Article 2 PDF

Preview

Summary

Peer review articles...

Description

© pojoslaw / istockphoto.com

Downloaded from https://journals.lww.com/mcnjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3XI41p+sDLxZJB+gF6NSmbd53/uGYyFbhbLRaEXHv8VQ= on 04/20/2019

INTERVENTIONS THAT ENHANCE

Breastfeeding Initiation, Duration, and Exclusivity: A SYSTEMATIC REVIEW

Natsuko K. Wood, PhD, RN, Nancy F. Woods, PhD, RN, FAAN, Susan T. Blackburn, PhD, RN, FAAN, and Elizabeth A. Sanders, PhD

Abstract Objective: The purpose of this review was to evaluate breastfeeding interventions trialed to date and recommend directions for future needs in breastfeeding research. Methods: A literature review was conducted using PubMed, CINAHL Plus, and PsycINFO databases to identify studies that evaluated efficacy or effectiveness of breastfeeding interventions on breastfeeding initiation, duration, or exclusivity as a primary, secondary, or tertiary outcome. Combinations of search terms included breastfeeding, feeding behavior, prenatal/ patient education, health promotion, social support, perinatal/prenatal/intrapartum/postnatal care, and postpartum period. Results: Six studies were included in this review, using PRISMA guidelines. Acquisition of knowledge and skills, emotional support by healthcare providers, and self-efficacy over maternal confidence in her ability to breastfeed were factors the intervention studies relied on to affect breastfeeding practices. Although these factors were addressed in the studies, breastfeeding mothers had difficulty transferring what they gained from interventions into their real-life breastfeeding practices as evidenced by the highest drop-off rate of exclusive breastfeeding in the early postpartum. Conclusions: There were conceptual limitations to the reviewed studies: (1) lack of understanding of maternal perception of infant behavior and (2) perceived insufficient milk as a remaining primary reason for breastfeeding discontinuation. There were methodological limitations: (1) lack of theory-based interventions and (2) lack of intervention fidelity. Future studies involving breastfeeding should focus on the causes of the problems driven by theory-based interventions integrated with intervention fidelity. Keywords: Breastfeeding; Perceived insufficient milk; Prenatal/postnatal care; Randomized controlled trials. September/October 2016

MCN

299

abstracts, respectively. Results from fforts to increase breastfeeding initiation, duration, and each database were exported to Endexclusivity have been initiNote. After duplicates were removed, ated during pregnancy and 261 abstracts were reviewed. Each throughout the postpartum period. abstract was reviewed for elements of Despite the Baby Friendly Hospital clinical trial design included in the abInitiative (World Health Organization stract selection criteria that were [WHO], 1998) geared toward probreastfeeding intervention tested, viding breastfeeding support, many control group used, randomization to mothers find breastfeeding challengstudy group, healthcare providers as ing after leaving the hospital, with interventionists, and breastfeeding the highest drop-off rate of exclusive status as study outcome. Studies breastfeeding noted in the first month targeting mothers with HIV-positive postpartum (Centers for Disease Constatus were excluded. Adolescent trol and Prevention, 2015). Perceived mothers were excluded due to influinsufficient milk is the primary reaence of developmental and socioson for early breastfeeding discondemographic characteristics on their tinuation worldwide (Brown, Dodds, breastfeeding decisions. Twenty-three Legge, Bryanton, & Semenic, 2014; full-length English studies were reCamurdan et al., 2008; Hauck, Fenviewed after study criteria were met. wick, Dhaliwal, & Butt, 2011). EstabCriteria included study outcomes of Breastfeeding interventions lishing as well as sustaining exclusive breastfeeding initiation, and/or durafocused on three factors: breastfeeding is the preferred outcome tion, and/or exclusivity as a primary, since WHO (1991) and the American and/or secondary, and/or tertiary outacquisition of knowledge Academy of Pediatrics (2012) recomcome, term singleton infants and mend exclusive breastfeeding for the mothers with no drug abuse during and skills in breastfeeding, first 6 months. However, various inthroughout the postparemotional support by healthcare pregnancy terventions to promote and sustain tum period. Exclusion criteria includexclusive breastfeeding have failed ed study outcomes focused solely on providers, and self-efficacy to achieve this goal. The purpose of breastfeeding-friendly hospital practhis review is to evaluate interventions over maternal confidence in her tices and skin-to-skin contact at the that have been trialed and recommend hospital. Based on this review process ability to breastfeed. directions for future needs in breastusing PRISMA guidelines (Moher, feeding research. Studies were anaLiberati, Tetzlaff, Altman, & The lyzed to (1) identify which factors, if PRISMA Group, 2009), six studies any, uniquely enhance initiation, duration, or exclusivity were identified that met the inclusion and exclusion criteria individually and those that simultaneously enhance all of of the study for further analysis (Figure 1). these components, (2) examine limits of known strategies to enhance breastfeeding practices, and (3) recommend fuResults ture directions in research. Three studies were conducted during the prenatal period and three studies during postpartum. Summary of reviewed studies is shown in Table 1. Table 2 provides a Method summary of factors and operational elements of intervenA literature search was conducted in January 2015 using tions. Each study is discussed in more detail as follows search engines in PubMed/MEDLINE (National Library during the prenatal and postpartum periods. of Medicine), CINAHL Plus (EBSCO), and PsycINFO (EBSCO) databases with consultation of a nursing liaison librarian at the University of Washington. In PubMed/ Prenatal Period Mattar et al. (2007) recruited 401 pregnant women with MEDLINE, appropriate medical subject headings (MeSH) various ethnic backgrounds in Singapore. The intervenwere used along with entry terms. Combinations of the tion occurred before 36 weeks gestation and had three following search terms were used to identify relevant studarms: Group A received breastfeeding education and ies: breastfeeding, feeding behavior, prenatal/patient educaindividual counseling by lactation counselors. Breasttion, health promotion, social support, perinatal/prenatal/ feeding education consisting of watching a 16-minute intrapartum/postnatal care, and postpartum period. Revideo and reading a pamphlet contained breastfeeding trieval was limited to randomized clinical trials/randomized benefits, feeding techniques, management of common controlled trials, humans, English language, female, and breastfeeding problems such as nipple pain and exJanuary 2004 to December 2014, focusing on the past pressing breast milk. Counseling delivered by lactation 10 years. The search strategies yielded 202 abstracts. counselors consisted of one 15-minute session for the Similar procedures were conducted in CINAHL Plus and assessment of nipple retraction and answering questions PsycINFO by using subheadings that yielded 42 and 19 300

