INITIATION OF BREASTFEEDING
1
Promoting Breastfeeding Initiation: Baby Friendly Hospital Initiative
Sheridan Brown, Jennifer Fevrier, Kaitlyn Higbie, Marc Manucal, Jorge Paulino,
Brittanie Smith, Emily Thrasher
On campus
Submitted in partial fulfillment of the requirements in the course
NURS 363: Nursing Science
Old Dominion University
NORFOLK, VIRGINIA
Fall, 2011
INITIATION OF BREASTFEEDING
2
Promoting Breastfeeding Initiation: Baby Friendly Hospital Initiative
The purpose of this assignment is to increase the learner’s ability to critically
analyze the steps in the research process and refine skills.
Research Topic
The research topic is increasing initiation of breastfeeding. Infants not breastfed
are likely to suffer health problems such as, ear infections, urinary tract infections and
even delayed complications such as Diabetes. Women who choose not to breastfeed are
at an increased risk for ovarian and breast cancer (Dyson, McCormick & Renfrew, 2008).
The Centers for Disease Control and Prevention’s (CDC) 2011 target goal for having
ever breastfed in the United States (US) is 81.9%, yet in 2010 only reached 74.6%.
Based on this statistic, the group decided to research reasons initiation of breastfeeding
has not increased despite the abundance of research in favor of breastfeeding.
Furthermore, studies discussing the United Nations Children’s Fund (UNICEF) and the
World Health Organization’s (WHO) Baby Friendly Hospital Initiative sparked the
group’s interest into researching possible methods of increasing initiation.
Research Problem and Purpose Statement
The research problem is initiation rates remain low despite the significant
documented health benefits of breastfeeding. Breastfeeding initiation rates fell
approximately 7% below the Healthy People 2010 goal for the United States (Centers for
Disease Control, 2011). Dodgson, Duckett, Garwick, and Graham (2002) and Spear
(2006) state “women report frequently finding health professionals, including their
physicians, lacking knowledge about lactation problems” (as cited in Watkins &
Dodgson, 2010, p. 224). In addition, other studies have found numerous clinicians within
INITIATION OF BREASTFEEDING
3
professional medical organizations “lack the basic breastfeeding knowledge needed to
support breastfeeding successfully” (Grossman et al., 2009, p.55).
Breastfeeding initiation for the purposes of this paper is defined as immediate
post-natal nursing. The purpose of this research study is to determine if implementing
several interventions from the Baby Friendly Hospital Initiative will increase the
initiation of breastfeeding. “Adequate evidence indicates that interventions to promote
and support breastfeeding increase the rates of initiation” (U.S. Preventive Services Task
Force, 2008, p.560). There are a number of factors that have been shown to influence
whether or not mothers initiate breastfeeding, including, but not limited to: little
education on breastfeeding techniques and benefits, lack of family or health care
professional support, as well as, implementing hospital policies (Mickens, Modeste,
Montgomery, & Taylor, 2009). Also, hospitals that used the BFHI policies were more
inclined to use the evidence based practices necessary to support breastfeeding initiation
(Weddig, Baker & Auld, 2011). Lower income mothers, teenagers, mothers with less
than a high school education, and mothers participating in government funded programs,
are less likely to initiate breastfeeding, whereas, Byrd, Balcazar, and Hummer (2001) and
Humphreys, Thompson, and Miner (1998) found “college educated women, women
living with a partner, and women who received any prenatal care are more likely to
intend to breastfeed” (as cited in Gill, Reifsnider, & Lucke, 2007, p. 709). Low initiation
rates are extremely significant because these infants may not be getting the nutrients or
immunity they need from their mothers in order to remain healthy and at optimal rates of
growth and functioning (Noel-Weiss, Rupp, Cragg, Bassett, & Woodend, 2006, p.616).
INITIATION OF BREASTFEEDING
4
Search for Sources
A variety of online search engines were used in order to complete this assignment.
From the Old Dominion University Library website, the following search engines were
used: CINAHL Plus, Cochrane Database of Systematic Reviews, SAGE Full-Text
Selection, Health Source: Nursing/Academic Edition, Medline, and PubMed. Google and
Google Scholar were also utilized. Searches for online websites included Healthy People
2010, CDC, WHO, UNICEF, and Baby Friendly USA. In order to get the most
applicable results for this paper the following key terms were searched:
o
o
o
o
o
Breastfeeding
Breastfeeding AND
Initiation
Breastfeeding AND
Interventions
Breastfeeding AND
Nursing or education
Breastfeeding AND
Healthy Baby Initiative
o
o
o
o
o
Nurs* AND
Breastfeeding
Breastfeeding AND
increasing initiation
Promoting breastfeeding
Baby Friendly Hospital
Initiative
Healthy People 201
Sources Consulted
After review and discussion, the resource literature was narrowed to several
nursing, medical, and health related journals, government studies, and informative
websites which supported the topic of interest. Internet sources provided ample research
data for both narrow and wide range samples. Three systematic reviews validated
effective interventions by comparing several previous research studies. LoBiondo-Wood
and Haber’s textbook Nursing Research: Methods and critical appraisal for evidencebased practice (2010) was used as a reference tool to compose the hypothesis, variables,
experimental design, and design validity sections.
INITIATION OF BREASTFEEDING
5
Hypothesis
The initial hypothesis suggested a correlation between breastfeeding initiation
and breastfeeding education, support, and hospital breastfeeding policies. The final
hypothesis proposes that mothers who deliver at hospitals implementing the Baby
Friendly Hospital Initiative (BFHI) are more likely to initiate breastfeeding policies,
education, and support compared to mothers who do not give birth at Baby Friendly
Hospitals. Ergo, a strong correlation between BFHI policies and increased breastfeeding
initiation exists. According to babyfriendlyusa.org 2010 data collected from around the
world, hospitals implementing BFHI had a positive impact on the successful initiation of
breastfeeding.
