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Practices and Policies in the Initiation of Breastfeeding
clinical studies Practices and Policies in the Initiation of Breastfeeding MARY J. RENFREW HOUSTON, RN, SCM, PHD, AND PEGGY ANNE FIELD, RN, SCM, PHD Despite increasing knowledge about factors affecting the initiation of breastfeeding, many mothers still encounter problems and discontinue breastfeeding earlier than desired. Many hospitals still have not implemented the practices that are known to be helpful in the establishment of breastfeeding. As a result, a study was conducted to examine the policies and practices affecting breastfeeding in hospitals in Alberta, Canada. A questionnairebased survey of all Alberta hospitals (including directors of nursing and staff nurses) found that many practices were still relatively inflexible; did not always reflect accurate, research-based information; and were not geared to the needs of mothers and infants. The implications of these findings are discussed.
Duration of breastfeeding is affected by the care given during the immediate postpartum period.'*' Indeed, the factors that affect breastfeeding during the first few days after birth have been the subject of extensive research during the past 10 to 15 years. Despite knowledge of the need for certain practices at this time, nursing care is still not always based on research findings. This is evidenced by the rapid rate of discontinuation of breastfeeding despite the increasing numbers of women choosing to breastfeed their inf a n t ~In. ~fact, ~ ~the discontinuation rate has shown little sign of improvement during the past 10 years, although nurses have become much more aware of t h e helpful and detrimental practices in this important Accepted: March 1988
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LITERATURE REVIEW
What are the helpful factors in the initiation of breastfeeding? A wealth of research has demonstrated that initiation of breastfeeding within the first two hours after the ability of mothers to breastfeed frequently and without a fixed schedule,739early and consistent support and teaching from hospital staff,"*" not giving additional fluids of any kind to infants on a routine basis," and the provision of close contact between mother and infant involving such practices a s rooming-in and mother-infant combined all encourage breastfeeding. Each of these practices has been well re~earched.".'~For example, Salariya et al. studied two variables, the time of initiation and the frequency of breastfeeding, and their relationship with breastfeeding in
111 mothers.' Using a random design and following the mothers for a period of 18 months, these researchers concluded that successful breastfeeding was related both to time of initiation (within two hours of birth) and frequency of breastfeeds (at approximately two-hour intervals). Several studies have shown the importance of accurate information and help during the early days of breastfeeding. Ladas studied 756 mothers in 1970, and found in her descriptive study that lack of information was related to all of the reasons given for premature discontinuation.'6 In another study, Eastham et al. examined 63 women and assessed their technical knowledge regarding breastfeeding.17Women who were better informed did better than women who were less informed. Minchin reviewed studies suggesting that cow's milk-based for-
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Many breastfeeding mothers still encounter problems and discontinue breastfeeding earlier than desired. mula given to neonates increases the incidence of atopic disease in those infants." In regard to other forms of supplementation, Herrera studied 136 breastfed infants in Baltimore in 1982.'' These infants were either routinely supplemented with glucose water or were not supplemented. At three months after birth, 81% of the unsupplemented infants were exclusively breastfed, compared with 53% of infants in the supplemented group. Although other studies have found no difference in similar groups, no studies have ever demonstrated that supplementation has benefits for the infant or mother. For example, Gray-Donald et al. found in their study of 1,402 newborns that formula supplementation was associated with reduced duration of breastfeeding.18 These researchers suggested that supplementation was a marker of problems rather than a cause of discontinuation. Contact between mother and infant, involving rooming-in and combined mother-infant nursing care, has been the subject of much r e ~ e a r c h . ' ~Sousa . ' ~ et al. examined the duration of breastfeeding in three groups of mother^.'^ Mothers with early skin-to-skin contact with their infants breastfed their infants significantly longer than those who were separated from their infants for a 12hour p e r i ~ d . ' ~ Are these practices consistently implemented as part of routine nursing care in hospitals? Several studies report that such practices are not r o ~ t i n e . 'For ~ ~ example, ~~ Hanvey and Post carried out a national questionnaire-based study
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of all hospitals in Canada and found that many well-established breastfeeding practices were not reported as being routine. Both Field and Filshie et al., using semistructured questionnaires" and observation,22respectively, found that hospital postpartum care did not always reflect the needs of mothers and infants. Field interviewed 44 mothers using a semistructured questionnaire and found that mothers frequently perceived that support was lacking during the postpartum period." As a result, the authors surveyed the existing nursing care policies and practices in hospitals in Alberta to examine whether or not nursing care of breastfeeding mothers during the first few days after birth reflected researchbased information.
METHODS Purpose and Sample The aim of this study was to identify existing hospital policies and practices that may enhance or hinder the establishment of breastfeeding. A questionnaire was mailed to directors of nursing in all Alberta hospitals with maternity beds (N = 104). A sample of 60 obstetric staff nurses was then obtained by asking directors of nursing (selected according to hospital size and area of the province) to distribute the questionnaire within their hospitals. A response rate of 93% (n = 97) of the directors of nursing and 77% (n = 46) of the staff nurses was achieved. Instrument A 39-item, semistructured questionnaire was developed by the authors.* This questionnaire was * A copy of the questionnaire can be obtained from the authors. (See address for correspondence.)
tested for content validity by a representative panel of clinicians and expert academics. Reliability was not established. The questionnaire covered a range of postpartum practices, from ward teaching to infant feeding. For the purposes of this article, only the areas directly affecting breastfeeding will be discussed. Procedure Respondents could check categories and add their own comments to each question. Responses to the questions were analyzed in two ways: the response categories were coded and entered onto a computer, where they were analyzed using the Statistical Package for Social Sciences program (SPPXs) and a content analysis was undertaken on the respondents' comments to each question. The assumption was made that directors of nursing (referred to as agency respondents) would reflect nursing policies in each institution, whereas staff nurse respondents would more clearly reflect actual nursing practice. For this reason, responses are reported for both groups separately. The different methods used in sampling both groups made applying tests of difference to the groups impossible. Thus, levels of significant difference are not given. Results were also analyzed according to the size of the institution (primary-, secondary-, or tertiary-care hospital). Because of the difference in numbers in each of these institutional groups (80 primary, 13 secondary, and 4 tertiary), tests of difference were not applied.
