- Email: [email protected]
Impact of support networks for breastfeeding: A multicentre study
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Women and Birth xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Original Research – Quantitative
Impact of support networks for breastfeeding: A multicentre study Isabel Baño-Piñeroa , María Emilia Martínez-Rocheb , Manuel Canteras-Jordanac, César Carrillo-Garcíad, Esteban Orenes-Piñeroe,* a
Mother and Child Pte. Ltd. (Singapore) and Department of Nursing, Murcia University, Murcia, Spain Obstetric-Gynaecological Teaching Unit (Midwifery), Department of Nursing, Murcia University, Murcia, Spain Department of Statistics, Preventive Medicine and Public Health, Murcia University, Murcia, Spain d General Management of Human Resources of the Murcian Health Service, Ministry of Health, Murcia, Spain e Department of Biochemistry and Molecular Biology-A, University of Murcia, Murcia, Spain b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 June 2017 Received in revised form 20 September 2017 Accepted 3 October 2017 Available online xxx
Background: The rates of breastfeeding worldwide are slowly improving since 1996. Europe is still trailing behind the global breastfeeding incidence and prevalence rates. Thus, breastfeeding promotion, protection, prolongation and support have become an important challenge as breastfeeding sharply decreases in the first six months of life. Objectives: The aim of this project is to determine, assess and identify the real impact of breastfeeding support networks in Murcia (Spain). Methods: After searching unsuccessfully for a validated questionnaire, a specific one was developed and validated for measuring the impact of formal and informal support networks through five dimensions: satisfaction, consultation, experience, problems and support. The questionnaire was provided to 500 mothers with experience in breastfeeding, who brought their children to baby paediatricians between 2 June and 27 November 2014. Upon completion of the survey and fieldwork, a detailed statistical analysis was conducted. Results: The degree of satisfaction perceived by the users of the services of support breastfeeding networks is remarkable. In addition, mothers who clarified their doubts and discussed their problems with health professionals and/or breastfeeding support networks were more likely to breastfeed for a longer duration compared to those who did not (p = 0.005). Furthermore, mothers who sought support in breastfeeding are more likely to breastfeed for more than 6 months (p < 0.0005). Conclusion: Based on this information, we conclude that breastfeeding support networks have a positive influence in the duration of a women’s decision to breastfeed. © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Breastfeeding support networks Lactation Validated questionnaire Satisfaction Duration of breastfeeding
Statement of significance
Problem or issue The drastic decline in prolonged breastfeeding rates is a current health problem that affects the mother, infant, family and society.
Abbreviations: AAP, American Academy of Pediatrics; AEP, Asociación Española de Pediatría, translated Spanish Association of Pediatrics; INE, Instituto Nacional de Estadística, translated Statistics National Institute; PANA, Programa de Atención al Niño y al Adolescente, translated Child and Adolescent Health Care Program. * Corresponding author at: Department of Biochemistry and Molecular BiologyA, University of Murcia, Avda. de las Fuerzas Armadas, s/n, Lorca, Murcia, 30800, Spain. E-mail address: [email protected] (E. Orenes-Piñero).
What is already known Europe is still trailing behind the global breastfeeding incidence and prevalence rates in the world. Similarly, in Spain, a downward trend in exclusive breastfeeding was found, falling from 66.2% at six weeks to 37.8% at six months. What this paper adds Mothers who clarified their doubts and discussed their problems with breastfeeding support networks are significantly more likely to breastfeed for a longer duration compared to those who did not.
https://doi.org/10.1016/j.wombi.2017.10.002 1871-5192/© 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: I. Baño-Piñero, et al., Impact of support networks for breastfeeding: A multicentre study, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.002
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1. Introduction Although abundant scientific evidence proving the benefits and superiority of human milk over any other type of infant nutrition is currently available in the literature,1–3 Europe is still trailing behind the global breastfeeding incidence and prevalence rates.4 In Spain, a downward trend in exclusive breastfeeding was found, falling from 66.2% at six weeks to 37.8% at six months. Conversely, mixed and artificial feeding exponentially increase with age, and artificial feeding shows the most significant increase from six weeks (27.6%) to six months (53.2%).5 The Region of Murcia, located in the Southeast of Spain, follows the same trend as other Spanish communities. Although breastfeeding rates at hospital discharge are high, prolonged breastfeeding remains a key objective of breastfeeding promotion, protection and support because breastfeeding sharply decreases in the first six months of life in our region.5 All studies reviewed show the importance and influence of both formal support (health care professionals) and informal support (community breastfeeding support groups, family and friends) on the families of infants.6–9 However, studies assessing the impact of breastfeeding support networks are very heterogeneous and often overlook some key aspects, including maternal and family characteristics, the type of support program used or the contexts in which support programs are applied.10 To better understand the actual impact of different breastfeeding support networks in the Region of Murcia, and after the validation of the questionnaire published in 2015,11 we decided to use this specific questionnaire for measuring the impact of formal and informal support networks through five dimensions: satisfaction, consultation, experience, problems and support.
the number of consultations provided or the most frequently demanded breastfeeding support professionals or services. - Experience before breastfeeding. This dimension referred to aspects that could positively or negatively affect the decision to breastfeed before problems developed or initial doubts emerged. - Problems during breastfeeding. This dimension focused on the main problems that breastfeeding women experienced and when they occurred. - Support perceived by users. This component encompassed the source of and need for breastfeeding support.
