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Maternity hospital practices and breast feeding self-efficacy in Finnish primiparous and multiparous women during the immediate postpartum period
Midwifery 30 (2014) 464–470
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Maternity hospital practices and breast feeding self-efficacy in Finnish primiparous and multiparous women during the immediate postpartum period Katja S. Koskinen, RNM, IBCLC, MSc (Breastfeeding Coordinator, Senior Planning Officer)a,b,n, Anna L. Aho, RN, PhD (Assistant Professor)c, Leena Hannula, RNM, PhD (Principal Lecturer)d, Marja Kaunonen, RN, PhD (Professor)c,e a
Department of Gynaecology and Pediatrics, Helsinki University Central Hospital, Helsinki, Finland National Institute for Health and Welfare, Helsinki, Finland School of Health Sciences, Nursing Science, University of Tampere, Finland d Faculty of Health Care and Nursing, Metropolia University of Applied Sciences, Helsinki, Finland e Pirkanmaa Hospital District, Science Center, Tampere, Finland b c
art ic l e i nf o
a b s t r a c t
Article history: Received 2 December 2012 Received in revised form 9 May 2013 Accepted 11 May 2013
Objective: to explore the relationship between maternity hospital practices and breast feeding selfefficacy. Design: the data were collected using a cross-sectional survey. The study is a part of a larger longitudinal research and development project called ‘Urban parenthood’. Setting: three urban maternity hospitals in Southern Finland. Participants: altogether 1400 questionnaires were given out and 573 primiparous and multiparous women completed the questionnaire within a week after childbirth. The response rate was 41%. Findings: early and successful initiation of breast feeding, rooming-in and exclusive breast feeding during the hospital stay were associated with higher maternal breast feeding self-efficacy in both primiparous and multiparous women. The reason (medical or non-medical), frequency or method (bottle or cup) for supplementation was not associated with breast feeding self-efficacy. Key conclusion and implications for practice: breast feeding experiences during the immediate postpartum period have an association with breast feeding self-efficacy. Mothers who are not able to initiate breast feeding within an hour after birth or whose infants are supplemented during the hospital stay may benefit from additional support and breast feeding counselling. & 2013 Elsevier Ltd. All rights reserved.
Keywords: Breast feeding Hospital practices Self-efficacy
Introduction Breast feeding provides all nutrients an infant requires during the first six months of life and is a significant part of healthy diet thereafter for at least one to two years. It supports infant's normal development and provides health benefits for the breast-feeding mother as well. Therefore exclusive breast feeding for six months and continued breast feeding with complementary foods thereafter is widely recommended (World Health Organization and UNICEF, 2003; EU Project on Promotion of Breastfeeding in Europe, 2004; American Academy of Pediatrics, 2012). Still in many countries these recommendations are not met. In European Union less than half of the infants receive any breast milk at six months of age (Harbers and
n
Correspondence to: Leppä vaarankatu 19 A 5, FI-02600 Espoo, Finland. E-mail address: katja.koskinen@thl.fi (K.S. Koskinen).
0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.05.003
Cattaneo, 2008). Even though almost all Finnish mothers initiate breast feeding, exclusive breast feeding rates are relatively low and the duration of any breast feeding is shorter than recommended. In 2010, according to national statistics, 71% of newborns received supplementation in maternity hospital, 47% of infants less than one month were exclusively breast fed and 58% were still breast fed at six months age (Uusitalo et al., 2012). The socio-demographic factors associated with early cessation of breast feeding are well known and include young maternal age, being unmarried, belonging to a minority group as well as low education and income level (Breastfeeding Support for Mothers and Families During Pregnancy and Birth and After Delivery. Nursing Guideline (online), 2010; Meedya et al., 2010; Uusitalo et al., 2012). Yet many mothers not belonging to these risk groups discontinue breast feeding prematurely. Therefore recognition of psychosocial factors related to breast feeding behaviour helps to identify individual mothers in need of additional breast feeding support.
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Maternal breast feeding self-efficacy during the first week after birth has been associated with continuation of exclusive breast feeding at four (Kingston et al., 2007; Gregory et al., 2008; McCarter-Spaulding and Dennis, 2010), eight (Wutke and Dennis, 2007), 12 (Alus Tokat et al., 2010) and 16 (Wutke and Dennis, 2007) weeks and any breast feeding at six months (Mossman et al., 2008; O'Brien et al., 2008; Wilhelm et al., 2008; McCarter-Spaulding and Dennis, 2010; Wilhelm et al., 2010). Breast feeding self-efficacy is a concept based on Albert Bandura's Social Learning Theory and is defined as a mother's perception of her ability to breast feed in a given situation (Dennis, 1999). The breast feeding self-efficacy is based on four sources of information: previous personal experience, observing others to breast feed, encouragement by others and physiological responses (Dennis, 1999; Dennis and Faux, 1999). The relationship between earlier breast feeding experience and breast feeding self-efficacy has been shown in several studies (Dennis, 2006; Wutke and Dennis, 2007; Gregory et al., 2008; Otsuka et al., 2008; Alus Tokat et al., 2010; McCarter-Spaulding and Dennis, 2010). Other factors related to breast feeding self-efficacy during the postpartum period include exclusive breast feeding (Gregory et al., 2008; Otsuka et al., 2008; McCarter-Spaulding and Dennis, 2010), social support from significant others (Dennis, 2006; Kingston et al., 2007; McCarter-Spaulding and Dennis, 2010), seeing pictures or videos of other mothers breast feeding (Kingston et al., 2007) and satisfaction with labour and childbirth care as well as postpartum care (Dennis, 2006). Maternity hospital practices are shown to have important impact on initiation and establishment of successful breast feeding. The practices based on the Baby-Friendly Hospital Initiative (BFHI) by World Health Organization (WHO) and UNICEF are an effective way to support breast feeding (DiGirolamo et al., 2001; Kramer et al., 2001; Murray et al., 2007; Breastfeeding Support for Mothers and Families During Pregnancy and Birth and After Delivery. Nursing Guideline (online), 2010). The key practices of the BFHI include immediate skin-to-skin contact after birth, early initiation of breast feeding, exclusive breast feeding, rooming-in and avoidance of the use of pacifiers or feeding bottles. All mothers should also be given information about the benefits and management of breast feeding both pre- and postnatally (World Health Organization and UNICEF, 2009). The early experiences of breast feeding can be assumed to affect maternal breast feeding self-efficacy especially in primiparous women but the relationship between maternity hospital practices and breast feeding self-efficacy has not been explored. In Finland practically all deliveries take place in hospitals. Normal births are attended by midwives and postpartum care is provided mainly by midwives and practical nurses. At the time of the study the average hospital stay after childbirth was 3.2 days (National Institute for Health and Welfare (THL), 2009). To date five of the 32 maternity hospitals have received Baby Friendly Hospital certification. No national data is available on the compliance of practices in Finnish maternity hospitals with the BFHI. The aim of this study was to explore the relationship between maternity hospital practices and breast feeding self-efficacy. The objectives of the study were (1) to describe maternity hospital practices, (2) to describe maternal breast feeding self-efficacy and (3) to examine factors associated to breast feeding self-efficacy in Finnish primiparous and multiparous women during the first week after the childbirth.
