Impact Of Breastfeeding Education Intervention On Rate Of Breastfeeding For Mothers Undergoing Caesarean Delivery – A Quasi-Experimental Study

Background

“The impact of breastfeeding education intervention on rate of breastfeeding for mothers undergoing caesarean delivery- a quasi-exprimental study”

Breastfeeding is a topic that has gained immense significance across age group, cultures, geographical locations and economic statuses. The general agreement is that the benefits of breastfeeding are multi-faceted. Research indicates that breastfeeding is directly linked to the positive health outcomes of the newborn as well as the new mother. As per the guidelines of WHO, exclusive breastfeeding helps in achieving optimal growth and other health benefits. In addition, there is a protective effect against high incidence of morbidity and mortality from gastrointestinal infections (Dieterich et al., 2013). Victora et al., (2016) opined that breastfeeding is effective in promoting maternal-infant bond as well. This is important since a high proportion of mothers, especially first-time mothers suffer postnatal depression and chances of detachment from the child. Apart from the maternal and infant health benefits, the economic, financial and social benefits of breastfeeding are also important. Despite the prominent acknowledgement of the copious benefits of breastfeeding, the prevalence of the same is not up-to-the-mark. Reports from communities across Australia reflect the issues that surround reduced rate of breastfeeding and poor knowledge of new mothers regarding the same. Lack of adequate knowledge combined with low-level confidence has been indicated to be the prime reason why the prevalence of breastfeeding is less across communities (Rollins et al., 2016). Breastfeeding education for mothers is probably the best way in which the issue can be addressed.

Against this background, there is a crucial demand for large-scale interventions considering breastfeeding education for increasing the prevalence of breastfeeding and appropriateness of it. Investigating the impact of breastfeeding education on mothers would be a desirable approach to augment the prevalence.

The primary aim of the proposed study is to undertake a quasi-experimental study to collect maximal level evidence of whether breastfeeding education program for women with caesarean delivery is effective in motivating them for breastfeeding and increasing the rates of the same practice.

Precisely, the aims of the study can be outlined as follows-

1. To study the efficiency of a prenatal breastfeeding education program for women electing caesarean section as a delivery model in terms of providing encouragement and fostering a positive attitude among the women
2. To analysse the efficacy of the prenatal breastfeeding education program in increasing the rate of exclusive breastfeeding within hospital and at two month postpartum

The proposed study would address the following research questions-

• Does prenatal breastfeeding education program help in encouraging and motivating women opting for caesarean delivery towards breastfeeding?
• Does prenatal breastfeeding education program increase the rate of exclusive breastfeeding within hospital and at two month postpartum?

The profits of breastfeeding for infant and maternal health are well documented. Breastfeeding is a non-substitutable and natural food for babies and WHO recommends sufficient and correct breastfeeding for all mothers. The necessity is prominent since infants are protected from a wide range of health complications after birth if they are breastfed. It is a practical nutrition as it is available on an immediate basis when required to feed the baby. For making breast-feeding exclusive, sufficient and infant-centred, mothers are to be educated on the different concepts pertaining to this topic. The aspects that are to be covered in such educative interactions are to include benefits, suitable methods, contraindications, gadgets. The best known modifiable factor for enhanced breastfeeding is self-efficacy, and the importance of this in relation to breastfeeding outcomes has drawn the notice of many. Self-efficacy is not to be confidence and includes an affirmation of the ability to carry out a behaviour as well as the strength of the belief. Educational interventions address this aspect. The relationship between the mother and the educator is important for understanding the concerns faced by the mother and the gap in knowledge. It is desirable that the educator is aware of the known informative and moralising principles while imparting the education. Important features that have an impact on the quality of education imparted are spiritual, socio-cultural and social characteristics of the participants (Stuart-Macadam, 2017). Ahmadi et al., (2016) in a longitudinal study had found that mothers with low levels of self-efficacy discontinued breastfeeding. Women with lack of confidence are twice likely to discontinue breastfeeding before completion of two months owing to a number of challenges.

Aims

Cunningham et al., (2017) argued that new mothers often are in the need of assistance and help from healthcare professionals rather than family members regarding breastfeeding. Lack of assistance and adequate information might lead to failure in appropriate breastfeeding. Education for a successful breastfeeding process needs to encompass two different stages; education before newborn delivery and supportive assistance provided afterwards. Early education is important for preparing a mother to take care of the newborn and nurse the baby. Eduction is known to raise the level of confidence in the care taking abilities with sufficient concern and support. Undeniably, support in the form of relevant education has been noted in a wide range of studies as a vital element influencing both the occurrence and extent of breastfeeding. A number of reviews have studied the impact of educational interventions on increase of breastfeeding. As the review by Pitts et al., (2015) highlighted that nursing counsellors improve breastfeeding initiation, exclusivity and length. A study carried out by the researchers Manahan et al., (2016) found out that duration of breastfeeding can be increased through formal education on the topic at the time of pregnancy and lactation consultation. The review of Lumbiganon et al., (2016) concluded that exclusive breastfeeding increases when the interventions provided mainly focus on education.