RESULTS First Breastfeed The majority of agency respondents (n = 74) indicated that infants were encouraged to breastfeed for the first time within two
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hours of delivery. Staff nurses reported that this figure may be even higher; 40 of the 46 staff nurses noted that infants would be offered the breast within two hours of birth. Twenty-six agency and 12 staff nurse respondents indicated that the infants would be offered the breast immediately after delivery. Twelve agency respondents and two staff nurses indicated that mothers and infants would wait two to eight hours after birth for the first breastfeed. Only 56 of the 97 agency respondents indicated that breastfed infants always had their first feeds from the breast, and 27 agency respondents indicated that breastfed infants sometimes had their first feeds from the breast. Twenty-three of the staff nurses always offered the breast a s the first feed. Nineteen nurses sometimes offered the breast as the first feed, with one staff nurse indicating that infants never had their first feeds from the breast. Of the substitute feeds given to infants as their first feed, the most common was water (64 agency respondents and 35 staff nurse respondents). Feeding Schedules
Agency and staff nurse respondents were in agreement that feeding breastfed infants when they cried o r appeared to be hungry was more common than feeding them on a fixed schedule (81 agency nurse and 32 staff nurse respondents). However, feeding schedules did still apply in some cases, especially to infants who weighed less than 2,500 g and during the first day or two after birth. The majority of staff nurses (n = 37) fed small infants every three hours. Nineteen agency respondents noted two feeds per hour for infants weighing less than 2,500 g, with 45 agency respondents reporting a three-feeds-perhour schedule. For infants weigh-
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Table 1. Additional Fluids Given to Breastfed Infants
Supplements between Breastfeeds
Fluid Water Glucose Formula Water and Glucose Water and Formula Glucose and Formula Water and Glucose and Formula Total Formula Total Additional Fluids
Complements with Breastfeeds
Agency Respondents (n = 97)
Staff Nurses (n = 46)
Agency Respondents (n = 97)
Staff Nurses (n = 46)
8 13
2 7 3 3 6 10 13 32 44
10 16 15 10 5 14 9 43 79
5 14 7 2 4 5
8 8 6 19 21 54 83
ing more than 2,500 g, 33 staff nurses and 44 agency respondents recommended four feeds per hour during the first day after birth. Length of Feeding Time
The majority of respondents indicated that mothers were advised to restrict the sucking time of their infants at the breast (62 of 97 agency nurses and 40 of 46 staff nurse respondents). The degree of restriction varied from allowing the infant to feed for as little as two minutes per breast per feed, to five minutes initially. N o agency o r staff nurse respondents indicated any problems with mothers choosing to breastfeed during the night. Ninetythree agency respondents and 40 staff nurses indicated that mothers could choose to breastfeed at night. No one refused to permit the practice. No one reported that any respondents actually encouraged breastfeeding at night. Supplementation and Complementation
Participants were also asked about additional fluids given to breastfed infants (Table 1). A small number of agency respon-
6 22 43
dents or staff nurses indicated that infants were never routinely supplemented between feedings (13 agency and 2 staff nurse respondents). All other infants were reported to be supplemented “always” or “occasionally.” Supplementation occurred in all classifications of hospitals. Of interest, however, was that no tertiary-care agency respondent or staff nurse respondent reported that infants were “always” supplemented. Of additional interest were the reports of 54 agency respondents and 32 staff nurse respondents that infants were likely to be routinely supplemented with formula (Table 1). Responses to the questions on complementary feeding of breastfed infants were similar to those of supplementary feeding (Table 1). Giving complementary feeds was routine either “always” (18 agency and 13 staff nurse respondents) o r “occasionally” (63 agency respondents and 29 staff nurse respondents). The types of fluids given were similar in nature to those given as supplementary feeds. Again, formula was used for a large number of infants. A number of respondents (n = 8) reported that giving additional fluids to infants was often a decision made by the medical staff, rather
November/December 1988 JOGNN
than the nursing staff. However, 28 agency respondents and 17 staff nurses noted that they still gave formula samples to breastfeeding mothers on discharge from hospital. Only 11 agency respondents and 10 staff nurse respondents indicated that infants could be supplemented with breastmilk from other mothers if necessary. The majority of respondents indicated that this was not possible at their institutions. The ability to use breastmilk from other mothers was substantially greater in tertiary-care institutions than in other hospitals, presumably because of the proximity of safe milk banking facilities.
infant to gain weight, and sore or bleeding nipples were also given as reasons for discontinuation of breastfeeding. Lethargy, prematurity, or a need for oxygen by the newborn were also cited a s reasons for discontinuing breastfeeding, though pumping of the breasts was recommended in these cases. In cases of maternal surgery, such a s tuba1 ligation, breastfeeding was continued once the mother’s condition stabilized. Cesarean section, with complications, was cited a s a contraindication t o breastfeeding, but the complications were not elucidated.
Routine Test Weighing
Respondents were asked if mothers were taught to express their breastmilk by a particular method. The most common combination of methods was hand and hand pump (45 agency and 16 staff nurse respondents). Use of t h e electric pump was rare.
Twenty-one agency respondents and nine staff nurses indicated that routine test weighing of infants before and after breastfeeding was a normal practice. Test weighing involves weighing the infant before and after feedings to assess the amount of feeding in terms of the weight differential. Only one of the tertiarycare hospitals reported routine test weighing as a normal practice.
Medical Reasons for Interrupting Breastfeeding Respondents were asked whether there were ever any occasions when t h e infant was stopped from breastfeeding while in the hospital for medical reasons. Sixty-seven agency respondents and 31 staff nurses reported awareness of such cases in their institutions. The most common reason given for this occurrence was jaundice and/or an elevated bilirubin level. The second most common reason given was if the mother was given antibiotics to combat infection. A temperature higher than 38.5”C, until a diagnosis was made, signs of mastitis or a breast abscess, failure of the
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Expression of Breastmilk
Teaching Breastfeeding Techniques All staff nurses indicated that all mothers were taught breastfeeding techniques (two agency respondents indicated that this was not the case). Staff nurses who most commonly taught these techniques were from all areas; delivery room, postpartum unit, and nursery. Seventeen agency respondents and four staff nurses indicated that one nurse in the hospital had special responsibility for breastfeeding. The majority of respondents who indicated that one nurse had special responsibility were from smaller, primarycare institutions where the nurse with primary responsibility for infant feeding probably had primary responsibility for all other aspects of care. The role of the lactation consultant or specialist in Alberta hospitals was not evident.
Community Resource Referral A relatively small number of agency respondents (n = 17) and staff nurses (n = 7) indicated that breastfeeding mothers were routinely referred to La Leche League. The majority of respondents (91 agency and 39 staff nurse respondents) indicated that they routinely notified t h e community health nurse if t h e mother was having problems with breastfeeding on discharge from hospital. However, only three staff nurses thought t h e community health nurse would visit within 72 hours of discharge. Most staff nurses thought that t h e community health nurse would visit between one and two weeks after discharge.
DISCUSSION The findings of this study substantiate the findings of Hanvey and Post,Ig Field,’l and Filshie et a1.” that hospital postpartum care in Alberta is still less than flexible and does not always reflect the needs of the mothers and infants. In light of the extensive research in the field of breastfeeding in recent years, this lack of flexibility indicates a marked gap between theory, o r recommended standards of practice, and the reported practice in Alberta hospitals. However, the high response rate from respondents may indicate an active interest in the topic. Most infants in Alberta hospitals were breastfed within two hours of birth. Early initial breastfeeding is recommended in several studies because evidence exists that this practice is associated with successful breastfeeding. However, a majority of breastfed infants in this study were still routinely receiving fluids other than breastmilk as supplements and/or complements, or as a feed before the first breastfeedings. Substantial evi-
42 l
dence exists to indicate that this practice is detrimental to the infant in several ways. Supplementary and/or complementary feeding may cause feeding problems if the additional fluids are given by the b ~ t t l e , 'reduce ~ the infant's feeding at the breast and the stimulation of the milk upp ply,'^ and introduce foreign substances t o the infant at a vulnerable time with a subsequent increase in the risk of developing atopic disease." The practice of giving additional fluids to infants was specifically criticized at the World Health Organization's 39th World Health Assembly." Generally, infants were fed when they cried o r appeared hungry, rather than on a fixed schedule. This practice is in accord with the practices shown by a number of studies to stimulate the milk supply and encourage successful b r e a ~ t f e e d i n g . ' ~ How~'~ ever, seven staff nurses indicated that infants were still fed on a fixed schedule, despite the known detrimental effects of this practice on the successful establishment of breastfeeding. Small infants (< 2,500 g) were more frequently fed by fixed schedule than infants weighing more than 2,500 g. Again, this may reflect routine practice rather than practice that is assessed for the individual infant. Small infants, if healthy, also require unrestricted access to the breast. Some nurses indicated that infants weighing more than 2,500 g were more likely to be fed by fixed schedule on the first day after birth. This practice is of interest because stimulation of the milk supply is affected by the frequency of feeding on the first day.7 True flexibility in feeding requires unrestricted contact from the time of birth. The infant's time on the breast was still generally restricted. Studies have shown that this is an arbitrary practice that limits t h e
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milk supply and protects the nipples only when the infant is not properly positioned-a problem that is preventable with good technique and teaching."-30 The findings of a number of studies over a period of many years suggest that infants should be left to regulate their own intakes and to stimulate the supply of breastmilk as much as Such self-regulation should include breastfeeding at night, which does not appear to be a common practice in Alberta hospitals, although mothers can choose t o d o so. A difference, however, does exist between a practice that is encouraged and one that is merely allowed.
