas, Texas.

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The impetus for this project was initiated by a group of certified nurse-midwife (CNM) providers who were concerned that breastfeeding education was not being adequately addressed in their practice. The purpose of this project was to create an evidence-based prenatal breastfeeding education program that could be delivered in an office setting. The aim of this project was to promote the initiation and continuation of exclusive breastfeeding for up to 6 months. Project outcomes were to evaluate maternal utilization and perceptions of the education program, the rate of breastfeeding initiation and maternal plans for continuation of breastfeeding, and the rate of provider documentation of breastfeeding education. Materials and Methods Setting

The project was approved by a university Institutional Review Board. The prenatal breastfeeding education program was implemented at a community obstetric and gynecologic practice in New Hampshire. The practice consisted of three CNMs. No formal practice-based prenatal breastfeeding education was being offered to pregnant women at the time of implementation. However, women were offered a 2-hour breastfeeding class at the area hospital for an additional cost. Population and sample

Pregnant women, receiving care from CNMs, between 32 weeks of gestation and birth were the targeted population. Women were eligible to participate if they entered Week 32 of pregnancy between September 6, 2013 and November 1, 2013. Demographic information was not collected from the women. Procedures and framework

The Ottawa Model of Research Use was the translational framework to guide this evidence-based project. The Ottawa Model emphasizes that a core component of practice change involves continuous assessment of each element (Table 1).16 The model is composed of three phases: assessing barriers and supports, monitoring the intervention and degree of use, and evaluating outcomes.17 Phase 1 was accomplished by an assessment of the practice environment for readiness and inclination to adopt an evidenced-based change prior to the decision to implement this project. Phase 2 was accomplished throughout implementation by monitoring utilization of the modules, reinforcement of the education, and midwife documentation of the education. Phase 3 was accomplished by analyzing the data from questionnaires that assessed patient utilization of the modules and perceptions of the breastfeeding education program. Table 1 shows specific details of how each phase was accomplished. Three breastfeeding modules were designed based on the Baby Friendly Hospital Initiative (BFHI) Steps 3–10,18 a systematic review of the evidence, and the breastfeeding curriculum of Noel-Weiss et al.8 (Table 1). The BFHI18 steps encompass breastfeeding education, skin-to-skin contact and rooming-in, avoiding pacifiers and supplementation, demand feeding, and providing breastfeeding resources. The curriculum of Noel-Weiss et al.8 included latch and positioning, maintaining lactation, infant signs of hunger and satisfaction, feeding frequency, skin-to-skin contact, and confidence building. Three modules were chosen because the current

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research suggests that recurrent education sessions are more effective than single education sessions. Each module was short, approximately 5–7 minutes in length, so that the participant could view the module while waiting for the provider in the examination room. The modules contained text, references, and images, providing a mixed-methodology education congruent with the recommendations of the current literature. The modules were programmed onto computer tablets, using a technology-based education methodology. A magnetic resource card containing breastfeeding support resources was created and given to all participating women as a reinforcement of the information presented on the tablets. At the 32-week visit, women were given a tablet, by the office nurse, containing an overview of the modules. This overview described the significance of breastfeeding education, listed references, and provided basic instructions for using the tablet. Twenty-three women were offered the education program, agreed to participate, and signed an informed consent form. Study participants were given a tablet by the office nurse when they presented for the 32-, 34-, and 36-week prenatal visits. The first screen on the tablet asked the woman to select her gestational age, which linked her to the appropriate module. Participants completed a short questionnaire at the end of each module to serve as a measure of participation and to assess learning of the content. Once the woman viewed the module and completed the learning assessment, the CNM collected the tablet. As part of the project, the CNMs were asked to facilitate discussion by asking questions pertinent to the module viewed during that visit. A laminated copy of the module content and a list of sample discussion questions were posted in each examination room. Examples of these discussion questions are ‘‘How long do you plan to breastfeed your baby?’’ and ‘‘What questions do you have about breastfeeding while in the hospital?’’ At the 36-week prenatal visit, the office nurse gave women the refrigerator magnet listing breastfeeding support resources. Also at the 36-week visit, the CNMs were asked to document that breastfeeding education occurred by checking a box in the women’s electronic medical records. A note, attached to the back of each tablet, served as a clinical reminder for the CNMs to document. Data collection and analysis

In addition to the short questionnaires at the end of each module, serving as a measure of participation and maternal learning of the content, women also completed a summative questionnaire at the 6-week postpartum visit to evaluate maternal perceptions of the modules and collect breastfeeding data. This questionnaire consisted of 13 questions to be answered yes or no, two multiple choice questions, and one short answer question. All of the questions were attitude-based questions. Sample questions are ‘‘Did you initiate breastfeeding your baby?’’ (yes or no), ‘‘What specific content was most helpful to you?’’ (multiple choice), and ‘‘If you answered ’other’ please explain’’ (short answer). Google Documents was used to administer all questionnaires and compile data. Descriptive statistics, in the form of percentages, were used to analyze all data. Breastfeeding data were compared with the Healthy People 2020 goals and current rates for breastfeeding outcomes. Breastfeeding outcomes were described in aggregate data as well as based on previous breastfeeding experience.