Mesters et al., (2013) have to say that a number of breastfeeding education program facilitate long duration breastfeeding. While some are successful some of them lead to failure. The provision of breastfeeding skill?based education antenatally leads to increased breastfeeding rate. Wojcicki, et al., (2016) pointed out that strategies for promoting breastfeeding education are to rest upon certain principles. These include the creation of a breastfeeding friendly environment, empowering mothers to make informed decisions, respecting mothers about decisions taken regarding breastfeeding, identifying barriers and exploring situations, sustaining support and including partners and families in the education process. The researchers further pointed out that peer breastfeeding support is also a noteworthy tool. Apart from educating the mothers on breastfeeding, it is necessary to motivate them and cultivate an enthusiastic and positive attitude towards the practice of breastfeeding. Women are to be given the opportunity and time to understand that breastfeeding is a pragmatic option. Discussing breastfeeding in a frequent manner is more effective since message delivered more frequently is more effective. Concepts are to be clear, and all doubts arising in the minds of the mother are to be addressed individually.

Non-judgemental and hands-on activities would be beneficial for building skills and knowledge. What holds prime value is that the risks and costs of not breastfeeding are to be educated with equal importance as the benefits of it. While knowledge of the positive impact of breastfeeding act as a motivating and encouraging factor, knowledge of the risks and costs associated would compel mothers to practice breastfeeding. A realistic understanding of the situation is more important in such cases (Mittal et al., 2016). Armstrong et al., (2014) in this regard state that education on breastfeeding is to be sensitive to the issues faced by women, such as culture, body image, economic condition and family support. Identification of barriers and implementation of solutions is imperative.

Research Questions

The proposed study would have a quasi-experimental design. A quasi-experiment is the experiential study undertaken for the estimation of the causal impact of any certain intervention of the target population wherein random assignment is not done (Flick, 2015). Such a design does not bear the characteristic of random assignment to control or treatment. Instead, such a design allows the researchers to control the assignment to the intervention through utilisation of some criteria apart from random allocation. The advantage of using such as design for the proposed study would be that threats to ecological validity would be minimised since the natural environment in which data would collect would not have the issues of artificiality.

Consideration is to be given to the ethical concern that all women enrolled for delivery by caesarean section in the hospital would have similar desire to be given emotional support and educational information. They would have equal needs of gaining postpartum breastfeeding help and related information. For this particular concern, the permuted-bock random allocation process would not be carried out in the similar time sequence for the participants of the study. Thus, the study would compare two groups over dissimilar time periods. The first part of data collection for the control group would be done for three months and the second part of the data collection would be done for the experimental group would be done for another three months leaving three months gap in between. The control group would be receiving standard hospital care while the experimental group would be receiving breastfeeding education program. It would also be desirable to conduct double-blinded procedure and self-selection bias. The double-blinded method is a significant part of the scientific research for preventing research outcomes from being impacted by the observer bias, both conscious and unconscious. It ensures impartiality into the research process (Panneerselvam, 2014).

The standard hospital care would be the set of interventions based on existing literature. The first aspect of the care process would be regular activities for the promotion of breastfeeding in the postnatal ward and prenatal checkup. Health teaching pamphlets would be disseminated for breastfeeding. Three hours after the delivery the infant would be placed to the postnatal ward, and the mother would receive education on different topic related to breastfeeding with a special focus on advantages of breastfeeding. The mothers would be discharged on the fifth day from the healthcare setting after the delivery.

The breastfeeding education interventional program would be marke by dissemination of a twenty-page booklet along with at least 20-minute videotape program and three follow up phone calls (Lumbiganon et al., 2016). The aim of this intervention would be multifacteted. Firstly, it would be beneficial for providing information on the complete set of benefits and advantages of commencing on breastfeeding after delivery. Secondly, resolving the difficulties and issues with exclusive breastfeeding would be achieved. Thirdly, how partners of the new mothers can help in breastbreasting would be demonstrated. The content of the education program would be suitably based on the analysis of existing relevant literature (Crook & Brandon, 2017). Certain dominant themes would be identified by the researchers that would be refined into the different topics. Apart from this standard phone call would form an elementary protocol for the education program. Reinforcement for the program would be upheld by the researchers through telephonic conversations. The first would be undertaken within two days of participant recruitment and the second would be undertaken a week afterwards. The calls would be made for reminding the participants to read through the content of the booklet in a thorough manner and practice the material contents on a regular basis. Practicing the materials would include answering a set of questions related to the subject matter. The draft of the education program would be reviewed by a set of experts for ensuring content validity. Minor modifications might be required before the final content is made ready.

