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Randomized Controlled Trial of a Prenatal Breastfeeding Self-Efficacy Intervention in Primiparous Women in Iran
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Randomized Controlled Trial of a Prenatal Breastfeeding Self-Efficacy Intervention in Primiparous Women in Iran Marzieh Araban, Zahra Karimian, Zohre Karimian Kakolaki, Karen A. McQueen, and Cindy-Lee Dennis
Correspondence Karen A. McQueen, PhD, Lakehead University School of Nursing, 955 Oliver Rd., Thunder Bay, ON P7B 5E1, Canada [email protected] Keywords breastfeeding self-efficacy exclusive breastfeeding intervention Iran randomized controlled trial
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ABSTRACT Objective: To determine the effects of a prenatal breastfeeding self-efficacy intervention on breastfeeding selfefficacy and breastfeeding outcomes. Design: Randomized controlled trial. Setting: Four health centers in Ahvaz, Iran. Participants: A total of 120 low-risk, nulliparous women between 35 and 37 weeks gestation who intended to breastfeed their singleton infants. Methods: Women were randomly assigned to receive the breastfeeding self-efficacy intervention (n ¼ 60) or standard care (n ¼ 60). The intervention was multifaceted and included two prenatal group sessions, an information package with breastfeeding images, and text messages until 8 weeks postpartum to promote exclusive breastfeeding. The primary outcome was breastfeeding self-efficacy measured with the Breastfeeding Self-Efficacy Scale–Short Form, translated into Persian, at 8 weeks postpartum. Additional outcomes included rates of breastfeeding exclusivity, duration, practices, satisfaction, and problems. Results: At 8 weeks postpartum, participants in the intervention group had significantly higher mean Breastfeeding Self-Efficacy Scale–Short Form scores and rates of exclusive breastfeeding than those in the control group. No significant group differences were found with regard to breastfeeding duration. Conclusion: Emerging evidence supports the use of breastfeeding self-efficacy interventions to improve breastfeeding self-efficacy and rates of exclusive breastfeeding. Further evaluation of this prenatal intervention is warranted.
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2018. https://doi.org/10.1016/j.jogn.2018.01.005 Accepted January 2018
Marzieh Araban, PhD, is an assistant professor in the Social Determinants of Health Research Center and the Department of Health Education and Promotion, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
(Continued)
The authors report no conflict of interest or relevant financial relationships.
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eading international health authorities recommend that all infants be exclusively breastfed for the first 6 months of life and up to 2 years with the addition of complementary foods (American Academy of Pediatrics, 2012; World Health Organization, 2001). This strong endorsement is based on convincing evidence that breastfeeding improves outcomes for infants and/or children (Bowatte et al., 2015; Cardwell et al., 2012; Horta, Loret de Mola, & Victora, 2015; Kramer & Kakuma, 2012; Lodge et al., 2015; Sankar et al., 2015), women (Ip et al., 2007), and society (Bartick et al., 2017). Recently, evidence from rigorous studies suggested that the advantages associated with breastfeeding are even greater than those
previously identified (Bartick et al., 2017; Rollins et al., 2016; Victora et al., 2016). Victora and colleagues (2016) evaluated the associations between breastfeeding and maternal and child outcomes among 28 systematic reviews and meta-analyses. They identified short-term benefits for children that included decreased mortality and morbidity and protection against child infections and malocclusion. Longer-term benefits included increased intelligence and probable reductions in noncommunicable diseases and obesity. In women, breastfeeding provided protection against breast cancer and improved birth spacing and may be beneficial in protecting against ovarian cancer
ª 2018 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
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Prenatal Breastfeeding Self-Efficacy Intervention
Increased rates of exclusive breastfeeding may help reduce rates of maternal and child death among low- and middle-income countries.
and type 2 diabetes. The benefits of breastfeeding for women and children were found across geographic boundaries and irrespective of whether families had high or low income. These findings are consistent with an analysis of the health and economic effects of suboptimal breastfeeding rates in the United States (Bartick et al., 2017). Researchers found that the low breastfeeding rates in the United States were associated with more than 3,340 premature maternal and child deaths and health care costs of more than $18 billion. Importantly, significant improvements in breastfeeding rates could prevent an estimated 823,000 child deaths and 20,000 breast cancer deaths every year (Victora et al., 2016). As such, breastfeeding could potentially be one of the top interventions for reducing mortality in children younger than 5 years of age.
middle-income countries, effective interventions are required to address suboptimal breastfeeding rates (Bartick et al., 2017; Rollins et al., 2016; Victora et al., 2016). Major public health efforts have been initiated in Iran to enhance breastfeeding during the past decade. In particular, 466 out of 566 hospitals have been accredited as Baby Friendly Hospitals (Olang et al., 2009). The Ministry of Health also has been active in breastfeeding promotion by providing breastfeeding booklets, pamphlets, CDs, and other educational materials. Despite these efforts, breastfeeding rates vary and are suboptimal (Noughabi et al., 2014; Olang et al., 2009). Addressing individual-level determinants of breastfeeding such as breastfeeding selfefficacy may be beneficial in improving breastfeeding outcomes in addition to current public health efforts. Breastfeeding self-efficacy, defined as a mother’s confidence in her ability to breastfeed (Dennis, 1999), has consistently been found to reliably predict breastfeeding duration and exclusivity among diverse groups of women in numerous countries (Blyth et al., 2002; Dai & Dennis, 2003; Otsuka, Dennis, Tatsuoka, & Jimba, 2008; Wutke & Dennis, 2007). Breastfeeding self-efficacy is an important variable because it is potentially modifiable and amenable to intervention (McQueen, Dennis, Stremler, & Norman, 2011). In addition, low breastfeeding self-efficacy has been positively associated with perceptions of insufficient milk supply (Dykes, Moran, Burt, & Edwards, 2003; Galipeau, Dumas, & Lepage, 2017), a prevalent factor that leads to early discontinuation of breastfeeding and supplementation with formula worldwide (Balogun, Dagvadorj, Anigo, Ota, & Sasaki, 2015; Mortazavi et al., 2015; Roostaee et al., 2015). Breastfeeding self-efficacy can be measured with the Breastfeeding Self-Efficacy Scale–Short Form (BSES-SF; Dennis, 2003), which has been translated and validated in more than 20 languages, including Persian (Araban, 2015). The breastfeeding self-efficacy framework (Dennis, 1999) also provides a theoretical basis for the development of an intervention to enhance breastfeeding self-efficacy. Thus, the primary aims of our study were to develop a breastfeeding selfefficacy intervention based on breastfeeding self-efficacy theory and determine the effects of the intervention on breastfeeding outcomes including breastfeeding self-efficacy, duration, and exclusivity in women in Ahvaz, Iran.
Cindy-Lee Dennis, PhD, is a professor in the Lawrence S. Bloomberg School of Nursing, University of Toronto, Toronto, ON, Canada.
Despite the compelling benefits associated with breastfeeding, many countries in the Middle East have lower rates of exclusive breastfeeding and continued breastfeeding than other low-income and middle-income countries (Victora et al., 2016). In Iran, the Demographic Health Survey (DHS) statistics from 2000 indicated that 90% of women nationwide initiated breastfeeding and that 44% exclusively breastfeed at 6 months (United Nations Children’s Fund, n.d.). However, 5 years later, the rate of exclusive breastfeeding at 6 months decreased to 27% (Olang, Farivar, Heidarzadeh, Strandvik, & Yngve, 2009). The practice of exclusive breastfeeding at 6 months varies greatly among different regions of Iran (Noughabi, Tehrani, Foroushani, Nayeri, & Baheiraei, 2014; Olang et al., 2009), and many areas show downward trends (Olang et al., 2009; Olang, Heidarzadeh, Strandvik, & Yngve, 2012; Torkzahrani, 2008). Overall, these findings suggest that many infants and mothers in Iran are not receiving the optimal benefits associated with exclusive breastfeeding. This is concerning because the mortality rate for children younger than 5 years old in this country in 2010 was 19.2, considerably greater than in Canada (5.6) and the United States (7.4; Acheampong, Ejiofor, & Salinas-Miranda, 2017). Because breastfeeding can help decrease preventable infant and child deaths among low- and
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Zahra Karimian, PhD, is an assistant professor in the Department of Midwifery, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran. Zohre Karimian Kakolaki, MSc, is a PhD student in the Health Education and Health Promotion Department, Public Health School, Shaheed Sadoughi University of Medical Sciences, Yazd, Iran. Karen A. McQueen, PhD, is an associate professor in the School of Nursing, Lakehead University, Thunder Bay, ON, Canada.
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Methods Design This was a prospecive, multisite, randomized controlled trial that was registered in the Iranian Registry of Clinical Trials (2012091010804N3). Research ethics approval was obtained from the committee of Ahvaz Jundishapur University of Medical Sciences. Participants were recruited from four prenatal clinics in West Ahvaz, Iran, from April 2014 to October 2015. These clinics were randomly selected from 21 clinics that offered prenatal services in that region. The region of West Ahvaz was selected because of its ethnically diverse population and low rates of exclusive breastfeeding.
Sample Women who were pregnant and spoke Persian, the official language of Iran, were eligible to participate in the study if they (a) were nulliparous, (b) had singlton fetuses, (c) intended to breastfeed, (d) were between 35 and 37 weeks gestation, and (e) had cell phones. Women were excluded from the study if they had any health condition that could interfere with breastfeeding, such as a high-risk pregancy (e.g., antepartum bleeding, low amniotic fluid volume) or any breast surgery.
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The number of participants required was calculated from the primary outcome, breastfeeding self-efficacy, and the difference between two groups’ BSES-SF scores. Our assumption that a difference of 3.5 points in BSES-SF scores would be clinically meaningful was based on an earlier study conducted in Iran. In that unpublished study, a 3.5-point difference in BSES-SF scores was associated with a significantly greater rate of exclusive breastfeeding (78%) compared with the control group (28%). To detect an increase of 3.5 points in breastfeeding self-efficacy, with a two-sided 5% significance level and a power of 80%, a sample size of 54 participants per group was required. Considering a loss–to–follow-up rate of approximately 10%, we set the minimum number of participants to be included in each group at 60.
Procedures From advertising the study at the four prenatal clinics, a list of potentially eligible women who were interested to learn more about the study was generated each day by clinic staff. A research nurse approached potential participants and provided a detailed study explanation and
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assessed eligibility at the prenatal clinic. After informed consent procedures, baseline demographic data and BSES-SF scores were collected, and women were randomized to an intervention group or control group. Randomization was achieved using sealed, opaque, sequentially numbered envelopes developed from a random number generator. A midwife who was not involved in the recruitment of participants prepared the envelopes. Women allocated to the control group (n ¼ 60) received standard prenatal and postpartum care. Women assigned to the intervention group (n ¼ 60) also received standard prenatal and postpartum care plus the breastfeeding self-efficacy intervention. All participants completed a follow-up questionnaire at the 8-week postpartum clinic visit with a research assistant blinded to group allocation. Standard care in Iran includes eight prenatal visits at a health care clinic with a midwife. In the hospital and postnatally, midwives also provide care, including lactation support, for all breastfeeding women.