I
Hospital staff in Alberta have still not implemented the practices that are 1 known to be helpful in the establish ment of breastfeeding.
I
Mothers were often taught to express milk, but use of the electric breast pump was rare. This method is fast and efficient, and pumps are now available for rent at reasonable costs. This method may especially benefit mothers with infants in neonatal intensive care units and mothers who have to return to work. Perhaps mothers were not taught this method because electric pumps were not widely available on these postpartum wards. Routine test weighing was not reported to be a widespread practice. Reports have suggested that this practice is detrimental t o breastfeeding by raising mothers' anxiety levels, and thus, interfering with the milk supply. In addition, routine test weighing is notoriously inaccurate unless carried out using accurate electronic scales, which a r e rarely available.32 A s one respondent commented, assessing t h e infant's
weight gain over time is better than routine test weighing. However, a number of respondents indicated that routine test weighing is still being done in some hospitals, despite the possible detrimental effects of the practice. The most common medical reason given for discontinuing breastfeeding was the development of jaundice o r an elevated bilirubin level in the infant. However, new evidence suggests that discontinuation of breastfeeding is not t h e correct management of jaundice, except in rare case^.^^-^' De Carvalho et al. postulate that the correct management of jaundice is to increase the amount of b r e a ~ t f e e d i n g .This ~ ~ decision is generally made by physicians. One must question whether these physicians are aware of the possible detrimental effects of this practice on the success of breastfeeding. Other medical indicators for discontinuation can be questioned. Mastitis resolves better if t h e mother breastfeeds freq ~ e n t l y . Sore ~ ~ . ~and ~ bleeding nipples are caused by incorrect positioning of the infant at the breast and will resolve with correct positioning rather than discontinuation of brea~tfeeding.~'-~~ In addition, failure to gain weight is rarely caused by breastfeeding but is more commonly a sign of a need for improvement in feeding technique." The lack of facilities for feeding infants with expressed milk was apparent. Milk banking facilities were not reported as being widely available in the province. This lack of facilities is a matter of concern because milk from other mothers has been shown to be a safe substitute for the infant's own mother's milk and is preferable to giving formula milk in many instance~.~'.~' Some hospitals still continue a policy of distributing packs of
Novernber/Decernber 1988 JOCNN
formula milk to breastfeeding mothers on discharge. However, this practice has been demonstrated to be detrimental to the In adsuccess of brea~tfeeding.4~ dition, this practice is in contravention to the World Health Organization Code of Marketing Breast Milk Substitutes, to which Canada is a signat01-y.~~ However, many of the comments regarding this practice indicated an increasing awareness of the detrimental effects of providing cow’s milk substitutes for breastfeeding infants. In addition, the reported incidence of distribution of the formula gift packs was less than that reported in Myres’ study in 1979 in which 80% of hospitals were distributing these p a ~ k s . 4 ~ NURSING IMPLICATIONS
Infant feeding practice needs to be more firmly based on tested practices. Flexible, frequent feeding; unrestricted feeding times; no additional fluids for breastfed infants; and breastfeeding as the first feeding for breastfed infants all need to be consistently implemented when appropriate. These previously tested and wellgrounded practices are still not reported to be common in Alberta hospitals. As a result, the medical reasons given for the discontinuation of breastfeeding must be clearly examined in the light of current knowledge. This is one area where cooperation and consultation between medical and nursing staff would be of great benefit. In addition, the routine use of test weighing in light of the detrimental effects on milk supply and the distribution of gift packs of formula milk to breastfeeding mothers on discharge from hospital should be questioned. Staff who teach infant feeding should be knowledgeable in the area, and have their knowledge updated to encourage accurate, consistent, advice to breastfeedNovember/December 1988 JOCNN
ing mothers. Written ward protocols need to be developed to encourage consistent teaching and advice, especially in the area of infant feeding. These protocols should be based on updated literature and input from mothers regarding the areas of need.
In this descriptive study, 97 directors of nursing and 46 staff nurses from hospitals in Alberta, Canada, responded to a questionnaire, identifying policies and practices affecting breastfeeding in Alberta hospitals. Further use could be made of the specialized voluntary support groups for postpartum mothers. Referral to these groups by ward staff could be more widespread. In addition, cooperation between medical and nursing staff in the postpartum area needs attention and improvement. In this study, some nursing staff were aware of needed changes in practice but were not able to alter practice without the approval of physicians. The implications of the need for medical and nursing cooperation in the care of postpartum women must be assessed and discussed. Recommendations for Future Research
Further research is required on the discrepancy between knowledge and practice. How can we best educate nurses to give consistent, soundly based information and assistance to postpartum mothers? Examination of the knowledge and practices of nursing and medical staff, and the best means of communication between medical and nursing staff, is also required. Finally, the development of the lactation consultant role is a
new challenge to nurses. This role and the connection with success in breastfeeding also must be examined. CONCLUSIONS
This descriptive study examined the policies and practices regarding infant feeding in Alberta hospitals. The results of this study and an examination of the relevant literature indicate that care of breastfeeding mothers and infants in Alberta hospitals remains somewhat inflexible. Some reports suggest that this care is improving, notably in flexible feeding regimens, and the decrease in the frequency of giving formula gift packs to breastfeeding mothers on discharge from hospital. However, areas of care remain that should be examined in relation to the needs of the mothers and infants rather than the needs of hospital routines. ACKNOWLEDGMENT This study was funded by the Alberta Foundation for Nursing Research.
REFERENCES 1. Reiff, M.I., and S.M. Essock-Vitale. 1985. Hospital influences on early infant feeding practices. Pediatrics. 762372-79. 2. Winikoff, B., D. Myers, V.H. Laukaran, and R. Stone. 1987. Overcoming obstacles to breastfeeding in a large municipal hospital: Applications of lessons learned. Pediatrics. 80:423-32. 3. Fieldhouse, R. 1984. A revivial in breastfeeding. Can J Public Health. 75: 128-32. 4. World Health Organization. 1982. The prevalence and duration of breastfeeding: A critical review of available information. World Health Stat Q. 2:91-117. 5. Martin, J., and J. Monk. 1982. Infant feeding 1980. London, OPCSI DHSS. 6. McNally, E., S. Hendricks, and 1. Horowitz. 1985. A look at breastfeeding trends in Canada: 1963-1982. Can J Public Health. 75: 101-07.
