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Effectiveness of professional breastfeeding home-support
RESEARCH ARTICLE Effectiveness of Professional Breastfeeding Home-Support PAULA SERAFINO-CROSS AND PATRICIA
R.
DONOVAN
Wesson Women's Clinic, Baystate Medical Center, Springfield, Massachusetts 01199 ABSTRACT The effect of professional home-support on the success of breastfeeding was investigated to determine whether breastfeeding women who received professional home-support would breastfeed longer than similar women who did not receive this support. Fifty-two volunteers of lower socio-economic status were recruited for this study from four obstetrical clinics and were randomly assigned to an intervention or a comparison group. Both groups received the standard clinic and in-hospital breastfeeding teaching and were given breastfeeding instruction in the hospital by the researcher. The women in the intervention group received, in addition, an average of seven home breastfeeding support contacts by the researcher over two months postpartum, and were provided with the researcher's phone number. Women in the comparison group did not receive home visits but had access to the clinic nutritionist if any questions or problems arose. More than half (61.5%) of the intervention group subjects were still breastfeeding at two months post-partum versus approximately one-third (34.6%) of the comparison group (p < 0.01). These results suggest that professional home breastfeeding support programs may be effective in increasing the duration of breastfeeding among this population, thereby achieving one of the Surgeon General's health objectives. (TNE:24:117-122,1992)
is not fully established before hospital discharge. Therefore, the need for profeSSional home-support is indicated. Home support studies. Research indicates that failure to continue breastfeeding, despite a strong desire to do so, is often due to lack of prompt and adequate medical support or access to the advice of experienced breastfeeders. Although there have been several studies on the effect of hospital practice on the initiation of breastfeeding, few researchers have studied what effect a profeSSional providing additional support once the nursing mother has returned home can have on breastfeeding duration or success. Houston et ai . (ll) studied home-support of 80 breastfeeding mothers in England and discovered a significant difference between the intervention and comparison groups at 12 weeks post-partum (p < 0.05) in the lower social classes, whereas there was no difference between the two groups in the highest social class. Kelly (12) also studied the effect of profeSSional homesupport on breastfeeding success in a group of 38 mothers. Although the results of this study showed that more mothers in the study group than in the control group were still breastfeeding at three, six and twelve weeks, the differences were not statistically Significant, possibly due to the sample size of 19 in each group. Other studies suggesting that close personal support may encourage successful breastfeeding (13, 14) have not included comparison groups. Studies conducted in the United States have investigated breastfeeding support systems other than home-support by health care profeSSionals. Saunders and Carroll (15) studied 150 predominantly Hispanic, low-income women. Breastfeeding intervention consisted of one hospital visit (1-3 days post-partum), a phone call or letter, and a structured group support class at two weeks post-partum. Results indicated that the intervention group conSistently and Significantly breastfed longer than did the control group. In another study of 40 low-income breastfeeding primiparous women, Barron et ai. (16) found that when breastfeeding assistance was available during the first two weeks post-partum, mean breastfeeding duration was 23.4
INTRODUCTION It is generally recognized that breastfeeding is the best method for feeding the term infant (1-4). However, it is well known that lower socioeconomic groups have a lower incidence and duration of breastfeeding than higher socioeconomic groups (5-9). In order to meet the Surgeon General's objective of increased breastfeeding incidence and duration (10), efforts to promote breastfeeding must be directed toward women who are less educated, have lower incomes and belong to minority groups. Also, the short hospital stay after giving birth that is presently advocated has resulted in less time for the professional staff to support the breastfeeding mother, whose milk supply often
Address for correspondence: Paula Serafino-Cross, M.S., R.D., Pediatric Gastroenterology and Nutrition of Westem Massachusetts, 780 Chestnut Street, Springfield, MA 01107. 0022-3182/9212403-0117$03.00/0 © 1992 SOCIETY FOR NUTRITION EDUCATION 117
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weeks, compared with 12.3 weeks when breastfeeding assistance was unavailable. Garza (17) reported similar results with 116 indigent mothers who were randomly asSigned to an experimental group or a comparison group. The experimental group received assistance from a lactation consultant for one month post-partum, with results indicating a 240% greater incidence of exclusive breastfeeding at 30 days than the comparison group. The present study was designed to determine if lowincome breastfeeding women who received extensive professional home-support continued to breastfeed longer than similar women who did not receive this support. In addition, reasons for early termination of breastfeeding were to be identified so that future prenatal teaching sessions could focus on these areas.
METHODS
Selection of study sample. This study enrolled 52 volunteers from four prenatal clinics in Springfield, Massachusetts, who during their pregnancy had indicated a desire to breastfeed their infants. Patients were continually recruited for this study during prenatal visits at the four clinics until the desired number was obtained. Eightynine women were approached to be in this study. Of this number, 80 agreed to participate; however, 28 had to be excluded for various reasons. Unfortunately, the typical breastfeeding incidence at these four clinics is unknown because clinic staff do not routinely compile these statistics. Informed consent of the participants was obtained by clinic nutritionists at prenatal visits. This study began in February 1986 and was completed by April 1987. Although there are complex formulas for determining an appropriate sample size, the profeSSional time commitment and the availability of cases were the factors determining the sample size for this study. Although the original goal of the study was to enroll 60 participants, it took 14 months to enroll just 52 participants from four clinics serving in total approximately 1,000 pregnant women per year. Screening criteria stated that the client had to be a firsttime breastfeeder or unsuccessful in previous attempts to breastfeed, defined as terminating breastfeeding in the first month due to problems. In addition, the client had to plan to breastfeed for two months or longer, and had to be English-speaking, due to lack of an available translator. Lastly, the client must have received breastfeeding instruction from the clinic nutritionist at some point during her prenatal care to assure uniform baseline information. Study design. While visiting the client in the hospital, the researcher, a trained and experienced breastfeeding counselor, explained the study briefly, reviewed the established protocol for teaching breastfeeding, and answered any questions that the client had. For this study, the re-
searcher provided breastfeeding support and education to women participating in the study while they remained in the hospital. After instruction was completed, the researcher randomized the clients into either the intervention group or the comparison group. Those clients aSSigned to the intervention group received additional breastfeeding support in the home and by phone for two months post-partum. Between five and eight visits were made per client, with a greater frequency of visits in the first two weeks, as this is the critical period for establishing breastfeeding. Visits lasted from 30-60 minutes and were arranged at the convenience of the client. The researcher provided her phone number to the client in the event that questions arose between visits. Counseling during home visits was generally in response to specific questions or problems raised by the mother, but the researcher also initiated conversation about important breastfeeding topics. Topics covered in the early weeks included management of engorgement, frequency of feeding, confidence and relaxation, stooling patterns, and determining adequate intake in the breastfed infant. At later visits, discussions centered around the expression and storage of breastmilk, nursing in public, dealing with fatigue, management of school or work while breastfeeding, growth spurts, and supplementation of breastmilk with formula, water or solid foods. Special topiCS that were covered included management of blocked milk ducts, tongue thrusting and inverted nipples. At each home visit, the mother completed a form outlining her problems and/or successes; breastfeeding topics discussed were also noted. Arecall of infant feeding in the past 24 hours was completed to determine the frequency of breastfeeding and other feeding. A questionnaire was completed at two months post-partum or when breastfeeding was terminated, whichever occurred sooner. The questionnaire used for this study was modified to increase the specificity of the answers from one previously in use by this obstetrical hospital. This version was then pre-tested with a small number of women. Additionally, the questionnaire was reviewed by both a public health professor and a maternal-child health nutritionist from the state university. Therefore, content validity was addressed, but sampling and construct validity were not. Reading level was not assessed; however, in most cases, the questionnaire was read to the patient by the researcher. Lastly, all women in the intervention group were contacted when their infants were six months or older to determine if they were still breastfeeding. Women asSigned to the comparison group were given a card with the name and phone number of the clinic nutritionists who could be contacted ifbreastfeeding problems or questions arose. At two months post-partum, these clients were contacted by phone or mail to complete the same questionnaire used for the intervention group to assure the collection of similar data, i.e., how many weeks