Intervention Our intervention was developed from a Canadian breastfeeding self-efficacy intervention (McQueen et al., 2011) that was based on Dennis (1999) breastfeeding self-efficacy framework. In her framework, Dennis (1999) conceptualized the role of breastfeeding self-efficacy to explain and predict behavior. The framework depicted sources that may affect a woman’s breastfeeding self-efficacy. Thus, the framework may be used to conceptualize the relationships among a woman’s self-efficacy (confidence to breastfeed successfully), consequences (response), and behavior and understand how a woman’s breastfeeding self-efficacy may be influenced (e.g., antecedents). With the use of this framework, the breastfeeding self-efficacy intervention was developed and pilot tested with 150 primiparous postpartum women in Canada (McQueen et al., 2011). The intervention was subsequently replicated with 74 women in China (Wu, Hu, McCoy, & Efird, 2014). We made modifications to the original pilot intervention (McQueen et al., 2011) for this study so the intervention could be delivered during the prenatal period. The revised intervention was reviewed with a focus group of breastfeeding experts in Ahvaz. The trial intervention was a multifaceted breastfeeding intervention provided by a research nurse with extensive breastfeeding knowledge and experience in assisting breastfeeding
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Prenatal Breastfeeding Self-Efficacy Intervention
women. The intervention included two 1-hour group-based breastfeeding education sessions, an information booklet with breastfeeding images, and biweekly text messages. The first group session was provided at the clinic when the participants were between 35 and 37 weeks gestation, and the second session occurred 1 week later. This time frame was selected because it is when breastfeeding education occurs as part of usual care in Iran. Each of the breastfeeding education sessions occurred in small groups of six women and focused on the antecedents (e.g., sources of information) that may be used to influence breastfeeding selfefficacy, including performance accomplishment (e.g., past experience with breastfeeding), vicarious experience (e.g., observation of women breastfeeding), verbal persuasion (e.g., encouragement from others), and physiologic cues (e.g., pain, anxiety, and fatigue; Dennis, 1999). Examples of the strategies used included providing information; facilitating discussion and practice with a doll to enhance performance accomplishment; having a breastfeeding woman attend the education session as a role model to demonstrate breastfeeding skills and answer questions (vicarious experience); giving positive verbal feedback and dispelling breastfeeding myths (verbal persuasion); and providing anticipatory guidance to acknowledge and normalize breastfeeding challenges (decrease anxiety).
baby’s behavior to know when your baby is full. This makes you feel powerful.
The information booklet, which was prepared by a health education specialist and validated by the expert panel, included written text (brief messages about breastfeeding) with images to reinforce the information. The images of the newborn were accompanied with messages such as “breastfeed your baby and you reduce his/her risk of developing disease and chronic conditions” and “becoming a mother is a unique part of a woman’s life that could be completed with breastfeeding.”
Breastfeeding Outcomes Questionnaire. The secondary outcomes were measured with the Breastfeeding Outcomes Questionnaire to assess infant feeding at 8 weeks postpartum. The questionnaire was developed for this study and included 11 items related to infant feeding method. The number of women who exclusively breastfed and practiced any breastfeeding at 8 weeks were key outcomes. Exclusive breastfeeding was defined as no other food or drink except breast milk and vitamins, minerals, or medication as proposed by the World Health Organization (2001). Breastfeeding duration was defined as the practice of any breastfeeding at 8 weeks. Women who had not breastfed in the past 24 hours were classified as formula-feeding. Additional outcomes included breastfeeding patterns (e.g., frequency and duration of feedings, night feedings, daytime feedings, demand feedings), perceived breastfeeding problems (e.g., nipple pain, engorgement, mastitis), audible swallowing, 6 to 8 wet diapers per day, softer breasts after feeding, and maternal
The text messages were sent twice weekly after the first antenatal group session and continued until 8 weeks postpartum. The frequency was determined as optimal by the expert panel to provide regular information without overwhelming the new mothers. The text messages were sent to provide positive encouragement and reinforce exclusive breastfeeding (verbal persuasion). Examples of text messages included Breast milk is always available, there is no need to buy it and You can rely on your own instincts and your
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Outcome Measures Breastfeeding Self-Efficacy Scale–Short Form. The primary outcome, breastfeeding selfefficacy, was measured with the Persian version of the BSES-SF (Araban, 2015) at baseline and at 8 weeks postpartum. The BSES-SF (Dennis, 2003) is a 14-item, 5-point self-report tool used to assess breastfeeding self-efficacy. Item responses range from 1 (not at all confident) to 5 (always confident), with higher scores as an indication of greater breastfeeding self-efficacy. The BSES-SF has shown internal consistency with a Cronbach’s alpha of .94 (Dennis, 2003). The BSES-SF has been translated into many languages and been consistently found to have robust reliability coefficients (Ip, Yeung, Choi, Chair, & Dennis, 2012; Pin˜eiro-Albero et al., 2013; Wutke & Dennis, 2007). For this study, the BSES-SF was translated into Persian, and one item (comfortably breastfeed with my family members present) was deleted because breastfeeding in the presence of family members is not a common practice in Iran. Total scores for the translated 13-item BSES-SF range from 13 to 65, with higher scores as an indication of greater breastfeeding self-efficacy. The Cronbach’s alpha coefficient for the translated BSES-SF was 0.92 (Araban, 2015) and 0.85 in our study.
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satisfaction with breastfeeding. Responses to the questions were dichotomous yes or no. The content validity of the questionnaire was examined by 15 expert reviewers in the field of midwifery, health education, and epidemiology.
Data Analysis We conducted all data analyses with the use of SPSS version 15 and an intention-to-treat approach. A two-sided signifcance level of .05 was used for all study outcomes. We calculated means and standard deviations for continuous data and used an independent t test to examine differences in BSES-SF scores between the two groups. For dichotomous data, frequencies and percentages were calculated, and the chi-square test was used to analyze differences between groups. Odds ratios and 95% confidence intervals (CIs) were also calculated.
Results
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Reporting Trials [CONSORT] flow chart). Followup rates at 8 weeks postpartum were high, with 56 (93.3%) participants in the intervention group and 54 (90%) participants in the control group who completed the 8-week postpartum questionnaire. The demographic characteristics of participants of both groups are presented in Table 1. The mean age of participants was 23.2 (standard deviation [SD] ¼ 4.11) years, and mean [M] gestational age at recruitment was 35.89 (SD ¼ 1.75) weeks. Gestational age at the time of birth was not recorded; however, the weight of the newborns was documented, and the overall mean (M ¼ 3,093 g, SD ¼ 351) was within the normal range for a term newborn. Baseline BSES-SF scores were similar between participants in the intervention (M ¼ 49.4, SD ¼ 4.3) and control groups (M ¼ 48.7, SD ¼ 6.9). There were no differences found between the two groups on baseline characteristics.
Sample Of the 140 women who were approached, 120 (85.7%) agreed to participate and were enrolled (see Figure 1 for the Consolidated Standards of
Breastfeeding Self-Efficacy The mean BSES-SF scores at 8 weeks postpartum were significantly higher among
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Figure 1. Consolidated Standards of Reporting Trials (CONSORT) flow chart for trial recruitment.
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Prenatal Breastfeeding Self-Efficacy Intervention
Table 1: Baseline Demographic Characteristics of Study Participants
Characteristic Age in years, M (SD)
Intervention Group
Control Group
All
(n ¼ 56)
(n ¼ 54)
p
23.62 (3.3)
24.12 (3.51)
23.12 (3.03)
.67
Gestation in weeks at recruitment, M (SD)
35.5 (1.3)
35.8 (2.13)
35.1 (1.79)
.49
Number of prenatal care visits, M (SD)
5.19 (1.72)
5.58 (1.78)
4.88 (1.6)
.82
3,093 (351)
3,099 (383)
3,087 (317)
.86
#Secondary
27 (24.5)
16 (28.6)
11 (20.4)
>Secondary
83 (75.5)
40 (71.4)
43 (79.6)
Infant birth weight in grams, M (SD) Woman’s education, n (%)
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.42
Husband’s education, n (%)
.37
#Secondary
36 (32.7)
15 (58.5)
21 (39.1)
>Secondary
74 (67.3)
41 (41.5)
33 (61.1)
Income level, n (%) Q6
.61
Poor
14 (12.7)
8 (14.3)
6 (11.1)
Fair/good
96 (87.3)
48 (85.7)
48 (88.9)
Mode of birth, n (%)
.33
Vaginal
68 (61.8)
32 (57.1)
36 (66.7)
Cesarean
42 (38.2)
24 (42.9)
18 (33.3)
Infant sex, n (%)
.09
Female
58 (52.7)
25 (44.6)
33 (61.1)
Male
52 (47.3)
31 (55.4)
21 (38.9)
Note. M ¼ mean; SD ¼ standard deviation.
participants in the intervention group (M ¼ 62.46, SD ¼ 4.22) compared with those in the control group (M ¼ 50.74, SD ¼ 4.88; p < .001; see Table 2). Participants who received the intervention were 2.89 times more likley to have higher BSES-SF scores at 8 weeks postpartum than those in the control group (95% CI [1.97, 4.32]).
Breastfeeding Outcomes The number of participants who breastfed exclusively was significantly greater in the intervention group (n ¼ 32 [57.1%]) at 8 weeks than in the control group (n ¼ 21 [38.9%], p ¼ .04). In particular, participants who received the intervention were more than twice as likely to be breastfeeding exclusively at 8 weeks postpartum compared with those in the control group (OR ¼ 2.28, 95% CI [1.03, 4.8]). Consistent with these findings, a significantly greater number of participants in the intervention group was breastfeeding on demand (n ¼ 49 [87.5%], p < .001) and breastfeeding at night (n ¼ 54 [96.4%], p < .001) compared with those in the control group (n ¼ 20 [37%] and n ¼ 17 [31.5%],
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respectively). More specifically, participants in the intervention group were 3 times more likely to breastfeed during the night (OR ¼ 3.06, 95% CI [2.06, 4.50]) and twice as likely to breastfeed on demand (OR ¼ 2.06, 95% CI [1.64, 3.39]) during the day than participants in the control group. Finally, twice the number of participants in the intervention group (n ¼ 36 [66.7%]) had longer breastfeeding sessions (> 5 minutes) compared with participants in the control group (n ¼ 18 [33%], p ¼ .001). The short breastfeeding sessions among control group participants is consistent with the greater rates of formula supplementation in this group. No significant differences were found between groups (p ¼ .91) for those who discontinued breastfeeding because an equal number of participants (n ¼ 13) discontinued breastfeeding in the intervention (23.2%) and control groups (24.1%) at 8 weeks postpartum. Most participants in both groups reported infant voidings of 6 to 8 diapers per day, audible swallowing, softer breasts after feeding, and satisfaction with
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Araban, M., Karimian, Z., Karimian Kakolaki, Z., McQueen, K. A., and Dennis, C.-L.
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breastfeeding. Although all participants reported satisfaction with breastfeeding, they also all reported that they experienced some breastfeeding problems.
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We identified that a prenatal group breastfeeding selfefficacy intervention increased breastfeeding self-efficacy and rates of exclusive breastfeeding at 8 weeks postpartum in women in Iran.