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7. Salariya, E., P. Easton, and J. Cater. 1978. Duration of breastfeeding after early initiation and frequent feeding. Lancet. 2:114143. 8. De Chateau, P., and J. Winberg. 1978. Immediate postpartum suckling contact a n d duration of breastfeeding. Journal o f Maternal and Child Health. 3:392-95. 9. Houston, M.J., P.W. Howie, and A S . McNeilly. 1983. Midwifery forum: Breastfeeding. Nursing Mirror. 156(Suppl):i-viii. 10. Fisher, C. 1981. Breastfeeding: A midwife’s view. Journal o f Maternal and Child Health. 6:52-57. 11. Minchin, M. 1985. Breastfeeding matters. Melbourne, Australia: Alma Publications/George Allen & Unwin. 12. Herrera, A.J. 1984. Supplemented versus unsupplemented breastfeeding. Perinatology/Neonatology. 8~70-71. 13. Sousa, R., J.H. Kennell, M. Klaus, and J. Urrutia. 1976. The effect of early mother-infant contact o n breastfeeding, infection and growth. In Breastfeeding and the mother, 179-93. Amsterdam: Ciba Foundation Symposium. 14. Cole, J.P. 1977. Breastfeeding in the Boston suburbs in relation to personal-social factors. Clin. Pediatr. 16:352-56. 15. Solberg, S. 1984. Indicators of successful breast feeding. In Maternal and infant health care: Recent Advances in Nursing Series, ed. M.J. Houston, 26-48. Edinburgh, Melbourne, New York: Churchill Livingstone. 16. Ladas, A.K. 1972. Information and social support as factors in t he outcome of breast feeding. Journal o f Applied Behavioural Science. 8:110-14. 17. Eastham, E., D. Smith, D. Poole, and G. Neligan. 1976. Further decline in breastfeeding. Br Med J. 1:305-07. 18. Dusdieker, L.B., B.M. Booth, P.J. Stumbo, and J.M. Eichenberger. 1985. Effect of supplemental fluids on human milk production. J Pediatr. 106:207-1 l. 18. Gray-Donald, K., M.S. Kramer, S. Munday, and D.G. Leduc. 1985. Effect of formula supplementation in the hospital on t he duration of breastfeeding: A controlled clinical trial. Pediatrics. 75:514-18. 19. Hanvey, L., and S. Post. 1986. Changing patterns in maternity care. Can Nurs. 82:28-34. 20. Ellis, D.M., and R.J. Hewat. 1983.
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Do nurses help or hinder mothers who breastfeed? J Adu Nurs. 8:281-88. Field, P.A. 1985. Parents’ reactions t o maternity care. Midwifery. 1:37-46. Filshie, S., J. Williams, M. O s bourn, O.E. Seniour, E.M. Symonds, and E.N.M. Baskett. 1981. Post-natal care in hospital-time for change. Int J Nurs Stud. 18:8995. Riordan, J. 1983. A practical guide to breastfeeding. St. Louis, Toronto, London: C.V. Mosby Co. Neville, M.R. 1983. Regulation o f mammary development and lactation, ed. M.C. Neville and M.R. Meifert, 104-33. New York and London: Plenum Press. World Health Organization. 1986. Infant and young child feeding. Thirty-Ninth World Health Assembly, Agenda Item 21. Neifert, M.R., a n d J.N. Seacat. 1986. A guide to successful breastfeeding. Contemporary Pediatrics. :6-2 1. Sjolin, S., Y. Hofvander, and C. Hillervik. 1977. Factors related to early termination of breastfeeding. Acta Paediatr Scand. 66:50511. Woolridge, M. 1986. The anatomy of infant sucking. Midwifery. 2:164-71. De Carvalho, M., S. Roberston, and M. Klaus. 1984. Does the duration and frequency of early breastfeeding affect nipple pain? Birth. 11~81-84. Illingworth, R.S., and D.G. Stone. 1952. Demand feeding in a maternity unit. Lancet. 1:683. De Chateau, P., H. Homberg, K. Jakobseen, and J. Winberg. 1977. A study of factors promoting and inhibiting lactation. Deu Med Child Neurol. 19:575-84. Houston, M.J., P.A. Howie, and A S . McNeilly. 1983. Factors affecting the duration of breastfeeding: 1;Measurement of breastmilk intake in t h e first week of life. Early Hum Deue. 8:49-54. Lascari, A.D. 1986. “Early” breastfeeding jaundice: Clinical significance. J Pediatrics. 108:156-58. De Carvalho, M., M. Klaus, and R.B. Merkatz. 1982. Frequency of breastfeeding and serum bilirubin concentration. A m J Dis Child. 136~737-38. Auerbach, K.A., and L.M. Gartner. 1987. Breastfeeding and human milk: Their association with jaundice in t h e neonate. ed. R.A.
Lawrence. Clin Perinatol. 14:89108. 36. Dilts, C.L. 1985. Nursing management of mastitis due t o breastfeeding. JOCNN. 14:286-88. 37. Thomsen, A.C., T. Espersen, and S. Maigaard. 1984. Course and treatment of milk stasis, non-infectious inflammation of the breast, and infectious mastitis in nursing women. Am J Obstet Cyn. 149:49295. 38. Woolridge, M. 1986. The aetiology of sore nipples. Midwifery. 2:16476. 39. Gunther, M. 1945. Sore nipples; causes and prevention. Lancet. 2:590. 40. Gunther, M. 1973. Infant feeding. London: Penguin Books. 41. Asquith, M.T., P.W. Pedrotti, D.K. Stevenson, and P. Sunshine. 1987. Clinical uses, collection and banking of human milk. ed. R.A. Lawrence. Clin Perinatol. 14:17386. 42. Cash, J., and G.P. Giacoia. 1981. Organization and operation of a human milk bank. JOCN Nurs. 10~434-38. 43. Bergevin, Y., C. Dougherty, and M.S. Kramer. 1983. Do infant formula samples shorten the duration of breastfeeding? Lancet. May: 1148-51. 44. World Health Organization. 1981. International Code o f Marketing Breastmilk Substitutes. Geneva: World Health Organization. 45. Myres, A.W. 1979. A retrospective look at infant feeding practices in Canada. Journal o f the Canadian Dietetic Association. 40:20 1- 10.
Address for correspondence: Peggy Anne Field, Faculty of Nursing, University of Alberta, 3-1 18, Clinical Sciences Building, Edmonton, Alberta, Canada T6G 2G3.
Mary J. Renfrew Houston is a midwifery researcher at the National Perinatal Epidemiology Unit, Radcliffe Infirmary, in Oxford, England. Dr. Houston is a member of the Royal College of Midwives, and the Alberta Association of Midwives. Peggy Anne Field is a professor of nursing at the University of Alberta in Edmonton, Alberta, Canada. Dr. Field is a member of NAACOG, the Alberta Association of Registered Nurses, and the Alberta Association of Midwives.