Methods Study settings The data were collected using a convenience sample in three urban maternity hospitals in Southern Finland between November
465
2007 and September 2008. The hospitals had at the time between 3300 and 5800 births per year. One of the three hospitals is a university level hospital in which mothers with high risk pregnancies are taken care of. The hospitals did not have a written breast feeding policy at the beginning of the study, but a common breast feeding policy based on the BFHI was signed by the management of all three hospitals in December 2007. Almost all nursing staff, i.e. midwives and practical nurses, had received basic 18 hour course on breast feeding counselling either offered by employer or during their education. None of the hospitals had received the Baby Friendly Hospital Certificate at the time of the study and the practices described in the Ten Steps to Successful Breastfeeding were not met in any of the hospitals. Especially supplementation of the newborns was common. Even though supplementation was not offered to every mother it was a common practice to offer supplementation for example if the infant was breast feeding frequently or the mother was feeling tired. The supplementation was also given on maternal request. Sample This study was a part of larger longitudinal research project ‘Urban parenthood’ which examined the welfare of families during the first year after childbirth. The data collection points for the project were at birth and six weeks as well as six and 12 months after childbirth. In two hospitals mothers were recruited during routine mid-pregnancy ultra-sound scan and in a third hospital on the post-natal ward after childbirth. This difference was due to the delay in research approval process in the third hospital (Hospital C). Mothers were eligible for the study if they were willing to participate, at least 18 years old, healthy, could communicate in Finnish, had singleton pregnancy without major obstetrical complications and gave birth to a healthy infant with no congenital abnormalities. Both primiparous and multiparous women were included in the study. Mothers who gave birth before 37 gestational weeks were excluded from the study. The data were collected by questionnaires which were distributed to mothers on the postnatal ward on discharge by hospital personnel. Mothers were instructed to return completed questionnaires either in the hospital or within a week by mail. Mothers were included in the study if the child was seven days old or younger at the time when the questionnaire was completed. Altogether 1400 questionnaires were given out to the mothers and 573 mothers (41%) were included in the study. The second questionnaire was sent at six weeks after childbirth to all mothers who had completed the first questionnaire. Altogether 339 (59%) returned the second questionnaire. Instruments All data were collected with self-report questionnaires. Breast feeding self-efficacy was measured with The Breastfeeding Self-Efficacy Scale—Short Form (BSES—SF) which is a 14-item self-report instrument (Dennis, 2003). All statements in the scale begin with the phrase ‘I can always’ and are presented positively. The mothers respond to every statement with 5-point Likert scale where 1 ¼not at all confident and 5 ¼always confident. The scores are summed to produce a range from 14 to 70, with higher levels indicating higher breast feeding self-efficacy. The scale was translated from English to Finnish using back-translation method. The Finnish version of the scale was piloted in June 2007. The internal consistency of the Finnish version BSES—SF in this study, using Cronbach α coefficient, was 0.93. Construct validity was measured by comparison of contrasted groups. According to Bandura (1997, p. 80) previous experience of the behaviour has strong influence on self-efficacy. Therefore it can be assumed that multiparous women with earlier breast feeding experience have
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higher breast feeding self-efficacy than primiparous women during the immediate post-partum period. In this sample multiparous women's median breast feeding self-efficacy was 60 (Q1–Q3 ¼ 55–65) and primiparous' 55 (Q1–Q3 ¼ 49–60). The difference was statistically significant (U¼ 21,918.5, po 0.001). The predictive validity was measured by comparing the breast feeding self-efficacy at hospital and breast feeding status at six weeks after birth. At the six week questionnaire the mothers were asked whether the child was exclusively breast fed, partially breast fed or weaned. Mothers who were exclusively breast feeding at six weeks had had a statistically significant higher breast feeding selfefficacy during the first week after birth (Md¼ 58, Q1–Q3 ¼54–62) than mothers who were partially breast feeding (Md¼53 Q1– Q3 ¼48–58) or were bottle feeding (Md¼ 52, Q1–Q3 ¼51–64, H¼24.0, df¼2, po0.001). Breast feeding advice from nursing professionals in maternity hospital was measured with a 8-item scale (Tarkka et al., 2000). The mothers were asked to evaluate with 5-point Osgood scale whether the breast feeding advice was inadequate or adequate, general or accurate, disapproving or encouraging, vague or understandable, routine like or individual, conflicting or consistent with previous knowledge, conflicting or consistent among ward personnel and mother centred or acknowledging both parents. The total score of the scale was calculated by summing the scores of all items and dividing the sum by the number of items. The total score varies between one and five, the higher the better. This is the first time the scale has been used to measure breast feeding advice obtained, but it has been used to measure overall advice from nursing staff on maternity ward (Salonen et al., 2008; Salonen et al., 2009). The Cronbach α coefficient of the scale was 0.86. Data analysis The data were analysed statistically with IBM SPSS Statistics version 19.0. Frequencies and percentages were used to describe maternal characteristics and maternity hospital practices. The differences between primiparous and multiparous women were examined with cross tabulation and significance of the differences was measured with χ². Because the dependent variable, breast feeding self-efficacy, was not normally distributed in the sample, non-parametric tests were used: for descriptive statistics medians and quartiles (Q1 ¼25th percentile and Q3 ¼ 75th percentile) and to determine differences between groups the Mann–Whitney U-test for two groups and Kruskal–Wallis H-test for three or more groups. The correlation between breast feeding self-efficacy and breast feeding advice from nursing professionals was measured with the Spearman correlation coefficient (Plichta and Kelvin, 2012). P values o0.05 were considered significant. A statistician was consulted in the selection of appropriate statistical tests. Ethical considerations An approval was received from the Research Ethics Committees of all the hospitals in the study. The participants in the study received both oral and written information of the study before making their decision to participate. A written consent was obtained (World Medical Association, 2008). The data were treated as confidential and anonymous.
Findings Maternal characteristics and previous breast feeding experience Half (n ¼307, 54%) of the respondents were first-time mothers. This differs from the Finnish national statistics of births and
newborns 2008 (National Institute for Health and Welfare (THL), 2009) where the percentage of primiparous women was 42%. The mean age of the mothers was 31 years (SD 4.4, range 18–43) which is near the national average in 2008, 30 years. The maternal characteristics are presented in Table 1. Statistically significant differences between primiparous and multiparous women in maternal characteristics were found in age and childbirth mode. As expected multiparous women were older than primiparous women (χ² ¼46.6, df ¼3, p o0.001). The primiparous women experienced assisted vaginal or caesarean birth significantly more often than the multiparous women (normal vaginal birth 68% versus 90%, assisted vaginal 15% versus 2% and caesarean section 17% versus 9%, χ² ¼46.0, df ¼2, po0.001). The only difference between the respondents in the different study hospitals was in parity. In Hospital A 53% (n ¼95) of mothers were primiparous, in Hospital B 66% (n ¼ 103) and Hospital C 46% (n ¼109) (χ² ¼14.6, df¼ 2, p o0.001). All multiparous women had breast fed earlier. Median breast feeding duration was 10 months (Q1–Q3 ¼6–13). The shortest duration was one month and the longest 28 months. Only 19% (n ¼48) of the mothers had breast fed less than 6 months and 39% (n ¼103) over one year. Most of the mothers rated their earlier breast feeding experience as positive (n ¼117, 44%) or very positive (n ¼113, 42%). None of the mothers had a very negative and only 15 (6%) mothers had a negative experience. In all, 20 mothers (8%) rated their earlier breast feeding as neither negative nor positive. Maternity hospital practices Most of the infants were put in skin-to-skin contact with their mother immediately after birth (n¼498, 87%). Almost all mothers with normal (n¼432, 97%) or assisted (n¼ 41, 82%) vaginal childbirth received their infants skin-to-skin, but only 32% (n¼24) after caesarean childbirth. The length of the skin–skin contact was not inquired. The first breast feeding occurred in 62% (n¼ 356) of the infants during the first hour after birth, in 13% (n ¼75) between one and two hours and 19% (n ¼108) between two and 12 hours after birth. Thirty three (6%) infants breast fed for the first time more than 12 hours after childbirth. None of the infants delivered with caesarean section breast fed within an hour of childbirth and only 9% (n ¼7) breast fed before they were two hours old. Most of the infants (n ¼487, 86%) managed to suckle during the first breast feed. In primiparous women successfulness (the infant Table 1 Demographic characteristics of respondents (n ¼573). Characteristics
Respondents
National data
n
n
(%)
(%)
Age, years −24 25–29 30–34 35–
45 180 247 100
(8) (31) (43) (18)
10,789 18,652 18,819 10,673
(18) (32) (32) (18)
Marital status Married or cohabitation Single
559 11
(98) (2)
– –
(92)
Education High school or less Vocational school College or technical school University degree or higher
46 82 175 264
(8) (14) (31) (46)
– – – –
Mode of childbirth Normal vaginal Assisted vaginal Caesarean section
445 50 76
(78) (9) (13)
43,984 4705 9807
(75) (8) (17)
K.S. Koskinen et al. / Midwifery 30 (2014) 464–470
suckled) and the timing of the first breast feed were associated (Table 2) but not in multiparous women. Most of the mothers rated their experience of the first breast feed as positive (n ¼200, 35%) or very positive (n¼ 306, 54%). Only three mothers (1%) had a negative and 58 (10%) neither negative nor positive experience of the first breast feed. Almost all mothers (n ¼519, 91%) had their infants rooming-in during the whole hospital stay. All mothers were breast feeding and two thirds (n ¼377) were exclusively breast feeding in the hospital. The multiparous women were more likely to breast feed exclusively (n ¼197, 74%) than primiparous women (n ¼182, 59%, χ² ¼19.7, df ¼ 2, p o0.001). Altogether 58 (10%) infants were supplemented for medical reason and 136 (24%) without medical reason. One third (n ¼64, 34%) of the supplemented infants received supplementation at almost every feed. Bottle feeding was the most common way of giving supplementation: 80% (n ¼157) of the supplemented infants received it by bottle. Breast feeding advice from personnel was rated positively (Md ¼4, Q1–Q3 ¼3.4–4.4). The majority of mothers assessed breast feeding advice as encouraging (n¼ 473, 86% score 4 or 5 on the Osgood scale), understandable (n ¼460, 84%), adequate (n ¼ 409, 75%), accurate (n ¼361, 66%), and individual (n ¼ 221, 59%). Most of the mothers (n ¼428, 78%) experienced advice consistent among ward personnel and with mother's previous knowledge (n ¼371, 68%). Only one quarter (n ¼139, 25%) of mothers thought that advice was acknowledging both parents. There were significant differences between the hospitals in infant's age at the first breast feed, the successfulness of the first breast feed, breast feeding status at hospital, method of supplementation and the use of pacifier (Table 3). Even though differences in mothers' experiences of breast feeding advice from personnel between the hospitals were sparse, they were statistically significant (Hospital A Md ¼4, Q1–Q3 ¼3.6–4.5, Hospital B Md¼ 4, Q1–Q3 ¼3.4–4.3, Hospital C Md ¼3,9, Q1–Q3 ¼ 3.3–4.3, H ¼6.6, df ¼2, p¼ 0.04). Altogether the hospital practices were most compatible with BFHI in Hospital A. Breast feeding self-efficacy The median breast feeding self-efficacy in the sample was 57 (Q1–Q3 ¼ 52–62). The mothers were most confident (highest frequency in score 4 and 5) about being satisfied with their breast feeding experience (n¼ 503, 89%), dealing with the fact that breast feeding can be time-consuming (n¼ 499, 88%) and breast feeding with other family members present (n¼493, 88%). The mothers were least confident (highest frequencies in score 1 and 2) about breast feeding without artificial milk supplementation (n¼80, 14%) and determining that infant is getting enough milk (n¼75, 13%). Factors related to breast feeding self-efficacy No relationship between maternal age, marital status or educational level and breast feeding self-efficacy was found. Multiparous women had higher breast feeding self-efficacy than primiparous Table 2 Timing and successfulnes of the first breast feed in primiparous women (n ¼307). Did the infant suckle on the first breast feed?