Discussion The purpose of our trial was to rigorously evaluate the effect of a multifaceted prenatal breastfeeding intervention on breastfeeding self-efficacy to improve breastfeeding outcomes in Iran. Overall,
the intervention increased the breastfeeding selfefficacy and rates of exclusive breastfeeding among participants by 18% at 8 weeks. Consistent with greater rates of exclusive breastfeeding
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Table 2: Breastfeeding Outcomes at 8 Weeks by Group
Breastfeeding Self-Efficacy Scale–Short Form score, M (SD)
Intervention
Control
OR [95% CI] or p
62.46 (4.22)
50.74 (4.88)
Exclusive breastfeeding, n (%)
32 (57.1)
21 (38.9)
2.28 [1.03, 4.8]
Any breastfeeding, n (%)
43 (76.7)
41 (75.9)
0.95 [0.40, 2.30]
Breastfeeding on demand during the night, n (%)
2.89 [1.97, 4.32]
3.06 [2.06, 4.5]
Yes
54 (96.4)
17 (31.5)
No
2 (3.6)
37 (68.5)
Breastfeeding on demand during the daytime, n (%)
2.36 [1.64, 3.39]
Yes
49 (87.5)
20 (37)
No
7 (12.5)
34 (63)
Audible swallowing, n (%)
ns
Yes
31 (55.4)
35 (54.8)
To some extent
25 (44.6)
19 (45.2)
Yes
22 (39.3)
19 (45.2)
No
34 (60.7)
35 (54.8)
56 (100)
54 (100)
Breasts softer after feeding, n (%)
ns
Breastfeeding problems, n (%) Yes No Q8
ns
0
Satisfaction with feeding, n (%)
56 (100)
0 54 (100)
ns
Yes No Feeding from both breasts, n (%)
ns
Yes
38 (67.9)
35 (64.8)
No
18 (31.1)
19 (25.2)
6–8 wet diapers per day, n (%)
ns
Yes
44 (78.6)
39 (2.2)
No
12 (21.4)
15 (27.8)
9 (16.1)
47 (86.9)
36 (66.7)
18 (33.3)
Duration of breastfeeding, n (%) Less than 5 minutes 5–10 minutes
.001
Note. M ¼ mean; ns, not significant; SD ¼ standard deviation.
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at 8 weeks, participants in the intervention group had significantly greater rates of on-demand breastfeeding and breastfeeding during the night compared with those in the control group. These findings suggested that the prenatal group education intervention incorporating the sources of self-efficacy had a beneficial effect on improving breastfeeding self-efficacy and exclusive breastfeeding in first-time mothers that warrants additional investigation. This is important given the low rates of exclusive breastfeeding found at 8 weeks in the intervention (57.1%) and control groups (38.9%). No significant differences were found between groups regarding breastfeeding duration rates at 8 weeks. Results of our study are consistent with other trials that have supported prenatal breastfeeding interventions as effective in increasing breastfeeding self-efficacy. Four randomized controlled trials were identified in which prenatal group interventions were evaluated with the primary outcome of breastfeeding self-efficacy and secondary outcomes of exclusive breastfeeding or breastfeeding duration (Ansari, Abedi, Hasanpoor, & Bani, 2014; Chan, Ip, & Choi, 2016; Kronborg, Væth, Olsen, & Harder, 2008; Noel-Weiss, Rupp, Cragg, Bassett, & Woodend, 2006). In all four trials, investigators found significantly greater breastfeeding self-efficacy measured with the breastfeeding self-efficacy scale in women who received the interventions than in the control groups. However, the findings of whether the intervention lead to improved breastfeeding outcomes was equivocal. In two of the trials, investigators found improved rates of breastfeeding exclusivity (Ansari et al., 2014; Chan et al., 2016), wheras in two others, no differences were identified between groups on breastfeeding duration or exclusivity (Kronborg et al., 2008; Noel-Weiss et al., 2006). Findings from a recent systematic review and metaanalysis, which included 11 studies on prenatal and/or postnatal breastfeeding self-efficacy interventions were also positive (Brockway, Benzies, & Hayden, 2017). Overall, the researchers found that for each 1-point increase in mean breastfeeding self-efficacy scores between the intervention and control groups, the odds of exclusive breastfeeding increased by 10% in the intervention group.
Q2
8
The importance of supportive breastfeeding interventions for women has been well established in the literature (Haroon, Das, Salam, Imdad, & Bhutta, 2013; Renfrew, McCormick, Wade,
Quinn, & Dowswell, 2012). Rollins (2016) advocated that efforts need to be scaled up to monitor breastfeeding interventions and trends in breastfeeding practices so that interventions that show effectiveness could be delivered to all mothers and infants. Interventions to improve rates of exclusive breastfeeding should include increasing women’s breastfeeding self-efficacy because it is imperative that women have the confidence to intitiate breastfeeding and overcome difficulties when encountered without providing formula. Our prenatal breastfeeding intervention focused on the four sources of breastfeeding self-efficacy (Dennis, 1999) so that women could not only master new breastfeeding skills but also increase their knowledge and confidence to breastfeed exclusively and persevere with challenges such as perceptions of insufficient milk supply. Many women often doubt their abilities to breastfeed and may be drawn to breast milk substitutes, leading to decreased exclusive breastfeeding (Chantry, Dewey, Peerson, Wagner, & Nommsen-Rivers, 2014; Rollins et al., 2016). To effectively protect, promote, and support breastfeeding, effective strategies are required at many levels in addition to those provided to women (Bartick et al., 2017; Rollins et al., 2016). Although supportive breastfeeding interventions have produced positive effects (Brockway et al., 2017), legal and policy directives that target social attitudes and norms, employment conditions, and health services to support women to breastfeed optimally are also required. Social constructs such as lack of paid maternity leave, indadequate access to lactation services, limited implementation of evidence-based practices to support breastfeeding, and the regulation of breast milk substitutes warrant attention. Although many hospitals are designated BabyFriendly in Iran, formula supplementation in the hospital (OR ¼ 0.41, 95% CI [0.17, 0.95]) and inconsistent infant feeding advice (OR ¼ 0.53, 95% CI [0.37, 0.78]) have had significant negative effects on exclusive breastfeeding (Noughabi et al., 2014). Likewise, women who return to work while breastfeeding is a relatively new phenomenon in Iran and has been associated with breastfeeding cessation (Valizadeh et al., 2017). The absence of policy in these areas to support breastfeeding (Noughabi et al., 2014; Valizadeh et al., 2017) provides barriers and contradicts the message that suboptimal breastfeeding has substantial effects on maternal and child health outcomes and costs (Bartick et al., 2017).
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Araban, M., Karimian, Z., Karimian Kakolaki, Z., McQueen, K. A., and Dennis, C.-L.
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Strengths of our study include the strong empirical and theoretical foundation for the intervention, random group assignment, the high rate of protocol adherence, and low loss to follow-up. Despite these strengths, potential limitations also exist, including that the study was limited to one geographic area in Iran, which decreases the generalizability of our findings. Because participants could not be blinded to group allocation, it is possible that there may have been some social desirability bias, with overestimation of breastfeeding outcomes. Reasons for breastfeeding discontinuation were not collected and may have provided additional information regarding breastfeeding duration.
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The findings from this study provide evidence that enhancing women’s breastfeeding self-efficacy can lead to improved rates of exclusive breastfeeding.
of the breastfeeding self-efficacy intervention in a larger sample is required before making recommendations for widespread use in practice.
REFERENCES Acheampong, M., Ejiofor, C., & Salinas-Miranda, A. (2017). An analysis of determinants of under-5 mortality across countries: Defining priorities to achieve targets in sustainable developmental goals. Maternal and Child Health Journal, 21(6), 1428–1447. https:// doi.org/10.1007/s10995-017-2260-9 American Academy of Pediatrics. (2012). Breastfeeding and the use of
Because the results of our study were encouraging, further testing of this intervention should be conducted in larger samples and with diverse populations. Additionally, future research is required to identify whether there is an optimal time for the delivery of a breastfeeding selfefficacy intervention and whether there is an optimal dosage to sustain breastfeeding exclusivity. In particular, future investigators may consider an extension of the intervention throughout the postpartum period so new mothers receive continued breastfeeding support. Our intervention incorporated all four sources of self-efficacy information; thus, it is unknown whether attention to all four sources is necessary or if an emphasis on a combination of two or more is sufficient. Future research is required to evaluate which source(s) of selfefficacy are most effective and warrant increased attention in interventions to increase breastfeeding self-efficacy.
human milk. Pediatrics, 129(3), e827–e841. https://doi.org/10. 1542/peds.2011-3552 Ansari, S., Abedi, P., Hasanpoor, S., & Bani, S. (2014). The effect of interventional program on breastfeeding self-efficacy and duration of exclusive breastfeeding in pregnant women in Ahvaz, Iran. International Scholarly Research Notices, 2014, e510793. https://doi.org/10.1155/2014/510793 Araban, M. (2015). The Persian version of Breastfeeding Self-Efficacy Scale–Short Form (BSES-SF): Translation and explanatory factor analysis assessment. Journal of Iranian Institute for Health Sciences Research, 15(1), 23–28. Balogun, O. O., Dagvadorj, A., Anigo, K. M., Ota, E., & Sasaki, S. (2015). Factors influencing breastfeeding exclusivity during the first 6 months of life in developing countries: A quantitative and qualitative systematic review. Maternal & Child Nutrition, 11(4), 433–451. https://doi.org/10.1111/mcn.12180 Bartick, M. C., Schwarz, E. B., Green, B. D., Jegier, B. J., Reinhold, A. G., Colaizy, T. T., … Stuebe, A. M. (2017). Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal & Child Nutrition, 13(1), e12366. https://doi.org/10.1111/mcn.12366 Blyth, R., Creedy, D. K., Dennis, C.-L., Moyle, W., Pratt, J., & De Vries, S. M. (2002). Effect of maternal confidence on breastfeeding duration: An application of breastfeeding self-efficacy theory. Birth: Issues in Perinatal Care, 29(4), 278–284. https://doi.org/ 10.1046/j.1523-536X.2002.00202.x
Conclusion Our results suggested that a group prenatal breastfeeding self-efficacy intervention based on breastfeeding self-efficacy theory may help increase women’s breastfeeding self-efficacy and lead to increased rates of exclusive breastfeeding in women in Ahvaz, Iran. Our findings add to the growing evidence regarding the saliency of breastfeeding self-efficacy as a modifiable variable that influences breastfeeding outcomes. Thus, the breastfeeding self-efficacy intervention shows potential as an effective intervention to increase rates of exclusive breastfeeding. Given the evidence that breastfeeding may help decrease maternal and child-related mortality in low- and middle-income countries, effective interventions to increase rates of exclusive breastfeeding are warranted. Rigorous evaluation
Bowatte, G., Tham, R., Allen, K. J., Tan, D. J., Lau, M., Dai, X., & Lodge, C. J. (2015). Breastfeeding and childhood acute otitis media: A systematic review and meta-analysis. Acta Paediatrica, 104(467), 85–95. https://doi.org/10.1111/apa.13151 Brockway, M., Benzies, K., & Hayden, K. (2017). Interventions to improve breastfeeding self-efficacy and resultant breastfeeding rates: A systematic review and meta-analysis. Journal of Human Lactation,
33(3),
486–499.
https://doi.org/10.1177/
0890334417707957 Campbell, M., Fitzpatrick, R., Haines, A., Kinmonth, A. L., Sandercock, P., Spiegelhalter, D., & Tyrer, P. (2000). Framework for design and evaluation of complex interventions to improve health. British Medical Journal, 321(7262), 694–696. https://doi. org/10.1136/bmj.321.7262.694
Q3
Cardwell, C. R., Stene, L. C., Ludvigsson, J., Rosenbauer, J., Cinek, O., Svensson, J., … Patterson, C. C. (2012). Breastfeeding and childhood-onset type 1 diabetes: A pooled analysis of individual participant data from 43 observational studies. Diabetes Care, 35(11), 2215–2225. https://doi.org/10. 2337/dc12-0438
JOGNN 2018; Vol. -, Issue -
FLA 5.5.0 DTD JOGN311_proof 31 January 2018 9:03 am ce
9
RESEARCH
1009 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020 1021 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 1032 1033 1034 1035 1036 1037 1038 1039 1040 1041 1042 1043 1044 1045 1046 1047 1048 1049 1050 1051 1052 1053 1054 1055 1056 1057 1058 1059 1060 1061 1062 1063 1064
Prenatal Breastfeeding Self-Efficacy Intervention
Chan, M. Y., Ip, W. Y., & Choi, K. C. (2016). The effect of a self-efficacy-
Database of Systematic Reviews, 2017(2), CD001141. https://
based educational programme on maternal breast feeding selfefficacy, breast feeding duration and exclusive breast feeding
McQueen, K. A., Dennis, C.-L., Stremler, R., & Norman, C. D. (2011).
rates: A longitudinal study. Midwifery, 36, 92–98. https://doi.org/
A pilot randomized controlled trial of a breastfeeding self-
10.1016/j.midw.2016.03.003
efficacy intervention with primiparous mothers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(1), 35–46.