© Halfpoint / istockphoto.com

E

volume 41

|

number 5

September/October 2016

Figure 1. PRISMA Flow Diagram of Study Selection for Inclusion in Review Total 263 records identified PubMed: 202 records CINAHL: 42 records PsycINFO: 19 records

Duplicates: 2

After duplicates were removed: 261

n = 238 records excluded based on titles and abstracts

Full-text articles review: 23

17 articles excluded due to incongruity with inclusion

Final review: 6

related to breastfeeding. Group B received only breastfeeding education. Group C was the control group who received none of the above but the usual prenatal care. Mothers in Group A (education and counseling) were more likely to exclusively or predominantly breastfeed at 3 months (OR 2.6, 95% CI [1.0, 5.7]) and 6 months postpartum (OR 2.4, 95% CI [1.0, 6.3]) compared with mothers in the control group. Mothers in Group A (education and counseling) were more likely to exclusively or predominantly breastfeed at 6 months postpartum (OR 2.5, 95% CI [1.0, 6.3]) compared with mothers in Group B (education alone). There was no significant difference on exclusive breastfeeding/predominant breastfeeding at 2 weeks postpartum or 6 weeks postpartum among the three groups. The highest drop-off rate occurred within 6 weeks postpartum when queried during a 6-month follow-up. Kronborg, Maimburg, and Væth (2012) compared knowledge, self-efficacy, and concerns related to breastfeeding among 1,193 highly educated primiparous pregnant women who received or did not receive a breastfeeding educational program in Denmark. The program was provided for couples between 30 and 35 weeks gestation and taught by midwives giving lectures, leading discussions, watching a video, and using a doll for practice. The intervention was given once for 2 hours. At 6 weeks, breastfeeding self-efficacy aimed at breastfeeding continuation for up to 4 months postpartum was not significantly different between the two groups. In the experimental September/October September/October 2016 2016

