The World Health Organization (WHO) Recommends Breastfeeding

Introduction

The benefits for both infant and maternal health are well documented. The World Health Organization (WHO) recommends breastfeeding exclusively for the first six months of life and continuation of breastfeeding for up to two years of age (Breastfeeding, 2018). The nutrients provided by breast milk are suited for growth and development of the infant and is associated with lower rates of gastrointestinal, respiratory, urinary tract infections and less atopic illness in the first year (Man & Yi, 2011). Benefits for breastfeeding mothers include the increased likelihood of losing the weight they may have gained during pregnancy, a lower incidence of developing premenopausal breast and/or ovarian cancer, and an enhanced self-image (Man & Yi, 2011).

Professional organizations, such as the American Academy of Pediatrics, also advocate the significant impact of reducing healthcare cost that breastfeeding can have. The risks for feeding prepared milk formulas include milk powder contamination, allergic reactions due to the cow milk and the storage of milk formulas. Breastfeeding greatly reduces these risks (Man & Yi, 2011).Since breastfeeding is a form of health promotion and disease prevention, education on this topic is important. International awareness about the known advantages of breastfeeding continues to be spread and as a result, “global support for the encouragement, commencement, and continuation of breastfeeding has been initiated” (Man & Yi, 2011). Despite this, research shows that many mothers from around the world are prematurely discontinuing to breastfeed.

More research needs to be conducted to understand the barriers to breastfeeding for the mothers, available prenatal breastfeeding education, and the effects of these educational programs on breastfeeding initiation rates. The purpose of this paper is to examine empirically-based studies related to prenatal breastfeeding education and pregnant women and the program effectiveness, with the goal to increase the breastfeeding initiation rate.Procedure for Obtaining StudiesThe following literature was obtained from the database Cumulative Index to Nursing and Allied Health Literature (CINAHL). The following key search words were included: prenatal education, prenatal education and breastfeeding, prenatal education and techniques, prenatal education and barriers, prenatal education and internet, prenatal education and waiting room, antenatal breastfeeding education, prenatal breastfeeding education, breastfeeding and technology, and prenatal education on breastfeeding and home setting. The years of study that were searched ranged from 2005-2019 to use the most accurate and up-to-date data. The search resulted in many journal articles that were relevant to the topic of breastfeeding education. Some suggested articles were not chosen because they were not relevant to the topic of breastfeeding education or were published 15 or more years ago.Review of LiteratureAvailable Prenatal Breastfeeding Education Programs Using Non-Technological MethodsIn a study by Parry, Tully, Hopper, Schildkamp, and Labbok (2018), the purpose was to assess and evaluate the acceptability and effects of the prenatal method Ready, Set, BABY (RSB) on infant feeding.

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The study consisted of 416 pregnant women, from multiple sites within the U.S. including two sites in Puerto Rico, aged 18 to 44 years old. The sample was 46.4% Hispanic, 38% non-Hispanic White, 11.9% non-Hispanic Black, and 3.7% Asian/Pacific Islander, American Indian/Alaskan Native, or multiracial. The educational material consisted of a 28-page color patient booklet and an educator flipchart with suggested text. After completing RSB, the participants completed a questionnaire that addressed their acceptability of infant feeding and maternity care practices. The results revealed an increase from 296 to 315 women who stated that they would continue to breastfeed for a longer duration. This study is an example of an experimental design, which us designed to provide the best evidence for claiming that a cause-and-effect relationship exists (Schmidt & Brown, p.175). By looking at differences between treated and non-treated subjects, this design is able to effectively and accurately provide best evidence for claiming that a cause-and-effect relationship exists because it’s always using a minimum of two groups for testing. Parry et al. (2018) concluded that prenatal breastfeeding education is an effective strategy for improving breastfeeding intentions and increases prenatal knowledge.In a study by Reyes et al., (2019), the purpose was to examine the influence of a school-based breastfeeding learning environment including breastfeeding education, outlooks, and forthcoming infant feeding intentions, secondary to adolescent females. Interventions were conducted in multiple countries including the United States. The studies included an educational breastfeeding intervention and young non-pregnant students to establish the influence of breastfeeding attitudes, knowledge, and future purposes. Participants included, 77 adolescent female students in grades nine and ten, who were enrolled in health education classes. The method of study that was used was quasi-experimental, composed of a pre-and post-test.