November/December 1988 JOCNN
REFEREE REVIEWERS Debbie Fraser Askin, RNC, BN St. Boniface General Hospital Winnipeg, Manitoba, Canada Susan Scheuring Barleben, RN, MSN. FNCC Colorado University School of Nursing Denver, Colorado Claudia Anderson Beckmann, R N , PhD Northwestern University Chicago, Illinois Charles R. B. Beckmann, MD, FACOG University of Illinois College of Medicine Chicago, Illinois Marie Annette Brown, RN, PhD, WHCNP University of Washington School of Nursing Seattle, Washington Jimmie Cash, RN, MSN St. Francis Hospital Tulsa, Oklahoma Gwen E. Chute, RN, MS, IBCLC University of North Dakota Grand Forks, North Dakota Ann Estes Edgil, RN. DSN University of Alabama School of Nursing Birmingham, Alabama Janice Gay, R N , DSN University of Alabama School of Nursing Birmingham, Alabama Larry Griffin, MD, FACOG Louisville, Kentucky
Judith Harris, RNC, M N Oklahoma Perinatal Continuing Education Program Oklahoma City, Oklahoma Roberta Karlman, MD Loyola University Medical Center Maywood, Illinois Michelle S. Knolla, MD, FACOG Omaha, Nebraska
Alicia Poslosky, R N , MSN Wilford Hall USAF Medical Center San Antonio, Texas Sharon B. Schnare, RN, MSN Harbor-UCLA Medical Center Torrance, California James Speichinger, MD. FACOG Madison, Wisconsin
Marcia Killien, R N , PhD University of Washington School of Nursing Seattle, Washington
Linda Staurovsky, R N , M N , C N M The University of Texas Health Science Center School of Nursing San Antonio, Texas
Debra L. Luegenbiehl, R N , PhD Union Hospital Terre Haute, Indiana
Claire W. Surr, RNC, MEd, CDE FAMESa' Therapies Westchester, Pennsylvania
Katharyn Antle May, R N , DNSc Vanderbilt University School of Nursing Nashville, Tennessee
Sharon Thee, R N , MSN, MA University of Iowa Child-Health Specialty Clinics Spencer, Iowa
Nancy J. McKee, R N , DNS Indiana State University School of Nursing Terre Haute, Indiana
Nan H. Troiano, R N , MSN Vanderbilt University Nashville, Tennessee
Anne E. McCormick, R N , MS Lincolnwood, Illinois
Joyce Marilyn Vickers, CNM, NPC Naval Branch Hospital Twentynine Palms, California
Mary L. Neumann, RNC, BSN Methodist Hospital Omaha, Nebraska Ellen Olshansky, RNC. DNSc University of Washington School of Nursing Seattle, Washington Patricia Pollert, RNC St. Luke's Hospitals Fargo, North Dakota
Susan Weekly, R N , BSN Methodist Hospital Omaha, Nebraska Mary Ann Wilson, RNC, MS Kaiser-Permanente East Hartford, Connecticut James Wheeler, MD, FACOG Yale University School of Medicine New Haven, Connecticut
I ATTENTION NAACOG MEMBERS
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Don't run the risk of not receiving future copies of JOGNN. Renew your NAACOG membership as soon as your membership renewal notice arrives in the mail. I
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Duration of breastfeeding is affected by the care given during the immediate postpartum period.'*' Indeed, the factors that affect breastfeeding during the first few days after birth have been the subject of extensive research during the past 10 to 15 years. Despite knowledge of the need for certain practices at this time, nursing care is still not always based on research findings. This is evidenced by the rapid rate of discontinuation of breastfeeding despite the increasing numbers of women choosing to breastfeed their inf a n t ~In. ~fact, ~ ~the discontinuation rate has shown little sign of improvement during the past 10 years, although nurses have become much more aware of t h e helpful and detrimental practices in this important Accepted: March 1988
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LITERATURE REVIEW
What are the helpful factors in the initiation of breastfeeding? A wealth of research has demonstrated that initiation of breastfeeding within the first two hours after the ability of mothers to breastfeed frequently and without a fixed schedule,739early and consistent support and teaching from hospital staff,"*" not giving additional fluids of any kind to infants on a routine basis," and the provision of close contact between mother and infant involving such practices a s rooming-in and mother-infant combined all encourage breastfeeding. Each of these practices has been well re~earched.".'~For example, Salariya et al. studied two variables, the time of initiation and the frequency of breastfeeding, and their relationship with breastfeeding in
111 mothers.' Using a random design and following the mothers for a period of 18 months, these researchers concluded that successful breastfeeding was related both to time of initiation (within two hours of birth) and frequency of breastfeeds (at approximately two-hour intervals). Several studies have shown the importance of accurate information and help during the early days of breastfeeding. Ladas studied 756 mothers in 1970, and found in her descriptive study that lack of information was related to all of the reasons given for premature discontinuation.'6 In another study, Eastham et al. examined 63 women and assessed their technical knowledge regarding breastfeeding.17Women who were better informed did better than women who were less informed. Minchin reviewed studies suggesting that cow's milk-based for-
Novernber/Decernber 1988 JOGNN
Many breastfeeding mothers still encounter problems and discontinue breastfeeding earlier than desired. mula given to neonates increases the incidence of atopic disease in those infants." In regard to other forms of supplementation, Herrera studied 136 breastfed infants in Baltimore in 1982.'' These infants were either routinely supplemented with glucose water or were not supplemented. At three months after birth, 81% of the unsupplemented infants were exclusively breastfed, compared with 53% of infants in the supplemented group. Although other studies have found no difference in similar groups, no studies have ever demonstrated that supplementation has benefits for the infant or mother. For example, Gray-Donald et al. found in their study of 1,402 newborns that formula supplementation was associated with reduced duration of breastfeeding.18 These researchers suggested that supplementation was a marker of problems rather than a cause of discontinuation. Contact between mother and infant, involving rooming-in and combined mother-infant nursing care, has been the subject of much r e ~ e a r c h . ' ~Sousa . ' ~ et al. examined the duration of breastfeeding in three groups of mother^.'^ Mothers with early skin-to-skin contact with their infants breastfed their infants significantly longer than those who were separated from their infants for a 12hour p e r i ~ d . ' ~ Are these practices consistently implemented as part of routine nursing care in hospitals? Several studies report that such practices are not r o ~ t i n e . 'For ~ ~ example, ~~ Hanvey and Post carried out a national questionnaire-based study
November/December 1988 JOCNN
of all hospitals in Canada and found that many well-established breastfeeding practices were not reported as being routine. Both Field and Filshie et al., using semistructured questionnaires" and observation,22respectively, found that hospital postpartum care did not always reflect the needs of mothers and infants. Field interviewed 44 mothers using a semistructured questionnaire and found that mothers frequently perceived that support was lacking during the postpartum period." As a result, the authors surveyed the existing nursing care policies and practices in hospitals in Alberta to examine whether or not nursing care of breastfeeding mothers during the first few days after birth reflected researchbased information.
METHODS Purpose and Sample The aim of this study was to identify existing hospital policies and practices that may enhance or hinder the establishment of breastfeeding. A questionnaire was mailed to directors of nursing in all Alberta hospitals with maternity beds (N = 104). A sample of 60 obstetric staff nurses was then obtained by asking directors of nursing (selected according to hospital size and area of the province) to distribute the questionnaire within their hospitals. A response rate of 93% (n = 97) of the directors of nursing and 77% (n = 46) of the staff nurses was achieved. Instrument A 39-item, semistructured questionnaire was developed by the authors.* This questionnaire was * A copy of the questionnaire can be obtained from the authors. (See address for correspondence.)
tested for content validity by a representative panel of clinicians and expert academics. Reliability was not established. The questionnaire covered a range of postpartum practices, from ward teaching to infant feeding. For the purposes of this article, only the areas directly affecting breastfeeding will be discussed. Procedure Respondents could check categories and add their own comments to each question. Responses to the questions were analyzed in two ways: the response categories were coded and entered onto a computer, where they were analyzed using the Statistical Package for Social Sciences program (SPPXs) and a content analysis was undertaken on the respondents' comments to each question. The assumption was made that directors of nursing (referred to as agency respondents) would reflect nursing policies in each institution, whereas staff nurse respondents would more clearly reflect actual nursing practice. For this reason, responses are reported for both groups separately. The different methods used in sampling both groups made applying tests of difference to the groups impossible. Thus, levels of significant difference are not given. Results were also analyzed according to the size of the institution (primary-, secondary-, or tertiary-care hospital). Because of the difference in numbers in each of these institutional groups (80 primary, 13 secondary, and 4 tertiary), tests of difference were not applied.