group, mothers with sufficient breastfeeding knowledge at 6 weeks postpartum continued to breastfeed longer than mothers without enough knowledge (HR 0.74; 95% CI [.58, .97]). There was no difference in breastfeeding concerns at 6 weeks between the two groups. Rate of any breastfeeding at 6 weeks was not different between the two groups. Noel-Weiss, Rupp, Cragg, Bassett, and Woodend (2006) evaluated effects of a 2.5-hour prenatal breastfeeding workshop on breastfeeding self-efficacy and breastfeeding duration in 110 primiparous pregnant women in Canada. The intervention was done after 34 weeks gestation and given once for 2.5 hours as a portion of a series of three prenatal workshops. The program was theoretically based using Bandura’s social cognitive theory and adult learning principles. Nurses and lactation consultants taught breastfeeding self-efficacy without the need to quantify breast milk supply. Mothers in the experimental group increased breastfeeding self-efficacy at 4 weeks postpartum but not at 8 weeks postpartum. Breastfeeding duration was not different between the two groups at 8 weeks postpartum. The most common reason for breastfeeding discontinuation was “lack of milk” alone or a combination of other variables that were not specified. Overall, factors of breastfeeding interventions relied on during the prenatal period consisted of three areas: acquisition of knowledge and skills, emotional support from healthcare providers, and self-efficacy over maternal MCN MCN

301 301

Table 1. Summary of Reviewed Studies (Prenatal: Mattar et al., 2007; Kronborg et al., 2012; Noel-Weiss et al., 2006, Postpartum: Coutinho et al., 2005; Kronborg et al., 2007; Labarere et al., 2005) First Author/ Year

Participants

Objective

Primary Outcome

Secondary/Tertiary Outcome

Prenatal Mattar et al. 2007

Singapore n = 401 Mean age: 30 Majority married Multiparous>Primiparous Multiparous with 63–76% prior BF experience Race and Ethnicity: Chinese, Indian, and Malaysian

EBF/predominant BF To evaluate the rates at 2 wk, 6 wk, 3 efficacy of prenatal educational interven- mo, and 6 mo pp tions on breastfeeding exclusivity and duration A: education and counseling B: education C: usual care

Overall BF rates at 2 wk, 6 wk, 3 mo, and 6 mo pp

Full/any BF duration To evaluate the efat 6 wk and 1 yr pp fect of an prenatal BF program on BF duration, knowledge, self-efficacy, and problems related to BF

BF knowledge, selfefficacy, and problems related to breastfeeding in the third trimester, at 6 wk, and 1 yr pp

Low income Kronborg et al. 2012

Less educated Denmark n = 1,193 Primiparous White Well educated Majority vaginal birth Married

Noel-Weiss et al. 2006

Canada n = 110 Primiparous Majority vaginal birth High family income Well educated

None To evaluate the effect BF self-efficacy, BF of a prenatal breast- rates and amount at 4 feeding workshop on wk and 8 wk pp BF self-efficacy and BF duration

Postpartum Coutinho et al. 2005

Brazil n = 350 Majority multiparous Majority vaginal birth Low income Less educated

Kronborg et al. 2007

Denmark n = 1,597 Both primiparous and multiparous with little BF experience

Labarere et al. 2005

French n = 231 Majority primiparous Majority used epidural Majority married Majority higher than high school educated Majority participated prenatal classes

To compare the effect of BF rates of two systems: (1) Baby Friendly Hospital (usual care) and (2) Baby Friendly Hospital combined with home interventions

EBF rates from birth None to 6 mo on 1 & 10 days pp and every mo in the first 6 mo

To evaluate the effect EBF rates during 6 mo BF self-efficacy and of home intervenfollow-up BF satisfaction tions on BF exclusivity and duration To determine the EBF rates at 4 wk efficacy of outpatient visit delivered by physicians

Any BF rates at 4 wk including BF duration, difficulties, and satisfaction

Note. BF = breastfeeding; EBF = exclusive breastfeeding; pp = postpartum.

302

volume 41

|

number 5

September/October 2016

September/October 2016

Table 2. Factors and Operational Elements of Intervention (Prenatal: Mattar et al., 2007; Kronborg et al., 2012; Noel-Weiss et al., 2006, Postpartum: Coutinho et al., 2005; Kronborg et al., 2007; Labarere et al., 2005) First Author/ Year

Providers

Places

Factors

Number of Sessions/ Duration

Timing

FollowUps

Before 36 wk gestation

2 wk, 6 wk, 3 mo, and 6 mo pp

Not reported

Fidelity

Prenatal Mattar et al. 2007

Lactation counselor

Hospital

Knowledge (BF benefits and manage- 1 time including ment of common BF problems) counseling Skills (BF techniques and BM for 15 min expression) Emotional support (reassurance about nipple assessment and BF concerns)

Kronborg et al. 2012

Midwife

Workshop in midwifery clinic

1 time for Knowledge (BF establishment and duration, and common BF problems) 2 hr Skills (infant care) BF self-efficacy (BF continuation for the first 4 mo pp) Emotional support (social network)

30–35 wk gestation

6 wk and 1 yr pp

3-day preparation course but only 1 day for BF module. Used scripted teaching manual. Course evaluation by participants at the end of the session.