2.2. Data collection
The study was designed as a cross-sectional study using a questionnaire previously developed and validated by our research team to assess the impact of different breastfeeding support networks for lactating women in the Region of Murcia.11
The questionnaire, after validated (previous pilot study)11 was used as a study tool for the fieldwork. It was administered from June 2 to November 27, 2014, at the four accredited health care centers in the Region of Murcia (Alcantarilla, Sangonera la Verde, San Andrés and El Palmar). The study was approved in May 2014 for the Center for Ethics and Research and the Continuing Training Unit of the Murcia Health Service. The target population comprised women who brought their infants to well-child checkups within the Child and Adolescent Health Care Program (Programa de Atención al Niño y al Adolescente PANA), had some breastfeeding experience (i.e., were breastfeeding at the time or had previously breastfed), could read and write in Spanish and volunteered to participate in the study. 430 valid questionnaires were obtained from a total of 500 questionnaires administered, since some of the questionnaires were rejected because were incomplete or with inconsistent answers. The women voluntarily participated in the study after receiving information on the study objective from the nurses who performed the well-child checkup and after signing the informed consent form. The anonymity of the study participants was guaranteed, and the respondents were never pressured to complete the questionnaire against their will.
2.1. Development and validation of the questionnaire
2.3. Statistical analysis
As part of a previous pilot study, the development and validation of the questionnaire was evaluated subjecting the survey to a breastfeeding expert’s opinion in the Region of Murcia.11 This pilot test was conducted between the months of March and April 2014. Briefly, for construction validity, a factor analysis was performed, which determined the different dimensions that the survey could measure. A description of each of the items on the statistics was conducted. Through principal component analysis, the total variance explained was obtained, determining the factors that define the elements. Through factor analysis, the questionnaire has a high internal consistency for its five components, obtaining values from 0.942 to 0.632. And a high percentage of total variance explained (11,157%–5093%). Giving rise to a relevant and valid, in terms of content and construction, instrument, capable of measuring the impact of breastfeeding support networks through 5 dimensions:
Continuous variables were analyzed for normal distribution using the Kolmogorov–Smirnov test. Continuous variables with normal distribution are expressed as means standard deviations, and those with nonparametric distribution are expressed as medians (interquartile ranges). Categorical variables are expressed as frequencies (percentages). Discrete variables were compared using the chi-squared test, whereas two continuous variables were correlated using the Pearson product-moment correlation test. A p-value <0.05 was considered significant. Statistical tests were performed using the Statistical Package for the Social Sciences (SPSS), version 21.0, for Windows software (Chicago, Illinois, USA).
2. Methods
- Degree of satisfaction or quality perceived by the users of breastfeeding support services. This dimension collected data related to the abilities of staff members of breastfeeding support networks and others to solve problems by listening, providing support and devoting time to breastfeeding mothers. - Consultations attended by users of the breastfeeding support services. This dimension collected data on all aspects related to
3. Results The mean age of the mothers who completed the questionnaire was 34.4 6.1 years, with ages ranging from 15 to 58 years. The average number of children per family was 1.86. The women’s nationality was mainly Spanish (90.7%). Among the mothers, 60.7% had graduated from university, and only 2.3% had no official education. The mother was working in 51.2% of the cases, and 14.2% were on maternity leave. The analysis of the time of breastfeeding cessation showed that the breastfeeding rates fell significantly after the infants were 6 months old (Fig. 1).
Please cite this article in press as: I. Baño-Piñero, et al., Impact of support networks for breastfeeding: A multicentre study, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.002
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their infant’s birth. After the first month, the first consultation is much less common, and in 30.9% cases, the women consulted no breastfeeding support professional or service (Fig. 3). Primary care pediatricians are the most in-demand health care professionals (30.7%), followed by health care center midwives (21.9%), maternity staff (15.1%), breastfeeding support groups (14.4%), family physicians (9.8%), delivery/recovery room professionals (8.1%), primary care nurses (6.5%), breastfeeding specialists at private and public clinics (4.7%), and lastly, emergency room staff (3.7%; Fig. 4). Breastfeeding training during the prenatal period positively affect mothers’ decisions to seek professional support for problems or doubts about breastfeeding (p = 0.004). The health care professionals with the greatest impact or influence on promoting breastfeeding during pregnancy are primary care nurses and midwives (86.3% of the women reported having asked their nurse or midwife breastfeeding-related questions during the pregnancy), according to our study. Mothers who consult health care professionals breastfeed longer than those who do not (p = 0.005) and are more likely to exclusively breastfeed until their infant is six months or older than mothers who do not seek such support (p < 0.0005). However, consultations with breastfeeding support groups also have a positive effect on breastfeeding duration (p < 0.0005). Fig. 1. Breastfeeding duration per months.
3.1. Satisfaction The degree of satisfaction was very high: 89.3% of the respondents were satisfied or very satisfied with the breastfeeding support services or the professionals they consulted (Fig. 2). The factors that positively affected the users’ degree of satisfaction with breastfeeding support networks were, among others, exclusive breastfeeding to 6 months of age or older (p < 0.0005); intention to breastfeed before or during pregnancy (p = 0.048); receiving maternal education during pregnancy (p = 0.003); receiving professional support in the delivery/recovery room (p = 0.015), maternity ward (p < 0.0005) or health care center (p < 0.0005); and having attended a midwife consultation (p = 0.049) or a breastfeeding support group (p = 0.004). Furthermore, receiving the first breastfeeding consultation on the infant’s first day of life (p = 0.007), starting breastfeeding within 30 min of birth (p = 0.043) and a positive breastfeeding experience with previous children (p = 0.005) also had a positive effect on user satisfaction.