Variables
The independent variables in this study are three of the interventions outlined by
the BFHI, breastfeeding education, support, and hospital policies. The dependent
variable is initiation of breastfeeding. Extraneous variables include ethnicity, educational
level, maternal age, marital status, income, and maternal and infant health status.
Additionally, culture is an important extraneous variable to acknowledge because culture
has an ever-present impact on all aspects of life, including initiation of breastfeeding.
The extraneous variables to control in this study would be ethnicity/race, educational
level, income, and maternal and baby health status. In the 2009 study, Sparks found that
“rural non-Hispanic black mothers have statistically significant lower odds ofinitiating
breastfeeding compared to urban non-Hispanic mothers” (p. 126). Studies also show
“Hispanic immigrants are more likely to breastfeed compared to their U.S. born
counterparts.”(Gill et al., 2007, p. 709). Interestingly, Galvin, Grossman, FeldmanWinter, Chaudhuri, and Merewood (2007) found that Cambodian women giving birth in
INITIATION OF BREASTFEEDING
6
the United States (US) had lower initiation rates, mainly due to lack of culturally
appropriate diet in the hospital setting. Education should be controlled in part because
“college educated women . . . are more likely to breastfeed” (Gill et al., 2007 p. 709).
Mickens et al. (2009) found “the lower income group (less than $18, 000) had
significantly less intention to breastfeed their babies” (p. 161). Maternal and infant
health status needs to be controlled because a mother or infant may have a condition that
prevents breastfeeding entirely, or there is not enough breast milk and supplementation
with formula must be required.
In order to produce a more thorough study, questions regarding culture/ethnicity,
education level, income, and maternal and child health status are included in the
Breastfeeding Questionnaire (Appendix A). Controlling these extraneous variables gives
the researchers a better idea of all the factors influencing whether or not a mother initiates
breastfeeding.
Design
Quantitative design was chosen to investigate the impact of interventions on the
initiation of breastfeeding. Quantitative design allows “multiple overlapping and unique
purposes” (LoBiondo-Wood & Haber, 2010, p.156). The design provides the plan or
blueprint for testing research questions and hypotheses, and involves structure and
strategy (LoBiondo-Wood & Haber, 2010). The specific design chosen was the trueexperimental design, providing pre-intervention demographic data, measurement of
dependent variables, randomized control-groups, and post-intervention results. Multiple
designs were considered, such as, qualitative, Solomon-four group and quasiexperimental. Although the Solomon-four group design could have been used, it did not
INITIATION OF BREASTFEEDING
7
provide baseline data for two of the sub-groups.
Promotion of breastfeeding starts with prenatal care and continues through postnatal care interventions. These interventions include education, support, and hospital
policies. Data will be collected from one group of mothers delivering at Hospital A (HA)
and another group of mothers delivering at Hospital B (HB) within a three month time
period. HA implements the Baby Friendly Hospital Initiative, including the prenatal care
interventions. The staff at HA is required to have“30 hours of formal classroom
instruction; 3-6 months of supervised work experience and continuing education”
(Shealy, Li, Benton & Grummer-Strawn, 2005, p. 17). Support from the staff has a great
effect on breastfeeding initiation. “Professionals need breastfeeding education to be able
to act as breastfeeding supporters” (Hannula, Kaunonen, & Tarkka, 2007, p.1141). In
addition, another study determined “the importance of certain ‘Baby Friendly’ maternitycare hospital practices in influencing breastfeeding outcome” (DiGirolamo, GrummerStrawn, & Fein, 2008, S46). The intervention group will have access to unlimited
prenatal education as well as professional and peer support based on Wade, Haining, and
Day’s finding that peer support positively influences breastfeeding initiation rates (2009).
Subjects will be required to attend at least five prenatal curricula. A researcher will be
attending all educational and support meetings to monitor participation.
This hospital provides classes that discuss effective breastfeeding techniques,
benefits of breastfeeding for mother and baby, and resources for assistance. A
randomized controlled study revealed that women who participated in prenatal
breastfeeding workshops had higher breastfeeding self-efficacy and duration than the
controlled group. Additionally, the study suggests that intending workshops during the
INITIATION OF BREASTFEEDING
8
first and second trimesters and increasing the length of workshops would result in even
higher results (Noel-Weiss, Rupp, Cragg, Bassett, & Woodend, 2006). The hospital’s
post-natal support includes the same education and support as prenatal in addition to a
hospital policy checklist. HB does not implement the Baby Friendly Hospital Initiative
and serves as the control. There are no prenatal or post-natal education or support
interventions. Postnatally, a survey (Appendix A) will be distributed to both HA and HB
participants, to include questions regarding their initiation of breastfeeding.
Design Validity
Threats to the internal validity of the designs above include history, maturation,
instrumentation, mortality, and selection bias. History could be a threat to the validity
because of events outside the experimental setting affecting the dependent variable. This
threat could result in changes in the study due to inside or outside experimental factors,
such as previous breastfeeding failures or history of breast cancer. Maturation could be a
threat to validity due to hormonal fluctuations throughout the prenatal period.
Instrumentation could be a threat to validity due to multiple group members collecting
observational data. Mortality could be a threat to validity due to miscarriages or maternal
or infant death at birth. Selection bias could be a threat to validity if a subject elected to
not participate in the study (LoBiondo-Wood & Haber, 2010).