Yes n
Infant's age at the first breast feed One hour or less More than one hour but less than two More than two hours but less than 12 More than 12 hours
144 29 68 11
(%)
(90) (73) (85) (52)
No n
16 11 12 10
(%)
p-Value
(10) p o 0.001 (28) (15) (48)
467
women (Md ¼60, Q1–Q3 ¼ 55–65 versus Md¼55, Q1–Q3 ¼49–60, U¼21,918.5, p o0.001). The longer the mother had breast fed previously and the more positive the earlier breast feeding experience was, the higher breast feeding self-efficacy she had (Table 4). The results of the comparison of breast feeding self-efficacy by hospital practices are presented in Table 5. Primi- and multiparous women were analysed separately because the effect of the earlier breast feeding experience might diminish the association between hospital practices and breast feeding self-efficacy. The hospital practices found to be associated with breast feeding self-efficacy in both primi- and multiparous women were timing and successfulness of the first breast feed, rooming-in and breast feeding status during the hospital stay. When the whole sample was analysed the mothers with normal vaginal childbirth had significantly higher BSES—SF score than mothers with assisted vaginal or caesarean births. However the difference in BSES—SF score diminished when primiparous and multiparous women were analysed separately (Table 5). This may be due to the low number of multiparous women in assisted vaginal or caesarean childbirth groups. In the whole sample mothers who breast fed their infant for the first time within an hour of the birth had the highest BSES—SF score (Table 5). When the score was explored by parity the picture got more complicated. In multiparous women the early initiation of breast feeding was related to higher breast feeding self-efficacy. In primiparous women mothers who initiated breast feeding during the first hour and those who initiated it between two and 12 hours had in average similar BSES—SF scores (Md¼56, Q1–Q3 ¼51–60 versus Md¼ 56, Q1–Q3 ¼49–60). Likewise the primiparous mothers who breast fed their infants first time during the second hour or more than 12 hours after the birth scored similarly (Md¼ 52, Q1–Q3 ¼ 49– 57 versus Md¼53, Q1–Q3 ¼47–56). In these two groups it was more common that the infant did not suckle during the first breast feed (Table 2). Mothers who had a very positive experience of the first breast feed had higher breast feeding self-efficacy than other mothers (H¼ 81.4, df¼3, po0.001). Breast feeding advice from nursing professional during hospital stay correlated positively with breast feeding self-efficacy. The relationship was fair (r ¼0.37, p o0.001). The correlation was stronger in primiparous than multiparous women (r ¼ 0.43, po 0.001 versus r ¼0.35, p o0.001).
Discussion This study examined the relationship between maternity hospital practices and breast feeding self-efficacy which has not been explored earlier. The results indicate that early breast feeding experiences have an association with mothers' confidence in breast feeding. Delayed first breast feed, partial or no rooming-in and supplementation of the newborn are associated with lower maternal breast feeding self-efficacy and thus a sign for the need of additional breast feeding support. In earlier studies breast feeding initiation within an hour and exclusive breast feeding in hospital has been shown to increase the duration of breast feeding (DiGirolamo et al., 2001; Murray et al., 2007). In this study the timing of the first breast feed is associated with breast feeding self-efficacy but not linearly. The initiation of breast feeding within an hour is associated with the highest breast feeding self-efficacy but between one hour and two hours with the lowest. This may indicate that there were some challenges in breast feeding initiation in the latter group, whereas most of the mothers who initiated breast feeding later than two hours of the childbirth gave birth by caesarean section and this was the first possibility to initiate breast feeding. This suggests that if the first breast feeding
468
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Table 3 Comparison of the maternity hospital practices by hospital. Hospital A
Hospital B
Hospital C
Total
n
%
n
%
n
%
Mode of childbirth Normal vaginal Assisted vaginal Caesarean
137 19 23
77 11 13
115 16 26
73 10 17
193 15 27
Skin-to-skin contact Yes No
153 26
86 15
131 25
84 16
Infant's age at the first breast feed One hour or less More than one hour but less than two More than two hours but less than 12 More than 12 hours
111 32 29 7
62 18 16 4
97 13 30 17
Did the infant latch? Yes No
163 14
92 8
Rooming-in Full-time Part-time or no rooming-in
164 12
Breast feeding status at hospital Exclusive breast feeding BF and supplementation for medical reason BF and supplementation without medical reason
p-value
n
%
82 6 12
445 50 76
78 9 13
p¼ 0.2
214 23
90 10
498 74
87 13
p ¼0.1
62 8 19 11
148 30 49 9
63 13 21 4
356 75 108 33
62 13 19 6
p¼ 0.01
132 20
87 13
192 44
81 19
487 78
86 14
p ¼0.007
93 7
137 20
87 13
218 17
92 7
519 49
91 9
p ¼0.1
145 14 20
81 8 11
94 21 42
60 13 27
140 23 74
59 10 31
379 58 136
66 10 24
po 0.001
Frequency of supplementation Once or twice Occasionally At almost every feed
2 23 8
6 70 24
8 30 23
13 49 38
20 44 33
21 45 34
30 97 64
16 51 34
p ¼0.1
Method of supplementation Bottle Cup feeding
17 18
49 51
50 14
78 22
90 7
93 7
157 39
80 20
po 0.001
15 159
8 89
29 125
19 81
86 147
37 63
130 431
23 77
po 0.001
Use of pacifier Yes No
Table 4 Length and experience of previous breast feeding and the BSES–SF scores in multiparous women. BSES—SF scores Md
Q1–Q3
p-Value
Length of previous breast feeding (the longest) o 6 months 48 (18) 6–12 months 107 (40) 412 months 103 (39)
56.5 60 63
51–62 55–64 58–67
po 0.001
Breast feeding experience 1 Very negative 2 Negative 3 Not negative nor positive 4 Positive 5 Very positive
51 52 58 64
44–61 49–61 54–62 60–67
po 0.001
n
0 15 20 117 113
attempt proceeds smoothly and is successful, it has a positive association with breast feeding self-efficacy. The mothers whose infants are supplemented during the hospital stay have lower breast feeding self-efficacy than mothers exclusively breast feeding. In this study the reason (with or without medical reason), method (bottle or cup) or frequency of supplementation was not associated with breast feeding self-efficacy. Earlier the effect of the reason for supplementation on breast feeding has been evaluated only in one study by Ekström et al. (2003). In the study supplementation without medical reasons was associated with shorter duration of exclusive or any breast feeding but supplementation with medical
(%)
(6) (8) (44) (42)
reason was not. The authors concluded that only the supplementation of a healthy newborn without medical reason may affect the maternal self-confidence. This explanation is not supported by this study. Supplementation of the breast-fed infants is a common practice in Finnish maternity hospitals and may at least partly explain the low incidence of exclusive breast feeding later (Uusitalo et al., 2012). The mothers in this study were least confident about breast feeding without artificial milk supplementation and determining that the infant is getting enough milk. In an earlier study by Laanterä et al. (2010) it has been shown that Finnish expectant parents' knowledge about breast feeding is inadequate. The parents do not know the
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469
Table 5 Comparison of the BSES—SF scores by maternity hospital practices and parity. All mothers
Primiparous
Md
Q1–Q3
p-value
Mode of childbirth Normal vaginal Assisted vaginal Caesarean
58 56 56
53–63 51–60 49–61
Skin-to-skin contact Yes No
57 57
Infant's age at the first breast feed One hour or less More than one hour but less than two More than two hours but less than 12 More than 12 hours
Multiparous
Md
Q1–Q3
p-value
Md
Q1–Q3
p-value
0.024
55 56 55
49–59 51–60 48–60
0.680
60 62 58
56–65 52–68 51–63
0.278
52–62 51–62
0.326
55 56
49–59 50–60
0.453
60 61
56–65 53–65
0.587
59 55 56 54
54–63 49–59 50–60 48–58
o0.001
56 52 56 53
51–60 46–57 49–60 47–56
0.038
61 57 59 58
56–66 53–62 51–64 54–64
0.019
Did the infant suckle on the first breast feed? Yes No
58 53
53–62 46–58
o0.001
56 51
51–60 45–56
o 0.001
61 58
56–66 51–63
0.037
Rooming-in 24 h Partial or no rooming-in
57 53
53–62 46–59
0.001
56 52
50–60 45–54
0.008
61 57
56–65 50–63
0.043
Breast feeding status at hospital Exclusive breast feeding Supplementation for medical reason Supplementation without medical reason
59 54 54
54–63 48–57 48–60
o0.001
57 53 52
52–60 48–57 45–58
o 0.001
61 56 57
57–66 49–61 51–62
o 0.001
Frequency of supplementation Once or twice Occasionally At almost every feed
53 55 53
46–59 48–60 48–57
0.239
52 54 52
43–59 47–59 45–56
0.467
54 57 56
47–61 51–62 51–61
0.671
Method of supplementation Bottle Cup feeding
54 56
48–59 50–60
0.329
52 55
45–57 49–59
0.207
56 58
51–62 51–55
0.397
Use of pacifier Yes No
58 57
51–62 52–62
0.881
53 56
46–60 50–60
0.148
60 60
55–65 56–66
0.564
current recommendations about exclusive breast feeding and many of them think that the supplementation of the newborn baby is necessary. DaMota et al. (2012) found in their study that the reasons for maternal request for supplementation of their newborns in hospital without medical reason included inadequate preparation for newborn behaviour and the breast feeding process. Mothers also used artificial milk as a solution to breast feeding problems. Putting all this data together maternal request for supplementation could be interpreted as a need for additional information, support and breast feeding counselling instead of low motivation to breast feed. This study confirms that in multiparous women the length and experience of previous breast feeding are associated with the breast feeding self-efficacy. Mothers who have breast fed less than six months or rate the experience as negative or neutral have lower or same breast feeding self-efficacy level as primiparous women. Even though it has been shown in earlier studies that parity is related to breast feeding self-efficacy (Dennis, 2006; Wutke and Dennis, 2007; Gregory et al., 2008; Otsuka et al., 2008; Alus Tokat et al., 2010; McCarter-Spaulding and Dennis, 2010) it has not been explored in this detail. The mothers in this study were satisfied with the quality of breast feeding advice from personnel. However the advice should be acknowledging both parents. Fathers and significant others have an important role as the main supporters of the breastfeeding mother after hospital discharge (Dennis, 2006; Kingston et al., 2007; Breastfeeding Support for Mothers and Families During Pregnancy and Birth and After Delivery. Nursing Guideline (online), 2010; McCarter-Spaulding and Dennis, 2010; Meedya et al., 2010).