A pretest questionnaire determined participants attitudes towards breastfeeding. They were given four choices: formula only, formula and breastmilk, breastmilk only, and unsure. An educational intervention was then implemented consisting of a 70-minute school-based educational breastfeeding session. The results revealed, the number of participants who planned to feed with both breast milk and formula, (combined feed) decreased from 64.9% to 49.3% while the number who planned to “exclusive feeding” increased from 16.9% to 37.7% (Reyes et al., 2019). One threat to the internal validity of this study would be maturation. When evaluating a group of adolescents about their perceptions of breastfeeding when they have not yet conceived, it is hard to determine whether they made their decision based independent variable or the influence of the adults providing the information.Breastfeeding Education Programs Using Technological MethodsA study by Huang et al. (2007), produced results that suggested web-based breastfeeding education contributes to knowledge and improvement of breastfeeding rates. The quasi-experimental design study evaluated women at 29-36 weeks of gestation in a hospital in Taiwan who used the internet on a regular basis. The women in the experimental group were exposed to web-based education and results revealed a higher mean of knowledge related to breastfeeding and reported a more positive attitude towards it than those in the control group, who received verbal and written breastfeeding education. Results showed women in the experimental group also exclusively breastfed for longer periods of time after birth than the control group. By using a quasi-experimental design, this research method would be ranked lower on the evidence hierarchy scale because it is lacking randomization (Schmidt & Brown, p.181).

While this may be a threat to the results, this article still provided a critical conclusion that the intervention was effective in expanding the periods of which women breastfeed and therefore is reputable.In a study detailed by Donna Manlongat (2017), the “purpose of this thesis was to explore the effects of providing self-directed study materials in the forms of breastfeeding education videos, smartphone applications, and reading materials to prenatal women during their third trimester appointments in the obstetrician’s waiting room” (Manlongat, 2017). These options were considered underutilized and provide cost-free breastfeeding education in the obstetricians’ waiting rooms that may alleviate some barriers women are faced with in accessing prenatal education. The study was conducted in two separate obstetrician offices with 4 obstetricians in Windsor-Essex County due to the adequate resources and space. Overall, the study sample of 121 participants contained women aged 18-45 years old (Manlongat, 2017). Participants completed surveys during their obstetrician visit and submitted them before their next appointment. The study proved that those who completed the resources and were actively involved in their education were found to have significantly increased attitudes and knowledge about breastfeeding after proper education was introduced to this prenatal population of women. This study was chosen because of the high number of participants involved increases the validity of the results as well as the flexibility of when the surveys were to be completed, allowing ample time for the participants to report feedback, improving the accuracy of the results.A Prenatal Breastfeeding Education Program Using Both Technological and Non-technological MethodsIn contrast, a study by Rosen et al., (2008), examined the impact of breastfeeding outcomes using different methods of prenatal breastfeeding education with a minimal use of technology. 194 mothers were split into three groups.

One group used video demonstration and group teaching by a lactation consultant. The second support group used a one-on-one teaching pre-and postnatal meeting led by a pediatrician and a lactation consultant. The last was a control group educated at prenatal visits only. The results revealed that for the women who received prenatal breastfeeding classes, breastfeeding rates increased at the six month period compared to the controls. Clinical implications of this study conclude that prenatal breastfeeding education influences the amount of time women breastfeed and suggest providers should consider offering classes to improve the rate of breastfeeding. This study uses multiple experimental group designs, “The advantage of the multiple-groups design is that it allows researchers to compare the effect of different interventions on the DV” (Schmidt & Brown, p.179).Barriers of Breastfeeding and the Effects on Breastfeeding Initiation RatesIn low-and middle-income countries, there are challenges and contextual factors that may affect the breastfeeding period, initiation, and implementation (Willumsen, 2016). In a study by Hogan (2001), researchers evaluated the barriers to breastfeeding that Eastern Nova Scotia women experience, as well as ways to increase breastfeeding rates in this region. The study consisted of 67 randomly selected females and three males that answered a questionnaire pertaining to barriers of breastfeeding. Randomization is the method this study used to select its participants which reduced threats to extraneous variables and ensures all subjects have the same probability of being selected (Schmidt & Brown, p.157). Results revealed that lack of knowledge, support, and time away from work, were the main reasons that inhibited women to breastfeed. The goal of the study was to promote breastfeeding for up to six months by implementing follow-up appointments post discharge, access to lactation consultants, and informational sessions. Hogan (2001), concluded that after the implemented interventions were done, breastfeeding rates increased 60.5% and durations rates increased to four months.

