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Effectiveness of A Breastfeeding Self-Efficacy Intervention (Do Hospital Practices Make A Difference)
Effectiveness of A Breastfeeding Self-Efficacy Intervention (Do Hospital Practices Make A Difference)
DOI 10.1007/s10995-013-1265-2
Abstract Breastfeeding self-efficacy interventions are BFHs, the intervention improved both breastfeeding self-
important for improving breastfeeding outcomes. However, efficacy through 4 weeks postpartum (p = 0.037) and the
the circumstances that may influence the effectiveness of exclusive breastfeeding rate at 4 weeks postpartum (AOR
the interventions are unclear, especially in the context of 2.32, 95 % CI 1.01–5.33). In nBFHs, however, no positive
hospitals with suboptimal infant feeding practices. Thus, effect was observed on breastfeeding self-efficacy (p =
we aimed to evaluate the effect of a self-efficacy inter- 0.982) or on the exclusive breastfeeding rate at 4 weeks
vention on breastfeeding self-efficacy and exclusive postpartum (AOR 0.97, 95 % CI 0.52–1.81); in nBFHs,
breastfeeding, and further assessed the difference in its supplementation was provided for breastfed infants and the
effect by hospital-routine type. In this intervention study mother and infant were separated in the vast majority of
with a control group, 781 pregnant women were recruited cases. Infant feeding status at 12 weeks was not improved in
from 2 ‘‘Baby-Friendly’’-certified hospitals (BFH) and 2 either hospital type. The intervention improved breastfeeding
non-Baby-Friendly Hospitals (nBFH) in Japan, and were self-efficacy and exclusive breastfeeding at 4 weeks post-
allocated to an intervention or control group. Participants partum only in BFHs. When breastfeeding self-efficacy
in the intervention group were provided with a breast- interventions are implemented, hospital infant feeding prac-
feeding self-efficacy workbook in their third trimester. The tices may need to be optimized beforehand.
primary outcome was breastfeeding self-efficacy and the
secondary outcome was infant feeding status. All analyses Keywords Baby-Friendly Hospitals Breastfeeding self-
were stratified by the type of hospital, BFH or nBFH. In efficacy Exclusive breastfeeding Intervention Japan
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Did not complete the follow-up Did not complete the follow-up
Did not complete the follow-up Did not complete the follow-up
Did not complete the follow-up Did not complete the follow-up
BFH: n=94 (69.1%), nBFH: n=189 (79.0%) BFH: n=111 (79.3%), nBFH: n=196 (73.7%)
Fig. 1 Participant flow through the study. Note. aExcluded when (n = 1), transfer to other hospital of the mother (n = 3) or infant
medical conditions were detected. The medical conditions for (n = 7), being under medical care for depression (n = 1), prevention
exclusion were as follows: stillbirth (n = 1), delivery before from breastfeeding (n = 7) and/or separation from infant (n = 4) for
37 weeks of gestation (n = 23), birth weight under 2,500 g more than 24 h. The total numbers do not equal the sum of those in
(n = 38), admission to NICU (n = 8), cleft palate in the infant the flow chart because of overlapping conditions
to 70, with higher scores indicating higher levels of status was measured by 24-h recall at 4 and 12 weeks and
breastfeeding self-efficacy. In this study, Cronbach’s a classified into six categories based on Labbok’s breastfeeding
coefficient for the Japanese version of the BSES-SF at classification: (1) full breastfeeding (exclusive and almost
baseline, before hospital discharge, and at 4 weeks post- exclusive breastfeeding), (2) high partial breastfeeding
partum was 0.95, 0.95, and 0.95, respectively. (breastfeeding for more than 80 % of the time), (3) medium
partial breastfeeding (breastfeeding for 20–80 % of the time),
Infant Feeding Status (4) low partial breastfeeding (breastfeeding for less than 20 %
of the time), (5) token breastfeeding (occasional breastfeed-
This outcome was measured using two separate methods: 24-h ing, not for nutritive purposes), and (6) formula feeding (only
recall and history since discharge. Current infant feeding formula feeding) [26, 27]. Further, infant feeding history since
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Completion and Use of Workbook BFHs (n = 72, 72.0 %) and the nBFHs (n = 121, 71.2 %).