Threats to external validity of the designs above include selection effects,
reactivity effects, and measurement effects. Selection effects can threaten validity
because subjects may choose not to participate thus offering a small sample size.
Reactivity effects also known as the Hawthorne Effect affects external validity because
of the subjects’ response to being studied. Even though measurement effects could be an
INITIATION OF BREASTFEEDING
9
external validity threat, it is not a threat to our design because of the lack of pre and post
testing (LoBiondo-Wood & Haber, 2010).
Rationale for Design
The quantitative design was chosen due to its cause and effect relationship
between early interventions and breastfeeding initiation. More specifically the design
was chosen because it offered pre-intervention demographic data, measurement of
dependent variables, randomized control-groups, and post-intervention results. The
Solomon-four group design was not chosen because it did not provide necessary baseline
data for two of the sub-groups included in the experiment. In addition, the quasiexperimental design was not chosen because “random assignment to the treatment or
control group may not have been undertaken, or there may not be a control group”
(LoBiondo-Wood & Haber, 2010, p. 186). The qualitative study design was not chosen
due its lack of variables, hypotheses, and sample sizes
Measurement Tools
The breastfeeding questionnaire and the focus group were the two most
commonly used measurement tools in the research sources consulted. The focus group
will be used to identify participants within a three month delivery period. The
questionnaire (Appendix A) will help identify whether or not the interventions,
education, support, and hospital policies were met. It will also help determine
demographic data about the participants. Identical questionnaires will be distributed to
both experimental groups at each hospital, postpartum.
INITIATION OF BREASTFEEDING
10
References
Baby-Friendly USA, Inc. (2010). Info for breastfeeding advocates/health care
professionals. Retrieved from http://babyfriendlyusa.org/eng/06.htm
Centers for Disease Control and Prevention. (2011). Breastfeeding report card—United
States, 2011. Retrieved from http://www.cdc.gov/breastfeeding/pdf/
2011BreastfeedingReportCard.pdf
DiGirolamo, A. M., Grummer-Strawn, L. M., & Fein, S. B. (2008). Effect of maternitycare practices on breastfeeding [Supplemental material]. Pediatrics, 122, S43-S50.
doi: 10.1542/peds.2008-1315e
Dyson, L., McCormick, F.M., & Renfrew, M.J. (2008). Interventions for promoting the
initiation of breastfeeding. Cochrane Database of Systematic Reviews 2005 (2), 140. doi: 10.2002/14651858.CD001688.pub2
Galvin, S., Grossman, X., Feldman-Winter, L., Chaudhuri, J., & Merewood, A. (2008).
A practical intervention to increase breastfeeding initiation among Cambodian
women in the US. Maternal and Child Health Journal, 12, 545-547. doi:
10.1007/s10995-007-0263-7
Gill, S.L., Reifsnider, E., & Lucke, J.F. (2007). Effects of support on the initiation and
duration of breastfeeding. Western Journal of Nursing Research, 29, 708-723.
doi: 10.1177/0193945906297376
Grossman, X., Chaudhuri, J., Feldman-Winter, L., Abrams, J., Newton, K.N., Philipp,
B.L., & Merewood, A. (2009). Hospital education in lactation practices (project
HELP): Does clinician education affect breastfeeding initiation and exclusivity in
INITIATION OF BREASTFEEDING
11
the hospital? Birth: Issues in Perinatal Care, 36, 54-59. doi: 10.1111/j.1523536X.2008.00295.x
Hannula, L., Kaunonen, M., & Tarkka, M-T. (2008). A systematic review of professional
support interventions for breastfeeding. Journal of Clinical Nursing, 17, 11321143. doi: 10.1111/j.1365-2702.2007.02239.x
LoBiondo-Wood, G. & Haber, J. (2010) Nursing Research: Methods and Critical
Appraisal for Evidence-Based Practice. (7th ed.) St. Louis, Missouri: Mosby
Elsevier
Mickens, A.D., Modeste, N., Montgomery, S., & Taylor, M. (2009). Peer support and
breastfeeding intentions among black WIC participants. Journal of Human
Lactation, 25, 157-162. doi: 10.1177/0890334409332438
Noel-Weiss, J., Rupp, A., Cragg, B., Bassett, V., & Woodend, A.K. (2006). Randomized
controlled trial to determine effects of prenatal breastfeeding workshop on
maternal breastfeeding self-efficacy and breastfeeding duration. Journal of
Obstetric, Gynecological, and Neonatal Nursing, 35, 616-624. doi:
10.1111/j.1552-6909.2006.00077.x
Shealy, K.R., Li, R., Benton-Davis, S., & Grummer-Strawn, L.M. (2005) The CDC
guide to breastfeeding interventions. Retrieved from http://www.cdc.gov/
breastfeeding/pdf/breastfeeding_interventions.pdf
Sparks, P. J. (2010). Rural-urban differences in breastfeeding initiation in the United
States. Journal of Human Lactation, 26, 118-129. doi:
10.1177/0890334409352854
INITIATION OF BREASTFEEDING
12
Wade, D., Haining, S., Day, A. (2009). Breastfeeding peer support: Are there additional
benefits? Community Practitioner, 82 (12), 30-33.
