Running head: INCREASING BREASTFEEDING AMONG MOTHERS 1

Increasing Breastfeeding Among Low Socio-economic Status Mothers

Using Breastfeeding Education

Tiffany Tran

University of South Florida

INCREASING BREASTFEEDING AMONG MOTHERS 2

Abstract

Clinical Problem: Low socio-economic status (SES) mothers frequently struggle to initiate and

continue breastfeeding, which is associated with positive infant and, perhaps, maternal outcomes.

Objective: The objective is to determine if breastfeeding education (BE) will increase the rates of

initiation and continuance of any and exclusive breastfeeding (ICAEB) in low SES mothers.

PubMed and CINAHL were accessed to attain clinical trials and guidelines regarding BE. The

key search terms employed included breastfeeding education, antenatal, prenatal, postnatal, low

SES, breastfeeding initiation (BI), breastfeeding continuance, and breastfeeding exclusivity.

Results: The American Academy of Pediatrics (AAP) and the Office of Disease Prevention and

Health Promotions (ODPHP) (2017) Healthy People 2020 (HP2020) objectives recommend

exclusively breastfeeding infants for the first six months of life. The literature illustrated an

increase in rates of ICAEB when patients received BE.

Conclusion: Patients who received a combination of antenatal and postnatal BE increased rates

of ICAEB. Even so, additional research is necessary to determine whether BE is the only, or

main, deficit that low SES mothers lack in breastfeeding support. Further investigation should be

conducted to enable generalization of the results of the literature review to low SES populations.
INCREASING BREASTFEEDING AMONG MOTHERS 3

Increasing Breastfeeding Among Low Socio-economic Status Mothers

Using Breastfeeding Education

In low socio-economic status (SES) settings, new mothers frequently struggle to initiate

and continue breastfeeding (Wong, Tak Fong, Yin Lee, Chu, & Tarrant, 2014). According to the

United States Preventive Services Task Force (USPSTF) (2016), exposure to human milk,

whether via breastfeeding or bottle-feeding expressed breast milk, is associated with positive

outcomes in neonates. Furthermore, breastfeeding may be associated with positive maternal

outcomes as well (United States Preventive Services Task Force [USPSTF], 2016). Use of

breastfeeding education (BE), both antenatal and postnatal, may help to increase the initiation

and continuance of any and exclusive breastfeeding (ICAEB) in this population.

For these reasons, a pertinent evidence-based practice (EBP) question is: (P) Among new

mothers of low SES, (I) does BE (C) compared to no BE, (O) affect the ICAEB (T) over three

months? The anticipated outcome measure for clinical improvement is an increased incidence of

ICAEB within this population. A literature search and review were employed to begin answering

this question.

Literature Search

PubMed and CINAHL were accessed to obtain clinical trials and guidelines regarding

BE. The key search terms utilized included breastfeeding education, antenatal, prenatal,

postnatal, low SES, breastfeeding initiation (BI), breastfeeding continuance, and breastfeeding

exclusivity. The publication years searched were 2012-2017.

Literature Review

Three randomized controlled trials (RCT) and two recommendations were applied to

appraise the efficacy of BE on ICAEB rates in low SES mothers. Using a single-blinded RCT,
INCREASING BREASTFEEDING AMONG MOTHERS 4

Bonuck et al. (2014) tested the hypothesis that mothers who received pre- and postnatal primary

care-based interventions, such as lactation consultations (LC) and electronic guidance regarding

care (EP), would increase breastfeeding duration and intensity compared to mothers who

received conventional care methods. The sample size was 275 pregnant women aged 18 years or

older, all of whom spoke either English or Spanish, were in their first or second trimester of a

singleton pregnancy, and were free of risk factors that would contraindicate breastfeeding. The

women were randomized into an LC combined with EP intervention group (n=129), or a

standard care control group (n=133). The intervention group received primary care based

interventions such as LC and EP postpartum while the control group received standard care.

Outcomes were measured using BI rates, breastfeeding exclusivity, and breastfeeding intensity

(percentage of all feedings that consisted of breast milk in the past seven days), at three months

postpartum. Additionally, total duration of breastfeeding was used. The authors reported that

mothers who received LC and EP achieved higher rates of BI, as well as higher rates of any and

exclusive breastfeeding (AEB), at one and three months (p<.05). Strengths of the study included

an RCT design, randomization was concealed from the mothers prior to enrollment, the mothers

in both groups were similar in regards to baseline clinical variables, the sample size was large

and rationale for participant attrition was provided. Additionally, the outcome measures were

valid and reliable, mothers were analyzed in their respective groups, follow-up interviews were

conducted long enough to study the effects of the intervention, and the control group was

appropriate. Weaknesses of the study included that it was impossible to blind providers to the

intervention group, as they had to provide LC and EP, and that the study was conducted at a

single site. The results suggested that mothers who receive LC and EP increase their rates of BI,

exclusivity and duration.