Chantry, C. J., Dewey, K. G., Peerson, J. M., Wagner, E. A., &
https://doi.org/10.1111/j.1552-6909.2010.01210.x
Nommsen-Rivers, L. A. (2014). In-hospital formula use increases early breastfeeding cessation among first-time mothers
Mortazavi, F., Mousavi, S. A., Chaman, R., Wambach, K. A., Mor-
intending to exclusively breastfeed. The Journal of Pediatrics,
tazavi, S. S., & Khosravi, A. (2015). Breastfeeding practices
164(6), 1339–1345.e5. https://doi.org/10.1016/j.jpeds.2013.12.
during the first month postpartum and associated factors:
035
Impact on breastfeeding survival. Iranian Red Crescent Medical Journal, 17(4), e27814. https://doi.org/10.5812/ircmj.
Dai, X., & Dennis, C.-L. (2003). Translation and validation of the
17(4)2015.27814
Breastfeeding Self-Efficacy Scale into Chinese. Journal of Midwifery & Women’s Health, 48(5), 350–356. https://doi.org/10.
Noel-Weiss, J., Rupp, A., Cragg, B., Bassett, V., & Woodend, A. K. (2006). Randomized controlled trial to determine effects of
1016/S1526-9523(03)00283-6 Dennis, C. L. (1999). Theoretical underpinnings of breastfeeding
prenatal breastfeeding workshop on maternal breastfeeding
confidence: A self-efficacy framework. Journal of Human
self-efficacy and breastfeeding duration. Journal of Obstetric,
Lactation, 15(3), 195–201.
Gynecologic, & Neonatal Nursing, 35(5), 616–624. https://doi. org/10.1111/j.1552-6909.2006.00077.x
Dennis, C.-L. (2003). The breastfeeding self-efficacy scale: Psychometric assessment of the short form. Journal of Obstetric, Gy-
Noughabi, Z. S., Tehrani, S. G., Foroushani, A. R., Nayeri, F., &
necologic, & Neonatal Nursing, 32(6), 734–744. https://doi.org/
Baheiraei, A. (2014). Prevalence and factors associated with
10.1177/0884217503258459
exclusive breastfeeding at 6 months of life in Tehran: A population-based study. Eastern Mediterranean Health Journal,
Dykes, F., Moran, V. H., Burt, S., & Edwards, J. (2003). Adolescent mothers
and
breastfeeding:
Experiences
and
20(1), 24–32.
support
needs—An exploratory study. Journal of Human Lactation,
Olang, B., Farivar, K., Heidarzadeh, A., Strandvik, B., & Yngve, A. (2009). Breastfeeding in Iran: Prevalence, duration and current
19(4), 391–401. https://doi.org/10.1177/0890334403257562
recommendations. International Breastfeeding Journal, 4(1), 8.
Galipeau, R., Dumas, L., & Lepage, M. (2017). Perception of not
https://doi.org/10.1186/1746-4358-4-8
having enough milk and actual milk production of first-time breastfeeding mothers: Is there a difference? Breastfeeding
Olang, B., Heidarzadeh, A., Strandvik, B., & Yngve, A. (2012). Rea-
Medicine, 12(4), 210–217. https://doi.org/10.1089/bfm.2016.
sons given by mothers for discontinuing breastfeeding in Iran.
0183
International Breastfeeding Journal, 7(1), 7. https://doi.org/10. 1186/1746-4358-7-7
Haroon, S., Das, J. K., Salam, R. A., Imdad, A., & Bhutta, Z. A. (2013). Breastfeeding promotion interventions and breastfeeding
Otsuka, K., Dennis, C.-L., Tatsuoka, H., & Jimba, M. (2008). The
practices: A systematic review. BMC Public Health, 13, S20.
relationship between breastfeeding self-efficacy and perceived
https://doi.org/10.1186/1471-2458-13-S3-S20
insufficient milk among Japanese mothers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(5), 546–555. https://doi.
Horta, B. L., Loret de Mola, C., & Victora, C. G. (2015). Long-term
org/10.1111/j.1552-6909.2008.00277.x
consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: A systematic review and
Pin˜eiro-Albero, R. M., Ramos-Pichardo, J. D., Oliver-Roig, A., Velan-
meta-analysis. Acta Paediatrica, 104(467), 30–37. https://doi.
drino-Nicola´s, A., Richart-Martı´nez, M., Garcı´a-de-Leo´n-Gon-
org/10.1111/apa.13133
za´lez, R., & Wells, K. J. (2013). The Spanish version of the
Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., …
Prenatal Breast-feeding Self-efficacy Scale: Reliability and val-
Lau, J. (2007). Breastfeeding and maternal and infant health
idity assessment. International Journal of Nursing Studies,
outcomes in developed countries. Evidence Report/Technology
50(10), 1385–1390. https://doi.org/10.1016/j.ijnurstu.2012.12. 010
Assessment, 153, 1–186. https://doi.org/10.1542/gr.18-2-15 Ip, W.-Y., Yeung, L.-S., Choi, K.-C., Chair, S.-Y., & Dennis, C.-L. (2012).
Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C. K.,
Translation and validation of the Hong Kong Chinese version of
Martines, J. C., & Lancet Breastfeeding Series Group. (2016).
the Breastfeeding Self-Efficacy Scale–Short Form. Research in
Why invest, and what it will take to improve breastfeeding
Nursing & Health, 35(5), 450–459. https://doi.org/10.1002/nur.
practices? Lancet, 387(10017), 491–504. https://doi.org/10. 1016/S0140-6736(15)01044-2
21493 Kramer, M. S., & Kakuma, R. (2012). Optimal duration of exclusive
Roostaee, F., Tabatabaei, S. M., Zaboli, M., Keykhaie, R., Sharifi-Rad,
breastfeeding. Cochrane Database of Systematic Reviews,
J., Shahrak, P., & Soroush, F. (2015). Breast-feeding continua-
2012(8),
tion in South-Eastern of Iran: The associated factors. Medical
CD003517.
https://doi.org/10.1002/14651858.
Archives, 69(2), 98–102. https://doi.org/10.5455/medarh.2015.
CD003517.pub2
69.98-102
Kronborg, H., Væth, M., Olsen, J., & Harder, I. (2008). Health visitors and breastfeeding support: Influence of knowledge and self-
Sankar, M. J., Sinha, B., Chowdhury, R., Bhandari, N., Taneja, S.,
efficacy. European Journal of Public Health, 18(3), 283–288.
Martines, J., & Bahl, R. (2015). Optimal breastfeeding practices
https://doi.org/10.1093/eurpub/ckm121
and infant and child mortality: A systematic review and meta-
Lodge, C. J., Tan, D. J., Lau, M. X. Z., Dai, X., Tham, R., Lowe, A. J., …
analysis. Acta Paediatrica, 104(467), 3–13. https://doi.org/10. 1111/apa.13147
Dharmage, S. C. (2015). Breastfeeding and asthma and allergies: A systematic review and meta-analysis. Acta Paediatr-
Torkzahrani, S. (2008). Commentary: Childbirth education in Iran. Journal of Perinatal Education, 17(3), 51–54. https://doi.org/10.
ica, 104(467), 38–53. https://doi.org/10.1111/apa.13132
1624/105812408X329601
McFadden, A., Gavine, A., Renfrew, M. J., Wade, A., Buchanan, P.,
10
Q4
doi.org/10.1002/14651858.CD001141.pub5
Taylor, J. L., … MacGillivray, S. (2017). Support for healthy
United Nations Children’s Fund. (n.d.). The state of the world’s children
breastfeeding mothers with healthy term babies. Cochrane
2008. Retrieved from www.unicef.org/sowc08/report/report.php
JOGNN, -, -–-; 2018. https://doi.org/10.1016/j.jogn.2018.01.005
FLA 5.5.0 DTD JOGN311_proof 31 January 2018 9:03 am ce
http://jognn.org
1065 1066 1067 1068 1069 1070 1071 1072 1073 1074 1075 1076 1077 1078 1079 1080 1081 1082 1083 1084 1085 1086 1087 1088 1089 1090 1091 1092 1093 1094 1095 1096 1097 1098 1099 1100 1101 1102 1103 1104 1105 1106 1107 1108 1109 1110 1111 1112 1113 1114 1115 1116 1117 1118 1119 1120
Araban, M., Karimian, Z., Karimian Kakolaki, Z., McQueen, K. A., and Dennis, C.-L.
1121
Valizadeh, S., Hosseinzadeh, M., Mohammadi, E., Hassankhani, H. M.,
1122
Fooladi, M., & Schmied, V. (2017). Addressing barriers to
1123 1124
from
1134
http://www.who.int/nutrition/publications/infantfeeding/
WHO_NHD_01.09/en
1135
health: Experiences of breastfeeding mothers after returning to
Wu, D. S., Hu, J., McCoy, T. P., & Efird, J. T. (2014). The effects of a
work. Nursing & Health Sciences, 19(1), 105–111. https://doi.
breastfeeding self-efficacy intervention on short-term breast-
org/10.1111/nhs.12324
feeding outcomes among primiparous mothers in Wuhan,
1137
China. Journal of Advanced Nursing, 70(8), 1867–1879. https://
1138
doi.org/10.1111/jan.12349
1139
1125
Victora, C. G., Bahl, R., Barros, A. J. D., Franc¸a, G. V. A., Horton, S.,
1126
Krasevec, J., … Lancet Breastfeeding Series Group. (2016).
1127
Breastfeeding in the 21st century: Epidemiology, mechanisms,
Wutke, K., & Dennis, C.-L. (2007). The reliability and validity of the
and lifelong effect. Lancet, 387(10017), 475–490. https://doi.