Only few studies have examined interventions targeted to increase maternal self-efficacy (Noel-Weiss et al., 2006; Hauck et al., 2007; Nichols et al., 2009; McQueen et al., 2011). In three of the studies (Noel-Weiss et al., 2006; Hauck et al., 2007; Nichols et al., 2009) the intervention occurred during pregnancy and in one (McQueen et al., 2011) during immediate post-partum period. In all of these studies the sample sizes were small and therefore no statistically significant differences between groups in breast feeding duration could be found. Therefore well-designed studies on breast feeding self-efficacy enhancing intervention are needed. Limitations Our study has several limitations. First of all the response rate was relatively low, 41%. The questionnaires were handed out to mothers by hospital personnel and in a busy ward the instruction given to mothers can be compromised. In the hospitals where mothers were recruited during the pregnancy the response rate was higher than in the hospital where mothers were recruited after childbirth (47% versus 34%). Life with a newborn can be quite demanding and mothers might just have forgotten to answer or return the questionnaires. Also the length of the study questionnaire may have affected the willingness to participate. No reminders were sent to the participants even though this could have increased the response rate to some extent. Secondly there are factors indicating that the sample does not represent the study population. The respondents had high educational level: almost half had university level or higher degree. In
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this study exclusive breast feeding rate at hospital was higher and duration of the previous breast feeding in multiparous women was longer than what Finnish national statistic indicates. All these factors suggest that the mothers in this study may be highly motivated to breast feed. This limits the generalisation of the results. Still if the maternity hospital practices have association with breast feeding self-efficacy in this highly motivated group of mothers it can be assumed that this is even the case in groups with lower motivation. In future studies an effort should be made to reach mothers with disadvantaged socio-economical status. Conclusion This study confirms that early breast feeding experiences and maternity hospital practices have an association with maternal breast feeding self-efficacy. Factors associated with low breast feeding self-efficacy include delayed initiation of breast feeding, difficulties with the first breast feed, partial or no rooming-in and supplementation of the newborn during the hospital stay. Also multiparous women with short duration of previous breast feeding and negative or neutral breast feeding experience need additional support. Self-efficacy enhancing interventions should be developed and evaluated. References Alus Tokat, M., Okumus, H., Dennis, C.L., 2010. Translation and psychometric assessment of the Breast-feeding Self-Efficacy Scale—Short Form among pregnant and postnatal women in Turkey. Midwifery 26, 101–108. American Academy of Pediatrics, 2012. Breastfeeding and the use of human milk. Pediatrics 129, e827–e841. Bandura, A., 1997. Self-Efficacy: The Exercise of Control. W.H. Freeman & Company, New York. Breastfeeding Support for Mothers and Families During Pregnancy and Birth and After Delivery. Nursing guideline (online), 2010. Working Group Set Up by Nursing Research Foundation. Nursing Research Foundation, Helsinki. Available online at: 〈http://www.hotus.fi〉 (last accessed 16 November 2012). DaMota, K., Bañuelos, J., Goldbronn, J., Vera-Beccera, L.E., Heinig, M.J., 2012. Maternal request for in-hospital supplementation of healthy breastfed infants among low-income women. Journal of Human Lactation 28, 476–482. DiGirolamo, A., Grummer-Strawn, L., Fein, S., 2001. Maternity care practices: implications for breastfeeding. Birth 28, 94–100. Dennis, C., 1999. Theoretical underpinnings of the breastfeeding confidence: a selfefficacy framework. Journal of Human Lactation 15, 195–201. Dennis, C., 2003. The Breastfeeding Self-Efficacy Scale: psychometric assessment of the short form. Journal of Obstetric, Gynecologic & Neonatal Nursing 32, 734–744. Dennis, C.E., 2006. Identifying predictors of breastfeeding self-efficacy in the immediate postpartum period. Research in Nursing & Health 29, 256–268. Dennis, C., Faux, S., 1999. Development and psychometric testing of the Breastfeeding Self-Efficacy Scale. Research in Nursing & Health 22, 399–409. Ekström, A., Widström, A.-M., Nissen, E., 2003. Duration of breastfeeding in Swedish primiparous and multiparous women. Journal of Human Lactation 19, 172–178. EU Project on Promotion of Breastfeeding in Europe, 2004. Protection, Promotion and Support of Breastfeeding in Europe: a Blueprint for Action. European Commission. Directorate Public Health and Risk Assessment, Luxembourg 〈http://ec.europa.eu/health/ph_projects/2002/promotion/fp_promotion_2002_ frep_18_en.pdf〉. (last accessed 16 November 2012). Gregory, A., Penrose, K., Morrison, C., Dennis, C., MacArthur, C., 2008. Psychometric properties of the Breastfeeding Self-Efficacy Scale—Short Form in an ethnically diverse U.K. sample. Public Health Nursing 25, 278–284. Harbers, M.M., Cattaneo, A., 2008. Percentage of infants breastfed at 6 months of age in Iceland, Norway, Switzerland and the EU-27. In: EUPHIX, EUphact. Bilthoven: RIVM, 〈http://www.euphix.org〉 EUphact\Determinants of health \Health behaviours\Breastfeeding. (last accessed 30 January 2012).