INCREASING BREASTFEEDING AMONG MOTHERS 5

Efrat, Esparza, Mendelson, and Lane (2015) designed a two-group RCT to examine the

hypothesis that low-income Hispanic women who received telephone-based BE (TBBE) from

lactation educators (LE) would increase rates of breastfeeding exclusivity compared to Hispanic

women who received standard care. The sample size was 289 pregnant self-identified Hispanic

women, all of whom were 26-34 weeks pregnant, Medicaid recipients, had telephone access, and

were not assigned to a Women Infants and Children (WIC) peer counselor. Upon delivery,

infants were assessed to ensure that they were healthy, full-term singletons, had not been

admitted to the neonatal intensive care unit (NICU), and did not have congenital abnormalities.

The mother-infant pairs were randomized into either the TBBE intervention group (n=146) or the

routine BE control group (n=143). In addition to the usual care, the TBBE intervention group

received postpartum calls from LE for breastfeeding support. These calls occurred twice during

the first week postpartum, then once per week from weeks 2-8 postpartum. The control group

received the usual care, but no additional phone calls postpartum. The outcomes were measured

by evaluating breastfeeding status as well as total duration of AEB. The authors reported that

mothers receiving TBBE achieved higher rates of AEB, as well as total duration of any

breastfeeding, than the control group (p<.001). Strengths of the study included an RCT design,

randomization was concealed from the pregnant women prior to enrollment, mother-infant pairs

in both groups were similar in baseline clinical variables, the study was conducted at five

different community health clinic sites, and rationale for participant attrition was provided. In

addition, the outcome measures were reliable, the mother-infant pairs were analyzed in their

respective groups, follow-up assessments were conducted long enough to study the effects of the

interventions, and the control group was appropriate. Weaknesses of the study included that the

providers were unable to be blinded to the intervention group due to the nature of the
INCREASING BREASTFEEDING AMONG MOTHERS 6

intervention, the study had an underpowered sample size, and the maternal-self reports of

breastfeeding were not necessarily valid, as the LEs served as the data collectors as well. The

results suggested that mothers receiving TBBE achieve higher rates of BI as well as total

duration of AEB.

Fu et al. (2014) conducted a multi-centered, three-arm, cluster RCT to determine the

effect of two types of postnatal professional support interventions (either three in-hospital

professional support sessions or weekly post-discharge breastfeeding telephone support for four

weeks) on AEB in comparison with mother-infant pairs who received standard care. The sample

size was 724 mothers, all of whom were aged 18 years or older, Hong Kong Chinese primiparas

who planned to stay in Hong Kong after giving birth, intending to breastfeed, and had no

contraindications for breastfeeding. When the infants were born, all were verified to be 37 weeks

or older with birthweight of 2,500 grams or more, five minute Apgar scores of eight or more, and

no congenital anomalies that would contraindicate breastfeeding. The mother-infant pairs were

randomized into one of three groups: an in-hospital support intervention group (n=191), a post-

discharge telephone support intervention group (n=269), and a standard care control group

(n=264). Outcomes were measured by the prevalence of AEB at one, two and three months

postpartum. Total duration of AEB was used as well. The authors reported that experimental

mother-infant pairs achieved higher rates of AEB at one and two months than control pairs

(p<.05). Strengths of the study included a cluster RCT design, randomization was concealed

from the mothers prior to enrollment, mother-infant pairs in both groups were similar in baseline

clinical variables, the sample size was large, the study was conducted at three different hospital

sites, and rationale for participant attrition was provided. In addition, the outcome measures were

valid and reliable, the mother-infant pairs were analyzed in their respective groups, follow-up
INCREASING BREASTFEEDING AMONG MOTHERS 7

assessments were conducted long enough to study the effects of the interventions, and the control

group was appropriate. A weakness of the study, however, included that the providers were

unable to be blinded to the intervention groups due to the nature of the intervention. The results

suggested that mothers who receive postnatal professional support interventions increase their

rates of AEB at one and two months postpartum.