3.3. Previous experience Of the mothers who were asked about breastfeeding previous children, 71.1% acknowledged having had a satisfactory breastfeeding experience, and only 16.2% reported a negative breastfeeding experience. A total of 81.9% of the pregnant women used epidural analgesia during delivery, and the newborn had to be admitted to the Neonatal Department after delivery in only 9.5% of cases. Skin-to-skin contact was performed in 84.4% cases, mostly (71.9%) within the first half hour after birth. Skin-to-skin contact (p < 0.0005), early breastfeeding after birth (p < 0.0005), singleton pregnancy (p < 0.0005), normal delivery (p = 0.006), delivery without epidural analgesia (p = 0.002) or newborn admission to the Neonatal Department (p = 0.04) and a positive previous breastfeeding experience (p < 0.0005) favor a higher incidence of exclusive breastfeeding up to
3.2. Consultations The first breastfeeding consultation most often occurs during the first 3 weeks of life, and the highest percentage of the participants (25.6%) reported receiving a consultation on the day of
Fig. 2. Degree of perceived satisfaction.
Fig. 3. First lactation consultation.
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in their circle and by their mothers, who had breastfed in 63.7% of cases. Feeling supported positively influences the decision to breastfeed for longer periods (p = 0.049). The main sources of support regarding the decision to breastfeed were the mothers’ partners (81.6%), followed by their mothers and friends. Support from health professionals as a significant influence was only reported by 23.3% of the participants, and non-professional support was the most relevant source (Fig. 6). Women who reported not feeling supported in their decision to breastfeed had doubts about the quality of their milk (p = 0.025), their breastfeeding ability (p = 0.011) and whether the baby was hungry (p = 0.004). Women who felt unsupported in their decision to breastfeed were more insecure and attended fewer consultations (p = 0.003) than those who felt supported. 4. Discussion Fig. 4. Health professional/support networks consulted.
6 months of life and subsequently a higher exclusive breastfeeding prevalence. 3.4. Problems Among the mothers, 72.8% acknowledged having had some breastfeeding-related problem. These problems mostly (57% cases) occurred during the first 3 weeks of life, although the highest percentage within this period occurred in the first day after birth (Fig. 5). The most commonly reported problem was cracked nipples (34.7%), followed by fatigue (33.3%), doubts about whether the baby was hungry (32.6%), pain (25.5%), poor latch-on (24.2%) and doubts about the breastfeeding position or technique (24%). 3.5. Support The analysis of factors that may affect the decision to breastfeed showed that 88.4% of the participants considered breastfeeding their baby during or even before their pregnancies. A total of 77.2% of the respondents were influenced by other breastfeeding women
Fig. 5. When did the problems appear?
Our study confirms that mothers who consult health care professionals breastfeed longer than those who do not consult. Furthermore, mothers who seek professional support are more likely to exclusively breastfeed up to six months or longer than mothers who seek no such support. Thus, breastfeeding support networks positively influence the prevalence and duration of breastfeeding, as observed previously.12 The degree of satisfaction with breastfeeding support also appears to depend on breastfeeding duration. Thus, we found that mothers who exclusively breastfed for 6 months or longer were very satisfied with the breastfeeding support networks they consulted, whereas the mothers who introduced supplemental nutrition, including artificial milk or solids, before 6 months of life were very unsatisfied. This corroborates reports that the degree of satisfaction with breastfeeding support networks depends on the duration of exclusive breastfeeding.13–15 At this point, it would be important to remark that although the degree of satisfaction is very high, it could be even higher, as mothers who were unsatisfied with the breastfeeding support networks were those who introduced supplemental nutrition, including artificial milk or solids before 6 months of life, and for that reason they were apparently not active seekers of breastfeeding support. Similarly, our study confirms that breastfeeding training during the prenatal period positively influences the decision to seek professional support when problems with or doubts about breastfeeding first occur, thereby positively influencing the prevalence and duration of breastfeeding.16 The general satisfaction perceived by users of breastfeeding support networks in the Region of Murcia was very good, with an overall mean of 3.5 out of 5 for the 9 statements measuring the degree of satisfaction. Other studies reviewed confirm that interventions aimed at supporting, promoting and protecting breastfeeding have a positive effect on the degree of satisfaction perceived by mothers.7–9,13 Our study shows that primary care nurses and midwives are the most influential health care professionals for promoting breastfeeding during pregnancy, consistent with previous findings.17,18 However, this issue is somewhat controversial because several other authors have highlighted the role of International BoardCertified Lactation Consultants (IBCLC) as breastfeeding promoters. It was stated that the number of Board-Certified Lactation Consultants a hospital employed was the only variable that predicted higher levels of support practices.19 Studies have also shown higher breastfeeding rates in hospitals offering IBCLC services compared with those that do not offer these services and a direct relationship between the availability these health care professionals and breastfeeding rates.20 Other authors have found that IBCLCs provide more positive and effective reinforcement than
Please cite this article in press as: I. Baño-Piñero, et al., Impact of support networks for breastfeeding: A multicentre study, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.002
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Fig. 6. Source of support.