Watkins, A.L & Dodgson, J.E. (2010). Breastfeeding educational interventions for health
professionals: A synthesis of intervention studies. Journal for Specialists in
Pediatric Nursing, 15, 223-232. doi: 10.1111/j.1744-6155.2010.00240.x
Weddig, J., Baker, S. S., Auld, G. (2011). Perspectives of hospital-based nurses on
breastfeeding initiation best practices. Journal of Journal of Obstetric,
Gynecological, and Neonatal Nursing, 40, 166-178. doi: 10.1111/j.15526909.2011.01232.x
INITIATION OF BREASTFEEDING
13
Appendix A
Breastfeeding Questionnaire
Please answer the following questions about breastfeeding
Age:
Ethnicity/Race:
Highest level of Education:
Household Income check below
o Less than $9,999
o $10,000 - $14,999
o $15,000 - $24,999
o $25,000 - $34,999
o $35,000 - $49,999
o $50,000 - $74,999
o $75,000 - $99,999
o $100,000 - $149,999
o $150,000 - $199,999
o $200,000 and above
1. Did you choose to breastfeed? If no, why not?
2. Did you give birth at a Baby Friendly hospital? If no, why not?
3. Have you had any prenatal (before birth) breast feeding education or classes? If
yes, check the boxes below to indicate type of education received.
□
□
□
□
□
□
□
Breastfeeding techniques (latching, positioning)
How to get started with breastfeeding
Internet or media sources (DVD, tape)
Home study
Benefits and management of breastfeeding
Breastfeeding brochures, pamphlets, or any written materialOther (list) __________________________________________________
4. Do you have adequate support? If yes, check the boxes below to indicate type of
support.
□
□
□
□
□
Family support
Peer support
Professional support (i.e. Doctor, Nurse, Lactation Consultant)
Group support
Other (please list) _____________________________________________
5. Did you start breastfeeding within a half-hour of birth? If no, please explain.
INITIATION OF BREASTFEEDING
6.
Was anyone available to help you with any questions you might have had
regarding breastfeeding? If yes, who?
7.
Were any artificial teats/nipples or pacifiers also called soothers given to
breastfeeding infants? Yes or No?
14
8. Did the breastfeeding infant receive any other food or drink, for example formulas
or supplements in a bottle, other than breast milk? Yes or No? If yes, what kind?
INITIATION OF BREASTFEEDING
15
Appendix B
Interlibrary Loan
INITIATION OF BREASTFEEDING
16
Appendix C
Annotated Bibliography
Baby-Friendly USA, Inc. (2010). Info for breastfeeding advocates/health care
professionals. Retrieved from http://babyfriendlyusa.org/eng/06.html
Baby-Friendly USA is an informational website that expectant mothers and health
care providers can use as a resource for breastfeeding. Mothers can learn what
the Baby Friendly Hospital Initiative (BFHI) is and the ten steps that help
promote, protect and support breastfeeding. Expecting mothers have the ability to
search for a Baby Friendly Hospital (BFH) all over the United States (U.S.). As
of now there are only 119 BFHs in the U.S. Hospitals can find out about how to
achieve the BFH designation, as well as information for advocates and health
professionals on the steps to promote breastfeeding.
Centers for Disease Control and Prevention. (2011). Breastfeeding report card—United
States, 2011. Retrieved from http://www.cdc.gov/breastfeeding/pdf/
2011BreastfeedingReportCard.pdf
The CDC gathers data from states and nations to identify trends in order to provide
the Breastfeeding Report Card. The report “compiles many types of data so states
can monitor progress, celebrate state successes, and identify opportunities to work
with health professionals, legislators, employers, business owners, community
advocates and family members to protect, promote and support breastfeeding”
(Center for Disease Control, 2011, para. 2). Less than 5% of infants are born in
Baby Friendly Hospitals. The states that follow national regulations showed an
increase in breastfeeding. States can use the report card to track their progress
INITIATION OF BREASTFEEDING
17
year to year, identify where changes need to be made, and implement changes to
increase breastfeeding success.
DiGirolamo, A. M., Grummer-Strawn, L. M., & Fein, S. B. (2008). Effect of
maternity-care practices on breastfeeding [Supplemental material]. Pediatrics, 122,
S43-S50. doi: 10.1542/peds.2008-1315e
This quantitative study analyzed the impact Baby Friendly hospital practices and
other maternity-care practices have on breastfeeding by comparing the Infant
Feeding Practices Study II (IFPSII) with data from the original 2001 Infant
Feeding Practices Study (IFPS I). The purpose was to “examine the current
prevalence and the individual and cumulative influences of a great number of
‘Baby-Friendly’ hospital practices on breastfeeding duration among mothers who
intended to breastfeed for at least 2 months postpartum” (DiGiorlamo, GrummerStrawn, & Fein, 2008, p. S43). This study hypothesized implementing Baby
Friendly hospital practices would increase breastfeeding duration for less than 6
weeks. The independent variables were indicators of six of the ten Baby Friendly
hospital practices. The dependent variable was postpartum breastfeeding duration
of less than 6 weeks. Demographic data “prenatal maternal smoking, number of
friends and relatives who breastfed, mother’s prenatal intentions to work after
birth, and prenatal attitudes toward breastfeeding” were controlled (p. S44). The
sample population, N = 1907, came from the US Food and Drug Administration’s
IFPS II survey of pregnant women and new mothers. The IFPS II sample came
from a consumer opinion panel of 500, 000 US homes that received prenatal and
postnatal questionnaires. This study focused on “mothers from the IFPS II who
INITIATION OF BREASTFEEDING
18
initiated breastfeeding and intended prenatally to breastfeed for > 2 months” (p.
S44). Inclusion criteria included healthy term or near-term infants, and singleton
infants. Statistics were analyzed using SAS institute’s SAS 9.1 statistical software.