J. of Nutr. Educ. Vol. 24, No. 3 Table 1.
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Characteristics of women in the intervention and comparison groups:
Factor
Level
Maternal Age
< 19 years
Parity Education Race Delivery Type WIC2 Participation
Intervention N= 26
Comparison N= 26
No. (%) 8 (31%) 14 (54%) 4 (15%) 18 (69%) 8 (31%) 7 (27%) 15 (58%) 4 (15%) 10 (38%) 8 (31%) 8 (31%) 17 (65%) 9 (35%) 24 (92%) 2 (8%)
No. (%) 6 (23%) 12 (46%) 8 (31%) 19 (73%) 7 (27%) 7 (27%) 14 (54%) 5 (19%) 11 (42%) 6 (23%) 9 (35%) 20 (77%) 6 (23%) 24 (92%) 2 (8%)
20-24 years ;::: 25 years Primipara Multipara 9-11 years 12 years ;::: 13 years White Black Other' Vaginal Cesarean Section Yes No
'Includes Puerto Rican, Mexican-American, Portuguese and Virgin Islanders. 2Women, Infants and Children Supplemental Food Program. "No significant differences were found between the intervention group and the comparison group with respect to the above variables.
the infant was breastfed, etc. No further contact was made with this group.
Data analysis. The statistical test used to analyze differences between the two groups for overall breastfeeding frequency was the Mantel-Haenszel test. This statistical test combines the chi-square test and p values. The Mantel-Haenszel test is more appropriate for this type of study than the chi-square statistic because it takes into account the fact that the same sample is being compared at each of the eight weeks; in other words, the data were continuous (18). A contingency table (2 X 2 table) was established for each of the eight weeks of the study. The proportions of women breastfeeding in both the intervention group and the comparison group were examined each week during the eight weeks of the study. For other statistical analyses, Pearson's Chi-Square statistic was used to compare the two groups. Statistical analysis was completed using the Biomedical Statistical Package, BMDP. For the purpose of this study, any subject who was breastfeeding for at least half of the infant's feedings was considered to be breastfeeding. Due to the study size (52 clients), all comparisons were made between breastfeeding women, as defined above, and bottlefeeding women.
RESULTS Randomization was effective in distributing women into comparable groups, with respect to maternal age, parity, education, race, delivery type, and WIC partiCipation (Table 1). No Significant differences were found between the two groups as assessed by Pearson's X2 statistic.
90
80
"
" ....
........._
"
_o..._.INTERVENTlON GROUP
" "....
. -. -
COMPARISON GROOP
p
WEEKS Figure 1. Breastfeeding mothers in the intervention group (n = 26) versus comparison group (n = 26) during the first eight weeks post-partum.
Of the 26 women in the intervention group, 61.5% were still breastfeeding at two months post-partum versus 34.6% in the comparison group. This difference was statistically Significant (p < 0.01) for both week seven and week eight (Figure 1). An average of seven home visits were made to intervention group participants. A total of 13 calls were made by women in the intervention group to the researcher. Only two calls were made by women in the comparison group to the clinic nutritionist. Based on the established criteria, only two women with nursing infants were categorized as bottlefeeding at two
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months post-partum. Both were in the comparison group. One of these mothers has never breastfed her infant more than one or two times a day from birth, due to problems with the infant's sucking (tongue thrusting). The other mother was only breastfeeding one or two times a day from week five on, due to severe anxiety over breastfeeding. FollOwing-up on the women in the intervention group revealed that 48% were still breastfeeding at six months. The researcher was unable to contact one-half of the comparison group mothers at six months. This may indicate an inherent difference between the stability of the two groups; however, if more contact had been made with this group throughout the study, it might have been less difficult to locate these women. Although both groups were quite transient, the established relationship with the researcher made it easier to contact the intervention group through friends, family, and the WIC program in which they were enrolled. . Only five women in the study reported that they had returned or would be returning to work. Of these five, returning to work was a factor in the termination of breastfeeding for only one woman. Three women were still breastfeeding at two months post-partum and one had stopped because she found it too demanding, although she had not yet returned to work. The most common reason given for the termination of breastfeeding in the comparison group was "insufficient milk" (35%), whereas only 10% gave this as a reason in the intervention group. "Sore nipples" was given as another common reason for the termination of breastfeeding, with 18% giving this reason in the comparison group and 10% in the intervention group. The most common reason for stopping breastfeeding in the intervention group was "I found it too demanding," 30% vs. 18% in the comparison group. DISCUSSION
Significance of professional home-support on breastfeeding duration. The results of this study indicate that there is a relationship between profeSSional home-support and continued breastfeeding at two months post-partum for women of low socioeconomic status. In the intervention group, 61.5% were still breastfeeding at two months vs. 34.6% in the comparison group. These results were statistically Significant (p < 0.01) and important because this type of study has not been conducted in the United States. Home-support studies conducted in England (11, 12) and Canada (19) used the Chi-square or Fisher's Exact test for statistical analysis. One study found statistical significance (11), one suggested borderline statistical significance (12), and one found no Significant differences between the experimental and the control group in terms of breastfeeding success (19). These studies did not exclude
preViously successful breastfeeders, as did the present study deSign. The present study design specified that both intervention and comparison groups receive additional breastfeeding counseling in the hospital before being randomized to groups. If only the intervention group had been counseled during their hospital stay, a more Significant difference between the two groups in respect to breastfeeding success might have been seen.