A study by Cato et al., (2019) evaluated the relationship between depressive symptoms during pregnancy and late initiation of the first breastfeeding session and their effect on exclusive breastfeeding at six weeks postpartum. The study consisted of 1,217 women 17 to 32 weeks pregnant, or six weeks postpartum. The experimental design was a longitudinal study that began in 2009 and has continued to 2019. The method used involved questionnaires inclusive of demographic data, breastfeeding information, and use of the Edinburgh Postnatal Depression Scale (EPS). An evaluative multi-regression model, identified an overall negative effect of the presence of depressive symptoms during pregnancy and a postponed first breastfeeding session as well as the recommended 6-month postnatal duration. Cato et al., (2019) concluded that due to these findings, women experiencing depressive symptoms could benefit from support focused on breastfeeding during the first few hours after giving birth.In a study conducted by McGinnis et al., (2018), researchers examined the impact of home visitors promoting breastfeeding to high-risk populations. Families across the state of New York were visited by paraprofessionals in their homes, totaling 3521 pregnant mothers who were at risk for poor child health and development. These visitors delivered interventions that included education on the benefits of breastfeeding and supporting their efforts pre-and postnatal.

The study was measured by the visitors reports of the “content and frequency of home visits, participant-reported breastfeeding initiation and duration, and covariates” (McGinnis et al., 2018). Results of the study concluded that “breastfeeding initiation increased by 1.5% for each one point increase in the percentage of prenatal home visits. Breastfeeding continuation during the first six months also increased with the percentage of earlier home visits that included breastfeeding discussions. Additionally, if a participant receives one more home visit during the third month, her likelihood of breastfeeding at 6 months increases by 11%” (McGinnis et al., 2018). This study proved that delivering breastfeeding education consistently during regular home visits is important for increasing breastfeeding rates (McGinnis et al., 2018).Cultural Barriers of Breastfeeding and the Effects on Breastfeeding Initiation RatesAccording to the Center for Disease Control, “Black infants are 21% less likely to have ever been breastfed than white infants,” (Peterson, 2019). A study by Beermann (2011), examined women’s initial stated purposes for not breastfeeding and encouragement of breastfeeding through an education class of women during their 40-weeks of pregnancy. The studied revealed that the main reason mothers choose to not breastfeed is due to race and ethnicity. Approximately 75% of African Americans’ prefer to bottle feed. Three different studies were taken in consideration which included: studies regarding maternal decision making, current practices, and prenatal education programs. From a prenatal clinic, 46 participants that were 20-36 weeks pregnant, over the age of 20, primiparas, and were willing to attend a 90-minute educational program on breastfeeding were chosen. The educational program integrated features of knowledge, affective learning, and skills of breastfeeding.

A control group of 46 women did not attend the educational program. The method of study used was quasi-experimental design that included a Maternal Breastfeeding Evaluation Scale. The scale range was 0 to 28, with the higher scores indicating better knowledge and skills about breastfeeding. The results revealed that at three days postpartum, participants in the experimental group had higher average knowledge scores 25.73 versus the control 20.34. Beermann, et al., (2011), demonstrated that the teaching programs were effective in increasing breastfeeding knowledge and satisfaction.Snider (2016), designed a study to determine the impact of breastfeeding rates through the implementation of a culturally important educational intervention for the Marshallese women, ages 18 to 44, at a hospital pursuing Baby-Friendly status. The Marshallese women in this population prefer to breastfeed, but have encountered many cultural barriers that have deterred them from exclusively breastfeeding for a significant amount of time. A quasi-experimental data analysis allowed researchers to examine the breastfeeding rates of Marshallese mothers. The interventions consisted of two parts: a culturally significant educational video and a written pamphlet that the mothers were able to review the information at home (Snider, 2016).