Results showed few women experienced all six Baby Friendly practices, but at
least half of the mothers experienced three or four practices. Only 14.4% of the
women had breastfeeding duration of less than 6 weeks postpartum. Not giving
pain medication to the mother during birth and feeding infants in the mother’s
room were found to increase duration. The researchers discovered utilizing more
Baby Friendly interventions resulted in an increase in the prevalence of
breastfeeding since the administration of the IFPS I. This suggests that a
significant association exists between implementing Baby Friendly practices and
increased breastfeeding initiation and duration; the more practices experienced by
the mothers, the more incidence of breastfeeding initiation and duration.
Therefore, the authors encourage hospitals to increase their use of “Baby Friendly”
practices in order to continue the upward trend. Limitations to this study were
using only maternal perceptions instead of hospital and maternal perceptions, lack
of data about hospital policies and whether or not the hospital staff followed the
policies, the method of measuring the results, as well as lack of a nationally
representative sample.
Gill, S.L., Reifsnider, E., & Lucke, J.F. (2007). Effects of support on the initiation and
duration of breastfeeding. Western Journal of Nursing Research, 29, 708-723. doi:
10.1177/0193945906297376
The purpose of this study was to ultimately increase breastfeeding initiation and
breastfeeding duration to 6 months through the use of a prenatal education and
INITIATION OF BREASTFEEDING
19
home-based postpartum support intervention program. The independent variable
was the implementation of breastfeeding interventions and the dependent variable
was the rate of initiation and length of breastfeeding duration. A quasiexperimental design was used to examine breastfeeding interventions among lowincome, Hispanic women from two maternity clinic waiting rooms, located in a
large Southwestern city in the United States. One-hundred women were recruited
for each of the two groups. Each woman that participated in the study was in the
second trimester of pregnancy and was of Hispanic, and more specifically
Mexican, descent. Initiation was measured through a phone call from the mother
reporting the method of feeding post-delivery. Duration was measured through
weekly phone calls inquiring about the method of feeding. Findings of the study
showed that women in the intervention group had “twice the odds of starting
breastfeeding, twice the odds of continuing breastfeeding for 6 months, and only
half the tendency to quit at any one time than did the control group”(Gill,
Reifsnider, & Lucke, 2007, p. 717-718). Research should be conducted on
Hispanic women from various parts of the United States to present more valid
conclusions. Also, research on other cultures should be performed to identify
more cultural trends in breastfeeding for more effective interventions.
Grossman, X., Chaudhuri, J., Feldman-Winter, L., Abrams, J., Newton, K.N., Philipp,
B.L., & Merewood, A. (2009). Hospital education in lactation practices (project
HELP): Does clinician education affect breastfeeding initiation and exclusivity in
the hospital? Birth: Issues in Perinatal Care, 36, 54-59. doi: 10.1111/j.1523536X.2008.00295.x
INITIATION OF BREASTFEEDING
20
The purpose of this quantitative study was to find “whether relevant
practitioner education would affect breastfeeding initiation and exclusivity at four
Massachusetts hospitals with low breastfeeding rates” (Grossman et al., 2009, p.
55). A clear hypothesis was not stated, yet the readers gather the hypothesis is that
practitioner education based on Project Hospital Education in Lactation Practices
(HELP) will increase breastfeeding initiation rates at four Massachusetts
hospitals. The independent variable is Project HELP and the dependent variable is
initiation rate. The authors designed Project HELP after another breastfeeding
initiative and used staff from a World Health Organization designated Baby
Friendly hospital to provide free training to staff at four hospitals with low
initiation rates. “Courses were taught on-site at the hospitals as a series of three,
4-hour sessions between March 31, 2005, and April 24, 2006” (p. 55). Topics in
the courses included many aspects of breastfeeding like problem solving for
maternal and infant problems, supplements, maternal issues with returning to
work, and many others. Statistical and demographic data was gathered from
medical charts before and after Project HELP. “To detect a 15 percentage point
increase in breastfeeding rates, using a two-sided test of significance (α = 0.05),
1,528 medical records were extracted” (p. 57). Only infants that initiated
breastfeeding exclusively with no supplements except glucose water were
included. A total of 1,347 records were used after excluding incomplete records,
infants in intensive care or transferred out of the hospital, mothers with HIV,
mothers using drugs, and infants who had died. After implementing Project
HELP, initiation rates increased at three hospitals. Breastfeeding initiation rates
INITIATION OF BREASTFEEDING
21
increased from 59 to 65% (p = 0.02) with all hospitals combined, yet “no
significant increase occurred in exclusive breastfeeding at individual hospitals or
across all four hospitals combined (31 to 32%, p = 0.62)” (p. 57). Maternal age,
birthplace, ethnicity, and hospital site all affected initiation. Low-income women
with public insurance had decreased rates of initiation. Unlike the findings of
other studies, this study showed “non-Hispanic black mothers were three times
more likely to initiated breastfeeding compared with non-Hispanic white
mothers” (p. 58). In all, the study found “professional education alone directly
increases breastfeeding initiation in the hospital” (p. 57). Limits to this study
include the “short time interval between the interventions and the post
intervention collection of breastfeeding rates,” and not measuring changes in
clinician attitudes (p. 58). The researchers conclude that more research needs to
be conducted to figure out which practitioners the education had the greatest
effect on and if educating practitioners can increase breastfeeding exclusivity.
This study needs to be conducted on many more hospitals to see if the results can
be generalized.