Reasons for the termination of breastfeeding. The most common reason for terminating breastfeeding in the intervention group was "I found it too demanding." This was also given as a common reason in the comparison group. It is possible that women in both groups may not have been prepared for the time commitment or the exclusive responsibility of feeding that accompanies early breastfeeding. Therefore, in educating women prenatally, it is important for the counselor to describe the time and commitment involved in breastfeeding realistically, along with stressing its many advantages. Inadequate milk supply was given as the most common reason for cessation of breastfeeding in the comparison group. It is known that most women are phYSiolOgically able to produce enough breast milk. One possible explanation of an insufficient milk supply is lack of confidence on the mother's part and/or a lack of technical information. However, because this was a group oflow-income women, the high stress lives that they often lead could also be responSible for an inadequate milk supply, through an effect on the let-down reflex. Lack of a support network, including family and friends, could also contribute to a lack of confidence and increased stress, resulting in a poor milk supply. This group of women may be helped to continue lactation by the intervention of a counselor. Sore nipples was also given as a common reason for stopping breastfeeding in the comparison group. These women reported that their sore nipples developed into cracked and bleeding nipples. These problems are usually due to improper positioning of the infant at the breast and/ or improper care of the nipples. Therefore, it is recommended that the counselor observe the baby's position at the breast and review nipple care. CONCLUSIONS The results of this study indicate the need for breastfeeding home-support for clients of low socioeconomic status in order to increase breastfeeding duration. The model presented in this study is a hospital-based program of breastfeeding home support that could be established in conjunction with the early discharge of post-partum women. Systematic networking among community health agencies, such as the WIC Program, EFNEP (Expanded Food and Nutrition Education Program), home health
J. of Nutr. Educ. Vol. 24, No.3
agencies and Visiting Nurse Associations, would help to strengthen this type of program. Area pediatricians or their staff should also be involved, so that breastfeeding support is consistent. One way to reduce the cost of implementing a homesupport program would be to use trained paraprofessionals rather than professionals to conduct home visits to breastfeeding women. An intervention program of this type, initiated by the New York EFNEP Program, trained paraprofeSSionals to help low-income women make an informed decision about infant feeding and to provide technical support for those women who chose to breastfeed (20).
The most critical component of the intervention is early contact with the breastfeeding mother. Although a visit to the mother in the hospital is important, it is even more important to visit the mother at home after the actual milk flow has begun. This visit should occur one to two days after discharge. After providing support for the first two weeks of breastfeeding, additional need for support could be assessed and further contacts tailored to the individual's needs. For lactation counselors, formal training on lactation through workshops, books and professional articles is important for building a strong knowledge base. Equally important is hands-on experience in working with breastfeeding mothers at a clinic, hospital or WIC program. Observation of the mother breastfeeding her infant is the key to the evaluation of problems, or potential problems, such as breast infections and cracked nipples. The counselor must be comfortable with this aspect of lactation education, open-minded and non-judgmental. In addition, a protocol for determining those mothers who would benefit from lactation counseling needs to be developed. Breastfeeding mothers who had cesarean sections and mothers of infants who were not allowed to breastfeed within 24 hours after delivery were two groups identified in this study who would benefit from access to a lactation counselor. Those who have no support person at home would be another group to target. Ideally, for a breastfeeding intervention program to increase the duration of breastfeeding, it should continue until lactation is well established and should be adapted to the individual's need for technical and emotional support.
NOTES AND REFERENCES 1 Nutrition Committee of the Canadian Paediatric Society and Committee on Nutrition of the American Academy of Pediatrics. A Commentary in celebration of the international year of the child: Breastfeeding. Pediatrics 62:591-601, 1979. 2 American Academy of Pediatrics. Policy statement based on task force report: The promotion of breast feeding. Pediatrics 69:654-661. 1982. 3 Nutrition Committee Canadian Paediatric SOciety. Breastfeeding: What is left besides the poetry? Canadian Journal of Public Health 69:13-20, 1978. 4 Position of the American Dietetic Association. Promotion of
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5 6 7 8 9 10 11 12 13 14 15 16
17
18 19 20
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breastfeeding. Journal of the American Dietetic Association 86(11):1580-1585, 1986. Martinez, G. and F. Krieger. 1984 milk feeding patterns in the United States. Pediatrics 76:1004-1008, 1985. Wright, H. and P. Walker. Prediction of duration of breastfeeding in primiparas. Journal of Epidemiology and Community Health 37:8994, 1983. Sloper, K., L. McKean, and J. Baum. Factors influencing breastfeeding. Archives of Disease in Childhood 50:165-170, 1975. West, C. Factors influencing the duration of breastfeeding. Journal of Biosocial Sciences 12:325-331, 1980. Hart, H., M. Bax, and S. Jenkins . Community influences on breastfeedings. Child: Care, Health, and Development 6:175-187, 1980. Report of the Surgeon General's workshop on breastfeeding and human lactation. June 11 and 12, 1984. United States Department of Health and Human Services. Pub. No. HRS-D-MC-84-2. Houston, M., P. Howie, A. Cook, and A. McNeilly. Do breastfeeding mothers get the home support they need? Health Bulletin 39(3):166172, 1981. Kelly, M. Will mothers breastfeed longer if health visitors give them more support? Health Visitor 56:407-409, 1983. Eastham, E., D. Smith, D. Poole, and G. Neligan. Further decline of breastfeeding. British Medical Journal 1:305-307, 1976. Verronen, P. Breastfeeding: Reasons for giving up and transient lactational crises. Acta Paediatrica Scandinavica 71:447-450, 1982. Saunders, S.E. and J. Carroll. Post-partum breastfeeding support: Impact on duration. Journal of the American Dietetic Association 88:213-221, 1988. Barron, S.P., H.W. Lane, T.E. Hannan, B. Struempler, and J.C. Williams. Factors influencing duration of breastfeeding among low-income women. Journal of the American Dietetic Association 88(12):1557-1561 , 1988. Garza, C. A support program for breastfeeding in a United States low-income urban population. Presented at the National Institute for Child Health and Development Workshop on Determinants of Choice and Duration of Infant Feeding. Chantilly, Virginia, June, 1981. Miller, R.G. Survival analysis. New York: John Wiley and Sons, 1981, pp.94-103. Lynch, S., A. Koch, G. Hislop, and A. Coldman. Evaluating the effect of a breastfeeding consultant on the duration of breastfeeding. Canadian Journal of Public Health 77:190-195, 1986. Cadwallader, A. and C. Olson. Use of a breastfeeding intervention by nutrition paraprofessionals. Journal of Nutrition Education 18(3):117-122, 1986.