The recommendations for the initiation and duration of breastfeeding stem from the

American Academy of Pediatrics (AAP) and the Healthy People 2020 (HP2020) objectives.

Firstly, the AAP (2017) recommends that infants are breastfed exclusively for the first six

months of life, and continue breastfeeding for the first year of life. Moreover, the Office of

Disease Prevention and Health Promotions (ODPHP) (2017) HP2020 goals for infant care

include objectives to increase the proportion of infants who receive any amount of breastfeeding

as well as the proportion of infants who are breastfed exclusively through three and six months

of age.

Synthesis

Bonuck et al. (2014) reported that mothers who received LC and EP achieved higher

rates of BI, as well as higher rates of AEB, at one and three months (p<.05). Efrat et al. (2015)

demonstrated that mothers receiving TBBE achieved higher rates of AEB, as well as total

duration of any breastfeeding, than the control group (p<.001). Further, Fu et al. (2014) reported

that experimental mother-infant pairs achieved higher rates of AEB at one and two months than

control pairs (p<.05). Finally, the recommendations from the AAP (2017) and the ODPHPs

(2017) HP2020 objectives suggest that infants should be breastfed, exclusively if possible,

through a minimum of the first six months of life.

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Research indicates that a combination of the usual care, antenatal BE and postpartum BE

increases the ICAEB. Despite the marked increase in breastfeeding rates, little research has been

done to demonstrate whether or not BE alone would suffice in increasing rates of breastfeeding

in low SES populations. Additional research is necessary to determine whether BE is the only, or

main, deficit that low SES mothers lack in breastfeeding support. Further investigation should be

conducted to enable generalization of the results of the literature review to low SES populations.

Clinical Recommendations

The AAP (2017) and the ODPHP (2017) recommend that infants are breastfed,

exclusively if possible, for a minimum of the first six months of life. In fact, whether the

exposure is through breastfeeding or pumping, the benefits of human milk are the same (Office

of Disease Prevention and Health Promotion [ODPHP], 2017). Breastfeeding can be used in

combination with pumping, and even freezing and thawing, of breast milk in order to provide

infants with the recommended six months of breast milk exposure. Research confirms that a

combination of antenatal and postnatal BE increases rates of ICAEB. Supplemental research

needs to be performed to evaluate whether this research can be generalized to low SES mothers.

Nonetheless, BE is another way to positively influence infant and maternal outcomes and lessen

overall health care costs.

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References

American Academy of Pediatrics. (2017). Breastfeeding initiatives: Frequently asked questions:

How long should I breastfeed my baby? Retrieved from

https://www2.aap.org/breastfeeding/faqsbreastfeeding.html#

Bonuck, K., Stuebe, A., Barnett, J., Labbok, M. H., Fletcher, J., & Bernstein, P. S. (2014). Effect

of primary care intervention on breastfeeding duration and intensity. American Journal of

Public Health, 104(S1), S119-27. doi:10.2105/AJPH.2013.301360

Efrat, M. W., Esparza, S., Mendelson, S. G., & Lane, C. J. (2015). The effect of lactation

educators implementing a telephone-based intervention among low-income Hispanics: A

randomised trial. Health Education Journal, 74(4), 424-441.

doi:10.1177/0017896914542666

Fu, I., Fong, D., Heys, M., Lee, I., Sham, A., Tarrant, M., . . . Lee, I. Y. (2014). Professional

breastfeeding support for first-time mothers: A multicentre cluster randomised controlled

trial. British Journal of Obstetrics & Gynaecology: An International Journal of

Obstetrics & Gynaecology, 121(13), 1673-1683. doi:10.1111/1471-0528.12884

Office of Disease Prevention and Health Promotion. (2017). Healthy people 2020: Topics &

objectives: Maternal, infant and child health. Retrieved from

https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-

health/objectives

United States Preventive Services Task Force. (2016). Primary care interventions to support

breastfeeding: US preventive services task force recommendation statement. Journal of

the American Medical Association, 316(16), 1688-1693. doi:10.1001/jama.2016.14697

Wong, K. L., Tak Fong, D. Y., Yin Lee, I. L., Chu, S., & Tarrant, M. (2014). Antenatal
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education to increase exclusive breastfeeding: A randomized controlled trial. Obstetrics

& Gynecology, 124(5), 961-968. doi:10.1097/AOG.0000000000000481