Hannula, L., Kaunonen, M., & Tarkka, M-T. (2008). A systematic review of professional
support interventions for breastfeeding. Journal of Clinical Nursing, 17, 11321143. doi: 10.1111/j.1365-2702.2007.02239.x
This systematic review without meta-analysis sought to find the answers to the
following questions (1) “how breastfeeding was professionally supported (a)
during the pregnancy (b) at the maternity hospital and (c) during postnatal time?”
and (2) “how effective are professional interventions in supporting
INITIATION OF BREASTFEEDING
22
breastfeeding?” (Hannula, Kaunonen, & Tarkka, 2008, p. 1135). Various
keywords such as breastfeeding, patient education, social support, and counseling
were entered into CINAHL, Medline, and Cochrane Central Register and resulted
in “a wide range of studies, surveys and reports” (p. 1133). Only European, North
American, Australian, and New Zealand studies were included if they met the
following criteria, breastfeeding based, professional or a combination of peer and
professional support, and “education of healthy mothers and infants from the
perspective of mothers or family members” (p. 1133). Exclusion criteria included
studies from non-developed countries, studies including unhealthy mothers or
infant, premature infants, formula use, as well as studies not focused on support of
breastfeeding. After sorting through 644 studies, a total of 36 studies were
chosen. The authors concluded the best approaches to successful breastfeeding
include a combination of education as well as peer and professional support that is
culturally appropriate.
Mickens, A.D., Modeste, N., Montgomery, S., & Taylor, M. (2009). Peer support and
breastfeeding intentions among black WIC participants. Journal of Human
Lactation, 25, 157-162. doi: 10.1177/0890334409332438
The purpose of this experimental study was to “examine breastfeeding intentions
among low-income black women and to determine whether attending a support
program would increase their breastfeeding intentions” (Mickens et al, 2009, p.
157). The researchers hypothesized if support networks were offered to black
women, breastfeeding efforts would increase. The independent variable of this
study was peer support group attendance, while the dependent variable was
INITIATION OF BREASTFEEDING
23
breastfeeding intentions. The sample size of this cross-sectional study consisted
of 109 pregnant black women between the ages of 18-45 who were recruited at
Women, Infants, and Children (WIC) clinics or by WIC staff in the Inland Empire
area of California. The study took place at a WIC clinic and some of the pregnant
women would attend their regular WIC appointment while others were chosen to
attend a peer group session. A questionnaire based on the social learning theory
was used to test the hypothesis. The questionnaire included 45 questions that
were knowledge based, and a 5-point scale was used for questions pertaining to
support in relation to the intentions of breastfeeding. The results of the study
indicated that “women who attended prenatal counseling sessions had higher
initiation and duration rates compared with women who did not attend such
sessions” (Mickens et al, 2009, p. 160). It also found low intention of
breastfeeding in women with incomes below $18,000. The small sample size, the
non-randomized selection process used, and the inability to provide causality
were some of the limitations of the study.
Noel-Weiss, J., Rupp, A., Cragg, B., Bassett, V., & Wooden, A. K. (2006). Randomized
control to determine effects of prenatal breastfeeding workshop on maternal
breastfeeding self-efficacy and breast feeding duration. Journal of Obstetric,
Gynecological, and Neonatal Nursing, 35, 616-624. doi: 10.1111/j.15526909.2006.0077.x
The purpose of this study was to assess the effect of a prenatal breastfeeding
workshop on maternal breastfeeding self-efficacy and breastfeeding duration. The
researchers had two hypotheses, (1) “a prenatal breastfeeding workshop, based on
INITIATION OF BREASTFEEDING
24
the theory of self-efficacy and on adult learning principles, increases maternal
breastfeeding self-efficacy in the early postpartum period, and (2) “increased
maternal breastfeeding self-efficacy results in increased breastfeeding duration”
(Noel-Weiss, Cragg, Bassett, & Woodend, 2006, p. 617). The method used was a
randomized control trial. The participants were nulliparous women expecting a
single child, an uncomplicated birth, planning to breastfeed, read and write in
English, and have a telephone. The total sample size consisted of 92 women
randomized into the control or intervention group (control 45 and intervention
47). The intervention consisted of 2.5 hours of prenatal breastfeeding workshop.
The initial data was collected at 34 weeks of gestation. The postpartum data
was collected at four and eight weeks by telephone using the postpartum
demographic questionnaire, the breastfeeding efficacy scale, and breastfeeding
duration questionnaire. The results of the data analysis show the effectiveness of
the breastfeeding workshop by increasing the average self-efficacy score and
breastfeeding duration for mothers who attended when compared to the control
group. Further research should be done in order to identify any barriers
contributing to the decrease of maternal breastfeeding self-efficacy and
breastfeeding duration. The limitation of this study could be the small number of
participants involved and criteria for participating in the study.
Wade, D., Haining, S., Day, A. (2009). Breastfeeding peer support: are there additional
benefits? Community Practitioner, 82(12), 30-33.
The purpose of this qualitative study was to find “whether offering women
additional support to help them to maintain their breastfeeding had a positive
INITIATION OF BREASTFEEDING
25
effect on other areas of their lives” (Wade, Haining, & Day, 2009, p 30-31). Two
focus groups consisting of a total of 16 women were used to obtain data by
answering questions regarding their peer support experience, how the women felt
the support impacted their breastfeeding, and whether or not the support affected
other parts of their lives. The study was conducted for one group on a Saturday
morning at the local community center and the other on a weekday at a local
children’s center; each participant was paid. Multiple themes emerged in the
study as a result of the responses such as improved mental health, increased selfesteem and confidence, parenting skills, improved family diet, breastfeeding
sustainability and poor hospital experience. The researchers concluded
“breastfeeding peer support seems to have a positive effect on the mental health,
self-esteem and confidence of the women who took part in this research” (Wade,
Haining & Day, 2009, p. 33). Limitations of this study include the small sample
size and potential bias of the focus group leader related to the fact that the leader
was a proponent of breastfeeding.