RESUME On a evalue !'influence d'un programme de support dispense a la maison par des professionnels sur Ie sucd~s de l'allaitement matemel afin de determiner si des femmes allaitantes regevant ce type d'aide allaiteraient leur enfant plus longtemps que celles qui ne Ie regevaient pas. Cinquante-deux femmes de faible niveau socio-economique ont ete recrutees, sur une base volontaire, dans quatre cliniques d'obstetrique et ont ete reparties au hasard entre un groupe d'intervention et un groupe temoin. Lex deux groupes ont re9u l'enseignement dispense de routine dans la clinique et a I'h6pital et ont re9u de la chercheure a l'h6pital, des directives sur l'allaitement. Les femmes du groupe d'intervention ont, de plus, re9u a sept reprises au cours des deux mois post-partum des visites de support de la chercheure a la maison et celle-ci leur a transmis son numero de telephone. Les femmes du groupe temoin n'ont pas re9u de visites a domicile mais avaient acces aux services de la nutritionniste de la clinique si elles se posaient des questions ou avaient des problemes au sujet de l'allaitement. Plus de la moitie (61,5%) des femmes du groupe d'intervention continuaient d'allaiter leur enfant deux mois apres sa naissance, alors qu'environ un tiers (34,6%) des femmes du groupe temoin continuaient de Ie faire (p < 0,01). Ces resultats suggerent qu'un programme de support a l'alIaitement dispense a la maison par des profession nels peut etre efficace pour prolonger fa duree de
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l'allaitement dans cette population, realisant ainsi l'un des objectifs de sante vises par Ie Surgeon General. Translated by Estelle Mongeau , Ph.D. RESUMEN Se investig6 el efecto de un programa de apoyo profesional en el hogar en el exito para amamantar con el objeto de determinar si las mujeres que recibieron este apoyo amamantaron por mas tiempo comparadas con un grupo similar que no recibi6 dicho apoyo. Cincuenta ydos voluntarias de nivel socioeconomico bajo fueron reclutadas de cuatro clfnicas obstetricas, y fueron asignadas aleatoriamente a un grupo de intervenci6n o a un grupo control. Ambos grupos recibieron el programa hospitalario estandar de educaci6n sobre tecnicas de amamantamien to, y recibieron instrucciones sobre amamantamiento por parte de la investigadora. Las mujeres del grupo de intervencion tuvieron ademas, un promedio de siete contactos domiciliarios
de apoyo para el amamantamiento con la investigadora y recibieron el telefono de la misma. Estos contactos se realizaron en el termino de los dos primeros meses postparto. Las madres del grupo de comparaci6n no recibieron visitas domiciliarias, pero ternan acceso al nutricionista de la clinica para consultar encaso de que tuvieran alguna pregunta 0 problema. Mas de la mitad (61.5%) de las madres en el grupo de intervenci6n continuaban amamanatando a los dos meses post parto comparado con aproximadamente un tercio (34.6%) de las madres del grupo de comparaci6n (p < 0.01). Estos resultados sugieren que los programas de apoyo profesional para el amamantamiento a nivel del hogar pueden ser eficaces para alargar la duraci6n del amamanatamiento en esta poblaci6n, alcanzando as( uno de los objetivos 'de salud del Director de los Servicios de Salus.· Translated by Teresa Gonzalez-Cossio ·(Surgeon General).
ANNOUNCEMENTS INTERNATIONAL CONFERENCE ON WOMEN AND ENVIRONMENT The First International Conference on Women and Environment will be held December 1-3, 1992, in Alexandria, Egypt. The conference has been organized to focus on the relationships between women and their natural surroundings and on the leading role women should play as environmental conservationists and educators of future generations. For further information, please contact: Prof. Dr. Samai Galal Saad, Department of Environmental Health, High Institute of Public Health, 165 EI-Horriya Avenue, Alexandria, Egypt. Telephone: 002(03)4215575/6. FAX: 002(03)4218436. LACTATION EDUCATOR TRAINING PROGRAM UCLA Extension's highly acclaimed Lactation Educator Training Program, deSigned to prepare health professionals and other interested people to be lactation educators, has two short programs still to be held in 1992: July 9-13, 1992 in Los Angeles, California; September 17-21, 1992 in Minneapolis, Minnesota. This continuing medical education activity meets the criteria for up to 22.5 credit hours in Category I of the Physician's Recognition Award of the American Medical Association and the California Medical Association Certificate in Continuing Medical Education. It has also been approved for 29 continuing education hours by the American Dietetic Association. Students can earn four units of credit in nursing. For further information, please contact: UCLA Extension, Department of Health Sciences, 10995 Le Conte Avenue, Room 614, Los Angeles, CA 90024, Attention: Lactation Programs. Telephone: (310)825-9187. MINORITY HEALTH ISSUES FOR AN EMERGING MAJORITY The Fourth National Minority Forum, Minority Health Issues for an Emerging Majority, sponsored by the National Heart, Lung, and Blood Institute (NHLBI) and the NHLBI Ad Hoc Committee on Minority Populations, will be held June 26-27, 1992 in Washington, DC. The conference agenda will offer a two-day array of information on research activities and community health programs that focus on culturally diverse populations. For further information, please contact: Matilde Alvarado, Minority Health Specialist, NHLBI Health Education Branch, BUilding 31, Room 4A-18, NIH, Bethesda, MD 208921(301)496-1051; or Jake Roberts, Meeting Planner, 7200 Wisconsin Avenue, Box 329, Bethesda, MD 20814-4820/(301)951-3275.