Hauck, Y., Hall, W.A., Jones, C., 2007. Prevalence, self-efficacy and perceptions of conflicting advice and self-management: effects of a breastfeeding journal. Journal of Advanced Nursing 57, 306–317. Kingston, D., Dennis, C., Sword, W., 2007. Exploring breast-feeding self-efficacy. Journal of Perinatal & Neonatal Nursing 21, 207–215. Kramer, M., Chalmers, B., Hodnett, E., et al., 2001. for the PROBIT study group, 2001. Promotion of breastfeeding intervention trial (PROBIT): a cluster-randomized trial in the Republic of Belarus. Journal of the American Medical Association 285, 413–420. Laanterä, S., Pietilä, A.-M., Pölkki, T., 2010. Knowledge of breastfeeding among pregnant mothers and fathers. Journal of Perinatal & Neonatal Nursing 24, 320–329. Meedya, S., Fahy, K., Kable, A., 2010. Factors that positively influence breastfeeding duration to 6 months: a literature review. Women and Birth 23, 135–145. McCarter-Spaulding, D., Dennis, C., 2010. Psychometric testing of the Breastfeeding Self-Efficacy Scale—Short Form in a sample of Black women in the United States. Research in Nursing & Health 33, 111–119. McQueen, K.A., Dennis, C.-L., Stemler, R., Norman, C.D., 2011. A pilot randomized controlled trial of a breastfeeding self-efficacy intervention with primiparous mothers. Journal of Obstetric, Gynecologic & Neonatal Nursing 40, 35–46. Mossman, M., Heaman, M., Dennis, C., Morris, M., 2008. The influence of adolescent mothers' breastfeeding confidence and attitudes on breastfeeding initiation and duration. Journal of Human Lactation 24, 268–277. Murray, E.K., Ricketts, S., Dellaport, J., 2007. Hospital practices that increase breastfeeding duration: result from a population based study. Birth 34, 202–211. National Institute for Health and Welfare (THL), 2009. Births and Newborns 2008. Official Statistics of Finland, Statistical Report 22/2009, /http://www.stakes.fi/ tilastot/tilastotiedotteet/2009/tr22_09.pdfS (16.11.2012). Nichols, J., Schutte, N.S., Brown, R.F., Dennis, C.L., Price, I., 2009. The impact of a selfefficacy intervention on short-term breast-feeding outcomes. Health Education & Behavior 36, 250–258. Noel-Weiss, J., Rupp, A., Gragg, B., Basset, V., Woodend, A.K., 2006. Randomized controlled trial to determine effects of prenatal breastfeeding workshop on maternal breastfeeding self-efficacy and breastfeeding duration. Journal of Obstetric, Gynecologic & Neonatal Nursing 35, 616–624. O'Brien, M., Buikstra, E., Hegney, D., 2008. The influence of psychological factors on breastfeeding duration. Journal of Advanced Nursing 63, 397–408. Otsuka, K., Dennis, C., Tatsuoka, H., Jimba, M., 2008. The relationship between breastfeeding self-efficacy and perceived insufficient milk among Japanese mothers. Journal of Obstetric, Gynecologic & Neonatal Nursing 37, 546–555. Plichta, S.B., Kelvin, E., 2012. Munro's Statistical Methods for Health Care Research, 6th edn. Lippincott Williams & Wilkins, Philadelphia. Salonen, A.H., Kaunonen, M., Åstedt-Kurki, P., Järvenpää, A.-L., Tarkka, M.-T., 2008. Development of an internet-based intervention for parents of infants. Journal of Advanced Nursing 64, 60–72. Salonen, A.H., Kaunonen, M., Åstedt-Kurki, P., Järvenpää, A.-L., Isoaho, H., Tarkka, M.-T., 2009. Parenting self-efficacy after childbirth. Journal of Advanced Nursing 65, 2324–2336. Tarkka, M.T., Paunonen, M., Laippala, P., 2000. How first-time mothers cope with child care while still in the maternity ward. International Journal of Nursing Practice 6, 97–104. Uusitalo, L., Nyberg, H., Pelkonen, M., Sarlio-Lähteenkorva, S., Hakulinen-Viitanen, T., Virtanen, S., 2012. Infant Feeding in Finland 2010. National Institute for Health and Welfare, Helsinki 〈http://www.thl.fi/thl-client/pdfs/ee5adaff-90c4-4005-a3ad77887817f091〉. (last accessed 16 November 2012). Wilhelm, S.L., Rodenhorst, T.K., Stepans, M., Hertzog, M., Berens, C., 2008. Influence of intention and self-efficacy levels on duration of breastfeeding for Midwest rural mothers. Applied Nursing Research 21, 123–130. Wilhelm, S., Rodenhorst-Weber, T., Flanders Stepans, M., Hertzog, M., 2010. The relationship between breastfeeding test weights and postpartum breastfeeding rates. Journal of Human Lactation 26, 168–174. World Health Organization, UNICEF, 2003. Global Strategy for Infant and Young Child Feeding. Geneva. World Health Organization, UNICEF, 2009. Baby-Friendly Hospital Initiative. Revised, Updated and Expanded for integrated Care. The WHO Document Production Services, Geneva. World Medical Association, 2008. WMA Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects. WMA The World Medical Association, France 〈http://www.wma.net/en/30publications/10policies/b3/index.html〉. (last accessed 16 November 2012). Wutke, K., Dennis, C., 2007. The reliability and validity of the Polish version of the Breastfeeding Self-Efficacy Scale—Short Form: translation and psychometric assessment. International Journal Nursing Studies 44, 1439–1446.
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Midwifery journal homepage: www.elsevier.com/midw
Maternity hospital practices and breast feeding self-efficacy in Finnish primiparous and multiparous women during the immediate postpartum period Katja S. Koskinen, RNM, IBCLC, MSc (Breastfeeding Coordinator, Senior Planning Officer)a,b,n, Anna L. Aho, RN, PhD (Assistant Professor)c, Leena Hannula, RNM, PhD (Principal Lecturer)d, Marja Kaunonen, RN, PhD (Professor)c,e a
Department of Gynaecology and Pediatrics, Helsinki University Central Hospital, Helsinki, Finland National Institute for Health and Welfare, Helsinki, Finland School of Health Sciences, Nursing Science, University of Tampere, Finland d Faculty of Health Care and Nursing, Metropolia University of Applied Sciences, Helsinki, Finland e Pirkanmaa Hospital District, Science Center, Tampere, Finland b c
art ic l e i nf o
a b s t r a c t
Article history: Received 2 December 2012 Received in revised form 9 May 2013 Accepted 11 May 2013
Objective: to explore the relationship between maternity hospital practices and breast feeding selfefficacy. Design: the data were collected using a cross-sectional survey. The study is a part of a larger longitudinal research and development project called ‘Urban parenthood’. Setting: three urban maternity hospitals in Southern Finland. Participants: altogether 1400 questionnaires were given out and 573 primiparous and multiparous women completed the questionnaire within a week after childbirth. The response rate was 41%. Findings: early and successful initiation of breast feeding, rooming-in and exclusive breast feeding during the hospital stay were associated with higher maternal breast feeding self-efficacy in both primiparous and multiparous women. The reason (medical or non-medical), frequency or method (bottle or cup) for supplementation was not associated with breast feeding self-efficacy. Key conclusion and implications for practice: breast feeding experiences during the immediate postpartum period have an association with breast feeding self-efficacy. Mothers who are not able to initiate breast feeding within an hour after birth or whose infants are supplemented during the hospital stay may benefit from additional support and breast feeding counselling. & 2013 Elsevier Ltd. All rights reserved.
Keywords: Breast feeding Hospital practices Self-efficacy
Introduction Breast feeding provides all nutrients an infant requires during the first six months of life and is a significant part of healthy diet thereafter for at least one to two years. It supports infant's normal development and provides health benefits for the breast-feeding mother as well. Therefore exclusive breast feeding for six months and continued breast feeding with complementary foods thereafter is widely recommended (World Health Organization and UNICEF, 2003; EU Project on Promotion of Breastfeeding in Europe, 2004; American Academy of Pediatrics, 2012). Still in many countries these recommendations are not met. In European Union less than half of the infants receive any breast milk at six months of age (Harbers and
n
Correspondence to: Leppä vaarankatu 19 A 5, FI-02600 Espoo, Finland. E-mail address: katja.koskinen@thl.fi (K.S. Koskinen).
0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.05.003
Cattaneo, 2008). Even though almost all Finnish mothers initiate breast feeding, exclusive breast feeding rates are relatively low and the duration of any breast feeding is shorter than recommended. In 2010, according to national statistics, 71% of newborns received supplementation in maternity hospital, 47% of infants less than one month were exclusively breast fed and 58% were still breast fed at six months age (Uusitalo et al., 2012). The socio-demographic factors associated with early cessation of breast feeding are well known and include young maternal age, being unmarried, belonging to a minority group as well as low education and income level (Breastfeeding Support for Mothers and Families During Pregnancy and Birth and After Delivery. Nursing Guideline (online), 2010; Meedya et al., 2010; Uusitalo et al., 2012). Yet many mothers not belonging to these risk groups discontinue breast feeding prematurely. Therefore recognition of psychosocial factors related to breast feeding behaviour helps to identify individual mothers in need of additional breast feeding support.
K.S. Koskinen et al. / Midwifery 30 (2014) 464–470
Maternal breast feeding self-efficacy during the first week after birth has been associated with continuation of exclusive breast feeding at four (Kingston et al., 2007; Gregory et al., 2008; McCarter-Spaulding and Dennis, 2010), eight (Wutke and Dennis, 2007), 12 (Alus Tokat et al., 2010) and 16 (Wutke and Dennis, 2007) weeks and any breast feeding at six months (Mossman et al., 2008; O'Brien et al., 2008; Wilhelm et al., 2008; McCarter-Spaulding and Dennis, 2010; Wilhelm et al., 2010). Breast feeding self-efficacy is a concept based on Albert Bandura's Social Learning Theory and is defined as a mother's perception of her ability to breast feed in a given situation (Dennis, 1999). The breast feeding self-efficacy is based on four sources of information: previous personal experience, observing others to breast feed, encouragement by others and physiological responses (Dennis, 1999; Dennis and Faux, 1999). The relationship between earlier breast feeding experience and breast feeding self-efficacy has been shown in several studies (Dennis, 2006; Wutke and Dennis, 2007; Gregory et al., 2008; Otsuka et al., 2008; Alus Tokat et al., 2010; McCarter-Spaulding and Dennis, 2010). Other factors related to breast feeding self-efficacy during the postpartum period include exclusive breast feeding (Gregory et al., 2008; Otsuka et al., 2008; McCarter-Spaulding and Dennis, 2010), social support from significant others (Dennis, 2006; Kingston et al., 2007; McCarter-Spaulding and Dennis, 2010), seeing pictures or videos of other mothers breast feeding (Kingston et al., 2007) and satisfaction with labour and childbirth care as well as postpartum care (Dennis, 2006). Maternity hospital practices are shown to have important impact on initiation and establishment of successful breast feeding. The practices based on the Baby-Friendly Hospital Initiative (BFHI) by World Health Organization (WHO) and UNICEF are an effective way to support breast feeding (DiGirolamo et al., 2001; Kramer et al., 2001; Murray et al., 2007; Breastfeeding Support for Mothers and Families During Pregnancy and Birth and After Delivery. Nursing Guideline (online), 2010). The key practices of the BFHI include immediate skin-to-skin contact after birth, early initiation of breast feeding, exclusive breast feeding, rooming-in and avoidance of the use of pacifiers or feeding bottles. All mothers should also be given information about the benefits and management of breast feeding both pre- and postnatally (World Health Organization and UNICEF, 2009). The early experiences of breast feeding can be assumed to affect maternal breast feeding self-efficacy especially in primiparous women but the relationship between maternity hospital practices and breast feeding self-efficacy has not been explored. In Finland practically all deliveries take place in hospitals. Normal births are attended by midwives and postpartum care is provided mainly by midwives and practical nurses. At the time of the study the average hospital stay after childbirth was 3.2 days (National Institute for Health and Welfare (THL), 2009). To date five of the 32 maternity hospitals have received Baby Friendly Hospital certification. No national data is available on the compliance of practices in Finnish maternity hospitals with the BFHI. The aim of this study was to explore the relationship between maternity hospital practices and breast feeding self-efficacy. The objectives of the study were (1) to describe maternity hospital practices, (2) to describe maternal breast feeding self-efficacy and (3) to examine factors associated to breast feeding self-efficacy in Finnish primiparous and multiparous women during the first week after the childbirth.