Watkins, A. L., & Dodgson, J. E. (2010). Breastfeeding educational interventions for
health professionals: A synthesis of intervention studies. Journal for Specialists in
Pediatric Nursing, 15(3), 223-232. doi: 10.1111/j.1744-6155.2010.00240.x
The specific topic of this review, educational interventions for health care
professionals, sought to determine the effectiveness of breastfeeding interventions
by healthcare professionals on duration of breastfeeding. This systematic review
without meta-analysis identified fourteen intervention studies focused on
increasing breastfeeding knowledge, self-confidence, and supportive behaviors of
INITIATION OF BREASTFEEDING
26
healthcare professionals, using the key search words breastfeeding, initiation,
duration, education, intervention, midwife, nursing, nursing education, physician,
resident, and randomized controlled trial (RTC) and CINAHL, ERIC (via CSA
Illumina), PsychInfo, MEDLINE, and Cochrane databases. Research sources
included power analysis studies, video/CD-ROM studies, supervised clinical
experiences, and clinical observation. Inclusion criteria were recent studies
(2002-2008) targeted from peer-reviewed, English language journals. Studies
from developing countries were excluded from the search criteria due to wide
contextual variables for breastfeeding initiation and duration. Out of the eightyseven studies initially identified, twenty-seven met the inclusion criteria. Twelve
were excluded because interventions did not include healthcare professionals.
Fourteen studies from fifteen articles were selected for the final sample in which a
content analysis process was used to answer the research objectives. The review
concluded that many health care providers are not receiving adequate and
consistent breastfeeding education to be competent, reliable resources to support
the mother-infant dyad. Women often consider the breastfeeding information
they receive from providers as minimal, conflicting, and unhelpful. The Baby
Friendly Hospital Initiative (BFHI) sets standards for provider education and has
been shown to be a successful breastfeeding support program in hospitals,
especially when support and encouragement interventions are implemented, as
well. Finally, it stresses that pediatric nurses are in a prime position to provide
the most effective, accessible breastfeeding intervention, so it is essential that they
be included, not only in breastfeeding education, but setting protocols, policies,
INITIATION OF BREASTFEEDING
27
and practice standards in hospitals and community-based settings to improve
breastfeeding initiation rates.
Weddig, J., Baker, S. S., Auld, G. (2011). Perspectives of hospital-based nurses on
breastfeeding initiation best practices. Journal of Journal of Obstetric,
Gynecological, and Neonatal Nursing, 40, 166-178. doi: 10.1111/j.15526909.2011.01232.x
The purpose of this qualitative study was to assess the knowledge of breastfeeding
among various registered nurses (RN) in hospital women and family care units
along with hospital policies related to initiation and support. The study design
used to compare the size of the hospital (small or large) as well as the
socioeconomic status (SES) was a purposeful 2 x 2 cross section sample. A total
of 46 Colorado hospitals providing childbirth were categorized into one of four
groups (large, high SES; large, low SES; small, high SES; small, low SES). A
total of eight hospitals, two from each category, were randomly chosen to take
part in this study. The researchers gathered their sample of 40 RN’s (all labor and
delivery RN’s with varying levels of education) by emailing, hanging flyers in the
hospital, and signing up nurses in person. The participants were given $25 cash in
return for signing up. The RN’s attended focus groups, containing four to ten
participants each, on breastfeeding-related topics. “Although the researchers
expected to see differences between large and small hospitals and/or high- and
low-SES hospitals,” the major differences were only seen between Baby Friendly
and non-Baby Friendly hospitals (Weddig, Baker, & Auld, 2011, p. 168). NonBaby Friendly hospital nurses’ knowledge was not in accordance with current
INITIATION OF BREASTFEEDING
28
best practices in breastfeeding initiation as opposed to RN’s Baby Friendly
hospitals. Factors affecting nurses’ knowledge included hospital lactation
policies, nurses’ limited education, high rates of surgical delivery, and lack of
continuity of care with responsibility transfer between nurses from labor to
postpartum care. Based on their findings, the researchers recommend hospitals
take the steps needed in to achieve the Baby Friendly Hospital status. This study
had a relatively small sample size, which may affect being able to generalize these
findings. Also, because the RN’s in the sample had differing levels of nursing
degrees, the results may have been skewed because some of the RN’s may have
had more education, and thus existing knowledge of breastfeeding practices.
INITIATION OF BREASTFEEDING
29
Honor Code
I have neither given nor received unauthorized aid on this examination (or other material
turned in for credit) nor do have reason to believe that anyone else has.
Signatures (electronic): Sheridan Brown, Jennifer Fevrier, Kaitlyn Higbie, Marc
Manucal, Jorge Paulino, Brittanie Smith, Emily Thrasher
Date: 2 November 2011
INITIATION OF BREASTFEEDING
30
Nursing 363
The Research Process
Purpose: The desired outcome of this activity is to increase the learner's ability
to critically analyze the steps in the research process. The learner will refine skills
of group process during the development of this assignment.
The grade was determined in the following manner:
Assignment



Discuss a research topic of interest
to the group
o Identify the topic
o Discuss how the group came
up with the idea. Please keep
the discussion to 1 brief
paragraph.
Identify and discuss the research
problem and purpose statement
o Identify a specific problem that
needs researched. Explain the
significance of the problem/
research purpose for nursing
practice. Discuss the nursing
research that can be found in
the literature being sure to cite
your sources and include them
on the reference page. Include
a purpose statement which
meets the requirement for a
feasible researchable purpose
as discussed in class.
o Discuss the effect of culture on
the research problem and
purpose.
Discuss the search for sources
which the group consulted to
complete this project.
Comments
good
Points
Pts
earned possible
2
2%
good
10
10%
good
5
5%
INITIATION OF BREASTFEEDING
o
o
o
o


31
Describe the databases and
search engines you used to
find appropriate sources.