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Table 1. Project Implementation Using the Ottowa Model of Research Use The Ottowa Model of Research Use Phase 1: Assess barriers and supports  Evidenced-based innovation  

Potential adopters Practice environment

Phase 2: Monitor intervention and degree of use  Implementation intervention strategies

Prenatal breastfeeding education project 

Extensive literature review 8 B BFHI Steps 3–10 and Noel-Weiss et al. (2006)  CNMs and women between 32 weeks of gestation and birth  SWOT analysis of site prior to implementation B Supportive 









Adoption

Phase 3: Evaluate outcomes  Monitor effectiveness of the intervention



3 breastfeeding education modules B Programmed to a computer tablet 8 B Based on BFHI and Noel-Weiss et al. (2006) curriculum B 5–7 minutes long B Utilizing mixed-methodology Module 1 objectives B Recognize the benefits of breastfeeding for both mom and baby B Understand the American Academy of Pediatrics’ recommendation for breastfeeding B Identify a good latch B Recognize ways to manage painful nipples B Identify various breastfeeding positions Module 2 objectives B Understand the basics of milk supply B Understand how to maintain lactation B Identify normal infant hunger cues and signs of infant satisfaction B Understand breastfeeding on demand and cluster feeding Module 3 objectives B Recognize adequate milk transfer B Identify signs that breastfeeding is successful B Identify the benefits of skin-to-skin contact B Recognize the benefits of rooming-in B Understand recommendations for supplementation and pacifier use B Review stories of breastfeeding success Clinical reminders B Note to remind CNMs to document breastfeeding education B Sample discussion questions in each exam room



End of module questionnaires assessing B Utilization of each module B Maternal learning of content  6-week postpartum questionnaire assessing B Summative perceptions B Breastfeeding data and future infant feeding plans

BFHI, Breastfeeding Friendly Hospital Initiative; CNM, certified nurse-midwife; SWOT, strengths, weaknesses, opportunities, and threats.

Results

Twenty-three women who were eligible chose to participate in this project. All 23 women (100%) answered the summary content-based questions at the end of each module. All review questions were answered correctly by all of the women, indicating understanding of the module content. Seventeen (74%) of the women reported learning a new benefit of breastfeeding from Module 1. The benefits identified by women as being new information were decreased risk of breast and ovarian cancer in the mother (n = 7), decreased risk of postpartum depression in the mother (n = 6), decreased risk of respiratory and gastrointestinal infections in the infant (n = 3), and decreased risk of obesity for the infant (n = 1) (Fig. 1). All of the women reported that viewing photographs related to latch and positioning were helpful.

Twenty-one of the 23 participants (91%) answered the 6week postpartum questionnaire; two women did not attend postpartum visits. All 21 women reported viewing Module 1, Module 2, and Module 3. Sixty-seven percent of women reported that they had previous breastfeeding experience (n = 14). At the 6-week postpartum visit, 95% of women reported that they initiated breastfeeding (n = 20), and 90% of the women who initiated breastfeeding were exclusively breastfeeding (n = 18). Seventy-one percent planned to exclusively breastfeed for 6 months (n = 15). The one woman who did not initiate breastfeeding had no prior breastfeeding experience. Sixty-seven percent (n = 14) of the women reported that the breastfeeding modules promoted or affirmed their decision to breastfeed, and 33% (n = 7) of the women reported that the breastfeeding modules had no effect on their decision to breastfeed. Of the women reporting that the modules had

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FIG. 1.