Methods Study settings The data were collected using a convenience sample in three urban maternity hospitals in Southern Finland between November
465
2007 and September 2008. The hospitals had at the time between 3300 and 5800 births per year. One of the three hospitals is a university level hospital in which mothers with high risk pregnancies are taken care of. The hospitals did not have a written breast feeding policy at the beginning of the study, but a common breast feeding policy based on the BFHI was signed by the management of all three hospitals in December 2007. Almost all nursing staff, i.e. midwives and practical nurses, had received basic 18 hour course on breast feeding counselling either offered by employer or during their education. None of the hospitals had received the Baby Friendly Hospital Certificate at the time of the study and the practices described in the Ten Steps to Successful Breastfeeding were not met in any of the hospitals. Especially supplementation of the newborns was common. Even though supplementation was not offered to every mother it was a common practice to offer supplementation for example if the infant was breast feeding frequently or the mother was feeling tired. The supplementation was also given on maternal request. Sample This study was a part of larger longitudinal research project ‘Urban parenthood’ which examined the welfare of families during the first year after childbirth. The data collection points for the project were at birth and six weeks as well as six and 12 months after childbirth. In two hospitals mothers were recruited during routine mid-pregnancy ultra-sound scan and in a third hospital on the post-natal ward after childbirth. This difference was due to the delay in research approval process in the third hospital (Hospital C). Mothers were eligible for the study if they were willing to participate, at least 18 years old, healthy, could communicate in Finnish, had singleton pregnancy without major obstetrical complications and gave birth to a healthy infant with no congenital abnormalities. Both primiparous and multiparous women were included in the study. Mothers who gave birth before 37 gestational weeks were excluded from the study. The data were collected by questionnaires which were distributed to mothers on the postnatal ward on discharge by hospital personnel. Mothers were instructed to return completed questionnaires either in the hospital or within a week by mail. Mothers were included in the study if the child was seven days old or younger at the time when the questionnaire was completed. Altogether 1400 questionnaires were given out to the mothers and 573 mothers (41%) were included in the study. The second questionnaire was sent at six weeks after childbirth to all mothers who had completed the first questionnaire. Altogether 339 (59%) returned the second questionnaire. Instruments All data were collected with self-report questionnaires. Breast feeding self-efficacy was measured with The Breastfeeding Self-Efficacy Scale—Short Form (BSES—SF) which is a 14-item self-report instrument (Dennis, 2003). All statements in the scale begin with the phrase ‘I can always’ and are presented positively. The mothers respond to every statement with 5-point Likert scale where 1 ¼not at all confident and 5 ¼always confident. The scores are summed to produce a range from 14 to 70, with higher levels indicating higher breast feeding self-efficacy. The scale was translated from English to Finnish using back-translation method. The Finnish version of the scale was piloted in June 2007. The internal consistency of the Finnish version BSES—SF in this study, using Cronbach α coefficient, was 0.93. Construct validity was measured by comparison of contrasted groups. According to Bandura (1997, p. 80) previous experience of the behaviour has strong influence on self-efficacy. Therefore it can be assumed that multiparous women with earlier breast feeding experience have
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higher breast feeding self-efficacy than primiparous women during the immediate post-partum period. In this sample multiparous women's median breast feeding self-efficacy was 60 (Q1–Q3 ¼ 55–65) and primiparous' 55 (Q1–Q3 ¼ 49–60). The difference was statistically significant (U¼ 21,918.5, po 0.001). The predictive validity was measured by comparing the breast feeding self-efficacy at hospital and breast feeding status at six weeks after birth. At the six week questionnaire the mothers were asked whether the child was exclusively breast fed, partially breast fed or weaned. Mothers who were exclusively breast feeding at six weeks had had a statistically significant higher breast feeding selfefficacy during the first week after birth (Md¼ 58, Q1–Q3 ¼54–62) than mothers who were partially breast feeding (Md¼53 Q1– Q3 ¼48–58) or were bottle feeding (Md¼ 52, Q1–Q3 ¼51–64, H¼24.0, df¼2, po0.001). Breast feeding advice from nursing professionals in maternity hospital was measured with a 8-item scale (Tarkka et al., 2000). The mothers were asked to evaluate with 5-point Osgood scale whether the breast feeding advice was inadequate or adequate, general or accurate, disapproving or encouraging, vague or understandable, routine like or individual, conflicting or consistent with previous knowledge, conflicting or consistent among ward personnel and mother centred or acknowledging both parents. The total score of the scale was calculated by summing the scores of all items and dividing the sum by the number of items. The total score varies between one and five, the higher the better. This is the first time the scale has been used to measure breast feeding advice obtained, but it has been used to measure overall advice from nursing staff on maternity ward (Salonen et al., 2008; Salonen et al., 2009). The Cronbach α coefficient of the scale was 0.86. Data analysis The data were analysed statistically with IBM SPSS Statistics version 19.0. Frequencies and percentages were used to describe maternal characteristics and maternity hospital practices. The differences between primiparous and multiparous women were examined with cross tabulation and significance of the differences was measured with χ². Because the dependent variable, breast feeding self-efficacy, was not normally distributed in the sample, non-parametric tests were used: for descriptive statistics medians and quartiles (Q1 ¼25th percentile and Q3 ¼ 75th percentile) and to determine differences between groups the Mann–Whitney U-test for two groups and Kruskal–Wallis H-test for three or more groups. The correlation between breast feeding self-efficacy and breast feeding advice from nursing professionals was measured with the Spearman correlation coefficient (Plichta and Kelvin, 2012). P values o0.05 were considered significant. A statistician was consulted in the selection of appropriate statistical tests. Ethical considerations An approval was received from the Research Ethics Committees of all the hospitals in the study. The participants in the study received both oral and written information of the study before making their decision to participate. A written consent was obtained (World Medical Association, 2008). The data were treated as confidential and anonymous.
Findings Maternal characteristics and previous breast feeding experience Half (n ¼307, 54%) of the respondents were first-time mothers. This differs from the Finnish national statistics of births and
newborns 2008 (National Institute for Health and Welfare (THL), 2009) where the percentage of primiparous women was 42%. The mean age of the mothers was 31 years (SD 4.4, range 18–43) which is near the national average in 2008, 30 years. The maternal characteristics are presented in Table 1. Statistically significant differences between primiparous and multiparous women in maternal characteristics were found in age and childbirth mode. As expected multiparous women were older than primiparous women (χ² ¼46.6, df ¼3, p o0.001). The primiparous women experienced assisted vaginal or caesarean birth significantly more often than the multiparous women (normal vaginal birth 68% versus 90%, assisted vaginal 15% versus 2% and caesarean section 17% versus 9%, χ² ¼46.0, df ¼2, po0.001). The only difference between the respondents in the different study hospitals was in parity. In Hospital A 53% (n ¼95) of mothers were primiparous, in Hospital B 66% (n ¼ 103) and Hospital C 46% (n ¼109) (χ² ¼14.6, df¼ 2, p o0.001). All multiparous women had breast fed earlier. Median breast feeding duration was 10 months (Q1–Q3 ¼6–13). The shortest duration was one month and the longest 28 months. Only 19% (n ¼48) of the mothers had breast fed less than 6 months and 39% (n ¼103) over one year. Most of the mothers rated their earlier breast feeding experience as positive (n ¼117, 44%) or very positive (n ¼113, 42%). None of the mothers had a very negative and only 15 (6%) mothers had a negative experience. In all, 20 mothers (8%) rated their earlier breast feeding as neither negative nor positive. Maternity hospital practices Most of the infants were put in skin-to-skin contact with their mother immediately after birth (n¼498, 87%). Almost all mothers with normal (n¼432, 97%) or assisted (n¼ 41, 82%) vaginal childbirth received their infants skin-to-skin, but only 32% (n¼24) after caesarean childbirth. The length of the skin–skin contact was not inquired. The first breast feeding occurred in 62% (n¼ 356) of the infants during the first hour after birth, in 13% (n ¼75) between one and two hours and 19% (n ¼108) between two and 12 hours after birth. Thirty three (6%) infants breast fed for the first time more than 12 hours after childbirth. None of the infants delivered with caesarean section breast fed within an hour of childbirth and only 9% (n ¼7) breast fed before they were two hours old. Most of the infants (n ¼487, 86%) managed to suckle during the first breast feed. In primiparous women successfulness (the infant Table 1 Demographic characteristics of respondents (n ¼573). Characteristics