Findings support that the breastfeeding interventions and exposure had a positive impact on breastfeeding practices during the hospital stay. These results are similar to that of Cato et al., (2019) and Beermann et al., (2011), in that women are more likely to breastfeed longer when supported and exposed to different types of education.In comparison, a study by Schilckau and Wilson (2005) developed an intervention that focused on promoting immigrant Hispanic women in the United States who bottle-fed to breastfeed their newborn. The hypothesis stated, women who receive PBE interventions will breastfeed for a longer period of time than those who do not. Eight participants that had previously moved from Central and South America, ages 19 to 34, were involved. The method used was a Software for Qualitative Data Analysis, “QSR NUD.IST.” The intervention, Prenatal Breastfeeding Education (PBE) was implemented. The goal was to increase knowledge and limit the negative viewpoints towards breastfeeding and to commit to a breastfeeding regimen.

A control group was implemented that only received minimum education from the research site. By 45 days, the tests revealed that 33% in the first level intervention group continue to breastfeed, and 56% in the second level intervention group continued to breastfeed. Results concluded that those that participated in the PBE interventions breastfed longer than those that did not.Health-Related Barriers of Breastfeeding Initiation RatesIn a case study conducted at Sunnybrook Health Sciences Centre in Toronto Ontario, Operations Director of the Women and Babies Program, Jo Watson, observed that pregnant females who had health risks, such as diabetes, were not reporting exclusively breastfeeding nearly as much as those without health risks. “On discharge from the Sunnybrook hospital, 75% of healthy mothers were exclusively breastfeeding their babies. But only 49% of mothers were exclusively breastfeeding if they had gestational diabetes. Jo says, ‘We were very disappointed to find that only 8% of mothers with type 2 diabetes were going home exclusively breastfeeding. We wanted to address the gaps” (Best Start Resource Centre, 2016). In 2011, the Diabetes in Pregnancy Clinic was formed and any woman with an abnormal glycemic test was enrolled (Best Start Resource Centre, 2016). Weekly visits to the clinic informed pregnant females with diabetes of the importance of breastfeeding and included teachings of different techniques and reiterated the advantages for both mom and baby.

Since then, the clinic has reported, “exclusive breastfeeding rates for women with diabetes went from 49 to 65%” (Best Start Resource Centre, 2016). This study demonstrates the importance of education for all pregnant females- not just those with minimal health risks.ConclusionAfter examining studies on the methods and effectiveness of breastfeeding education and exposure, there are many studies that support and prove that exposure to breastfeeding implementations influence the initiation and duration of breastfeeding. Based on the research articles found, the type of education or lack thereof about breastfeeding greatly influences the decision and duration of breastfeeding postpartum. A systematic review of the available evidence suggests that breastfeeding education is effective in increasing both the rate of breastfeeding initiation and breastfeeding duration (Willumsen, 2016).

Clinical implications of breastfeeding education include “teaching nursing students the factors that influence breastfeeding outcomes so that they can identify patients at an increased risk for breastfeeding cessation and increase their awareness of breastfeeding resources within the community” (Manlongat, 2017). It is important for nurses to be aware of the benefits of breastfeeding and assist in providing education to pregnant females.

References

• World Health Organization – Breastfeeding
• American Academy of Pediatrics – Benefits of Breastfeeding
• Man & Yi (2011) – Benefits of Breastfeeding for Infants and Mothers
• Victora et al. (2016) – Breastfeeding in the 21st Century: Epidemiology, Mechanisms, and Lifelong Effect
• Horta et al. (2015) – Breastfeeding and Chronic Disease in Childhood and Adolescence: A Review of Evidence
• Horta et al. (2015) – Early Nutrition and Long-Term Health: Mechanisms, Consequences, and Opportunities
• Ip et al. (2007) – Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries
• Victora et al. (2016) – How Changes in coverage affect equity in breastfeeding interventions?