Literature Review and Rationale

The patient demographic information would include the level of education, age, professional background and the rationale for selecting caesarean delivery. Breastfeeding attitude is to be determined with the help of Breastfeeding Attitude Scale proposed by researchers Teng and group. The scale would consist of 28 items, and every item would be answered on a five-point scale. In this scale, 1 would refer to strong disagreement, and 5 would refer to strong disagreement.  A high score would indicate a positive attitude towards breastfeeding. There would be three categories in the scale; the benefits and values of breastfeeding, the interplay of breastfeeding and the chances of replacing the breast milk with alternative options.

The sampling criteria would be women aged between 36-39 weeks pregnancy deciding on the ceaserean model of delivery. The participants need to communicate in English and must be agreeing on taking part in the study. The participants would be selected from a reputed,  large urban hospital in Australia.  A study carried out by Haroon et al., (2013) indicates that the participants might feel the need of discussing or inquiring the methods of the study pertaining to educational intervention. Thus it would be desirable in the proposed study that the study for control group would be undertaken in the first three months and the study for the experimental group would be undertaken three months later, for dealing with the information bias mentioned above.

Statistical power analysis would be used for calculating the required sample size. An alpha of 0.05, a beta of 0.2 and a delta parameter of 0.30 would be assumed on the basis of Cohen’s rule for effect size value. This would be beneficial for detecting the differences in change in the breastfeeding attitude of the participants which is the primary outcome of the study (Offredy & Vickers, 2013). After the formula for sample size estimation is applied, it is found that the sample sie would be effective with 45 subjects in each of the two groups. Initially, a larger sample size would be selected since there are chances of loss of participants owing to different concerns. These would include the inability to contact the participants and health complications of the mothers. 

The participants included in the experimental group would be provided with a free booklet along with the video. On an average 15-20 minutes would be spent on the phone calls and explaining the main directs of the booklet. The participants included in the control group would not be given the breastfeeding booklet, phone call or video. Standard care would be given to both the groups in respect to delivery and pregnancy. This would include access to breastfeeding support in the respective ward of the hospital (Pitts et al., 2015).

The second phase of data would be collected five days after delivery when the breastfeeding attitude would be studied post-test. The breastfeeding and rooming-in rates would be calculated. The duration of time the baby and the mother shared the same room would be recorded, excluding the time when the baby would be receiving any form of medical treatment. It would be kept in mind  not to separate the mother and the infant for more than two and a half hours. In case they did not share the same room for the day the case would be dismissed. Breastfeeding would be divided into two categories; exclusive and non-exclusive breastfeeding. Exclusive breastfeeding would not include any baby food formulation or water. The non-exclusive breastfeeding would comprise of a combination of breast milk and water or baby formulation. Personal interviews and observations about breastfeeding and rooming-in together with the medical record would enable the researchers to estimate the rates of the same at the time of postpartum hospital stay in an accurate manner. As opined by Flick (2015) personal interviews are important for extracting optimal data from participants as the views and opinions of the participants can be known in details. The advantages of face-to-face personal interviews are many. Accurate screening is the most important benefit of interviews. Non-verbal and verbal cues can be understood in this process. Focus can be kept on the control over the interview. The participants can be guided in answering all the questions properly. Observations help in collecting data in the natural settings. Chances of bias is less in such cases. The third lag of data would be collected one month after the delivery. 

Study Design

Statistical data analysis would be carried out with the help of SPSS statistical software package. Clinical characteristics and demographic data would be organised as the mean and standard deviation for continous variables and as proportions for categorical variables. For comparing the difference between the groups after and before the test, it would be desirable to use the paired t-test for analysing the continuous endpoint, that is breastfeeding attitude. The paired t-test is used for comparing the two population means between two samples. The observation of one sample can be compared to that of another sample. In such a test, the subject is measure twice and thus results in pairs of observations. Statistical value is determined by the p-value  (Panneerselvam, 2014). It would be desirable to use the McNemar test for analysis of categorical endpoint, which are exclusive breastfeeding rates and rooming-in. This particular test is a significant statistical test used on paired nomial data. McNemar’s test is widely used for comparing dependent proportions. The tests would be performed at 5% significance level.