Respondents
National data
n
n
(%)
(%)
Age, years −24 25–29 30–34 35–
45 180 247 100
(8) (31) (43) (18)
10,789 18,652 18,819 10,673
(18) (32) (32) (18)
Marital status Married or cohabitation Single
559 11
(98) (2)
– –
(92)
Education High school or less Vocational school College or technical school University degree or higher
46 82 175 264
(8) (14) (31) (46)
– – – –
Mode of childbirth Normal vaginal Assisted vaginal Caesarean section
445 50 76
(78) (9) (13)
43,984 4705 9807
(75) (8) (17)
K.S. Koskinen et al. / Midwifery 30 (2014) 464–470
suckled) and the timing of the first breast feed were associated (Table 2) but not in multiparous women. Most of the mothers rated their experience of the first breast feed as positive (n ¼200, 35%) or very positive (n¼ 306, 54%). Only three mothers (1%) had a negative and 58 (10%) neither negative nor positive experience of the first breast feed. Almost all mothers (n ¼519, 91%) had their infants rooming-in during the whole hospital stay. All mothers were breast feeding and two thirds (n ¼377) were exclusively breast feeding in the hospital. The multiparous women were more likely to breast feed exclusively (n ¼197, 74%) than primiparous women (n ¼182, 59%, χ² ¼19.7, df ¼ 2, p o0.001). Altogether 58 (10%) infants were supplemented for medical reason and 136 (24%) without medical reason. One third (n ¼64, 34%) of the supplemented infants received supplementation at almost every feed. Bottle feeding was the most common way of giving supplementation: 80% (n ¼157) of the supplemented infants received it by bottle. Breast feeding advice from personnel was rated positively (Md ¼4, Q1–Q3 ¼3.4–4.4). The majority of mothers assessed breast feeding advice as encouraging (n¼ 473, 86% score 4 or 5 on the Osgood scale), understandable (n ¼460, 84%), adequate (n ¼ 409, 75%), accurate (n ¼361, 66%), and individual (n ¼ 221, 59%). Most of the mothers (n ¼428, 78%) experienced advice consistent among ward personnel and with mother's previous knowledge (n ¼371, 68%). Only one quarter (n ¼139, 25%) of mothers thought that advice was acknowledging both parents. There were significant differences between the hospitals in infant's age at the first breast feed, the successfulness of the first breast feed, breast feeding status at hospital, method of supplementation and the use of pacifier (Table 3). Even though differences in mothers' experiences of breast feeding advice from personnel between the hospitals were sparse, they were statistically significant (Hospital A Md ¼4, Q1–Q3 ¼3.6–4.5, Hospital B Md¼ 4, Q1–Q3 ¼3.4–4.3, Hospital C Md ¼3,9, Q1–Q3 ¼ 3.3–4.3, H ¼6.6, df ¼2, p¼ 0.04). Altogether the hospital practices were most compatible with BFHI in Hospital A. Breast feeding self-efficacy The median breast feeding self-efficacy in the sample was 57 (Q1–Q3 ¼ 52–62). The mothers were most confident (highest frequency in score 4 and 5) about being satisfied with their breast feeding experience (n¼ 503, 89%), dealing with the fact that breast feeding can be time-consuming (n¼ 499, 88%) and breast feeding with other family members present (n¼493, 88%). The mothers were least confident (highest frequencies in score 1 and 2) about breast feeding without artificial milk supplementation (n¼80, 14%) and determining that infant is getting enough milk (n¼75, 13%). Factors related to breast feeding self-efficacy No relationship between maternal age, marital status or educational level and breast feeding self-efficacy was found. Multiparous women had higher breast feeding self-efficacy than primiparous Table 2 Timing and successfulnes of the first breast feed in primiparous women (n ¼307). Did the infant suckle on the first breast feed?
Yes n
Infant's age at the first breast feed One hour or less More than one hour but less than two More than two hours but less than 12 More than 12 hours
144 29 68 11
(%)
(90) (73) (85) (52)
No n
16 11 12 10
(%)
p-Value
(10) p o 0.001 (28) (15) (48)
467
women (Md ¼60, Q1–Q3 ¼ 55–65 versus Md¼55, Q1–Q3 ¼49–60, U¼21,918.5, p o0.001). The longer the mother had breast fed previously and the more positive the earlier breast feeding experience was, the higher breast feeding self-efficacy she had (Table 4). The results of the comparison of breast feeding self-efficacy by hospital practices are presented in Table 5. Primi- and multiparous women were analysed separately because the effect of the earlier breast feeding experience might diminish the association between hospital practices and breast feeding self-efficacy. The hospital practices found to be associated with breast feeding self-efficacy in both primi- and multiparous women were timing and successfulness of the first breast feed, rooming-in and breast feeding status during the hospital stay. When the whole sample was analysed the mothers with normal vaginal childbirth had significantly higher BSES—SF score than mothers with assisted vaginal or caesarean births. However the difference in BSES—SF score diminished when primiparous and multiparous women were analysed separately (Table 5). This may be due to the low number of multiparous women in assisted vaginal or caesarean childbirth groups. In the whole sample mothers who breast fed their infant for the first time within an hour of the birth had the highest BSES—SF score (Table 5). When the score was explored by parity the picture got more complicated. In multiparous women the early initiation of breast feeding was related to higher breast feeding self-efficacy. In primiparous women mothers who initiated breast feeding during the first hour and those who initiated it between two and 12 hours had in average similar BSES—SF scores (Md¼56, Q1–Q3 ¼51–60 versus Md¼ 56, Q1–Q3 ¼49–60). Likewise the primiparous mothers who breast fed their infants first time during the second hour or more than 12 hours after the birth scored similarly (Md¼ 52, Q1–Q3 ¼ 49– 57 versus Md¼53, Q1–Q3 ¼47–56). In these two groups it was more common that the infant did not suckle during the first breast feed (Table 2). Mothers who had a very positive experience of the first breast feed had higher breast feeding self-efficacy than other mothers (H¼ 81.4, df¼3, po0.001). Breast feeding advice from nursing professional during hospital stay correlated positively with breast feeding self-efficacy. The relationship was fair (r ¼0.37, p o0.001). The correlation was stronger in primiparous than multiparous women (r ¼ 0.43, po 0.001 versus r ¼0.35, p o0.001).
Discussion This study examined the relationship between maternity hospital practices and breast feeding self-efficacy which has not been explored earlier. The results indicate that early breast feeding experiences have an association with mothers' confidence in breast feeding. Delayed first breast feed, partial or no rooming-in and supplementation of the newborn are associated with lower maternal breast feeding self-efficacy and thus a sign for the need of additional breast feeding support. In earlier studies breast feeding initiation within an hour and exclusive breast feeding in hospital has been shown to increase the duration of breast feeding (DiGirolamo et al., 2001; Murray et al., 2007). In this study the timing of the first breast feed is associated with breast feeding self-efficacy but not linearly. The initiation of breast feeding within an hour is associated with the highest breast feeding self-efficacy but between one hour and two hours with the lowest. This may indicate that there were some challenges in breast feeding initiation in the latter group, whereas most of the mothers who initiated breast feeding later than two hours of the childbirth gave birth by caesarean section and this was the first possibility to initiate breast feeding. This suggests that if the first breast feeding
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Table 3 Comparison of the maternity hospital practices by hospital. Hospital A
Hospital B
Hospital C
Total
n
%
n
%
n
%
Mode of childbirth Normal vaginal Assisted vaginal Caesarean
137 19 23
77 11 13
115 16 26
73 10 17
193 15 27
Skin-to-skin contact Yes No
153 26
86 15
131 25
84 16
Infant's age at the first breast feed One hour or less More than one hour but less than two More than two hours but less than 12 More than 12 hours
111 32 29 7
62 18 16 4
97 13 30 17
Did the infant latch? Yes No
163 14
92 8
Rooming-in Full-time Part-time or no rooming-in
164 12
Breast feeding status at hospital Exclusive breast feeding BF and supplementation for medical reason BF and supplementation without medical reason
p-value
n
%
82 6 12
445 50 76
78 9 13
p¼ 0.2
214 23
90 10
498 74
87 13
p ¼0.1
62 8 19 11
148 30 49 9
63 13 21 4
356 75 108 33
62 13 19 6
p¼ 0.01
132 20
87 13
192 44
81 19
487 78
86 14
p ¼0.007
93 7
137 20
87 13
218 17
92 7
519 49
91 9
p ¼0.1
145 14 20
81 8 11
94 21 42
60 13 27
140 23 74
59 10 31
379 58 136
66 10 24
po 0.001
Frequency of supplementation Once or twice Occasionally At almost every feed
2 23 8
6 70 24
8 30 23
13 49 38
20 44 33
21 45 34
30 97 64
16 51 34
p ¼0.1
Method of supplementation Bottle Cup feeding
17 18
49 51
50 14
78 22
90 7
93 7
157 39
80 20
po 0.001
15 159
8 89
29 125
19 81
86 147
37 63
130 431
23 77
po 0.001
Use of pacifier Yes No
Table 4 Length and experience of previous breast feeding and the BSES–SF scores in multiparous women. BSES—SF scores Md
Q1–Q3
p-Value
Length of previous breast feeding (the longest) o 6 months 48 (18) 6–12 months 107 (40) 412 months 103 (39)
56.5 60 63
51–62 55–64 58–67
po 0.001
Breast feeding experience 1 Very negative 2 Negative 3 Not negative nor positive 4 Positive 5 Very positive
51 52 58 64
44–61 49–61 54–62 60–67
po 0.001
n
0 15 20 117 113
attempt proceeds smoothly and is successful, it has a positive association with breast feeding self-efficacy. The mothers whose infants are supplemented during the hospital stay have lower breast feeding self-efficacy than mothers exclusively breast feeding. In this study the reason (with or without medical reason), method (bottle or cup) or frequency of supplementation was not associated with breast feeding self-efficacy. Earlier the effect of the reason for supplementation on breast feeding has been evaluated only in one study by Ekström et al. (2003). In the study supplementation without medical reasons was associated with shorter duration of exclusive or any breast feeding but supplementation with medical