RESULTS First Breastfeed The majority of agency respondents (n = 74) indicated that infants were encouraged to breastfeed for the first time within two
419
hours of delivery. Staff nurses reported that this figure may be even higher; 40 of the 46 staff nurses noted that infants would be offered the breast within two hours of birth. Twenty-six agency and 12 staff nurse respondents indicated that the infants would be offered the breast immediately after delivery. Twelve agency respondents and two staff nurses indicated that mothers and infants would wait two to eight hours after birth for the first breastfeed. Only 56 of the 97 agency respondents indicated that breastfed infants always had their first feeds from the breast, and 27 agency respondents indicated that breastfed infants sometimes had their first feeds from the breast. Twenty-three of the staff nurses always offered the breast a s the first feed. Nineteen nurses sometimes offered the breast as the first feed, with one staff nurse indicating that infants never had their first feeds from the breast. Of the substitute feeds given to infants as their first feed, the most common was water (64 agency respondents and 35 staff nurse respondents). Feeding Schedules
Agency and staff nurse respondents were in agreement that feeding breastfed infants when they cried o r appeared to be hungry was more common than feeding them on a fixed schedule (81 agency nurse and 32 staff nurse respondents). However, feeding schedules did still apply in some cases, especially to infants who weighed less than 2,500 g and during the first day or two after birth. The majority of staff nurses (n = 37) fed small infants every three hours. Nineteen agency respondents noted two feeds per hour for infants weighing less than 2,500 g, with 45 agency respondents reporting a three-feeds-perhour schedule. For infants weigh-
420
Table 1. Additional Fluids Given to Breastfed Infants
Supplements between Breastfeeds
Fluid Water Glucose Formula Water and Glucose Water and Formula Glucose and Formula Water and Glucose and Formula Total Formula Total Additional Fluids
Complements with Breastfeeds
Agency Respondents (n = 97)
Staff Nurses (n = 46)
Agency Respondents (n = 97)
Staff Nurses (n = 46)
8 13
2 7 3 3 6 10 13 32 44
10 16 15 10 5 14 9 43 79
5 14 7 2 4 5
8 8 6 19 21 54 83
ing more than 2,500 g, 33 staff nurses and 44 agency respondents recommended four feeds per hour during the first day after birth. Length of Feeding Time
The majority of respondents indicated that mothers were advised to restrict the sucking time of their infants at the breast (62 of 97 agency nurses and 40 of 46 staff nurse respondents). The degree of restriction varied from allowing the infant to feed for as little as two minutes per breast per feed, to five minutes initially. N o agency o r staff nurse respondents indicated any problems with mothers choosing to breastfeed during the night. Ninetythree agency respondents and 40 staff nurses indicated that mothers could choose to breastfeed at night. No one refused to permit the practice. No one reported that any respondents actually encouraged breastfeeding at night. Supplementation and Complementation
Participants were also asked about additional fluids given to breastfed infants (Table 1). A small number of agency respon-
6 22 43
dents or staff nurses indicated that infants were never routinely supplemented between feedings (13 agency and 2 staff nurse respondents). All other infants were reported to be supplemented “always” or “occasionally.” Supplementation occurred in all classifications of hospitals. Of interest, however, was that no tertiary-care agency respondent or staff nurse respondent reported that infants were “always” supplemented. Of additional interest were the reports of 54 agency respondents and 32 staff nurse respondents that infants were likely to be routinely supplemented with formula (Table 1). Responses to the questions on complementary feeding of breastfed infants were similar to those of supplementary feeding (Table 1). Giving complementary feeds was routine either “always” (18 agency and 13 staff nurse respondents) o r “occasionally” (63 agency respondents and 29 staff nurse respondents). The types of fluids given were similar in nature to those given as supplementary feeds. Again, formula was used for a large number of infants. A number of respondents (n = 8) reported that giving additional fluids to infants was often a decision made by the medical staff, rather
November/December 1988 JOGNN
than the nursing staff. However, 28 agency respondents and 17 staff nurses noted that they still gave formula samples to breastfeeding mothers on discharge from hospital. Only 11 agency respondents and 10 staff nurse respondents indicated that infants could be supplemented with breastmilk from other mothers if necessary. The majority of respondents indicated that this was not possible at their institutions. The ability to use breastmilk from other mothers was substantially greater in tertiary-care institutions than in other hospitals, presumably because of the proximity of safe milk banking facilities.
infant to gain weight, and sore or bleeding nipples were also given as reasons for discontinuation of breastfeeding. Lethargy, prematurity, or a need for oxygen by the newborn were also cited a s reasons for discontinuing breastfeeding, though pumping of the breasts was recommended in these cases. In cases of maternal surgery, such a s tuba1 ligation, breastfeeding was continued once the mother’s condition stabilized. Cesarean section, with complications, was cited a s a contraindication t o breastfeeding, but the complications were not elucidated.
Routine Test Weighing
Respondents were asked if mothers were taught to express their breastmilk by a particular method. The most common combination of methods was hand and hand pump (45 agency and 16 staff nurse respondents). Use of t h e electric pump was rare.
Twenty-one agency respondents and nine staff nurses indicated that routine test weighing of infants before and after breastfeeding was a normal practice. Test weighing involves weighing the infant before and after feedings to assess the amount of feeding in terms of the weight differential. Only one of the tertiarycare hospitals reported routine test weighing as a normal practice.
Medical Reasons for Interrupting Breastfeeding Respondents were asked whether there were ever any occasions when t h e infant was stopped from breastfeeding while in the hospital for medical reasons. Sixty-seven agency respondents and 31 staff nurses reported awareness of such cases in their institutions. The most common reason given for this occurrence was jaundice and/or an elevated bilirubin level. The second most common reason given was if the mother was given antibiotics to combat infection. A temperature higher than 38.5”C, until a diagnosis was made, signs of mastitis or a breast abscess, failure of the
November/December 1988 JOGNN
Expression of Breastmilk
Teaching Breastfeeding Techniques All staff nurses indicated that all mothers were taught breastfeeding techniques (two agency respondents indicated that this was not the case). Staff nurses who most commonly taught these techniques were from all areas; delivery room, postpartum unit, and nursery. Seventeen agency respondents and four staff nurses indicated that one nurse in the hospital had special responsibility for breastfeeding. The majority of respondents who indicated that one nurse had special responsibility were from smaller, primarycare institutions where the nurse with primary responsibility for infant feeding probably had primary responsibility for all other aspects of care. The role of the lactation consultant or specialist in Alberta hospitals was not evident.
Community Resource Referral A relatively small number of agency respondents (n = 17) and staff nurses (n = 7) indicated that breastfeeding mothers were routinely referred to La Leche League. The majority of respondents (91 agency and 39 staff nurse respondents) indicated that they routinely notified t h e community health nurse if t h e mother was having problems with breastfeeding on discharge from hospital. However, only three staff nurses thought t h e community health nurse would visit within 72 hours of discharge. Most staff nurses thought that t h e community health nurse would visit between one and two weeks after discharge.