other health care professionals, including nurses or doctors.21,22 Furthermore, several other studies have shown that the presence of IBCLCs in maternity and pediatrics wards is associated with higher rates of breastfeeding initiation and longer durations.22 We found no scientific study showing the effectiveness of these professionals for promoting, protecting and supporting breastfeeding in Spain in contrast to several other countries, possibly because the IBCLC is not recognized by the health system in Spain. We also overlooked the IBCLC in our questionnaire for that reason. Our study shows that skin-to-skin contact, early breastfeeding initiation after birth, singleton pregnancy, non-use of epidural analgesia, non-admission of the newborn to the neonatal department and a previous positive breastfeeding experience are associated with an increased incidence of breastfeeding and a longer exclusive breastfeeding duration up to the infant’s sixth month. However, the correlation between delivery type and breastfeeding duration is somewhat controversial. Thus, some authors suggest that normal delivery favors a longer duration of exclusive breastfeeding23 ; whereas in another study was found that children born by cesarean section had a higher prevalence of breastfeeding than those born vaginally.24 Other authors agree that cesarean delivery has a negative influence on cognitive recovery after general anesthesia and delays exclusive breastfeeding at discharge, albeit with no subsequent influence.25,26 Our study also shows that skin-to-skin contact positively influences exclusive breastfeeding up to 6 months of life or longer. Another study concludes that early skin-to-skin contact positively affects breastfeeding during the immediate postpartum period but found no significant differences after the first month of life.27 Our study shows that breastfeeding-related problems during the first 3 weeks of life, including cracked nipples, painful breastfeeding or latch-on problems, are the main reasons for breastfeeding cessation. Other authors emphasize the importance of treating the most common problems during the first few days of life and highlight the importance of interventions and follow-up by health care professionals during the first days of breastfeeding.28 Conversely, our study shows that women who feel unsupported attend fewer consultations and therefore breastfeed for shorter periods than those who feel supported. This finding shows the importance and influence of formal and informal breastfeeding support networks on breastfeeding. Similarly, the lack of support creates insecurity in women when breastfeeding, as other authors have also reported.29 Thus, support is the most effective strategy for achieving high breastfeeding initiation rates; therefore, breastfeeding support services are indispensable in all health care systems. Similarly, inadequate professional support may have a very negative impact on breastfeeding.30 Changes must be introduced to improve health care services, focus their activities on the specific
needs of the population and demand minimum breastfeeding training from professionals who work with infants. The potential limitations of this study should be noted. First, although the study was conducted at the four accredited health care centers in the Region of Murcia, most patients were Caucasian and Hispanic, and therefore, the data should be extrapolated to other ethnic groups with caution. Secondly, the sample size of the present study was limited, possibly resulting in loss of statistical significance in some of the analyses. Thus, larger studies are required to confirm our observations. However, the results of this study provide valuable insights and may serve to guide future studies in this area. 5. Conclusion Breastfeeding support networks positively influence the prevalence and duration of breastfeeding. Thus, formal and informal support favors longer periods of exclusive breastfeeding, whereas the lack of support leaves women feeling insecure when breastfeeding. Therefore, good policies and intervention strategies are needed to promote, protect, and support breastfeeding to improve the health problems we face today. We must join forces to continue improving and advancing this public health mission. Funding statement The authors received no financial support for the research, authorship, and/or publication of this article. Acknowledgment Dr. Esteban Orenes-Piñero is supported by a postdoctoral contract from Instituto Murciano de Investigación Biosanitaria Virgen de la Arrixaca (IMIB-Arrixaca), Murcia, Spain. References 1. AAP. Policy statement: breastfeeding and the use of human milk. Pediatrics 2012;129:827–41. 2. Lawrence RA, Lawrence RM. Breastfeeding. A guide for the medical profession. Edicio´n en espan˜ol de la 6a edicio´n de la obra original en ingle´s. Madrid: Elsevier; 2007. 3. WHO. Estrategia Mundial para la alimentacio´n del lactante y del nin˜o pequen˜o. Ginebra: OMS; 2002. Retrieved from http://www.who.int/nutrition/publications/infantfeeding/gs_infant_feeding_spa.pdf. 4. UNICEF. Estado mundial de la infancia 2013. 2013. Retrieved from http://www. unicef.org/spanish/sowc2013/files/SPANISH_SOWC2013_Lores.pdf. 5. Ortega JA, Pastor-Torres E, Martínez-Lorente I, Bosch-Giménez VM, QuesadaLópez JJ. Proyecto Malama en la Región de Murcia (España). An Pediatr 2008;68:447–53. 6. Baño-Piñero I, Carrillo-García C, Thambidurai U, Martínez-Roche ME. The Baby Café concept as an international network of support to breastfeeding. Cultura de los Cuidados 2015;19:19–33.
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7. Hongo H, Nanishi K, Shibanuma A, Jimba M. Is baby-friendly breastfeeding support in maternity hospitals associated with breastfeeding satisfaction among Japanese mothers? Matern Child Health J 2015;19:1252–62. 8. MacVicar S, Wilcock S. The effectiveness and maternal satisfaction of interventions supporting the establishment of breast-feeding for women from disadvantaged groups: a comprehensive systematic review protocol. JBI Database Syst Rev Implement Rep 2013;11:48–63. 9. Renfrew MJ, McCormick FM, Wade A, Quinn B, Dowswell T. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev 20125:CD001141. 10. WHO. Salud de la madre, el recie´n nacido, del nin˜o y del adolescente. 2014. Retrieved from http://www.who.int/maternal_child_adolescent/topics/newborn/nutrition/breastfeeding/es/. 11. Baño-Piñero I, Canteras-Jordana M, Carrillo-García C, López-Araez A, Martínez-Roche ME. Development and validation of an instrument designed to measure the impact of networks of support for breastfeeding. Nutr Hosp 2015;31:1525–32. 12. Gau ML. Evaluation of a lactation intervention program to encourage breastfeeding: a longitudinal study. Int J Nurs Stud 2004;41:425–35. 13. Chin LY, Amir LH. Survey of patient satisfaction with the Breastfeeding Education and Support Services of The Royal Women's Hospital, Melbourne. BMC Health Serv Res 2008;8:83. 14. Hallowell SG, Froh EB, Spatz DL. Human milk and breastfeeding: an intervention to mitigate toxic stress. Nurs Outlook 2017;65:58–67. 15. Mulcahy H, Phelan A, Corcoran P, Leahy-Warren P. Examining the breastfeeding support resources of the public health nursing services in Ireland. J Clin Nurs 2012;21:1097–108. 16. Martínez-Galiano JM, Delgado-Rodríguez M. Early initiation of breastfeeding is benefited by maternal education program. Rev Assoc Med Bras 2013;59:254– 7. 17. Roll CL, Cheater F. Expectant parents’ view of factors influencing infant feeding decisions in the antenatal period: a systematic review. Int J Nurs Stud 2016;60:145–55. 18. Buckner E, Matsubara M. Support network utilization by breastfeeding mothers. J Hum Lact 1993;9:231–5.