Polish version of the Breastfeeding Self-Efficacy Scale–Short
org/10.1016/S0140-6736(15)01024-7
Form: Translation and psychometric assessment. International
1128
RESEARCH
1129
World Health Organization. (2001). The optimal duration of exclusive
1130
breastfeeding: Report of an expert consultation. Retrieved
1136
1140 1141
Journal of Nursing Studies, 44(8), 1439–1446. https://doi.org/
1142
10.1016/j.ijnurstu.2006.08.001
1143
1131
1144
1132
1145
1133
1146
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Randomized Controlled Trial of a Prenatal Breastfeeding Self-Efficacy Intervention in Primiparous Women in Iran Marzieh Araban, Zahra Karimian, Zohre Karimian Kakolaki, Karen A. McQueen, and Cindy-Lee Dennis
Correspondence Karen A. McQueen, PhD, Lakehead University School of Nursing, 955 Oliver Rd., Thunder Bay, ON P7B 5E1, Canada [email protected] Keywords breastfeeding self-efficacy exclusive breastfeeding intervention Iran randomized controlled trial
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ABSTRACT Objective: To determine the effects of a prenatal breastfeeding self-efficacy intervention on breastfeeding selfefficacy and breastfeeding outcomes. Design: Randomized controlled trial. Setting: Four health centers in Ahvaz, Iran. Participants: A total of 120 low-risk, nulliparous women between 35 and 37 weeks gestation who intended to breastfeed their singleton infants. Methods: Women were randomly assigned to receive the breastfeeding self-efficacy intervention (n ¼ 60) or standard care (n ¼ 60). The intervention was multifaceted and included two prenatal group sessions, an information package with breastfeeding images, and text messages until 8 weeks postpartum to promote exclusive breastfeeding. The primary outcome was breastfeeding self-efficacy measured with the Breastfeeding Self-Efficacy Scale–Short Form, translated into Persian, at 8 weeks postpartum. Additional outcomes included rates of breastfeeding exclusivity, duration, practices, satisfaction, and problems. Results: At 8 weeks postpartum, participants in the intervention group had significantly higher mean Breastfeeding Self-Efficacy Scale–Short Form scores and rates of exclusive breastfeeding than those in the control group. No significant group differences were found with regard to breastfeeding duration. Conclusion: Emerging evidence supports the use of breastfeeding self-efficacy interventions to improve breastfeeding self-efficacy and rates of exclusive breastfeeding. Further evaluation of this prenatal intervention is warranted.
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Marzieh Araban, PhD, is an assistant professor in the Social Determinants of Health Research Center and the Department of Health Education and Promotion, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
(Continued)
The authors report no conflict of interest or relevant financial relationships.
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eading international health authorities recommend that all infants be exclusively breastfed for the first 6 months of life and up to 2 years with the addition of complementary foods (American Academy of Pediatrics, 2012; World Health Organization, 2001). This strong endorsement is based on convincing evidence that breastfeeding improves outcomes for infants and/or children (Bowatte et al., 2015; Cardwell et al., 2012; Horta, Loret de Mola, & Victora, 2015; Kramer & Kakuma, 2012; Lodge et al., 2015; Sankar et al., 2015), women (Ip et al., 2007), and society (Bartick et al., 2017). Recently, evidence from rigorous studies suggested that the advantages associated with breastfeeding are even greater than those
previously identified (Bartick et al., 2017; Rollins et al., 2016; Victora et al., 2016). Victora and colleagues (2016) evaluated the associations between breastfeeding and maternal and child outcomes among 28 systematic reviews and meta-analyses. They identified short-term benefits for children that included decreased mortality and morbidity and protection against child infections and malocclusion. Longer-term benefits included increased intelligence and probable reductions in noncommunicable diseases and obesity. In women, breastfeeding provided protection against breast cancer and improved birth spacing and may be beneficial in protecting against ovarian cancer
ª 2018 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
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Increased rates of exclusive breastfeeding may help reduce rates of maternal and child death among low- and middle-income countries.
and type 2 diabetes. The benefits of breastfeeding for women and children were found across geographic boundaries and irrespective of whether families had high or low income. These findings are consistent with an analysis of the health and economic effects of suboptimal breastfeeding rates in the United States (Bartick et al., 2017). Researchers found that the low breastfeeding rates in the United States were associated with more than 3,340 premature maternal and child deaths and health care costs of more than $18 billion. Importantly, significant improvements in breastfeeding rates could prevent an estimated 823,000 child deaths and 20,000 breast cancer deaths every year (Victora et al., 2016). As such, breastfeeding could potentially be one of the top interventions for reducing mortality in children younger than 5 years of age.
middle-income countries, effective interventions are required to address suboptimal breastfeeding rates (Bartick et al., 2017; Rollins et al., 2016; Victora et al., 2016). Major public health efforts have been initiated in Iran to enhance breastfeeding during the past decade. In particular, 466 out of 566 hospitals have been accredited as Baby Friendly Hospitals (Olang et al., 2009). The Ministry of Health also has been active in breastfeeding promotion by providing breastfeeding booklets, pamphlets, CDs, and other educational materials. Despite these efforts, breastfeeding rates vary and are suboptimal (Noughabi et al., 2014; Olang et al., 2009). Addressing individual-level determinants of breastfeeding such as breastfeeding selfefficacy may be beneficial in improving breastfeeding outcomes in addition to current public health efforts. Breastfeeding self-efficacy, defined as a mother’s confidence in her ability to breastfeed (Dennis, 1999), has consistently been found to reliably predict breastfeeding duration and exclusivity among diverse groups of women in numerous countries (Blyth et al., 2002; Dai & Dennis, 2003; Otsuka, Dennis, Tatsuoka, & Jimba, 2008; Wutke & Dennis, 2007). Breastfeeding self-efficacy is an important variable because it is potentially modifiable and amenable to intervention (McQueen, Dennis, Stremler, & Norman, 2011). In addition, low breastfeeding self-efficacy has been positively associated with perceptions of insufficient milk supply (Dykes, Moran, Burt, & Edwards, 2003; Galipeau, Dumas, & Lepage, 2017), a prevalent factor that leads to early discontinuation of breastfeeding and supplementation with formula worldwide (Balogun, Dagvadorj, Anigo, Ota, & Sasaki, 2015; Mortazavi et al., 2015; Roostaee et al., 2015). Breastfeeding self-efficacy can be measured with the Breastfeeding Self-Efficacy Scale–Short Form (BSES-SF; Dennis, 2003), which has been translated and validated in more than 20 languages, including Persian (Araban, 2015). The breastfeeding self-efficacy framework (Dennis, 1999) also provides a theoretical basis for the development of an intervention to enhance breastfeeding self-efficacy. Thus, the primary aims of our study were to develop a breastfeeding selfefficacy intervention based on breastfeeding self-efficacy theory and determine the effects of the intervention on breastfeeding outcomes including breastfeeding self-efficacy, duration, and exclusivity in women in Ahvaz, Iran.
Cindy-Lee Dennis, PhD, is a professor in the Lawrence S. Bloomberg School of Nursing, University of Toronto, Toronto, ON, Canada.
Despite the compelling benefits associated with breastfeeding, many countries in the Middle East have lower rates of exclusive breastfeeding and continued breastfeeding than other low-income and middle-income countries (Victora et al., 2016). In Iran, the Demographic Health Survey (DHS) statistics from 2000 indicated that 90% of women nationwide initiated breastfeeding and that 44% exclusively breastfeed at 6 months (United Nations Children’s Fund, n.d.). However, 5 years later, the rate of exclusive breastfeeding at 6 months decreased to 27% (Olang, Farivar, Heidarzadeh, Strandvik, & Yngve, 2009). The practice of exclusive breastfeeding at 6 months varies greatly among different regions of Iran (Noughabi, Tehrani, Foroushani, Nayeri, & Baheiraei, 2014; Olang et al., 2009), and many areas show downward trends (Olang et al., 2009; Olang, Heidarzadeh, Strandvik, & Yngve, 2012; Torkzahrani, 2008). Overall, these findings suggest that many infants and mothers in Iran are not receiving the optimal benefits associated with exclusive breastfeeding. This is concerning because the mortality rate for children younger than 5 years old in this country in 2010 was 19.2, considerably greater than in Canada (5.6) and the United States (7.4; Acheampong, Ejiofor, & Salinas-Miranda, 2017). Because breastfeeding can help decrease preventable infant and child deaths among low- and
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Zahra Karimian, PhD, is an assistant professor in the Department of Midwifery, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran. Zohre Karimian Kakolaki, MSc, is a PhD student in the Health Education and Health Promotion Department, Public Health School, Shaheed Sadoughi University of Medical Sciences, Yazd, Iran. Karen A. McQueen, PhD, is an associate professor in the School of Nursing, Lakehead University, Thunder Bay, ON, Canada.
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Methods Design This was a prospecive, multisite, randomized controlled trial that was registered in the Iranian Registry of Clinical Trials (2012091010804N3). Research ethics approval was obtained from the committee of Ahvaz Jundishapur University of Medical Sciences. Participants were recruited from four prenatal clinics in West Ahvaz, Iran, from April 2014 to October 2015. These clinics were randomly selected from 21 clinics that offered prenatal services in that region. The region of West Ahvaz was selected because of its ethnically diverse population and low rates of exclusive breastfeeding.
Sample Women who were pregnant and spoke Persian, the official language of Iran, were eligible to participate in the study if they (a) were nulliparous, (b) had singlton fetuses, (c) intended to breastfeed, (d) were between 35 and 37 weeks gestation, and (e) had cell phones. Women were excluded from the study if they had any health condition that could interfere with breastfeeding, such as a high-risk pregancy (e.g., antepartum bleeding, low amniotic fluid volume) or any breast surgery.
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The number of participants required was calculated from the primary outcome, breastfeeding self-efficacy, and the difference between two groups’ BSES-SF scores. Our assumption that a difference of 3.5 points in BSES-SF scores would be clinically meaningful was based on an earlier study conducted in Iran. In that unpublished study, a 3.5-point difference in BSES-SF scores was associated with a significantly greater rate of exclusive breastfeeding (78%) compared with the control group (28%). To detect an increase of 3.5 points in breastfeeding self-efficacy, with a two-sided 5% significance level and a power of 80%, a sample size of 54 participants per group was required. Considering a loss–to–follow-up rate of approximately 10%, we set the minimum number of participants to be included in each group at 60.
Procedures From advertising the study at the four prenatal clinics, a list of potentially eligible women who were interested to learn more about the study was generated each day by clinic staff. A research nurse approached potential participants and provided a detailed study explanation and
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assessed eligibility at the prenatal clinic. After informed consent procedures, baseline demographic data and BSES-SF scores were collected, and women were randomized to an intervention group or control group. Randomization was achieved using sealed, opaque, sequentially numbered envelopes developed from a random number generator. A midwife who was not involved in the recruitment of participants prepared the envelopes. Women allocated to the control group (n ¼ 60) received standard prenatal and postpartum care. Women assigned to the intervention group (n ¼ 60) also received standard prenatal and postpartum care plus the breastfeeding self-efficacy intervention. All participants completed a follow-up questionnaire at the 8-week postpartum clinic visit with a research assistant blinded to group allocation. Standard care in Iran includes eight prenatal visits at a health care clinic with a midwife. In the hospital and postnatally, midwives also provide care, including lactation support, for all breastfeeding women.