DISCUSSION The findings of this study substantiate the findings of Hanvey and Post,Ig Field,’l and Filshie et a1.” that hospital postpartum care in Alberta is still less than flexible and does not always reflect the needs of the mothers and infants. In light of the extensive research in the field of breastfeeding in recent years, this lack of flexibility indicates a marked gap between theory, o r recommended standards of practice, and the reported practice in Alberta hospitals. However, the high response rate from respondents may indicate an active interest in the topic. Most infants in Alberta hospitals were breastfed within two hours of birth. Early initial breastfeeding is recommended in several studies because evidence exists that this practice is associated with successful breastfeeding. However, a majority of breastfed infants in this study were still routinely receiving fluids other than breastmilk as supplements and/or complements, or as a feed before the first breastfeedings. Substantial evi-
42 l
dence exists to indicate that this practice is detrimental to the infant in several ways. Supplementary and/or complementary feeding may cause feeding problems if the additional fluids are given by the b ~ t t l e , 'reduce ~ the infant's feeding at the breast and the stimulation of the milk upp ply,'^ and introduce foreign substances t o the infant at a vulnerable time with a subsequent increase in the risk of developing atopic disease." The practice of giving additional fluids to infants was specifically criticized at the World Health Organization's 39th World Health Assembly." Generally, infants were fed when they cried o r appeared hungry, rather than on a fixed schedule. This practice is in accord with the practices shown by a number of studies to stimulate the milk supply and encourage successful b r e a ~ t f e e d i n g . ' ~ How~'~ ever, seven staff nurses indicated that infants were still fed on a fixed schedule, despite the known detrimental effects of this practice on the successful establishment of breastfeeding. Small infants (< 2,500 g) were more frequently fed by fixed schedule than infants weighing more than 2,500 g. Again, this may reflect routine practice rather than practice that is assessed for the individual infant. Small infants, if healthy, also require unrestricted access to the breast. Some nurses indicated that infants weighing more than 2,500 g were more likely to be fed by fixed schedule on the first day after birth. This practice is of interest because stimulation of the milk supply is affected by the frequency of feeding on the first day.7 True flexibility in feeding requires unrestricted contact from the time of birth. The infant's time on the breast was still generally restricted. Studies have shown that this is an arbitrary practice that limits t h e
422
milk supply and protects the nipples only when the infant is not properly positioned-a problem that is preventable with good technique and teaching."-30 The findings of a number of studies over a period of many years suggest that infants should be left to regulate their own intakes and to stimulate the supply of breastmilk as much as Such self-regulation should include breastfeeding at night, which does not appear to be a common practice in Alberta hospitals, although mothers can choose t o d o so. A difference, however, does exist between a practice that is encouraged and one that is merely allowed.
I
Hospital staff in Alberta have still not implemented the practices that are 1 known to be helpful in the establish ment of breastfeeding.
I
Mothers were often taught to express milk, but use of the electric breast pump was rare. This method is fast and efficient, and pumps are now available for rent at reasonable costs. This method may especially benefit mothers with infants in neonatal intensive care units and mothers who have to return to work. Perhaps mothers were not taught this method because electric pumps were not widely available on these postpartum wards. Routine test weighing was not reported to be a widespread practice. Reports have suggested that this practice is detrimental t o breastfeeding by raising mothers' anxiety levels, and thus, interfering with the milk supply. In addition, routine test weighing is notoriously inaccurate unless carried out using accurate electronic scales, which a r e rarely available.32 A s one respondent commented, assessing t h e infant's
weight gain over time is better than routine test weighing. However, a number of respondents indicated that routine test weighing is still being done in some hospitals, despite the possible detrimental effects of the practice. The most common medical reason given for discontinuing breastfeeding was the development of jaundice o r an elevated bilirubin level in the infant. However, new evidence suggests that discontinuation of breastfeeding is not t h e correct management of jaundice, except in rare case^.^^-^' De Carvalho et al. postulate that the correct management of jaundice is to increase the amount of b r e a ~ t f e e d i n g .This ~ ~ decision is generally made by physicians. One must question whether these physicians are aware of the possible detrimental effects of this practice on the success of breastfeeding. Other medical indicators for discontinuation can be questioned. Mastitis resolves better if t h e mother breastfeeds freq ~ e n t l y . Sore ~ ~ . ~and ~ bleeding nipples are caused by incorrect positioning of the infant at the breast and will resolve with correct positioning rather than discontinuation of brea~tfeeding.~'-~~ In addition, failure to gain weight is rarely caused by breastfeeding but is more commonly a sign of a need for improvement in feeding technique." The lack of facilities for feeding infants with expressed milk was apparent. Milk banking facilities were not reported as being widely available in the province. This lack of facilities is a matter of concern because milk from other mothers has been shown to be a safe substitute for the infant's own mother's milk and is preferable to giving formula milk in many instance~.~'.~' Some hospitals still continue a policy of distributing packs of
Novernber/Decernber 1988 JOCNN
formula milk to breastfeeding mothers on discharge. However, this practice has been demonstrated to be detrimental to the In adsuccess of brea~tfeeding.4~ dition, this practice is in contravention to the World Health Organization Code of Marketing Breast Milk Substitutes, to which Canada is a signat01-y.~~ However, many of the comments regarding this practice indicated an increasing awareness of the detrimental effects of providing cow’s milk substitutes for breastfeeding infants. In addition, the reported incidence of distribution of the formula gift packs was less than that reported in Myres’ study in 1979 in which 80% of hospitals were distributing these p a ~ k s . 4 ~ NURSING IMPLICATIONS
Infant feeding practice needs to be more firmly based on tested practices. Flexible, frequent feeding; unrestricted feeding times; no additional fluids for breastfed infants; and breastfeeding as the first feeding for breastfed infants all need to be consistently implemented when appropriate. These previously tested and wellgrounded practices are still not reported to be common in Alberta hospitals. As a result, the medical reasons given for the discontinuation of breastfeeding must be clearly examined in the light of current knowledge. This is one area where cooperation and consultation between medical and nursing staff would be of great benefit. In addition, the routine use of test weighing in light of the detrimental effects on milk supply and the distribution of gift packs of formula milk to breastfeeding mothers on discharge from hospital should be questioned. Staff who teach infant feeding should be knowledgeable in the area, and have their knowledge updated to encourage accurate, consistent, advice to breastfeedNovember/December 1988 JOCNN
ing mothers. Written ward protocols need to be developed to encourage consistent teaching and advice, especially in the area of infant feeding. These protocols should be based on updated literature and input from mothers regarding the areas of need.
In this descriptive study, 97 directors of nursing and 46 staff nurses from hospitals in Alberta, Canada, responded to a questionnaire, identifying policies and practices affecting breastfeeding in Alberta hospitals. Further use could be made of the specialized voluntary support groups for postpartum mothers. Referral to these groups by ward staff could be more widespread. In addition, cooperation between medical and nursing staff in the postpartum area needs attention and improvement. In this study, some nursing staff were aware of needed changes in practice but were not able to alter practice without the approval of physicians. The implications of the need for medical and nursing cooperation in the care of postpartum women must be assessed and discussed. Recommendations for Future Research
Further research is required on the discrepancy between knowledge and practice. How can we best educate nurses to give consistent, soundly based information and assistance to postpartum mothers? Examination of the knowledge and practices of nursing and medical staff, and the best means of communication between medical and nursing staff, is also required. Finally, the development of the lactation consultant role is a
new challenge to nurses. This role and the connection with success in breastfeeding also must be examined. CONCLUSIONS
This descriptive study examined the policies and practices regarding infant feeding in Alberta hospitals. The results of this study and an examination of the relevant literature indicate that care of breastfeeding mothers and infants in Alberta hospitals remains somewhat inflexible. Some reports suggest that this care is improving, notably in flexible feeding regimens, and the decrease in the frequency of giving formula gift packs to breastfeeding mothers on discharge from hospital. However, areas of care remain that should be examined in relation to the needs of the mothers and infants rather than the needs of hospital routines. ACKNOWLEDGMENT This study was funded by the Alberta Foundation for Nursing Research.
REFERENCES 1. Reiff, M.I., and S.M. Essock-Vitale. 1985. Hospital influences on early infant feeding practices. Pediatrics. 762372-79. 2. Winikoff, B., D. Myers, V.H. Laukaran, and R. Stone. 1987. Overcoming obstacles to breastfeeding in a large municipal hospital: Applications of lessons learned. Pediatrics. 80:423-32. 3. Fieldhouse, R. 1984. A revivial in breastfeeding. Can J Public Health. 75: 128-32. 4. World Health Organization. 1982. The prevalence and duration of breastfeeding: A critical review of available information. World Health Stat Q. 2:91-117. 5. Martin, J., and J. Monk. 1982. Infant feeding 1980. London, OPCSI DHSS. 6. McNally, E., S. Hendricks, and 1. Horowitz. 1985. A look at breastfeeding trends in Canada: 1963-1982. Can J Public Health. 75: 101-07.