19. Dodgson JE, Watkins AL, Choi M. Evaluation of supportive breastfeeding hospital practices: a community perspective. Av.enferm 2010;28:17–30. 20. Castrucci BC, Hoover KL, Lim S, Maus KC. A comparison of breastfeeding rates in urban birth cohort among women delivering infants at hospitals that employ and do not employ lactation consultant. J Public Health Manag Pract 2006;12:578–85. 21. Humenick SS, Hill PD, Spiegelberg PL. Breastfeeding and health professional encouragement. J Hum Lact 1998;14:305–10. 22. Thurman SE, Allen PJ. Integrating lactation consultants into primary health care services: are lactation consultants affecting breastfeeding success? Pediatr Nurs 2008;34:419–25. 23. Cakmak H, Kuguoglu S. Comparison of the breastfeeding patterns of mothers who delivered their babies per vagina and via cesarean section: an observational study using the LATCH breastfeeding charting system. Int J Nurs Stud 2007;44:1128–37. 24. Díaz CE, López R, Herrera I, Arena D, Giraldo C, Gonzáles L. Factors associated with breastfeeding in children less than one year of age in the city of Cartagena, Colombia. Colomb Me´d 2011;42:26–34. _ Demiraran Y, Ersoy Ö, Karagöz I, _ Sezen G, et al. Effects of 25. Kutlucan L, Seker SI, different anesthesia protocols on lactation in the postpartum period. J Turk Ger Gynecol Assoc 2014;15:233–8. 26. Zuppa AA, Alighieri G, Riccardi R, Cavani M, Iafisco A, Cota F, et al. Epidural analgesia, neonatal care and breastfeeding. Ital J Pediatr 2014;29:40–82. 27. Moore ER, Anderson GC. Randomized controlled trial of very early motherinfant skin-to-skin contact and breastfeeding status. J Midwifery Womens Health 2010;52:116–25. 28. Hauck YL, Fenwick J, Dhaliwal SS, Butt J, Schimied V. The association between women’s perceptions of professional support and problems experienced on breastfeeding cessation: a western australian study. J Hum Lact 2011;27:49–57. 29. Baumgartel KL, Spatz DL. WIC (The special supplemental nutrition program for women, infant, and children): policy versus practice regarding breastfeeding. Nurs Outlook 2013;61:466–70. 30. McInnes RJ, Chambers JA. Supporting breastfeeding mothers: qualitative synthesis. J Adv Nurs 2008;62:407–27.
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Women and Birth xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Original Research – Quantitative
Impact of support networks for breastfeeding: A multicentre study Isabel Baño-Piñeroa , María Emilia Martínez-Rocheb , Manuel Canteras-Jordanac, César Carrillo-Garcíad, Esteban Orenes-Piñeroe,* a
Mother and Child Pte. Ltd. (Singapore) and Department of Nursing, Murcia University, Murcia, Spain Obstetric-Gynaecological Teaching Unit (Midwifery), Department of Nursing, Murcia University, Murcia, Spain Department of Statistics, Preventive Medicine and Public Health, Murcia University, Murcia, Spain d General Management of Human Resources of the Murcian Health Service, Ministry of Health, Murcia, Spain e Department of Biochemistry and Molecular Biology-A, University of Murcia, Murcia, Spain b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 June 2017 Received in revised form 20 September 2017 Accepted 3 October 2017 Available online xxx
Background: The rates of breastfeeding worldwide are slowly improving since 1996. Europe is still trailing behind the global breastfeeding incidence and prevalence rates. Thus, breastfeeding promotion, protection, prolongation and support have become an important challenge as breastfeeding sharply decreases in the first six months of life. Objectives: The aim of this project is to determine, assess and identify the real impact of breastfeeding support networks in Murcia (Spain). Methods: After searching unsuccessfully for a validated questionnaire, a specific one was developed and validated for measuring the impact of formal and informal support networks through five dimensions: satisfaction, consultation, experience, problems and support. The questionnaire was provided to 500 mothers with experience in breastfeeding, who brought their children to baby paediatricians between 2 June and 27 November 2014. Upon completion of the survey and fieldwork, a detailed statistical analysis was conducted. Results: The degree of satisfaction perceived by the users of the services of support breastfeeding networks is remarkable. In addition, mothers who clarified their doubts and discussed their problems with health professionals and/or breastfeeding support networks were more likely to breastfeed for a longer duration compared to those who did not (p = 0.005). Furthermore, mothers who sought support in breastfeeding are more likely to breastfeed for more than 6 months (p < 0.0005). Conclusion: Based on this information, we conclude that breastfeeding support networks have a positive influence in the duration of a women’s decision to breastfeed. © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Breastfeeding support networks Lactation Validated questionnaire Satisfaction Duration of breastfeeding
Statement of significance
Problem or issue The drastic decline in prolonged breastfeeding rates is a current health problem that affects the mother, infant, family and society.
Abbreviations: AAP, American Academy of Pediatrics; AEP, Asociación Española de Pediatría, translated Spanish Association of Pediatrics; INE, Instituto Nacional de Estadística, translated Statistics National Institute; PANA, Programa de Atención al Niño y al Adolescente, translated Child and Adolescent Health Care Program. * Corresponding author at: Department of Biochemistry and Molecular BiologyA, University of Murcia, Avda. de las Fuerzas Armadas, s/n, Lorca, Murcia, 30800, Spain. E-mail address: [email protected] (E. Orenes-Piñero).