Intervention Our intervention was developed from a Canadian breastfeeding self-efficacy intervention (McQueen et al., 2011) that was based on Dennis (1999) breastfeeding self-efficacy framework. In her framework, Dennis (1999) conceptualized the role of breastfeeding self-efficacy to explain and predict behavior. The framework depicted sources that may affect a woman’s breastfeeding self-efficacy. Thus, the framework may be used to conceptualize the relationships among a woman’s self-efficacy (confidence to breastfeed successfully), consequences (response), and behavior and understand how a woman’s breastfeeding self-efficacy may be influenced (e.g., antecedents). With the use of this framework, the breastfeeding self-efficacy intervention was developed and pilot tested with 150 primiparous postpartum women in Canada (McQueen et al., 2011). The intervention was subsequently replicated with 74 women in China (Wu, Hu, McCoy, & Efird, 2014). We made modifications to the original pilot intervention (McQueen et al., 2011) for this study so the intervention could be delivered during the prenatal period. The revised intervention was reviewed with a focus group of breastfeeding experts in Ahvaz. The trial intervention was a multifaceted breastfeeding intervention provided by a research nurse with extensive breastfeeding knowledge and experience in assisting breastfeeding
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Prenatal Breastfeeding Self-Efficacy Intervention
women. The intervention included two 1-hour group-based breastfeeding education sessions, an information booklet with breastfeeding images, and biweekly text messages. The first group session was provided at the clinic when the participants were between 35 and 37 weeks gestation, and the second session occurred 1 week later. This time frame was selected because it is when breastfeeding education occurs as part of usual care in Iran. Each of the breastfeeding education sessions occurred in small groups of six women and focused on the antecedents (e.g., sources of information) that may be used to influence breastfeeding selfefficacy, including performance accomplishment (e.g., past experience with breastfeeding), vicarious experience (e.g., observation of women breastfeeding), verbal persuasion (e.g., encouragement from others), and physiologic cues (e.g., pain, anxiety, and fatigue; Dennis, 1999). Examples of the strategies used included providing information; facilitating discussion and practice with a doll to enhance performance accomplishment; having a breastfeeding woman attend the education session as a role model to demonstrate breastfeeding skills and answer questions (vicarious experience); giving positive verbal feedback and dispelling breastfeeding myths (verbal persuasion); and providing anticipatory guidance to acknowledge and normalize breastfeeding challenges (decrease anxiety).
baby’s behavior to know when your baby is full. This makes you feel powerful.
The information booklet, which was prepared by a health education specialist and validated by the expert panel, included written text (brief messages about breastfeeding) with images to reinforce the information. The images of the newborn were accompanied with messages such as “breastfeed your baby and you reduce his/her risk of developing disease and chronic conditions” and “becoming a mother is a unique part of a woman’s life that could be completed with breastfeeding.”
Breastfeeding Outcomes Questionnaire. The secondary outcomes were measured with the Breastfeeding Outcomes Questionnaire to assess infant feeding at 8 weeks postpartum. The questionnaire was developed for this study and included 11 items related to infant feeding method. The number of women who exclusively breastfed and practiced any breastfeeding at 8 weeks were key outcomes. Exclusive breastfeeding was defined as no other food or drink except breast milk and vitamins, minerals, or medication as proposed by the World Health Organization (2001). Breastfeeding duration was defined as the practice of any breastfeeding at 8 weeks. Women who had not breastfed in the past 24 hours were classified as formula-feeding. Additional outcomes included breastfeeding patterns (e.g., frequency and duration of feedings, night feedings, daytime feedings, demand feedings), perceived breastfeeding problems (e.g., nipple pain, engorgement, mastitis), audible swallowing, 6 to 8 wet diapers per day, softer breasts after feeding, and maternal
The text messages were sent twice weekly after the first antenatal group session and continued until 8 weeks postpartum. The frequency was determined as optimal by the expert panel to provide regular information without overwhelming the new mothers. The text messages were sent to provide positive encouragement and reinforce exclusive breastfeeding (verbal persuasion). Examples of text messages included Breast milk is always available, there is no need to buy it and You can rely on your own instincts and your
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Outcome Measures Breastfeeding Self-Efficacy Scale–Short Form. The primary outcome, breastfeeding selfefficacy, was measured with the Persian version of the BSES-SF (Araban, 2015) at baseline and at 8 weeks postpartum. The BSES-SF (Dennis, 2003) is a 14-item, 5-point self-report tool used to assess breastfeeding self-efficacy. Item responses range from 1 (not at all confident) to 5 (always confident), with higher scores as an indication of greater breastfeeding self-efficacy. The BSES-SF has shown internal consistency with a Cronbach’s alpha of .94 (Dennis, 2003). The BSES-SF has been translated into many languages and been consistently found to have robust reliability coefficients (Ip, Yeung, Choi, Chair, & Dennis, 2012; Pin˜eiro-Albero et al., 2013; Wutke & Dennis, 2007). For this study, the BSES-SF was translated into Persian, and one item (comfortably breastfeed with my family members present) was deleted because breastfeeding in the presence of family members is not a common practice in Iran. Total scores for the translated 13-item BSES-SF range from 13 to 65, with higher scores as an indication of greater breastfeeding self-efficacy. The Cronbach’s alpha coefficient for the translated BSES-SF was 0.92 (Araban, 2015) and 0.85 in our study.
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satisfaction with breastfeeding. Responses to the questions were dichotomous yes or no. The content validity of the questionnaire was examined by 15 expert reviewers in the field of midwifery, health education, and epidemiology.
Data Analysis We conducted all data analyses with the use of SPSS version 15 and an intention-to-treat approach. A two-sided signifcance level of .05 was used for all study outcomes. We calculated means and standard deviations for continuous data and used an independent t test to examine differences in BSES-SF scores between the two groups. For dichotomous data, frequencies and percentages were calculated, and the chi-square test was used to analyze differences between groups. Odds ratios and 95% confidence intervals (CIs) were also calculated.
Results
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Reporting Trials [CONSORT] flow chart). Followup rates at 8 weeks postpartum were high, with 56 (93.3%) participants in the intervention group and 54 (90%) participants in the control group who completed the 8-week postpartum questionnaire. The demographic characteristics of participants of both groups are presented in Table 1. The mean age of participants was 23.2 (standard deviation [SD] ¼ 4.11) years, and mean [M] gestational age at recruitment was 35.89 (SD ¼ 1.75) weeks. Gestational age at the time of birth was not recorded; however, the weight of the newborns was documented, and the overall mean (M ¼ 3,093 g, SD ¼ 351) was within the normal range for a term newborn. Baseline BSES-SF scores were similar between participants in the intervention (M ¼ 49.4, SD ¼ 4.3) and control groups (M ¼ 48.7, SD ¼ 6.9). There were no differences found between the two groups on baseline characteristics.
Sample Of the 140 women who were approached, 120 (85.7%) agreed to participate and were enrolled (see Figure 1 for the Consolidated Standards of
Breastfeeding Self-Efficacy The mean BSES-SF scores at 8 weeks postpartum were significantly higher among
print & web 4C=FPO
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Figure 1. Consolidated Standards of Reporting Trials (CONSORT) flow chart for trial recruitment.
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Prenatal Breastfeeding Self-Efficacy Intervention
Table 1: Baseline Demographic Characteristics of Study Participants
Characteristic Age in years, M (SD)
Intervention Group
Control Group
All
(n ¼ 56)
(n ¼ 54)
p
23.62 (3.3)
24.12 (3.51)
23.12 (3.03)
.67
Gestation in weeks at recruitment, M (SD)
35.5 (1.3)
35.8 (2.13)
35.1 (1.79)
.49
Number of prenatal care visits, M (SD)
5.19 (1.72)
5.58 (1.78)
4.88 (1.6)
.82
3,093 (351)
3,099 (383)
3,087 (317)
.86
#Secondary
27 (24.5)
16 (28.6)
11 (20.4)
>Secondary
83 (75.5)
40 (71.4)
43 (79.6)
Infant birth weight in grams, M (SD) Woman’s education, n (%)
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.42
Husband’s education, n (%)
.37
#Secondary
36 (32.7)
15 (58.5)
21 (39.1)
>Secondary
74 (67.3)
41 (41.5)
33 (61.1)
Income level, n (%) Q6
.61
Poor
14 (12.7)
8 (14.3)
6 (11.1)
Fair/good
96 (87.3)
48 (85.7)
48 (88.9)
Mode of birth, n (%)
.33
Vaginal
68 (61.8)
32 (57.1)
36 (66.7)
Cesarean
42 (38.2)
24 (42.9)
18 (33.3)
Infant sex, n (%)
.09
Female
58 (52.7)
25 (44.6)
33 (61.1)
Male
52 (47.3)
31 (55.4)
21 (38.9)
Note. M ¼ mean; SD ¼ standard deviation.
participants in the intervention group (M ¼ 62.46, SD ¼ 4.22) compared with those in the control group (M ¼ 50.74, SD ¼ 4.88; p < .001; see Table 2). Participants who received the intervention were 2.89 times more likley to have higher BSES-SF scores at 8 weeks postpartum than those in the control group (95% CI [1.97, 4.32]).
Breastfeeding Outcomes The number of participants who breastfed exclusively was significantly greater in the intervention group (n ¼ 32 [57.1%]) at 8 weeks than in the control group (n ¼ 21 [38.9%], p ¼ .04). In particular, participants who received the intervention were more than twice as likely to be breastfeeding exclusively at 8 weeks postpartum compared with those in the control group (OR ¼ 2.28, 95% CI [1.03, 4.8]). Consistent with these findings, a significantly greater number of participants in the intervention group was breastfeeding on demand (n ¼ 49 [87.5%], p < .001) and breastfeeding at night (n ¼ 54 [96.4%], p < .001) compared with those in the control group (n ¼ 20 [37%] and n ¼ 17 [31.5%],
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respectively). More specifically, participants in the intervention group were 3 times more likely to breastfeed during the night (OR ¼ 3.06, 95% CI [2.06, 4.50]) and twice as likely to breastfeed on demand (OR ¼ 2.06, 95% CI [1.64, 3.39]) during the day than participants in the control group. Finally, twice the number of participants in the intervention group (n ¼ 36 [66.7%]) had longer breastfeeding sessions (> 5 minutes) compared with participants in the control group (n ¼ 18 [33%], p ¼ .001). The short breastfeeding sessions among control group participants is consistent with the greater rates of formula supplementation in this group. No significant differences were found between groups (p ¼ .91) for those who discontinued breastfeeding because an equal number of participants (n ¼ 13) discontinued breastfeeding in the intervention (23.2%) and control groups (24.1%) at 8 weeks postpartum. Most participants in both groups reported infant voidings of 6 to 8 diapers per day, audible swallowing, softer breasts after feeding, and satisfaction with
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breastfeeding. Although all participants reported satisfaction with breastfeeding, they also all reported that they experienced some breastfeeding problems.
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We identified that a prenatal group breastfeeding selfefficacy intervention increased breastfeeding self-efficacy and rates of exclusive breastfeeding at 8 weeks postpartum in women in Iran.