Ethics is a key consideration for primary research with human participants. The reason behind this is that involvement of human participants in a research might take different forms. Approval is indispensable to be taken from the local committee (Pelletier et al., 2015). The proposed study is to receive approval from the ethics committee. It would be imperative to get written informed consent from each of the participants before commencing on the enrollment for the study. Informed consent is the knowledge of the impending risks intrinsic in participating in research and personal or general benefits from the study. The participants are to be explained thoroughly the aims and scope of the research. The purpose of the same is also to be explained to the participants. Any doubts or clarification from the participant’s side would be resolved immediately. Subjects who would not meet the criteria about the basic attributes would need to complete the pretest about breastfeeding attitude.

The three basic ethical principles that would be abided by are respect for participants, beneficence and justice. Participants are to be treated as autonomous agents, and they would not be pressurised to take part in the study. Further, the participants would have the option of quitting the study under any unavoidable circumstances. There would be no penalty or prejudice for the same. Special considerations would be taken for those who would not be able to understand the information adequately while communicating. In addition, for securing the wellbeing of the participants, the actions taken are to protect them from any possible harm or injury. The concept is much more than mere physical injury. Incidents of embarrassment and stress are to be avoided. In addition, equal opportunity would be given to every possible participant, irrespective of eduction level, status and race. This would ensure justice. The patient information would be maintained with privacy and confidentiality as ethical principles (Faden et al., 2014).

The aim of the proposed study would be to augment the success rate of breastfeeding among women choosing to deliver their baby through the caesarean model. The intervention would be the education program that would potentially help in promoting the beliefs and attitude of breastfeeding and rate of infants and mothers sharing a room apart from exclusive breastfeeding. The study would be providing an answer to the question of whether learning levels of mothers before the delivery process is increased after going through the intervention process. The positive affect of the breastfeeding educational initiative is likely to be achieved at the end of the program. It is further expected that the women from the intervention group would have increased the urge to breastfeed their infants as compared to the control group. It is known that knowledge on a particular health topic influences the attitude towards the practice of the same. There is a change in the behaviour due to the change in the level of knowldge (Haider et al., 2014). Images and videos have been proved to allow mothers boost heir level of confidence and reduce anxiety as they move towards a more difficult phase of their lives. The expected outcome is that education of breastfeeding would raise the knowledge and subsequent attitude, thereby increasing the rate of breastfeeding by mothers who would consider exclusive breastfeeding.

Data Collection

As per the previous studies conducted in this regard, repeated sessions carried out for viewing, reading and practising of educational materials is essential for obtaining successful breastfeeding results. Stress is given on the fact that after undergoing a successful caesarean section, mothers are to be educated properly on the appropriate breastfeeding postures and techniques (Crook & Brandon, 2017). The study would, therefore, suggest whether mothers undergoing caesarean delivery would need to be educated for a longer duration as compared to those undergoing normal delivery.

Global health organisations are promoting the valuable concept that mothers and newborns are to be in the vicinity for the effective nursing process. The findings of the study would be important for gaining information on whether professional education is helpful in directing the willingness of mothers to breastfeed their babies. In future, breastfeeding education programs can be set up based on the results of this study. The number of women delivering child through caesarean delivery model is high. Thus this study would be a guiding source for helping construct beneficial educational programs. Chances are high that the proposed educational materials would be passed on to different areas of the country for increasing the rate of breastfeeding across communities (Haroon et al., 2013).

The proposed study would be helpful for healthcare professionals across the community, especially the nurses, when addressing the needs of new mothers and promoting their health and wellbeing. The rate of infant mortality due to long term and short term complications would also be reduced considerably. As the study overview would present clear and affirmative results, persuasive evidence would be available to support recommendations for healthcare authorities on breastfeeding. National goals for breastfeeding can be modified based on this. The goals and recommendations for breastfeeding would be an optimal way for reducing the burden of complications arising from non-adherence to breastfeeding.

The following is the timeline of the proposed study that would be strictly adhered to.

Work to be done	Month 1	Month 2	Month 3	Month 4-9	Month 10	Month 11-12
Ethics clearance	·
Project set-up		·
Development of intervention		·
Enrolment of participants			·
Intervention implementation			·
First round of data collection				·
Second round of data collection				·
Third round of data collection				·
Data entry and analysis					·
Preparation of scientific paper						·

It is suitable to outline a budget for the complete project so that resource allocation is done adequately. The following is the finanicial information for the project that has been estimated at 3116500 dollars. It is expected that the study would be controlled within this budget.