Noel-Weiss et al. 2006

RNs who are lactation consultants

Workshop Knowledge and BF self-efficacy (BM 1 time for 2.5 hr in hospital supply without quantifying it) Skills (infant care) Emotional support (social network)

After 34 wk gestation

4 wk and 8 wk pp

Not reported

Trained maternity staff at Baby Friendly Hospital

Home

Postpartum Coutinho et al. 2005

Knowledge and skills (BF technique, milk flow, infant satiety, manual expression, BF problems, feedings of other liquid, use of bottles and pacifiers, and BF attitudes of the family)

Early pp 10 times 30 min for each visit including BF assessment and guidance

20 hr training including 18 hr WHO 3, 7, 15 & training course and 2 hr focusing on 30 days, how to provide emotional support. biweekly during 2 mo pp and monthly visits between 3 mo and 6 mo pp

1–3 times Within including BF 5 wk pp assessment, modeling, and feedback

5 wk pp

Emotional support

Kronborg et al. 2007

RN

Home

Knowledge and skills (self-regulated BF, hunger cues, suffi cient milk, and interaction with infant) BF self-efficacy (BM supply without quantifying it)

MCN

Emotional support Labarere et al. 2005

Physician

303

Physician’s office

Knowledge and skills (management 1 time of BF problems and infant health) including Emotional support counseling

Note. BF = breastfeeding; BM = breast milk; pp = postpartum; RN = registered nurse.

2 wk pp

18 hr WHO BF training course and how to provide emotional support. Used scripted teaching manual. 1 yr supplementary training provided for RN.

4 wk pp

5 hr training to improve BF knowledge and counseling skills based on the guidelines.

© pojoslaw / istockphoto.com

Future studies involving breastfeeding should focus on modifiable causes of the problem driven by theory-based interventions integrated with intervention fidelity

confidence in her ability to breastfeed. Knowledge that was delivered in all three studies about understanding benefits of breastfeeding, types and methods of feeding, and infant behavior are essential prerequisites for successful breastfeeding behavior. One study showed breastfeeding knowledge increased breastfeeding duration. However, knowing about breastfeeding problems did not decrease breastfeeding concerns during postpartum (Kronborg et al., 2012). One study showed that clarification of breastfeeding doubts and/or myths reassured pregnant women and helped them to continue pursuing exclusive/predominant breastfeeding (Mattar et al., 2007). Three studies delivered skills such as positioning and latch-on (Mattar et al.) or infant care (Kronborg et al., 2012; Noel-Weiss et al., 2006). Emotional support was provided in all three studies but in different forms. In counseling, emotional support was provided by listening to issues and concerns about breastfeeding from low socioeconomic pregnant women and giving reflective responses (Mattar et al.). Emotional support for the pregnant women with high socioeconomic status was embedded in discussions in the prenatal breastfeeding workshop; feelings and concerns about breastfeeding were shared and discussed with other pregnant women (Kronborg et al., 2012; Noel-Weiss et al.). Two studies examined breastfeeding self-efficacy following breastfeeding educational interventions (Kronborg et al., 2012; Noel-Weiss et al.). Kronborg et al. (2012) focused self-efficacy on outcome expectation; breastfeeding continuation for the first 4 months postpartum. Maternal confidence in her ability to breastfeed without quantifying the amount of breast milk was the emphasis for the study by Noel-Weiss et al. (2006). Most of the prenatal breastfeeding interventions began in the third trimester and were aimed at increasing the rate of breastfeeding exclusivity and duration as primary or secondary outcomes (Kronborg et al., 2012; Mattar et al., 2007; Noel-Weiss et al., 2006). In addition to breastfeeding outcomes, Noel-Weiss et al. (2006) measured breastfeeding self-efficacy as primary outcome and Kronborg et al. (2012) measured knowledge, self-efficacy, and problems related to breastfeeding as secondary outcomes. Prenatal breastfeeding intervention typically occurred within a formally structured setting such as a prenatal breastfeeding workshop at the hospital or on an individual level given at the hospital. Providers who gave the interventions included midwives, lactation counselors, and maternity nurses who were also lactation consultants. The educational sessions took place only once. 304

volume 41

|

number 5

Duration of individual counseling...