Discussion The purpose of our trial was to rigorously evaluate the effect of a multifaceted prenatal breastfeeding intervention on breastfeeding self-efficacy to improve breastfeeding outcomes in Iran. Overall,
the intervention increased the breastfeeding selfefficacy and rates of exclusive breastfeeding among participants by 18% at 8 weeks. Consistent with greater rates of exclusive breastfeeding
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Table 2: Breastfeeding Outcomes at 8 Weeks by Group
Breastfeeding Self-Efficacy Scale–Short Form score, M (SD)
Intervention
Control
OR [95% CI] or p
62.46 (4.22)
50.74 (4.88)
Exclusive breastfeeding, n (%)
32 (57.1)
21 (38.9)
2.28 [1.03, 4.8]
Any breastfeeding, n (%)
43 (76.7)
41 (75.9)
0.95 [0.40, 2.30]
Breastfeeding on demand during the night, n (%)
2.89 [1.97, 4.32]
3.06 [2.06, 4.5]
Yes
54 (96.4)
17 (31.5)
No
2 (3.6)
37 (68.5)
Breastfeeding on demand during the daytime, n (%)
2.36 [1.64, 3.39]
Yes
49 (87.5)
20 (37)
No
7 (12.5)
34 (63)
Audible swallowing, n (%)
ns
Yes
31 (55.4)
35 (54.8)
To some extent
25 (44.6)
19 (45.2)
Yes
22 (39.3)
19 (45.2)
No
34 (60.7)
35 (54.8)
56 (100)
54 (100)
Breasts softer after feeding, n (%)
ns
Breastfeeding problems, n (%) Yes No Q8
ns
0
Satisfaction with feeding, n (%)
56 (100)
0 54 (100)
ns
Yes No Feeding from both breasts, n (%)
ns
Yes
38 (67.9)
35 (64.8)
No
18 (31.1)
19 (25.2)
6–8 wet diapers per day, n (%)
ns
Yes
44 (78.6)
39 (2.2)
No
12 (21.4)
15 (27.8)
9 (16.1)
47 (86.9)
36 (66.7)
18 (33.3)
Duration of breastfeeding, n (%) Less than 5 minutes 5–10 minutes
.001
Note. M ¼ mean; ns, not significant; SD ¼ standard deviation.
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Prenatal Breastfeeding Self-Efficacy Intervention
at 8 weeks, participants in the intervention group had significantly greater rates of on-demand breastfeeding and breastfeeding during the night compared with those in the control group. These findings suggested that the prenatal group education intervention incorporating the sources of self-efficacy had a beneficial effect on improving breastfeeding self-efficacy and exclusive breastfeeding in first-time mothers that warrants additional investigation. This is important given the low rates of exclusive breastfeeding found at 8 weeks in the intervention (57.1%) and control groups (38.9%). No significant differences were found between groups regarding breastfeeding duration rates at 8 weeks. Results of our study are consistent with other trials that have supported prenatal breastfeeding interventions as effective in increasing breastfeeding self-efficacy. Four randomized controlled trials were identified in which prenatal group interventions were evaluated with the primary outcome of breastfeeding self-efficacy and secondary outcomes of exclusive breastfeeding or breastfeeding duration (Ansari, Abedi, Hasanpoor, & Bani, 2014; Chan, Ip, & Choi, 2016; Kronborg, Væth, Olsen, & Harder, 2008; Noel-Weiss, Rupp, Cragg, Bassett, & Woodend, 2006). In all four trials, investigators found significantly greater breastfeeding self-efficacy measured with the breastfeeding self-efficacy scale in women who received the interventions than in the control groups. However, the findings of whether the intervention lead to improved breastfeeding outcomes was equivocal. In two of the trials, investigators found improved rates of breastfeeding exclusivity (Ansari et al., 2014; Chan et al., 2016), wheras in two others, no differences were identified between groups on breastfeeding duration or exclusivity (Kronborg et al., 2008; Noel-Weiss et al., 2006). Findings from a recent systematic review and metaanalysis, which included 11 studies on prenatal and/or postnatal breastfeeding self-efficacy interventions were also positive (Brockway, Benzies, & Hayden, 2017). Overall, the researchers found that for each 1-point increase in mean breastfeeding self-efficacy scores between the intervention and control groups, the odds of exclusive breastfeeding increased by 10% in the intervention group.
Q2
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The importance of supportive breastfeeding interventions for women has been well established in the literature (Haroon, Das, Salam, Imdad, & Bhutta, 2013; Renfrew, McCormick, Wade,
Quinn, & Dowswell, 2012). Rollins (2016) advocated that efforts need to be scaled up to monitor breastfeeding interventions and trends in breastfeeding practices so that interventions that show effectiveness could be delivered to all mothers and infants. Interventions to improve rates of exclusive breastfeeding should include increasing women’s breastfeeding self-efficacy because it is imperative that women have the confidence to intitiate breastfeeding and overcome difficulties when encountered without providing formula. Our prenatal breastfeeding intervention focused on the four sources of breastfeeding self-efficacy (Dennis, 1999) so that women could not only master new breastfeeding skills but also increase their knowledge and confidence to breastfeed exclusively and persevere with challenges such as perceptions of insufficient milk supply. Many women often doubt their abilities to breastfeed and may be drawn to breast milk substitutes, leading to decreased exclusive breastfeeding (Chantry, Dewey, Peerson, Wagner, & Nommsen-Rivers, 2014; Rollins et al., 2016). To effectively protect, promote, and support breastfeeding, effective strategies are required at many levels in addition to those provided to women (Bartick et al., 2017; Rollins et al., 2016). Although supportive breastfeeding interventions have produced positive effects (Brockway et al., 2017), legal and policy directives that target social attitudes and norms, employment conditions, and health services to support women to breastfeed optimally are also required. Social constructs such as lack of paid maternity leave, indadequate access to lactation services, limited implementation of evidence-based practices to support breastfeeding, and the regulation of breast milk substitutes warrant attention. Although many hospitals are designated BabyFriendly in Iran, formula supplementation in the hospital (OR ¼ 0.41, 95% CI [0.17, 0.95]) and inconsistent infant feeding advice (OR ¼ 0.53, 95% CI [0.37, 0.78]) have had significant negative effects on exclusive breastfeeding (Noughabi et al., 2014). Likewise, women who return to work while breastfeeding is a relatively new phenomenon in Iran and has been associated with breastfeeding cessation (Valizadeh et al., 2017). The absence of policy in these areas to support breastfeeding (Noughabi et al., 2014; Valizadeh et al., 2017) provides barriers and contradicts the message that suboptimal breastfeeding has substantial effects on maternal and child health outcomes and costs (Bartick et al., 2017).
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Araban, M., Karimian, Z., Karimian Kakolaki, Z., McQueen, K. A., and Dennis, C.-L.
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Strengths of our study include the strong empirical and theoretical foundation for the intervention, random group assignment, the high rate of protocol adherence, and low loss to follow-up. Despite these strengths, potential limitations also exist, including that the study was limited to one geographic area in Iran, which decreases the generalizability of our findings. Because participants could not be blinded to group allocation, it is possible that there may have been some social desirability bias, with overestimation of breastfeeding outcomes. Reasons for breastfeeding discontinuation were not collected and may have provided additional information regarding breastfeeding duration.
953 954 955 956 957 958 959 960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975 976 977 978 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 995 996 997 998 999 1000 1001 1002 1003 1004 1005 1006 1007 1008
The findings from this study provide evidence that enhancing women’s breastfeeding self-efficacy can lead to improved rates of exclusive breastfeeding.
of the breastfeeding self-efficacy intervention in a larger sample is required before making recommendations for widespread use in practice.
REFERENCES Acheampong, M., Ejiofor, C., & Salinas-Miranda, A. (2017). An analysis of determinants of under-5 mortality across countries: Defining priorities to achieve targets in sustainable developmental goals. Maternal and Child Health Journal, 21(6), 1428–1447. https:// doi.org/10.1007/s10995-017-2260-9 American Academy of Pediatrics. (2012). Breastfeeding and the use of
Because the results of our study were encouraging, further testing of this intervention should be conducted in larger samples and with diverse populations. Additionally, future research is required to identify whether there is an optimal time for the delivery of a breastfeeding selfefficacy intervention and whether there is an optimal dosage to sustain breastfeeding exclusivity. In particular, future investigators may consider an extension of the intervention throughout the postpartum period so new mothers receive continued breastfeeding support. Our intervention incorporated all four sources of self-efficacy information; thus, it is unknown whether attention to all four sources is necessary or if an emphasis on a combination of two or more is sufficient. Future research is required to evaluate which source(s) of selfefficacy are most effective and warrant increased attention in interventions to increase breastfeeding self-efficacy.
human milk. Pediatrics, 129(3), e827–e841. https://doi.org/10. 1542/peds.2011-3552 Ansari, S., Abedi, P., Hasanpoor, S., & Bani, S. (2014). The effect of interventional program on breastfeeding self-efficacy and duration of exclusive breastfeeding in pregnant women in Ahvaz, Iran. International Scholarly Research Notices, 2014, e510793. https://doi.org/10.1155/2014/510793 Araban, M. (2015). The Persian version of Breastfeeding Self-Efficacy Scale–Short Form (BSES-SF): Translation and explanatory factor analysis assessment. Journal of Iranian Institute for Health Sciences Research, 15(1), 23–28. Balogun, O. O., Dagvadorj, A., Anigo, K. M., Ota, E., & Sasaki, S. (2015). Factors influencing breastfeeding exclusivity during the first 6 months of life in developing countries: A quantitative and qualitative systematic review. Maternal & Child Nutrition, 11(4), 433–451. https://doi.org/10.1111/mcn.12180 Bartick, M. C., Schwarz, E. B., Green, B. D., Jegier, B. J., Reinhold, A. G., Colaizy, T. T., … Stuebe, A. M. (2017). Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal & Child Nutrition, 13(1), e12366. https://doi.org/10.1111/mcn.12366 Blyth, R., Creedy, D. K., Dennis, C.-L., Moyle, W., Pratt, J., & De Vries, S. M. (2002). Effect of maternal confidence on breastfeeding duration: An application of breastfeeding self-efficacy theory. Birth: Issues in Perinatal Care, 29(4), 278–284. https://doi.org/ 10.1046/j.1523-536X.2002.00202.x
Conclusion Our results suggested that a group prenatal breastfeeding self-efficacy intervention based on breastfeeding self-efficacy theory may help increase women’s breastfeeding self-efficacy and lead to increased rates of exclusive breastfeeding in women in Ahvaz, Iran. Our findings add to the growing evidence regarding the saliency of breastfeeding self-efficacy as a modifiable variable that influences breastfeeding outcomes. Thus, the breastfeeding self-efficacy intervention shows potential as an effective intervention to increase rates of exclusive breastfeeding. Given the evidence that breastfeeding may help decrease maternal and child-related mortality in low- and middle-income countries, effective interventions to increase rates of exclusive breastfeeding are warranted. Rigorous evaluation
Bowatte, G., Tham, R., Allen, K. J., Tan, D. J., Lau, M., Dai, X., & Lodge, C. J. (2015). Breastfeeding and childhood acute otitis media: A systematic review and meta-analysis. Acta Paediatrica, 104(467), 85–95. https://doi.org/10.1111/apa.13151 Brockway, M., Benzies, K., & Hayden, K. (2017). Interventions to improve breastfeeding self-efficacy and resultant breastfeeding rates: A systematic review and meta-analysis. Journal of Human Lactation,
33(3),
486–499.
https://doi.org/10.1177/
0890334417707957 Campbell, M., Fitzpatrick, R., Haines, A., Kinmonth, A. L., Sandercock, P., Spiegelhalter, D., & Tyrer, P. (2000). Framework for design and evaluation of complex interventions to improve health. British Medical Journal, 321(7262), 694–696. https://doi. org/10.1136/bmj.321.7262.694
Q3
Cardwell, C. R., Stene, L. C., Ludvigsson, J., Rosenbauer, J., Cinek, O., Svensson, J., … Patterson, C. C. (2012). Breastfeeding and childhood-onset type 1 diabetes: A pooled analysis of individual participant data from 43 observational studies. Diabetes Care, 35(11), 2215–2225. https://doi.org/10. 2337/dc12-0438
JOGNN 2018; Vol. -, Issue -
FLA 5.5.0 DTD JOGN311_proof 31 January 2018 9:03 am ce
9
RESEARCH
1009 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020 1021 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 1032 1033 1034 1035 1036 1037 1038 1039 1040 1041 1042 1043 1044 1045 1046 1047 1048 1049 1050 1051 1052 1053 1054 1055 1056 1057 1058 1059 1060 1061 1062 1063 1064
Prenatal Breastfeeding Self-Efficacy Intervention
Chan, M. Y., Ip, W. Y., & Choi, K. C. (2016). The effect of a self-efficacy-
Database of Systematic Reviews, 2017(2), CD001141. https://
based educational programme on maternal breast feeding selfefficacy, breast feeding duration and exclusive breast feeding
McQueen, K. A., Dennis, C.-L., Stremler, R., & Norman, C. D. (2011).
rates: A longitudinal study. Midwifery, 36, 92–98. https://doi.org/
A pilot randomized controlled trial of a breastfeeding self-
10.1016/j.midw.2016.03.003
efficacy intervention with primiparous mothers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(1), 35–46.