R.
DONOVAN
Wesson Women's Clinic, Baystate Medical Center, Springfield, Massachusetts 01199 ABSTRACT The effect of professional home-support on the success of breastfeeding was investigated to determine whether breastfeeding women who received professional home-support would breastfeed longer than similar women who did not receive this support. Fifty-two volunteers of lower socio-economic status were recruited for this study from four obstetrical clinics and were randomly assigned to an intervention or a comparison group. Both groups received the standard clinic and in-hospital breastfeeding teaching and were given breastfeeding instruction in the hospital by the researcher. The women in the intervention group received, in addition, an average of seven home breastfeeding support contacts by the researcher over two months postpartum, and were provided with the researcher's phone number. Women in the comparison group did not receive home visits but had access to the clinic nutritionist if any questions or problems arose. More than half (61.5%) of the intervention group subjects were still breastfeeding at two months post-partum versus approximately one-third (34.6%) of the comparison group (p < 0.01). These results suggest that professional home breastfeeding support programs may be effective in increasing the duration of breastfeeding among this population, thereby achieving one of the Surgeon General's health objectives. (TNE:24:117-122,1992)
is not fully established before hospital discharge. Therefore, the need for profeSSional home-support is indicated. Home support studies. Research indicates that failure to continue breastfeeding, despite a strong desire to do so, is often due to lack of prompt and adequate medical support or access to the advice of experienced breastfeeders. Although there have been several studies on the effect of hospital practice on the initiation of breastfeeding, few researchers have studied what effect a profeSSional providing additional support once the nursing mother has returned home can have on breastfeeding duration or success. Houston et ai . (ll) studied home-support of 80 breastfeeding mothers in England and discovered a significant difference between the intervention and comparison groups at 12 weeks post-partum (p < 0.05) in the lower social classes, whereas there was no difference between the two groups in the highest social class. Kelly (12) also studied the effect of profeSSional homesupport on breastfeeding success in a group of 38 mothers. Although the results of this study showed that more mothers in the study group than in the control group were still breastfeeding at three, six and twelve weeks, the differences were not statistically Significant, possibly due to the sample size of 19 in each group. Other studies suggesting that close personal support may encourage successful breastfeeding (13, 14) have not included comparison groups. Studies conducted in the United States have investigated breastfeeding support systems other than home-support by health care profeSSionals. Saunders and Carroll (15) studied 150 predominantly Hispanic, low-income women. Breastfeeding intervention consisted of one hospital visit (1-3 days post-partum), a phone call or letter, and a structured group support class at two weeks post-partum. Results indicated that the intervention group conSistently and Significantly breastfed longer than did the control group. In another study of 40 low-income breastfeeding primiparous women, Barron et ai. (16) found that when breastfeeding assistance was available during the first two weeks post-partum, mean breastfeeding duration was 23.4
INTRODUCTION It is generally recognized that breastfeeding is the best method for feeding the term infant (1-4). However, it is well known that lower socioeconomic groups have a lower incidence and duration of breastfeeding than higher socioeconomic groups (5-9). In order to meet the Surgeon General's objective of increased breastfeeding incidence and duration (10), efforts to promote breastfeeding must be directed toward women who are less educated, have lower incomes and belong to minority groups. Also, the short hospital stay after giving birth that is presently advocated has resulted in less time for the professional staff to support the breastfeeding mother, whose milk supply often
Address for correspondence: Paula Serafino-Cross, M.S., R.D., Pediatric Gastroenterology and Nutrition of Westem Massachusetts, 780 Chestnut Street, Springfield, MA 01107. 0022-3182/9212403-0117$03.00/0 © 1992 SOCIETY FOR NUTRITION EDUCATION 117
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weeks, compared with 12.3 weeks when breastfeeding assistance was unavailable. Garza (17) reported similar results with 116 indigent mothers who were randomly asSigned to an experimental group or a comparison group. The experimental group received assistance from a lactation consultant for one month post-partum, with results indicating a 240% greater incidence of exclusive breastfeeding at 30 days than the comparison group. The present study was designed to determine if lowincome breastfeeding women who received extensive professional home-support continued to breastfeed longer than similar women who did not receive this support. In addition, reasons for early termination of breastfeeding were to be identified so that future prenatal teaching sessions could focus on these areas.
METHODS
Selection of study sample. This study enrolled 52 volunteers from four prenatal clinics in Springfield, Massachusetts, who during their pregnancy had indicated a desire to breastfeed their infants. Patients were continually recruited for this study during prenatal visits at the four clinics until the desired number was obtained. Eightynine women were approached to be in this study. Of this number, 80 agreed to participate; however, 28 had to be excluded for various reasons. Unfortunately, the typical breastfeeding incidence at these four clinics is unknown because clinic staff do not routinely compile these statistics. Informed consent of the participants was obtained by clinic nutritionists at prenatal visits. This study began in February 1986 and was completed by April 1987. Although there are complex formulas for determining an appropriate sample size, the profeSSional time commitment and the availability of cases were the factors determining the sample size for this study. Although the original goal of the study was to enroll 60 participants, it took 14 months to enroll just 52 participants from four clinics serving in total approximately 1,000 pregnant women per year. Screening criteria stated that the client had to be a firsttime breastfeeder or unsuccessful in previous attempts to breastfeed, defined as terminating breastfeeding in the first month due to problems. In addition, the client had to plan to breastfeed for two months or longer, and had to be English-speaking, due to lack of an available translator. Lastly, the client must have received breastfeeding instruction from the clinic nutritionist at some point during her prenatal care to assure uniform baseline information. Study design. While visiting the client in the hospital, the researcher, a trained and experienced breastfeeding counselor, explained the study briefly, reviewed the established protocol for teaching breastfeeding, and answered any questions that the client had. For this study, the re-
searcher provided breastfeeding support and education to women participating in the study while they remained in the hospital. After instruction was completed, the researcher randomized the clients into either the intervention group or the comparison group. Those clients aSSigned to the intervention group received additional breastfeeding support in the home and by phone for two months post-partum. Between five and eight visits were made per client, with a greater frequency of visits in the first two weeks, as this is the critical period for establishing breastfeeding. Visits lasted from 30-60 minutes and were arranged at the convenience of the client. The researcher provided her phone number to the client in the event that questions arose between visits. Counseling during home visits was generally in response to specific questions or problems raised by the mother, but the researcher also initiated conversation about important breastfeeding topics. Topics covered in the early weeks included management of engorgement, frequency of feeding, confidence and relaxation, stooling patterns, and determining adequate intake in the breastfed infant. At later visits, discussions centered around the expression and storage of breastmilk, nursing in public, dealing with fatigue, management of school or work while breastfeeding, growth spurts, and supplementation of breastmilk with formula, water or solid foods. Special topiCS that were covered included management of blocked milk ducts, tongue thrusting and inverted nipples. At each home visit, the mother completed a form outlining her problems and/or successes; breastfeeding topics discussed were also noted. Arecall of infant feeding in the past 24 hours was completed to determine the frequency of breastfeeding and other feeding. A questionnaire was completed at two months post-partum or when breastfeeding was terminated, whichever occurred sooner. The questionnaire used for this study was modified to increase the specificity of the answers from one previously in use by this obstetrical hospital. This version was then pre-tested with a small number of women. Additionally, the questionnaire was reviewed by both a public health professor and a maternal-child health nutritionist from the state university. Therefore, content validity was addressed, but sampling and construct validity were not. Reading level was not assessed; however, in most cases, the questionnaire was read to the patient by the researcher. Lastly, all women in the intervention group were contacted when their infants were six months or older to determine if they were still breastfeeding. Women asSigned to the comparison group were given a card with the name and phone number of the clinic nutritionists who could be contacted ifbreastfeeding problems or questions arose. At two months post-partum, these clients were contacted by phone or mail to complete the same questionnaire used for the intervention group to assure the collection of similar data, i.e., how many weeks