What is already known Europe is still trailing behind the global breastfeeding incidence and prevalence rates in the world. Similarly, in Spain, a downward trend in exclusive breastfeeding was found, falling from 66.2% at six weeks to 37.8% at six months. What this paper adds Mothers who clarified their doubts and discussed their problems with breastfeeding support networks are significantly more likely to breastfeed for a longer duration compared to those who did not.
https://doi.org/10.1016/j.wombi.2017.10.002 1871-5192/© 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: I. Baño-Piñero, et al., Impact of support networks for breastfeeding: A multicentre study, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.002
G Model WOMBI 722 No. of Pages 6
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1. Introduction Although abundant scientific evidence proving the benefits and superiority of human milk over any other type of infant nutrition is currently available in the literature,1–3 Europe is still trailing behind the global breastfeeding incidence and prevalence rates.4 In Spain, a downward trend in exclusive breastfeeding was found, falling from 66.2% at six weeks to 37.8% at six months. Conversely, mixed and artificial feeding exponentially increase with age, and artificial feeding shows the most significant increase from six weeks (27.6%) to six months (53.2%).5 The Region of Murcia, located in the Southeast of Spain, follows the same trend as other Spanish communities. Although breastfeeding rates at hospital discharge are high, prolonged breastfeeding remains a key objective of breastfeeding promotion, protection and support because breastfeeding sharply decreases in the first six months of life in our region.5 All studies reviewed show the importance and influence of both formal support (health care professionals) and informal support (community breastfeeding support groups, family and friends) on the families of infants.6–9 However, studies assessing the impact of breastfeeding support networks are very heterogeneous and often overlook some key aspects, including maternal and family characteristics, the type of support program used or the contexts in which support programs are applied.10 To better understand the actual impact of different breastfeeding support networks in the Region of Murcia, and after the validation of the questionnaire published in 2015,11 we decided to use this specific questionnaire for measuring the impact of formal and informal support networks through five dimensions: satisfaction, consultation, experience, problems and support.
the number of consultations provided or the most frequently demanded breastfeeding support professionals or services. - Experience before breastfeeding. This dimension referred to aspects that could positively or negatively affect the decision to breastfeed before problems developed or initial doubts emerged. - Problems during breastfeeding. This dimension focused on the main problems that breastfeeding women experienced and when they occurred. - Support perceived by users. This component encompassed the source of and need for breastfeeding support.
2.2. Data collection
The study was designed as a cross-sectional study using a questionnaire previously developed and validated by our research team to assess the impact of different breastfeeding support networks for lactating women in the Region of Murcia.11
The questionnaire, after validated (previous pilot study)11 was used as a study tool for the fieldwork. It was administered from June 2 to November 27, 2014, at the four accredited health care centers in the Region of Murcia (Alcantarilla, Sangonera la Verde, San Andrés and El Palmar). The study was approved in May 2014 for the Center for Ethics and Research and the Continuing Training Unit of the Murcia Health Service. The target population comprised women who brought their infants to well-child checkups within the Child and Adolescent Health Care Program (Programa de Atención al Niño y al Adolescente PANA), had some breastfeeding experience (i.e., were breastfeeding at the time or had previously breastfed), could read and write in Spanish and volunteered to participate in the study. 430 valid questionnaires were obtained from a total of 500 questionnaires administered, since some of the questionnaires were rejected because were incomplete or with inconsistent answers. The women voluntarily participated in the study after receiving information on the study objective from the nurses who performed the well-child checkup and after signing the informed consent form. The anonymity of the study participants was guaranteed, and the respondents were never pressured to complete the questionnaire against their will.
2.1. Development and validation of the questionnaire
2.3. Statistical analysis
As part of a previous pilot study, the development and validation of the questionnaire was evaluated subjecting the survey to a breastfeeding expert’s opinion in the Region of Murcia.11 This pilot test was conducted between the months of March and April 2014. Briefly, for construction validity, a factor analysis was performed, which determined the different dimensions that the survey could measure. A description of each of the items on the statistics was conducted. Through principal component analysis, the total variance explained was obtained, determining the factors that define the elements. Through factor analysis, the questionnaire has a high internal consistency for its five components, obtaining values from 0.942 to 0.632. And a high percentage of total variance explained (11,157%–5093%). Giving rise to a relevant and valid, in terms of content and construction, instrument, capable of measuring the impact of breastfeeding support networks through 5 dimensions:
Continuous variables were analyzed for normal distribution using the Kolmogorov–Smirnov test. Continuous variables with normal distribution are expressed as means standard deviations, and those with nonparametric distribution are expressed as medians (interquartile ranges). Categorical variables are expressed as frequencies (percentages). Discrete variables were compared using the chi-squared test, whereas two continuous variables were correlated using the Pearson product-moment correlation test. A p-value <0.05 was considered significant. Statistical tests were performed using the Statistical Package for the Social Sciences (SPSS), version 21.0, for Windows software (Chicago, Illinois, USA).
2. Methods
- Degree of satisfaction or quality perceived by the users of breastfeeding support services. This dimension collected data related to the abilities of staff members of breastfeeding support networks and others to solve problems by listening, providing support and devoting time to breastfeeding mothers. - Consultations attended by users of the breastfeeding support services. This dimension collected data on all aspects related to
3. Results The mean age of the mothers who completed the questionnaire was 34.4 6.1 years, with ages ranging from 15 to 58 years. The average number of children per family was 1.86. The women’s nationality was mainly Spanish (90.7%). Among the mothers, 60.7% had graduated from university, and only 2.3% had no official education. The mother was working in 51.2% of the cases, and 14.2% were on maternity leave. The analysis of the time of breastfeeding cessation showed that the breastfeeding rates fell significantly after the infants were 6 months old (Fig. 1).