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Benefits of breastfeeding identified by women as being new information.

no effect on their decision to breastfeed, five had successfully breastfed in the past, one had not breastfed in the past and did not initiate breastfeeding, and one had no prior breastfeeding experience and stopped exclusively breastfeeding before the 6-week postpartum visit. One (5%) participant reported that she would have preferred group-based education. Twentynine percent (n = 6) of the women reported also attending the hospital’s breastfeeding class. Of the women who attended the hospital’s breastfeeding class, one had breastfed in the past, and five had not. Content areas reported in the 6-week postpartum questionnaire as being the most helpful content area of the modules were latch and positioning (n = 7),

FIG. 2.

benefits of breastfeeding (n = 7), milk supply (n = 6), and maintaining lactation (n = 6) (Fig. 2). The CNMs documented breastfeeding education in the women’s medical records 52% of the time (n = 12). Discussion

The results generated by this study are favorable when compared with the Centers for Disease Control and Prevention’s Breastfeeding Report Card19 and the Healthy People 2020 goals20 for the United States. As of 2010, 88.5% of women in New Hampshire initiate breastfeeding,19 whereas

Content areas reported as being most helpful.

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95% of women in this project initiated breastfeeding. The results are also higher than the Healthy People 2020 goal of 81.6% for breastfeeding initiation.20 When comparing women’s plans for continuation of exclusive breastfeeding for 6 months, 71% of the women planned to exclusively breastfeed for 6 months, whereas the Healthy People 2020 goal is 25.5%, and the New Hampshire rate is 24.9%.19,20 Ninety-five percent of women reported that they preferred individual education over group-based education. This is congruent with the current literature that shows individual education, compared with group-based education, is more effective and is preferable to participants.5,6 Recently, the Academy of Breastfeeding Medicine adapted the BFHI steps to create the Breastfeeding-Friendly Physician’s Office.21 The Breastfeeding-Friendly Physician’s Office protocol teaches breastfeeding policy, education, and individual provider guidance in the office setting.21 Corriveau et al.22 conducted a study with 757 mother–infant dyads, evaluating the effects of the Breastfeeding-Friendly Physician’s Office protocol in a pediatrician office setting. When comparing pre- and postintervention data, the researchers found a significant increase in exclusive breastfeeding rates.22 The results of the study of Corriveau et al.22 and this project suggest that provider-delivered breastfeeding education and support may help increase breastfeeding initiation, duration, and exclusivity. A strength of this project is that women identified areas of new knowledge about the benefits of breastfeeding and helpful content related to breastfeeding; this included 14 women that had already breastfed. The content that women identified as most helpful in this project is congruent with the top five reasons for early discontinuation of breastfeeding.2,3 These summary data provide information related to important content areas to include in other breastfeeding classes (Figs. 1 and 2). Additionally, all eligible women chose to participate, indicating the program was welcomed by women. Furthermore, the tablet methodology was well accepted by women and should be used in future studies. There are several limitations in this project’s design. The small sample size is one limitation. Another limitation of this study is the short time frame for follow-up and the purely descriptive design. Many factors during the 6-week postpartum period can influence the continuation of breastfeeding that were not assessed in this project. Current breastfeeding policy addresses prenatal care, hospital care, and the workplace. However, the lying-in period, the first several postpartum weeks, has not been addressed in breastfeeding policy recommendations, and further study during this time is sorely needed. As this project was not able to extend to 6 months postpartum, it examined women’s intention to breastfeed exclusively for 6 months rather than actual breastfeeding rates at 6 months. It would be beneficial for future studies to examine breastfeeding exclusivity at 6 months. Based on this study design, results cannot be purely correlated with this breastfeeding education program. Women in a midwifery practice may be more likely to initiate breastfeeding compared with women choosing physicianled care. Another limitation is that the questionnaires did not ask what information had the greatest impact on the choice to breastfeed or impacted the women’s plans to initiate or continue breastfeeding. This information would be beneficial

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in revising this office-based curriculum and for identifying important ways to further promote breastfeeding. The breastfeeding class offered by the hospital is another limitation to this project, as the results cannot be only accredited to the breastfeeding modules for the six women that attended the hospital course. Actual CNM discussion with the women after the modules were viewed was not assessed, nor what the discussion entailed. Assessing whether or not CNMs facilitated breastfeeding discussions should be included in future studies. Furthermore, the rate of CNM documentation of the education was low; however, the electronic medical record system was relatively new to the practice, which may have influenced documentation rates. This project did not evaluate CNM satisfaction with the education program or willingness to permanently adopt this practice change. It would be beneficial for future studies to include postimplementation questionnaires for the CNMs evaluating satisfaction, willingness to continue the practice change, and comfort with facilitating breastfeeding discussions with women. Although satisfaction was not formally evaluated, the CNMs anecdotally expressed their satisfaction with the project. After the project’s conclusion, the CNMs have continued to offer the modules to women seeking breastfeeding information. Conclusions