J. of Nutr. Educ. Vol. 24, No. 3 Table 1.
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Characteristics of women in the intervention and comparison groups:
Factor
Level
Maternal Age
< 19 years
Parity Education Race Delivery Type WIC2 Participation
Intervention N= 26
Comparison N= 26
No. (%) 8 (31%) 14 (54%) 4 (15%) 18 (69%) 8 (31%) 7 (27%) 15 (58%) 4 (15%) 10 (38%) 8 (31%) 8 (31%) 17 (65%) 9 (35%) 24 (92%) 2 (8%)
No. (%) 6 (23%) 12 (46%) 8 (31%) 19 (73%) 7 (27%) 7 (27%) 14 (54%) 5 (19%) 11 (42%) 6 (23%) 9 (35%) 20 (77%) 6 (23%) 24 (92%) 2 (8%)
20-24 years ;::: 25 years Primipara Multipara 9-11 years 12 years ;::: 13 years White Black Other' Vaginal Cesarean Section Yes No
'Includes Puerto Rican, Mexican-American, Portuguese and Virgin Islanders. 2Women, Infants and Children Supplemental Food Program. "No significant differences were found between the intervention group and the comparison group with respect to the above variables.
the infant was breastfed, etc. No further contact was made with this group.
Data analysis. The statistical test used to analyze differences between the two groups for overall breastfeeding frequency was the Mantel-Haenszel test. This statistical test combines the chi-square test and p values. The Mantel-Haenszel test is more appropriate for this type of study than the chi-square statistic because it takes into account the fact that the same sample is being compared at each of the eight weeks; in other words, the data were continuous (18). A contingency table (2 X 2 table) was established for each of the eight weeks of the study. The proportions of women breastfeeding in both the intervention group and the comparison group were examined each week during the eight weeks of the study. For other statistical analyses, Pearson's Chi-Square statistic was used to compare the two groups. Statistical analysis was completed using the Biomedical Statistical Package, BMDP. For the purpose of this study, any subject who was breastfeeding for at least half of the infant's feedings was considered to be breastfeeding. Due to the study size (52 clients), all comparisons were made between breastfeeding women, as defined above, and bottlefeeding women.
RESULTS Randomization was effective in distributing women into comparable groups, with respect to maternal age, parity, education, race, delivery type, and WIC partiCipation (Table 1). No Significant differences were found between the two groups as assessed by Pearson's X2 statistic.
90
80
"
" ....
........._
"
_o..._.INTERVENTlON GROUP
" "....
. -. -
COMPARISON GROOP
p
WEEKS Figure 1. Breastfeeding mothers in the intervention group (n = 26) versus comparison group (n = 26) during the first eight weeks post-partum.
Of the 26 women in the intervention group, 61.5% were still breastfeeding at two months post-partum versus 34.6% in the comparison group. This difference was statistically Significant (p < 0.01) for both week seven and week eight (Figure 1). An average of seven home visits were made to intervention group participants. A total of 13 calls were made by women in the intervention group to the researcher. Only two calls were made by women in the comparison group to the clinic nutritionist. Based on the established criteria, only two women with nursing infants were categorized as bottlefeeding at two
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months post-partum. Both were in the comparison group. One of these mothers has never breastfed her infant more than one or two times a day from birth, due to problems with the infant's sucking (tongue thrusting). The other mother was only breastfeeding one or two times a day from week five on, due to severe anxiety over breastfeeding. FollOwing-up on the women in the intervention group revealed that 48% were still breastfeeding at six months. The researcher was unable to contact one-half of the comparison group mothers at six months. This may indicate an inherent difference between the stability of the two groups; however, if more contact had been made with this group throughout the study, it might have been less difficult to locate these women. Although both groups were quite transient, the established relationship with the researcher made it easier to contact the intervention group through friends, family, and the WIC program in which they were enrolled. . Only five women in the study reported that they had returned or would be returning to work. Of these five, returning to work was a factor in the termination of breastfeeding for only one woman. Three women were still breastfeeding at two months post-partum and one had stopped because she found it too demanding, although she had not yet returned to work. The most common reason given for the termination of breastfeeding in the comparison group was "insufficient milk" (35%), whereas only 10% gave this as a reason in the intervention group. "Sore nipples" was given as another common reason for the termination of breastfeeding, with 18% giving this reason in the comparison group and 10% in the intervention group. The most common reason for stopping breastfeeding in the intervention group was "I found it too demanding," 30% vs. 18% in the comparison group. DISCUSSION
Significance of professional home-support on breastfeeding duration. The results of this study indicate that there is a relationship between profeSSional home-support and continued breastfeeding at two months post-partum for women of low socioeconomic status. In the intervention group, 61.5% were still breastfeeding at two months vs. 34.6% in the comparison group. These results were statistically Significant (p < 0.01) and important because this type of study has not been conducted in the United States. Home-support studies conducted in England (11, 12) and Canada (19) used the Chi-square or Fisher's Exact test for statistical analysis. One study found statistical significance (11), one suggested borderline statistical significance (12), and one found no Significant differences between the experimental and the control group in terms of breastfeeding success (19). These studies did not exclude
preViously successful breastfeeders, as did the present study deSign. The present study design specified that both intervention and comparison groups receive additional breastfeeding counseling in the hospital before being randomized to groups. If only the intervention group had been counseled during their hospital stay, a more Significant difference between the two groups in respect to breastfeeding success might have been seen.