(%)
(6) (8) (44) (42)
reason was not. The authors concluded that only the supplementation of a healthy newborn without medical reason may affect the maternal self-confidence. This explanation is not supported by this study. Supplementation of the breast-fed infants is a common practice in Finnish maternity hospitals and may at least partly explain the low incidence of exclusive breast feeding later (Uusitalo et al., 2012). The mothers in this study were least confident about breast feeding without artificial milk supplementation and determining that the infant is getting enough milk. In an earlier study by Laanterä et al. (2010) it has been shown that Finnish expectant parents' knowledge about breast feeding is inadequate. The parents do not know the
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469
Table 5 Comparison of the BSES—SF scores by maternity hospital practices and parity. All mothers
Primiparous
Md
Q1–Q3
p-value
Mode of childbirth Normal vaginal Assisted vaginal Caesarean
58 56 56
53–63 51–60 49–61
Skin-to-skin contact Yes No
57 57
Infant's age at the first breast feed One hour or less More than one hour but less than two More than two hours but less than 12 More than 12 hours
Multiparous
Md
Q1–Q3
p-value
Md
Q1–Q3
p-value
0.024
55 56 55
49–59 51–60 48–60
0.680
60 62 58
56–65 52–68 51–63
0.278
52–62 51–62
0.326
55 56
49–59 50–60
0.453
60 61
56–65 53–65
0.587
59 55 56 54
54–63 49–59 50–60 48–58
o0.001
56 52 56 53
51–60 46–57 49–60 47–56
0.038
61 57 59 58
56–66 53–62 51–64 54–64
0.019
Did the infant suckle on the first breast feed? Yes No
58 53
53–62 46–58
o0.001
56 51
51–60 45–56
o 0.001
61 58
56–66 51–63
0.037
Rooming-in 24 h Partial or no rooming-in
57 53
53–62 46–59
0.001
56 52
50–60 45–54
0.008
61 57
56–65 50–63
0.043
Breast feeding status at hospital Exclusive breast feeding Supplementation for medical reason Supplementation without medical reason
59 54 54
54–63 48–57 48–60
o0.001
57 53 52
52–60 48–57 45–58
o 0.001
61 56 57
57–66 49–61 51–62
o 0.001
Frequency of supplementation Once or twice Occasionally At almost every feed
53 55 53
46–59 48–60 48–57
0.239
52 54 52
43–59 47–59 45–56
0.467
54 57 56
47–61 51–62 51–61
0.671
Method of supplementation Bottle Cup feeding
54 56
48–59 50–60
0.329
52 55
45–57 49–59
0.207
56 58
51–62 51–55
0.397
Use of pacifier Yes No
58 57
51–62 52–62
0.881
53 56
46–60 50–60
0.148
60 60
55–65 56–66
0.564
current recommendations about exclusive breast feeding and many of them think that the supplementation of the newborn baby is necessary. DaMota et al. (2012) found in their study that the reasons for maternal request for supplementation of their newborns in hospital without medical reason included inadequate preparation for newborn behaviour and the breast feeding process. Mothers also used artificial milk as a solution to breast feeding problems. Putting all this data together maternal request for supplementation could be interpreted as a need for additional information, support and breast feeding counselling instead of low motivation to breast feed. This study confirms that in multiparous women the length and experience of previous breast feeding are associated with the breast feeding self-efficacy. Mothers who have breast fed less than six months or rate the experience as negative or neutral have lower or same breast feeding self-efficacy level as primiparous women. Even though it has been shown in earlier studies that parity is related to breast feeding self-efficacy (Dennis, 2006; Wutke and Dennis, 2007; Gregory et al., 2008; Otsuka et al., 2008; Alus Tokat et al., 2010; McCarter-Spaulding and Dennis, 2010) it has not been explored in this detail. The mothers in this study were satisfied with the quality of breast feeding advice from personnel. However the advice should be acknowledging both parents. Fathers and significant others have an important role as the main supporters of the breastfeeding mother after hospital discharge (Dennis, 2006; Kingston et al., 2007; Breastfeeding Support for Mothers and Families During Pregnancy and Birth and After Delivery. Nursing Guideline (online), 2010; McCarter-Spaulding and Dennis, 2010; Meedya et al., 2010).
Only few studies have examined interventions targeted to increase maternal self-efficacy (Noel-Weiss et al., 2006; Hauck et al., 2007; Nichols et al., 2009; McQueen et al., 2011). In three of the studies (Noel-Weiss et al., 2006; Hauck et al., 2007; Nichols et al., 2009) the intervention occurred during pregnancy and in one (McQueen et al., 2011) during immediate post-partum period. In all of these studies the sample sizes were small and therefore no statistically significant differences between groups in breast feeding duration could be found. Therefore well-designed studies on breast feeding self-efficacy enhancing intervention are needed. Limitations Our study has several limitations. First of all the response rate was relatively low, 41%. The questionnaires were handed out to mothers by hospital personnel and in a busy ward the instruction given to mothers can be compromised. In the hospitals where mothers were recruited during the pregnancy the response rate was higher than in the hospital where mothers were recruited after childbirth (47% versus 34%). Life with a newborn can be quite demanding and mothers might just have forgotten to answer or return the questionnaires. Also the length of the study questionnaire may have affected the willingness to participate. No reminders were sent to the participants even though this could have increased the response rate to some extent. Secondly there are factors indicating that the sample does not represent the study population. The respondents had high educational level: almost half had university level or higher degree. In
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this study exclusive breast feeding rate at hospital was higher and duration of the previous breast feeding in multiparous women was longer than what Finnish national statistic indicates. All these factors suggest that the mothers in this study may be highly motivated to breast feed. This limits the generalisation of the results. Still if the maternity hospital practices have association with breast feeding self-efficacy in this highly motivated group of mothers it can be assumed that this is even the case in groups with lower motivation. In future studies an effort should be made to reach mothers with disadvantaged socio-economical status. Conclusion This study confirms that early breast feeding experiences and maternity hospital practices have an association with maternal breast feeding self-efficacy. Factors associated with low breast feeding self-efficacy include delayed initiation of breast feeding, difficulties with the first breast feed, partial or no rooming-in and supplementation of the newborn during the hospital stay. Also multiparous women with short duration of previous breast feeding and negative or neutral breast feeding experience need additional support. Self-efficacy enhancing interventions should be developed and evaluated. References Alus Tokat, M., Okumus, H., Dennis, C.L., 2010. Translation and psychometric assessment of the Breast-feeding Self-Efficacy Scale—Short Form among pregnant and postnatal women in Turkey. Midwifery 26, 101–108. American Academy of Pediatrics, 2012. Breastfeeding and the use of human milk. Pediatrics 129, e827–e841. Bandura, A., 1997. Self-Efficacy: The Exercise of Control. W.H. Freeman & Company, New York. Breastfeeding Support for Mothers and Families During Pregnancy and Birth and After Delivery. Nursing guideline (online), 2010. Working Group Set Up by Nursing Research Foundation. Nursing Research Foundation, Helsinki. Available online at: 〈http://www.hotus.fi〉 (last accessed 16 November 2012). DaMota, K., Bañuelos, J., Goldbronn, J., Vera-Beccera, L.E., Heinig, M.J., 2012. Maternal request for in-hospital supplementation of healthy breastfed infants among low-income women. Journal of Human Lactation 28, 476–482. DiGirolamo, A., Grummer-Strawn, L., Fein, S., 2001. Maternity care practices: implications for breastfeeding. Birth 28, 94–100. Dennis, C., 1999. Theoretical underpinnings of the breastfeeding confidence: a selfefficacy framework. Journal of Human Lactation 15, 195–201. Dennis, C., 2003. The Breastfeeding Self-Efficacy Scale: psychometric assessment of the short form. Journal of Obstetric, Gynecologic & Neonatal Nursing 32, 734–744. Dennis, C.E., 2006. Identifying predictors of breastfeeding self-efficacy in the immediate postpartum period. Research in Nursing & Health 29, 256–268. Dennis, C., Faux, S., 1999. Development and psychometric testing of the Breastfeeding Self-Efficacy Scale. Research in Nursing & Health 22, 399–409. Ekström, A., Widström, A.-M., Nissen, E., 2003. Duration of breastfeeding in Swedish primiparous and multiparous women. Journal of Human Lactation 19, 172–178. EU Project on Promotion of Breastfeeding in Europe, 2004. Protection, Promotion and Support of Breastfeeding in Europe: a Blueprint for Action. European Commission. Directorate Public Health and Risk Assessment, Luxembourg 〈http://ec.europa.eu/health/ph_projects/2002/promotion/fp_promotion_2002_ frep_18_en.pdf〉. (last accessed 16 November 2012). Gregory, A., Penrose, K., Morrison, C., Dennis, C., MacArthur, C., 2008. Psychometric properties of the Breastfeeding Self-Efficacy Scale—Short Form in an ethnically diverse U.K. sample. Public Health Nursing 25, 278–284. Harbers, M.M., Cattaneo, A., 2008. Percentage of infants breastfed at 6 months of age in Iceland, Norway, Switzerland and the EU-27. In: EUPHIX, EUphact. Bilthoven: RIVM, 〈http://www.euphix.org〉 EUphact\Determinants of health \Health behaviours\Breastfeeding. (last accessed 30 January 2012).
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