This breastfeeding education program encompassed several features reported by current research as increasing breastfeeding initiation, duration, and exclusivity. Mixedmethodology, recurrent education, individual education, and technology-based education were used. These results indicate that this method of delivering breastfeeding education provided evidence-based information that women found beneficial based on participation rates, identification of new knowledge, and feedback related to content that was helpful to them. Prenatal breastfeeding education successfully increases breastfeeding initiation and the rate and duration of exclusive breastfeeding; however, further research is necessary to determine the impact of this program on breastfeeding initiation and success. Disclosure Statement

No competing financial interests exist. References

1. American Academy of Pediatrics. Policy statement: Breastfeeding and the use of human milk. Pediatrics 2013; 129:827–841. 2. McLeod D, Pullon S, Cookson T. Factors influencing continuation of breastfeeding in a cohort of women. J Hum Lact 2002;18:335–343. 3. Brand E, Kothari C, Stark M. Factors related to breastfeeding discontinuation between hospital discharge and 2 weeks postpartum. J Perinat Educ 2011;20:36–44. 4. Odom EC, Sconlon KS, Perrine CG, et al. Reasons for earlier than desired cessation of breastfeeding. Pediatrics 2013;131:e726–e732. 5. Dyson L, McCormick F, Renfrew M. Interventions for promoting the initiation of breastfeeding. Cochrane Database Syst Rev 2005;(2):CD001688.

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6. Hannula L, Kaunonen M, Tarkka M. A systematic review of professional support interventions for breastfeeding. J Clin Nurs 2008;17:1132–1143. 7. Mellin P, Poplawski D, Gole A, et al. Impact of a formal breastfeeding education program. MCN Am J Matern Child Nurs 2011;36:82–90. 8. Noel-Weiss J, Rupp A, Cragg B, et al. Randomized controlled trial to determine effects of prenatal breastfeeding workshop on maternal breastfeeding self-efficacy and breastfeeding duration. JOGNN 2006;35:616–624. 9. Mattar C, Chong Y, Rauff M, et al. Simple antenatal preparation to improve breastfeeding practice: A randomized controlled trial. Obstet Gynecol 2007;109:73–80. 10. Huang M, Kuo S, Avery M, et al. Evaluating effects of a prenatal web-based breastfeeding education programme in Taiwan. J Clin Nurs 2007;16:1571–1579. 11. Pate B. A systematic review of the effectiveness of breastfeeding intervention delivery methods. JOGNN 2009;38:642–653. 12. Rosen I, Krueger M, Carney L, et al. Prenatal breastfeeding education and breastfeeding outcomes. MCN Am J Matern Child Nurs 2008;33:315–319. 13. Paz-Pascual C, Pinedo I, de Pedro M, et al. Design and process of the EMA Cohort Study: The value of antenatal education in childbirth and breastfeeding. BMC Nurs 2008;7:5. 14. Lumbiganon P, Martis R, Laopaiboon M, et al. Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane Database Syst Rev 2012;9:CD006425. 15. Cheng W, Thompson C, Smith J, et al. A web-based breastfeeding education program. J Perinat Educ 2003;12:29–41. 16. Campbell B. Applying knowledge to generate action: A community-based knowledge translation framework. J Contin Educ Health Prof 2010;30:65–71.

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17. White KM, Dudley-Brown S. Translation of Evidence into Nursing and Health Care Practice. Springer Publishing, New York, 2012. 18. United Nations Children’s Fund. The Baby-Friendly Hospital Initiative. January 12, 2005. Available at www.unicef.org/ nutrition/index_24806.html (accessed February 28, 2014). 19. Centers for Disease Control. Breastfeeding Report Card— United States, 2012. August 2012. Available at www.cdc .gov/breastfeeding/pdf/2012BreastfeedingReportCard.pdf (accessed February 28, 2014). 20. HealthyPeople.gov. Maternal, Infant, and Child Health. August 28, 2013. Available at www.healthypeople.gov/ 2020/topicsobjectives2020/objectiveslist.aspx?topicId = 26 (accessed February 28, 2014). 21. Grawey AE, Marinelli KA, Holmes AV. ABM Clinical Protocol #14: Breastfeeding-friendly physician’s office: Optimizing care for infants and children. Breastfeed Med 2013;8:237–242. 22. Corriveau S, Drake E, Kellams A, et al. Evaluation of an office protocol to increase exclusivity of breastfeeding. Pediatrics 2013;131:942–950.

Address correspondence to: Adrienne Pitts, DNP Baylor University Louise Herrington School of Nursing 3700 Worth Street Dallas, TX 75246 E-mail: [email protected]

Incorporating breastfeeding education into prenatal care.

Prenatal breastfeeding education increases breastfeeding initiation, exclusivity, and duration. Current research regarding antenatal breastfeeding edu...
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