Reasons for the termination of breastfeeding. The most common reason for terminating breastfeeding in the intervention group was "I found it too demanding." This was also given as a common reason in the comparison group. It is possible that women in both groups may not have been prepared for the time commitment or the exclusive responsibility of feeding that accompanies early breastfeeding. Therefore, in educating women prenatally, it is important for the counselor to describe the time and commitment involved in breastfeeding realistically, along with stressing its many advantages. Inadequate milk supply was given as the most common reason for cessation of breastfeeding in the comparison group. It is known that most women are phYSiolOgically able to produce enough breast milk. One possible explanation of an insufficient milk supply is lack of confidence on the mother's part and/or a lack of technical information. However, because this was a group oflow-income women, the high stress lives that they often lead could also be responSible for an inadequate milk supply, through an effect on the let-down reflex. Lack of a support network, including family and friends, could also contribute to a lack of confidence and increased stress, resulting in a poor milk supply. This group of women may be helped to continue lactation by the intervention of a counselor. Sore nipples was also given as a common reason for stopping breastfeeding in the comparison group. These women reported that their sore nipples developed into cracked and bleeding nipples. These problems are usually due to improper positioning of the infant at the breast and/ or improper care of the nipples. Therefore, it is recommended that the counselor observe the baby's position at the breast and review nipple care. CONCLUSIONS The results of this study indicate the need for breastfeeding home-support for clients of low socioeconomic status in order to increase breastfeeding duration. The model presented in this study is a hospital-based program of breastfeeding home support that could be established in conjunction with the early discharge of post-partum women. Systematic networking among community health agencies, such as the WIC Program, EFNEP (Expanded Food and Nutrition Education Program), home health
J. of Nutr. Educ. Vol. 24, No.3
agencies and Visiting Nurse Associations, would help to strengthen this type of program. Area pediatricians or their staff should also be involved, so that breastfeeding support is consistent. One way to reduce the cost of implementing a homesupport program would be to use trained paraprofessionals rather than professionals to conduct home visits to breastfeeding women. An intervention program of this type, initiated by the New York EFNEP Program, trained paraprofeSSionals to help low-income women make an informed decision about infant feeding and to provide technical support for those women who chose to breastfeed (20).
The most critical component of the intervention is early contact with the breastfeeding mother. Although a visit to the mother in the hospital is important, it is even more important to visit the mother at home after the actual milk flow has begun. This visit should occur one to two days after discharge. After providing support for the first two weeks of breastfeeding, additional need for support could be assessed and further contacts tailored to the individual's needs. For lactation counselors, formal training on lactation through workshops, books and professional articles is important for building a strong knowledge base. Equally important is hands-on experience in working with breastfeeding mothers at a clinic, hospital or WIC program. Observation of the mother breastfeeding her infant is the key to the evaluation of problems, or potential problems, such as breast infections and cracked nipples. The counselor must be comfortable with this aspect of lactation education, open-minded and non-judgmental. In addition, a protocol for determining those mothers who would benefit from lactation counseling needs to be developed. Breastfeeding mothers who had cesarean sections and mothers of infants who were not allowed to breastfeed within 24 hours after delivery were two groups identified in this study who would benefit from access to a lactation counselor. Those who have no support person at home would be another group to target. Ideally, for a breastfeeding intervention program to increase the duration of breastfeeding, it should continue until lactation is well established and should be adapted to the individual's need for technical and emotional support.
NOTES AND REFERENCES 1 Nutrition Committee of the Canadian Paediatric Society and Committee on Nutrition of the American Academy of Pediatrics. A Commentary in celebration of the international year of the child: Breastfeeding. Pediatrics 62:591-601, 1979. 2 American Academy of Pediatrics. Policy statement based on task force report: The promotion of breast feeding. Pediatrics 69:654-661. 1982. 3 Nutrition Committee Canadian Paediatric SOciety. Breastfeeding: What is left besides the poetry? Canadian Journal of Public Health 69:13-20, 1978. 4 Position of the American Dietetic Association. Promotion of
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17
18 19 20
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breastfeeding. Journal of the American Dietetic Association 86(11):1580-1585, 1986. Martinez, G. and F. Krieger. 1984 milk feeding patterns in the United States. Pediatrics 76:1004-1008, 1985. Wright, H. and P. Walker. Prediction of duration of breastfeeding in primiparas. Journal of Epidemiology and Community Health 37:8994, 1983. Sloper, K., L. McKean, and J. Baum. Factors influencing breastfeeding. Archives of Disease in Childhood 50:165-170, 1975. West, C. Factors influencing the duration of breastfeeding. Journal of Biosocial Sciences 12:325-331, 1980. Hart, H., M. Bax, and S. Jenkins . Community influences on breastfeedings. Child: Care, Health, and Development 6:175-187, 1980. Report of the Surgeon General's workshop on breastfeeding and human lactation. June 11 and 12, 1984. United States Department of Health and Human Services. Pub. No. HRS-D-MC-84-2. Houston, M., P. Howie, A. Cook, and A. McNeilly. Do breastfeeding mothers get the home support they need? Health Bulletin 39(3):166172, 1981. Kelly, M. Will mothers breastfeed longer if health visitors give them more support? Health Visitor 56:407-409, 1983. Eastham, E., D. Smith, D. Poole, and G. Neligan. Further decline of breastfeeding. British Medical Journal 1:305-307, 1976. Verronen, P. Breastfeeding: Reasons for giving up and transient lactational crises. Acta Paediatrica Scandinavica 71:447-450, 1982. Saunders, S.E. and J. Carroll. Post-partum breastfeeding support: Impact on duration. Journal of the American Dietetic Association 88:213-221, 1988. Barron, S.P., H.W. Lane, T.E. Hannan, B. Struempler, and J.C. Williams. Factors influencing duration of breastfeeding among low-income women. Journal of the American Dietetic Association 88(12):1557-1561 , 1988. Garza, C. A support program for breastfeeding in a United States low-income urban population. Presented at the National Institute for Child Health and Development Workshop on Determinants of Choice and Duration of Infant Feeding. Chantilly, Virginia, June, 1981. Miller, R.G. Survival analysis. New York: John Wiley and Sons, 1981, pp.94-103. Lynch, S., A. Koch, G. Hislop, and A. Coldman. Evaluating the effect of a breastfeeding consultant on the duration of breastfeeding. Canadian Journal of Public Health 77:190-195, 1986. Cadwallader, A. and C. Olson. Use of a breastfeeding intervention by nutrition paraprofessionals. Journal of Nutrition Education 18(3):117-122, 1986.