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7. Salariya, E., P. Easton, and J. Cater. 1978. Duration of breastfeeding after early initiation and frequent feeding. Lancet. 2:114143. 8. De Chateau, P., and J. Winberg. 1978. Immediate postpartum suckling contact a n d duration of breastfeeding. Journal o f Maternal and Child Health. 3:392-95. 9. Houston, M.J., P.W. Howie, and A S . McNeilly. 1983. Midwifery forum: Breastfeeding. Nursing Mirror. 156(Suppl):i-viii. 10. Fisher, C. 1981. Breastfeeding: A midwife’s view. Journal o f Maternal and Child Health. 6:52-57. 11. Minchin, M. 1985. Breastfeeding matters. Melbourne, Australia: Alma Publications/George Allen & Unwin. 12. Herrera, A.J. 1984. Supplemented versus unsupplemented breastfeeding. Perinatology/Neonatology. 8~70-71. 13. Sousa, R., J.H. Kennell, M. Klaus, and J. Urrutia. 1976. The effect of early mother-infant contact o n breastfeeding, infection and growth. In Breastfeeding and the mother, 179-93. Amsterdam: Ciba Foundation Symposium. 14. Cole, J.P. 1977. Breastfeeding in the Boston suburbs in relation to personal-social factors. Clin. Pediatr. 16:352-56. 15. Solberg, S. 1984. Indicators of successful breast feeding. In Maternal and infant health care: Recent Advances in Nursing Series, ed. M.J. Houston, 26-48. Edinburgh, Melbourne, New York: Churchill Livingstone. 16. Ladas, A.K. 1972. Information and social support as factors in t he outcome of breast feeding. Journal o f Applied Behavioural Science. 8:110-14. 17. Eastham, E., D. Smith, D. Poole, and G. Neligan. 1976. Further decline in breastfeeding. Br Med J. 1:305-07. 18. Dusdieker, L.B., B.M. Booth, P.J. Stumbo, and J.M. Eichenberger. 1985. Effect of supplemental fluids on human milk production. J Pediatr. 106:207-1 l. 18. Gray-Donald, K., M.S. Kramer, S. Munday, and D.G. Leduc. 1985. Effect of formula supplementation in the hospital on t he duration of breastfeeding: A controlled clinical trial. Pediatrics. 75:514-18. 19. Hanvey, L., and S. Post. 1986. Changing patterns in maternity care. Can Nurs. 82:28-34. 20. Ellis, D.M., and R.J. Hewat. 1983.
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Lawrence. Clin Perinatol. 14:89108. 36. Dilts, C.L. 1985. Nursing management of mastitis due t o breastfeeding. JOCNN. 14:286-88. 37. Thomsen, A.C., T. Espersen, and S. Maigaard. 1984. Course and treatment of milk stasis, non-infectious inflammation of the breast, and infectious mastitis in nursing women. Am J Obstet Cyn. 149:49295. 38. Woolridge, M. 1986. The aetiology of sore nipples. Midwifery. 2:16476. 39. Gunther, M. 1945. Sore nipples; causes and prevention. Lancet. 2:590. 40. Gunther, M. 1973. Infant feeding. London: Penguin Books. 41. Asquith, M.T., P.W. Pedrotti, D.K. Stevenson, and P. Sunshine. 1987. Clinical uses, collection and banking of human milk. ed. R.A. Lawrence. Clin Perinatol. 14:17386. 42. Cash, J., and G.P. Giacoia. 1981. Organization and operation of a human milk bank. JOCN Nurs. 10~434-38. 43. Bergevin, Y., C. Dougherty, and M.S. Kramer. 1983. Do infant formula samples shorten the duration of breastfeeding? Lancet. May: 1148-51. 44. World Health Organization. 1981. International Code o f Marketing Breastmilk Substitutes. Geneva: World Health Organization. 45. Myres, A.W. 1979. A retrospective look at infant feeding practices in Canada. Journal o f the Canadian Dietetic Association. 40:20 1- 10.
Address for correspondence: Peggy Anne Field, Faculty of Nursing, University of Alberta, 3-1 18, Clinical Sciences Building, Edmonton, Alberta, Canada T6G 2G3.
Mary J. Renfrew Houston is a midwifery researcher at the National Perinatal Epidemiology Unit, Radcliffe Infirmary, in Oxford, England. Dr. Houston is a member of the Royal College of Midwives, and the Alberta Association of Midwives. Peggy Anne Field is a professor of nursing at the University of Alberta in Edmonton, Alberta, Canada. Dr. Field is a member of NAACOG, the Alberta Association of Registered Nurses, and the Alberta Association of Midwives.
November/December 1988 JOCNN
REFEREE REVIEWERS Debbie Fraser Askin, RNC, BN St. Boniface General Hospital Winnipeg, Manitoba, Canada Susan Scheuring Barleben, RN, MSN. FNCC Colorado University School of Nursing Denver, Colorado Claudia Anderson Beckmann, R N , PhD Northwestern University Chicago, Illinois Charles R. B. Beckmann, MD, FACOG University of Illinois College of Medicine Chicago, Illinois Marie Annette Brown, RN, PhD, WHCNP University of Washington School of Nursing Seattle, Washington Jimmie Cash, RN, MSN St. Francis Hospital Tulsa, Oklahoma Gwen E. Chute, RN, MS, IBCLC University of North Dakota Grand Forks, North Dakota Ann Estes Edgil, RN. DSN University of Alabama School of Nursing Birmingham, Alabama Janice Gay, R N , DSN University of Alabama School of Nursing Birmingham, Alabama Larry Griffin, MD, FACOG Louisville, Kentucky
Judith Harris, RNC, M N Oklahoma Perinatal Continuing Education Program Oklahoma City, Oklahoma Roberta Karlman, MD Loyola University Medical Center Maywood, Illinois Michelle S. Knolla, MD, FACOG Omaha, Nebraska
Alicia Poslosky, R N , MSN Wilford Hall USAF Medical Center San Antonio, Texas Sharon B. Schnare, RN, MSN Harbor-UCLA Medical Center Torrance, California James Speichinger, MD. FACOG Madison, Wisconsin
Marcia Killien, R N , PhD University of Washington School of Nursing Seattle, Washington
Linda Staurovsky, R N , M N , C N M The University of Texas Health Science Center School of Nursing San Antonio, Texas
Debra L. Luegenbiehl, R N , PhD Union Hospital Terre Haute, Indiana
Claire W. Surr, RNC, MEd, CDE FAMESa' Therapies Westchester, Pennsylvania
Katharyn Antle May, R N , DNSc Vanderbilt University School of Nursing Nashville, Tennessee
Sharon Thee, R N , MSN, MA University of Iowa Child-Health Specialty Clinics Spencer, Iowa
Nancy J. McKee, R N , DNS Indiana State University School of Nursing Terre Haute, Indiana
Nan H. Troiano, R N , MSN Vanderbilt University Nashville, Tennessee
Anne E. McCormick, R N , MS Lincolnwood, Illinois
Joyce Marilyn Vickers, CNM, NPC Naval Branch Hospital Twentynine Palms, California
Mary L. Neumann, RNC, BSN Methodist Hospital Omaha, Nebraska Ellen Olshansky, RNC. DNSc University of Washington School of Nursing Seattle, Washington Patricia Pollert, RNC St. Luke's Hospitals Fargo, North Dakota
Susan Weekly, R N , BSN Methodist Hospital Omaha, Nebraska Mary Ann Wilson, RNC, MS Kaiser-Permanente East Hartford, Connecticut James Wheeler, MD, FACOG Yale University School of Medicine New Haven, Connecticut
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