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their infant’s birth. After the first month, the first consultation is much less common, and in 30.9% cases, the women consulted no breastfeeding support professional or service (Fig. 3). Primary care pediatricians are the most in-demand health care professionals (30.7%), followed by health care center midwives (21.9%), maternity staff (15.1%), breastfeeding support groups (14.4%), family physicians (9.8%), delivery/recovery room professionals (8.1%), primary care nurses (6.5%), breastfeeding specialists at private and public clinics (4.7%), and lastly, emergency room staff (3.7%; Fig. 4). Breastfeeding training during the prenatal period positively affect mothers’ decisions to seek professional support for problems or doubts about breastfeeding (p = 0.004). The health care professionals with the greatest impact or influence on promoting breastfeeding during pregnancy are primary care nurses and midwives (86.3% of the women reported having asked their nurse or midwife breastfeeding-related questions during the pregnancy), according to our study. Mothers who consult health care professionals breastfeed longer than those who do not (p = 0.005) and are more likely to exclusively breastfeed until their infant is six months or older than mothers who do not seek such support (p < 0.0005). However, consultations with breastfeeding support groups also have a positive effect on breastfeeding duration (p < 0.0005). Fig. 1. Breastfeeding duration per months.
3.1. Satisfaction The degree of satisfaction was very high: 89.3% of the respondents were satisfied or very satisfied with the breastfeeding support services or the professionals they consulted (Fig. 2). The factors that positively affected the users’ degree of satisfaction with breastfeeding support networks were, among others, exclusive breastfeeding to 6 months of age or older (p < 0.0005); intention to breastfeed before or during pregnancy (p = 0.048); receiving maternal education during pregnancy (p = 0.003); receiving professional support in the delivery/recovery room (p = 0.015), maternity ward (p < 0.0005) or health care center (p < 0.0005); and having attended a midwife consultation (p = 0.049) or a breastfeeding support group (p = 0.004). Furthermore, receiving the first breastfeeding consultation on the infant’s first day of life (p = 0.007), starting breastfeeding within 30 min of birth (p = 0.043) and a positive breastfeeding experience with previous children (p = 0.005) also had a positive effect on user satisfaction.
3.3. Previous experience Of the mothers who were asked about breastfeeding previous children, 71.1% acknowledged having had a satisfactory breastfeeding experience, and only 16.2% reported a negative breastfeeding experience. A total of 81.9% of the pregnant women used epidural analgesia during delivery, and the newborn had to be admitted to the Neonatal Department after delivery in only 9.5% of cases. Skin-to-skin contact was performed in 84.4% cases, mostly (71.9%) within the first half hour after birth. Skin-to-skin contact (p < 0.0005), early breastfeeding after birth (p < 0.0005), singleton pregnancy (p < 0.0005), normal delivery (p = 0.006), delivery without epidural analgesia (p = 0.002) or newborn admission to the Neonatal Department (p = 0.04) and a positive previous breastfeeding experience (p < 0.0005) favor a higher incidence of exclusive breastfeeding up to
3.2. Consultations The first breastfeeding consultation most often occurs during the first 3 weeks of life, and the highest percentage of the participants (25.6%) reported receiving a consultation on the day of
Fig. 2. Degree of perceived satisfaction.
Fig. 3. First lactation consultation.
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in their circle and by their mothers, who had breastfed in 63.7% of cases. Feeling supported positively influences the decision to breastfeed for longer periods (p = 0.049). The main sources of support regarding the decision to breastfeed were the mothers’ partners (81.6%), followed by their mothers and friends. Support from health professionals as a significant influence was only reported by 23.3% of the participants, and non-professional support was the most relevant source (Fig. 6). Women who reported not feeling supported in their decision to breastfeed had doubts about the quality of their milk (p = 0.025), their breastfeeding ability (p = 0.011) and whether the baby was hungry (p = 0.004). Women who felt unsupported in their decision to breastfeed were more insecure and attended fewer consultations (p = 0.003) than those who felt supported. 4. Discussion Fig. 4. Health professional/support networks consulted.
6 months of life and subsequently a higher exclusive breastfeeding prevalence. 3.4. Problems Among the mothers, 72.8% acknowledged having had some breastfeeding-related problem. These problems mostly (57% cases) occurred during the first 3 weeks of life, although the highest percentage within this period occurred in the first day after birth (Fig. 5). The most commonly reported problem was cracked nipples (34.7%), followed by fatigue (33.3%), doubts about whether the baby was hungry (32.6%), pain (25.5%), poor latch-on (24.2%) and doubts about the breastfeeding position or technique (24%). 3.5. Support The analysis of factors that may affect the decision to breastfeed showed that 88.4% of the participants considered breastfeeding their baby during or even before their pregnancies. A total of 77.2% of the respondents were influenced by other breastfeeding women
Fig. 5. When did the problems appear?
Our study confirms that mothers who consult health care professionals breastfeed longer than those who do not consult. Furthermore, mothers who seek professional support are more likely to exclusively breastfeed up to six months or longer than mothers who seek no such support. Thus, breastfeeding support networks positively influence the prevalence and duration of breastfeeding, as observed previously.12 The degree of satisfaction with breastfeeding support also appears to depend on breastfeeding duration. Thus, we found that mothers who exclusively breastfed for 6 months or longer were very satisfied with the breastfeeding support networks they consulted, whereas the mothers who introduced supplemental nutrition, including artificial milk or solids, before 6 months of life were very unsatisfied. This corroborates reports that the degree of satisfaction with breastfeeding support networks depends on the duration of exclusive breastfeeding.13–15 At this point, it would be important to remark that although the degree of satisfaction is very high, it could be even higher, as mothers who were unsatisfied with the breastfeeding support networks were those who introduced supplemental nutrition, including artificial milk or solids before 6 months of life, and for that reason they were apparently not active seekers of breastfeeding support. Similarly, our study confirms that breastfeeding training during the prenatal period positively influences the decision to seek professional support when problems with or doubts about breastfeeding first occur, thereby positively influencing the prevalence and duration of breastfeeding.16 The general satisfaction perceived by users of breastfeeding support networks in the Region of Murcia was very good, with an overall mean of 3.5 out of 5 for the 9 statements measuring the degree of satisfaction. Other studies reviewed confirm that interventions aimed at supporting, promoting and protecting breastfeeding have a positive effect on the degree of satisfaction perceived by mothers.7–9,13 Our study shows that primary care nurses and midwives are the most influential health care professionals for promoting breastfeeding during pregnancy, consistent with previous findings.17,18 However, this issue is somewhat controversial because several other authors have highlighted the role of International BoardCertified Lactation Consultants (IBCLC) as breastfeeding promoters. It was stated that the number of Board-Certified Lactation Consultants a hospital employed was the only variable that predicted higher levels of support practices.19 Studies have also shown higher breastfeeding rates in hospitals offering IBCLC services compared with those that do not offer these services and a direct relationship between the availability these health care professionals and breastfeeding rates.20 Other authors have found that IBCLCs provide more positive and effective reinforcement than
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Fig. 6. Source of support.