Resource	Budget (in $)
Consumables and materials	20,00000
Equipment	250000
Staff salary	150000
Travel and communication	200000
Miscellaneous costs	110000
Total direct costs	2710000
Total indirect costs	406500
Grand total	3116500

References

Ahmadi, S., Kazemi, F., Masoumi, S. Z., Parsa, P., & Roshanaei, G. (2016). Intervention based on BASNEF model increases exclusive breastfeeding in preterm infants in Iran: a randomized controlled trial. International breastfeeding journal, 11(1), 30.

Armstrong, J., Abraham, E. C., Squair, M., Brogan, Y., & Merewood, A. (2014). Exclusive breastfeeding, complementary feeding, and food choices in UK infants. Journal of Human Lactation, 30(2), 201-208.

Crook, K., & Brandon, D. (2017). Prenatal Breastfeeding Education: Impact on Infants With Neonatal Abstinence Syndrome. Advances in Neonatal Care, 17(4), 299-305.

Cunningham, A. S. (2017). Breastfeeding: adaptive behavior for child health and longevity. Breastfeeding: Bicultural Perspectives.

Dieterich, C. M., Felice, J. P., O’Sullivan, E., & Rasmussen, K. M. (2013). Breastfeeding and health outcomes for the mother-infant dyad. Pediatric Clinics of North America, 60(1), 31.

Faden, R. R., Beauchamp, T. L., & Kass, N. E. (2014). Informed consent, comparative effectiveness, and learning health care. N Engl J Med, 370(8), 766-768.

Flick, U. (2015). Introducing research methodology: A beginner’s guide to doing a research project. Sage.

Haider, S. J., Chang, L. V., Bolton, T. A., Gold, J. G., & Olson, B. H. (2014). An evaluation of the effects of a breastfeeding support program on health outcomes. Health services research, 49(6), 2017-2034.

Haroon, S., Das, J. K., Salam, R. A., Imdad, A., & Bhutta, Z. A. (2013). Breastfeeding promotion interventions and breastfeeding practices: a systematic review. BMC public health, 13(3), S20

Lumbiganon, P., Martis, R., Laopaiboon, M., Festin, M. R., Ho, J. J., & Hakimi, M. (2016). Antenatal breastfeeding education for increasing breastfeeding duration. The Cochrane Library.

Manahan, K., Kerver, J., Olson, B., & Rozga, M. (2016). Topic and Timing of Breastfeeding Education is Associated with Reasons for Breastfeeding Discontinuation. Journal of the Academy of Nutrition and Dietetics, 116(9), A34.

Mesters, I., Gijsbers, B., Bartholomew, K., Knottnerus, J. A., & Van Schayck, O. C. (2013). Social cognitive changes resulting from an effective breastfeeding education program. Breastfeeding Medicine, 8(1), 23-30.

Mittal, H., Goyal, D. K., Jain, J., & Khandelwal, A. (2016). Assessment of knowledge of mothers regarding benefits of exclusive breast feeding in mother and children: a hospital based study. International Journal Of Community Medicine And Public Health, 3(11), 2993-2996.

Offredy, M., & Vickers, P. (2013). Developing a healthcare research proposal: An interactive student guide. John Wiley & Sons.

Panneerselvam, R. (2014). Research methodology. PHI Learning Pvt. Ltd..

Pelletier, C., Stevenson, F., Chrysikou, V., Park, S., & Gibson, W. (2015). Reconsidering ‘ethics’ and ‘quality’in healthcare research: the case for an iterative ethical paradigm. BMC Health Services Research.

Pitts, A., Faucher, M. A., & Spencer, R. (2015). Incorporating breastfeeding education into prenatal care. Breastfeeding Medicine, 10(2), 118-123.

Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C. K., Martines, J. C., … & Group, T. L. B. S. (2016). Why invest, and what it will take to improve breastfeeding practices?. The Lancet, 387(10017), 491-504.

Stuart-Macadam, P. (2017). Breastfeeding: Bicultural Perspectives. Routledge.

Victora, C. G., Bahl, R., Barros, A. J., França, G. V., Horton, S., Krasevec, J., … & Group, T. L. B. S. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017), 475-490.

Wojcicki, J. M., Heyman, M. B., Elwan, D., Lin, J., Blackburn, E., & Epel, E. (2016). Early exclusive breastfeeding is associated with longer telomeres in Latino preschool children. The American journal of clinical nutrition, 104(2), 397-405.