List key terms used for each
type of search.
Discuss how they were
combined.
Please be very specific about
the terms used in the search.
The presentation of terms
should reflect the information
presented in the ODU Library:
Searching the Literature * (see
web addresses for these library
“how to” sites below).
Discuss the number and type of
sources consulted to complete this
project. Include AS AN APPENDIX
an annotated bibliography containing
10 of the sources consulted.
In order to get full credit for this
section the 10 sources in the
annotated bibliography must meet all
of the following criteria:
o The annotated bibliography
must consist of a reference
citation for each source in
appropriate APA format
followed by a 5-7 sentence
paragraph summarizing the
research study, article, or web
site. Summaries of 8 or more
sentences may result in points
deleted IF the summary
contains information that is not
required in the information
below. If the authors’ exact
words are used in the summary
you MUST either enclose the
direct quote in quotation marks
or indent as specified by APA
format.
o AT LEAST SIX of your sources
must be reports of actual
good
20
20%
INITIATION OF BREASTFEEDING
o
o
o
o
nursing research studies.
These articles must report the
result of a single research
study. This section will be
strictly graded.
The summary of a quantitative
research study must discuss at
least the purpose, study
question or hypothesis,
variables studied, sample size
and characteristics, design,
setting, data collection tool/
method, other relevant data
collection information, findings
and critique of the study. The
summary of a qualitative study
must discuss the topic/ study
question, sample size and
characteristics, design,
themes/ findings and critique of
the study.
A MINIMUM OF TWO must be
from appropriate professional
internet sources which contain
evidence based
information. Examples of these
include guidelines for
practice, a relevant
professional organization web
page etc. List the URL
according to APA format. If you
are not sure if a site is
appropriately professional,
please check with the
instructor.
The summary of the web site
must include information on the
evidence based and other
resources available on the web
site which are related to the
group’s topic.
A MINIMUM OF ONE
ARTICLE must be a systematic
review with or without a metaanalysis.
32
INITIATION OF BREASTFEEDING
o
o
o
o
o
The summary of the systematic
review must include the
specific question or topic of the
review, the search strategy
including databases, sources
of research, and keywords,
inclusion and exclusion criteria
for selecting articles for
detailed review, the number
and type of studies it reviewed,
whether or not it included a
meta-analysis and its’
conclusion about the overall
research findings relating to the
topic.
A MINIMUM OF ONE article
must be obtained thru
interlibrary loan or must be a
hard copy of an article which
our library only has in print and
not electronically. Submit the
coversheet verifying that it was
obtained thru interlibrary loan
to the appropriate section of
Blackboard or if copied from
the library’s print copy submit a
copy in class on the day the
assignment is due.
The annotated bibliography
article entries must be from
peer reviewed journals.
Remember all the references
must be recent (within last 5
years with the exception of
some classic articles -- if not
sure whether an older article is
appropriate, please email the
instructor for permission to use
an older article). All sources
must be appropriate for the
topic area.
References utilized for the
paper must be listed on the
Reference page as well as
cited in the text of the paper
33
INITIATION OF BREASTFEEDING
34
and/or in the annotated
bibliography. The citation for all
of the articles listed in the
annotated bibliography must be
listed on the references page &
the Appendix.


Discuss an appropriate hypothesis
which is consistent with the purpose
statement.
o Include the group’s first draft of
a hypothesis and a corrected
hypothesis that was reached
by consensus among the
group.
o Utilize all the criteria discussed
in class and in your text.
Identify the following variables in your
hypothesis:
o Independent
o Dependent
o Extraneous variables that could
be present in the study.
 Discuss whether the
extraneous variables
should be controlled or
not controlled.
 Discuss the rationale for
controlling or not
controlling. Be specific;
utilize criteria from class
or text.
 Discuss whether or not
culture is an extraneous
or study variable in this
study.
Not clear -1
9
10%
good
10
10%
INITIATION OF BREASTFEEDING

Discuss why culture is or
is not an extraneous or
study variable in this
study.
Design
o Identify the specific design types that
could be used with your hypothesis
[usually there is more than one type
that could be used] Identify the
SPECIFIC design the group decided
to use. This should discuss the
subcategory of the design – as well as
the broader category. At least two
design types that are appropriate for
your hypothesis must be discussed.
o Necessary information will include
when the intervention will occur, and
when the measurement of the
variables will occur – all at once (for
some designs) or at different times
(for other designs). Be specific about
when, where, why, by whom, and
how.
o Discuss any issues of cultural
sensitivity that must be considered in
the data collection strategies.


35
Design Validity
o What are the threats to internal
validity with EACH of the
designs considered above?
o What are the threats to
external validity with EACH
of the designs?
Rationale for the group's choice of
one design over the others.
o Be specific
good
15
15%
good
10
10%
good
5
5%
INITIATION OF BREASTFEEDING
o


36
Support with information from
class or text
Discuss the two most common
measurement tools or methods
which the sources you consulted used
to measure your dependent variable.
Include the name of the measurement
tool if one was used and describe the
tool or method used. As appropriate
give the number of questions, whether
it was self report, observational
measurement etc.
good
3
3%
Form
o
o
o
Grammar
Spelling
APA style
APA errors -1
10
10%
Group grade:
* Note: your individual grade may
be different based on the
evaluation of your participation
submitted by your peers.
98%
Sheridan Brown, Jennifer Fevrier, Kaitlyn Higbie, Marc Manucal, Jorge Paulino,
Brittanie Smith, Emily Thrasher
INITIATION OF BREASTFEEDING
37