RESUME On a evalue !'influence d'un programme de support dispense a la maison par des professionnels sur Ie sucd~s de l'allaitement matemel afin de determiner si des femmes allaitantes regevant ce type d'aide allaiteraient leur enfant plus longtemps que celles qui ne Ie regevaient pas. Cinquante-deux femmes de faible niveau socio-economique ont ete recrutees, sur une base volontaire, dans quatre cliniques d'obstetrique et ont ete reparties au hasard entre un groupe d'intervention et un groupe temoin. Lex deux groupes ont re9u l'enseignement dispense de routine dans la clinique et a I'h6pital et ont re9u de la chercheure a l'h6pital, des directives sur l'allaitement. Les femmes du groupe d'intervention ont, de plus, re9u a sept reprises au cours des deux mois post-partum des visites de support de la chercheure a la maison et celle-ci leur a transmis son numero de telephone. Les femmes du groupe temoin n'ont pas re9u de visites a domicile mais avaient acces aux services de la nutritionniste de la clinique si elles se posaient des questions ou avaient des problemes au sujet de l'allaitement. Plus de la moitie (61,5%) des femmes du groupe d'intervention continuaient d'allaiter leur enfant deux mois apres sa naissance, alors qu'environ un tiers (34,6%) des femmes du groupe temoin continuaient de Ie faire (p < 0,01). Ces resultats suggerent qu'un programme de support a l'alIaitement dispense a la maison par des profession nels peut etre efficace pour prolonger fa duree de
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l'allaitement dans cette population, realisant ainsi l'un des objectifs de sante vises par Ie Surgeon General. Translated by Estelle Mongeau , Ph.D. RESUMEN Se investig6 el efecto de un programa de apoyo profesional en el hogar en el exito para amamantar con el objeto de determinar si las mujeres que recibieron este apoyo amamantaron por mas tiempo comparadas con un grupo similar que no recibi6 dicho apoyo. Cincuenta ydos voluntarias de nivel socioeconomico bajo fueron reclutadas de cuatro clfnicas obstetricas, y fueron asignadas aleatoriamente a un grupo de intervenci6n o a un grupo control. Ambos grupos recibieron el programa hospitalario estandar de educaci6n sobre tecnicas de amamantamien to, y recibieron instrucciones sobre amamantamiento por parte de la investigadora. Las mujeres del grupo de intervencion tuvieron ademas, un promedio de siete contactos domiciliarios
de apoyo para el amamantamiento con la investigadora y recibieron el telefono de la misma. Estos contactos se realizaron en el termino de los dos primeros meses postparto. Las madres del grupo de comparaci6n no recibieron visitas domiciliarias, pero ternan acceso al nutricionista de la clinica para consultar encaso de que tuvieran alguna pregunta 0 problema. Mas de la mitad (61.5%) de las madres en el grupo de intervenci6n continuaban amamanatando a los dos meses post parto comparado con aproximadamente un tercio (34.6%) de las madres del grupo de comparaci6n (p < 0.01). Estos resultados sugieren que los programas de apoyo profesional para el amamantamiento a nivel del hogar pueden ser eficaces para alargar la duraci6n del amamanatamiento en esta poblaci6n, alcanzando as( uno de los objetivos 'de salud del Director de los Servicios de Salus.· Translated by Teresa Gonzalez-Cossio ·(Surgeon General).
ANNOUNCEMENTS INTERNATIONAL CONFERENCE ON WOMEN AND ENVIRONMENT The First International Conference on Women and Environment will be held December 1-3, 1992, in Alexandria, Egypt. The conference has been organized to focus on the relationships between women and their natural surroundings and on the leading role women should play as environmental conservationists and educators of future generations. For further information, please contact: Prof. Dr. Samai Galal Saad, Department of Environmental Health, High Institute of Public Health, 165 EI-Horriya Avenue, Alexandria, Egypt. Telephone: 002(03)4215575/6. FAX: 002(03)4218436. LACTATION EDUCATOR TRAINING PROGRAM UCLA Extension's highly acclaimed Lactation Educator Training Program, deSigned to prepare health professionals and other interested people to be lactation educators, has two short programs still to be held in 1992: July 9-13, 1992 in Los Angeles, California; September 17-21, 1992 in Minneapolis, Minnesota. This continuing medical education activity meets the criteria for up to 22.5 credit hours in Category I of the Physician's Recognition Award of the American Medical Association and the California Medical Association Certificate in Continuing Medical Education. It has also been approved for 29 continuing education hours by the American Dietetic Association. Students can earn four units of credit in nursing. For further information, please contact: UCLA Extension, Department of Health Sciences, 10995 Le Conte Avenue, Room 614, Los Angeles, CA 90024, Attention: Lactation Programs. Telephone: (310)825-9187. MINORITY HEALTH ISSUES FOR AN EMERGING MAJORITY The Fourth National Minority Forum, Minority Health Issues for an Emerging Majority, sponsored by the National Heart, Lung, and Blood Institute (NHLBI) and the NHLBI Ad Hoc Committee on Minority Populations, will be held June 26-27, 1992 in Washington, DC. The conference agenda will offer a two-day array of information on research activities and community health programs that focus on culturally diverse populations. For further information, please contact: Matilde Alvarado, Minority Health Specialist, NHLBI Health Education Branch, BUilding 31, Room 4A-18, NIH, Bethesda, MD 208921(301)496-1051; or Jake Roberts, Meeting Planner, 7200 Wisconsin Avenue, Box 329, Bethesda, MD 20814-4820/(301)951-3275.