Chantry, C. J., Dewey, K. G., Peerson, J. M., Wagner, E. A., &
https://doi.org/10.1111/j.1552-6909.2010.01210.x
Nommsen-Rivers, L. A. (2014). In-hospital formula use increases early breastfeeding cessation among first-time mothers
Mortazavi, F., Mousavi, S. A., Chaman, R., Wambach, K. A., Mor-
intending to exclusively breastfeed. The Journal of Pediatrics,
tazavi, S. S., & Khosravi, A. (2015). Breastfeeding practices
164(6), 1339–1345.e5. https://doi.org/10.1016/j.jpeds.2013.12.
during the first month postpartum and associated factors:
035
Impact on breastfeeding survival. Iranian Red Crescent Medical Journal, 17(4), e27814. https://doi.org/10.5812/ircmj.
Dai, X., & Dennis, C.-L. (2003). Translation and validation of the
17(4)2015.27814
Breastfeeding Self-Efficacy Scale into Chinese. Journal of Midwifery & Women’s Health, 48(5), 350–356. https://doi.org/10.
Noel-Weiss, J., Rupp, A., Cragg, B., Bassett, V., & Woodend, A. K. (2006). Randomized controlled trial to determine effects of
1016/S1526-9523(03)00283-6 Dennis, C. L. (1999). Theoretical underpinnings of breastfeeding
prenatal breastfeeding workshop on maternal breastfeeding
confidence: A self-efficacy framework. Journal of Human
self-efficacy and breastfeeding duration. Journal of Obstetric,
Lactation, 15(3), 195–201.
Gynecologic, & Neonatal Nursing, 35(5), 616–624. https://doi. org/10.1111/j.1552-6909.2006.00077.x
Dennis, C.-L. (2003). The breastfeeding self-efficacy scale: Psychometric assessment of the short form. Journal of Obstetric, Gy-
Noughabi, Z. S., Tehrani, S. G., Foroushani, A. R., Nayeri, F., &
necologic, & Neonatal Nursing, 32(6), 734–744. https://doi.org/
Baheiraei, A. (2014). Prevalence and factors associated with
10.1177/0884217503258459
exclusive breastfeeding at 6 months of life in Tehran: A population-based study. Eastern Mediterranean Health Journal,
Dykes, F., Moran, V. H., Burt, S., & Edwards, J. (2003). Adolescent mothers
and
breastfeeding:
Experiences
and
20(1), 24–32.
support
needs—An exploratory study. Journal of Human Lactation,
Olang, B., Farivar, K., Heidarzadeh, A., Strandvik, B., & Yngve, A. (2009). Breastfeeding in Iran: Prevalence, duration and current
19(4), 391–401. https://doi.org/10.1177/0890334403257562
recommendations. International Breastfeeding Journal, 4(1), 8.
Galipeau, R., Dumas, L., & Lepage, M. (2017). Perception of not
https://doi.org/10.1186/1746-4358-4-8
having enough milk and actual milk production of first-time breastfeeding mothers: Is there a difference? Breastfeeding
Olang, B., Heidarzadeh, A., Strandvik, B., & Yngve, A. (2012). Rea-
Medicine, 12(4), 210–217. https://doi.org/10.1089/bfm.2016.
sons given by mothers for discontinuing breastfeeding in Iran.
0183
International Breastfeeding Journal, 7(1), 7. https://doi.org/10. 1186/1746-4358-7-7
Haroon, S., Das, J. K., Salam, R. A., Imdad, A., & Bhutta, Z. A. (2013). Breastfeeding promotion interventions and breastfeeding
Otsuka, K., Dennis, C.-L., Tatsuoka, H., & Jimba, M. (2008). The
practices: A systematic review. BMC Public Health, 13, S20.
relationship between breastfeeding self-efficacy and perceived
https://doi.org/10.1186/1471-2458-13-S3-S20
insufficient milk among Japanese mothers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(5), 546–555. https://doi.
Horta, B. L., Loret de Mola, C., & Victora, C. G. (2015). Long-term
org/10.1111/j.1552-6909.2008.00277.x
consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: A systematic review and
Pin˜eiro-Albero, R. M., Ramos-Pichardo, J. D., Oliver-Roig, A., Velan-
meta-analysis. Acta Paediatrica, 104(467), 30–37. https://doi.
drino-Nicola´s, A., Richart-Martı´nez, M., Garcı´a-de-Leo´n-Gon-
org/10.1111/apa.13133
za´lez, R., & Wells, K. J. (2013). The Spanish version of the
Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., …
Prenatal Breast-feeding Self-efficacy Scale: Reliability and val-
Lau, J. (2007). Breastfeeding and maternal and infant health
idity assessment. International Journal of Nursing Studies,
outcomes in developed countries. Evidence Report/Technology
50(10), 1385–1390. https://doi.org/10.1016/j.ijnurstu.2012.12. 010
Assessment, 153, 1–186. https://doi.org/10.1542/gr.18-2-15 Ip, W.-Y., Yeung, L.-S., Choi, K.-C., Chair, S.-Y., & Dennis, C.-L. (2012).
Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C. K.,
Translation and validation of the Hong Kong Chinese version of
Martines, J. C., & Lancet Breastfeeding Series Group. (2016).
the Breastfeeding Self-Efficacy Scale–Short Form. Research in
Why invest, and what it will take to improve breastfeeding
Nursing & Health, 35(5), 450–459. https://doi.org/10.1002/nur.
practices? Lancet, 387(10017), 491–504. https://doi.org/10. 1016/S0140-6736(15)01044-2
21493 Kramer, M. S., & Kakuma, R. (2012). Optimal duration of exclusive
Roostaee, F., Tabatabaei, S. M., Zaboli, M., Keykhaie, R., Sharifi-Rad,
breastfeeding. Cochrane Database of Systematic Reviews,
J., Shahrak, P., & Soroush, F. (2015). Breast-feeding continua-
2012(8),
tion in South-Eastern of Iran: The associated factors. Medical
CD003517.
https://doi.org/10.1002/14651858.
Archives, 69(2), 98–102. https://doi.org/10.5455/medarh.2015.
CD003517.pub2
69.98-102
Kronborg, H., Væth, M., Olsen, J., & Harder, I. (2008). Health visitors and breastfeeding support: Influence of knowledge and self-
Sankar, M. J., Sinha, B., Chowdhury, R., Bhandari, N., Taneja, S.,
efficacy. European Journal of Public Health, 18(3), 283–288.
Martines, J., & Bahl, R. (2015). Optimal breastfeeding practices
https://doi.org/10.1093/eurpub/ckm121
and infant and child mortality: A systematic review and meta-
Lodge, C. J., Tan, D. J., Lau, M. X. Z., Dai, X., Tham, R., Lowe, A. J., …
analysis. Acta Paediatrica, 104(467), 3–13. https://doi.org/10. 1111/apa.13147
Dharmage, S. C. (2015). Breastfeeding and asthma and allergies: A systematic review and meta-analysis. Acta Paediatr-
Torkzahrani, S. (2008). Commentary: Childbirth education in Iran. Journal of Perinatal Education, 17(3), 51–54. https://doi.org/10.
ica, 104(467), 38–53. https://doi.org/10.1111/apa.13132
1624/105812408X329601
McFadden, A., Gavine, A., Renfrew, M. J., Wade, A., Buchanan, P.,
10
Q4
doi.org/10.1002/14651858.CD001141.pub5
Taylor, J. L., … MacGillivray, S. (2017). Support for healthy
United Nations Children’s Fund. (n.d.). The state of the world’s children
breastfeeding mothers with healthy term babies. Cochrane
2008. Retrieved from www.unicef.org/sowc08/report/report.php
JOGNN, -, -–-; 2018. https://doi.org/10.1016/j.jogn.2018.01.005
FLA 5.5.0 DTD JOGN311_proof 31 January 2018 9:03 am ce
http://jognn.org
1065 1066 1067 1068 1069 1070 1071 1072 1073 1074 1075 1076 1077 1078 1079 1080 1081 1082 1083 1084 1085 1086 1087 1088 1089 1090 1091 1092 1093 1094 1095 1096 1097 1098 1099 1100 1101 1102 1103 1104 1105 1106 1107 1108 1109 1110 1111 1112 1113 1114 1115 1116 1117 1118 1119 1120
Araban, M., Karimian, Z., Karimian Kakolaki, Z., McQueen, K. A., and Dennis, C.-L.
1121
Valizadeh, S., Hosseinzadeh, M., Mohammadi, E., Hassankhani, H. M.,
1122
Fooladi, M., & Schmied, V. (2017). Addressing barriers to
1123 1124
from
1134
http://www.who.int/nutrition/publications/infantfeeding/
WHO_NHD_01.09/en
1135
health: Experiences of breastfeeding mothers after returning to
Wu, D. S., Hu, J., McCoy, T. P., & Efird, J. T. (2014). The effects of a
work. Nursing & Health Sciences, 19(1), 105–111. https://doi.
breastfeeding self-efficacy intervention on short-term breast-
org/10.1111/nhs.12324
feeding outcomes among primiparous mothers in Wuhan,
1137
China. Journal of Advanced Nursing, 70(8), 1867–1879. https://
1138
doi.org/10.1111/jan.12349
1139
1125
Victora, C. G., Bahl, R., Barros, A. J. D., Franc¸a, G. V. A., Horton, S.,
1126
Krasevec, J., … Lancet Breastfeeding Series Group. (2016).
1127
Breastfeeding in the 21st century: Epidemiology, mechanisms,
Wutke, K., & Dennis, C.-L. (2007). The reliability and validity of the
and lifelong effect. Lancet, 387(10017), 475–490. https://doi.
Polish version of the Breastfeeding Self-Efficacy Scale–Short
org/10.1016/S0140-6736(15)01024-7
Form: Translation and psychometric assessment. International
1128
RESEARCH
1129
World Health Organization. (2001). The optimal duration of exclusive
1130
breastfeeding: Report of an expert consultation. Retrieved
1136
1140 1141
Journal of Nursing Studies, 44(8), 1439–1446. https://doi.org/
1142
10.1016/j.ijnurstu.2006.08.001
1143
1131
1144
1132
1145
1133
1146
JOGNN 2018; Vol. -, Issue -
FLA 5.5.0 DTD JOGN311_proof 31 January 2018 9:03 am ce
11