other health care professionals, including nurses or doctors.21,22 Furthermore, several other studies have shown that the presence of IBCLCs in maternity and pediatrics wards is associated with higher rates of breastfeeding initiation and longer durations.22 We found no scientific study showing the effectiveness of these professionals for promoting, protecting and supporting breastfeeding in Spain in contrast to several other countries, possibly because the IBCLC is not recognized by the health system in Spain. We also overlooked the IBCLC in our questionnaire for that reason. Our study shows that skin-to-skin contact, early breastfeeding initiation after birth, singleton pregnancy, non-use of epidural analgesia, non-admission of the newborn to the neonatal department and a previous positive breastfeeding experience are associated with an increased incidence of breastfeeding and a longer exclusive breastfeeding duration up to the infant’s sixth month. However, the correlation between delivery type and breastfeeding duration is somewhat controversial. Thus, some authors suggest that normal delivery favors a longer duration of exclusive breastfeeding23 ; whereas in another study was found that children born by cesarean section had a higher prevalence of breastfeeding than those born vaginally.24 Other authors agree that cesarean delivery has a negative influence on cognitive recovery after general anesthesia and delays exclusive breastfeeding at discharge, albeit with no subsequent influence.25,26 Our study also shows that skin-to-skin contact positively influences exclusive breastfeeding up to 6 months of life or longer. Another study concludes that early skin-to-skin contact positively affects breastfeeding during the immediate postpartum period but found no significant differences after the first month of life.27 Our study shows that breastfeeding-related problems during the first 3 weeks of life, including cracked nipples, painful breastfeeding or latch-on problems, are the main reasons for breastfeeding cessation. Other authors emphasize the importance of treating the most common problems during the first few days of life and highlight the importance of interventions and follow-up by health care professionals during the first days of breastfeeding.28 Conversely, our study shows that women who feel unsupported attend fewer consultations and therefore breastfeed for shorter periods than those who feel supported. This finding shows the importance and influence of formal and informal breastfeeding support networks on breastfeeding. Similarly, the lack of support creates insecurity in women when breastfeeding, as other authors have also reported.29 Thus, support is the most effective strategy for achieving high breastfeeding initiation rates; therefore, breastfeeding support services are indispensable in all health care systems. Similarly, inadequate professional support may have a very negative impact on breastfeeding.30 Changes must be introduced to improve health care services, focus their activities on the specific
needs of the population and demand minimum breastfeeding training from professionals who work with infants. The potential limitations of this study should be noted. First, although the study was conducted at the four accredited health care centers in the Region of Murcia, most patients were Caucasian and Hispanic, and therefore, the data should be extrapolated to other ethnic groups with caution. Secondly, the sample size of the present study was limited, possibly resulting in loss of statistical significance in some of the analyses. Thus, larger studies are required to confirm our observations. However, the results of this study provide valuable insights and may serve to guide future studies in this area. 5. Conclusion Breastfeeding support networks positively influence the prevalence and duration of breastfeeding. Thus, formal and informal support favors longer periods of exclusive breastfeeding, whereas the lack of support leaves women feeling insecure when breastfeeding. Therefore, good policies and intervention strategies are needed to promote, protect, and support breastfeeding to improve the health problems we face today. We must join forces to continue improving and advancing this public health mission. Funding statement The authors received no financial support for the research, authorship, and/or publication of this article. Acknowledgment Dr. Esteban Orenes-Piñero is supported by a postdoctoral contract from Instituto Murciano de Investigación Biosanitaria Virgen de la Arrixaca (IMIB-Arrixaca), Murcia, Spain. References 1. AAP. Policy statement: breastfeeding and the use of human milk. Pediatrics 2012;129:827–41. 2. Lawrence RA, Lawrence RM. Breastfeeding. A guide for the medical profession. Edicio´n en espan˜ol de la 6a edicio´n de la obra original en ingle´s. Madrid: Elsevier; 2007. 3. WHO. Estrategia Mundial para la alimentacio´n del lactante y del nin˜o pequen˜o. Ginebra: OMS; 2002. Retrieved from http://www.who.int/nutrition/publications/infantfeeding/gs_infant_feeding_spa.pdf. 4. UNICEF. Estado mundial de la infancia 2013. 2013. Retrieved from http://www. unicef.org/spanish/sowc2013/files/SPANISH_SOWC2013_Lores.pdf. 5. Ortega JA, Pastor-Torres E, Martínez-Lorente I, Bosch-Giménez VM, QuesadaLópez JJ. Proyecto Malama en la Región de Murcia (España). An Pediatr 2008;68:447–53. 6. Baño-Piñero I, Carrillo-García C, Thambidurai U, Martínez-Roche ME. The Baby Café concept as an international network of support to breastfeeding. Cultura de los Cuidados 2015;19:19–33.
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