Among them, 42 (58.3 %) in the BFHs and 79 (65.3 %) in
The majority of the participants in the intervention group the nBFHs also responded to the questions in the work-
read most of the contents of the workbook in both the book. While 35.4 % (n = 35) of the women who received
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the workbook in the BFHs reviewed the workbook after reported that the hospital staff members assessed their
they initiated breastfeeding, 39.9 % (n = 63) did so in the infants as needing supplementation because of insufficient
nBFHs (p = 0.468). Among the women who returned milk supply. Insufficient milk supply was significantly less
the evaluation of the workbook, the majority assessed the common in BFHs [n = 25 (10.9 %), p \ 0.001].
workbook as being beneficial for breastfeeding in both the
BFHs (n = 68, 72.4 %) and the nBFHs (n = 112, 71.3 %,
p = 0.960). Discussion
Breastfeeding Self-Efficacy Overall, our study had three major findings. First, the self-
efficacy intervention enhanced breastfeeding self-efficacy
Figure 2 shows the changes in BSES-SF scores from and improved the exclusive breastfeeding rate at 4 weeks
baseline to 4 weeks postpartum in the intervention and postpartum in BFHs. Second, such positive effects through
control groups in both types of hospitals. BESE-SF score the intervention were not observed in nBFHs. Finally,
increased with time within all groups. While the increase breastfeeding exclusivity at 12 weeks postpartum was not
was larger in the intervention group than in the control improved following the intervention, even in BFHs.
group in BFHs, it was similar between the two groups in The findings suggest that the self-efficacy intervention
nBFHs. After controlling for potential confounding factors improved breastfeeding self-efficacy and short-term
and time, the intervention resulted in an increase in the exclusive breastfeeding in BFHs. After controlling for
BSES-SF total score through 4 weeks postpartum in BFHs, confounding factors, women in the intervention group were
but it had no effect on breastfeeding self-efficacy in nBFHs found to have a significantly greater increase in breast-
(Table 2). feeding self-efficacy than did women in the control group
in BFHs. Equally important is the finding that the exclusive
Infant Feeding Status breastfeeding rate at 4 weeks postpartum was improved in
BFHs. These positive effects are consistent with other
Table 3 shows infant feeding status distribution in inter- breastfeeding self-efficacy intervention studies which have
vention and control groups. Infant feeding status was evaluated interventions based on self-efficacy theory [17–
substantially different between mothers in BFHs and those 20]. In BFHs, therefore, an intervention to enhance
in nBFHs at 4 and 12 weeks postpartum. The impact of the breastfeeding self-efficacy is a promising approach to
intervention on infant feeding status was also remarkably improve exclusive breastfeeding.
different between mothers in BFHs and those in nBFHs. However, the intervention did not have a positive effect
The intervention improved the exclusive breastfeeding rate on breastfeeding self-efficacy and exclusive breastfeeding
at 4 weeks postpartum in BFHs. Also, the full breastfeed- in nBFHs. Consistent with the theory that self-efficacy
ing rate at 4 weeks postpartum was higher in the inter- improves with repeated practice of a certain performance
vention group than in the control group; however, the [10, 16, 25], the breastfeeding self-efficacy score increased
difference was not statistically significant. In nBFHs, no as time passed after the initiation of breastfeeding both in
positive effect of the intervention was observed in infant the intervention group and in the control group in BFHs
feeding status at 4 weeks postpartum. In addition, the and nBFHs alike. However, although women in nBFHs
intervention had no effect at 12 weeks postpartum in either used the intervention workbook more intensively than did
BFH or nBFH hospitals. women in BFHs, the intervention did not have a significant
effect on breastfeeding self-efficacy scores in nBFHs. This
Infant Feeding Practices at Hospitals is a clinically important finding, especially for regions
where infant feeding practices in hospitals are often sub-
All the infant feeding practices investigated were signifi- optimal. It suggests that hospital routine can hinder the
cantly different between the BFHs and nBFHs, with the development of breastfeeding self-efficacy, despite the
exception of Step 10. Most importantly, while the majority willingness of and effort put in by women to improve
of participants in BFHs reported giving no supplementation breastfeeding self-efficacy.
to breastfed infants and rooming-in, only a few reported In this study, the following obstacles were found in
giving no supplementation and rooming-in in nBFHs nBFHs: supplementation to breastfed infants, no rooming-
(Table 4). in for the day and night, and provision of artificial teats to
The main reason given by mothers in nBFHs for supple- breastfed infants. In addition, compared with women in
mentation was staff members’ perception of insufficient milk BFHs, significantly fewer women in nBFHs reported
supply. Out of 427 women who participated in the survey receiving information about the benefits and management
before discharge in nBFHs, 68.1 % (n = 291) of the women of breastfeeding, instructions on how to breastfeed, early
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42.7 (10.0)
43.1 (10.8)
42.4 (11.5)
a
The Japanese version of the Breastfeeding Self-Efficacy Scale-Short Form, ranges from 14 to 70, with
higher scores indicating higher levels of breastfeeding self-efficacy.
Table 2 Impact on breastfeeding self-efficacy through 4 weeks postpartum in Baby-Friendly Hospitals and non-Baby-Friendly Hospitals
Variable Baby-Friendly Hospitals Non-Baby-Friendly Hospitals
Ba 95 % CI for B p Ba 95 % CI for B p
initiation of breastfeeding, and breastfeeding on demand. We found that the intervention was not effective in
To enhance breastfeeding self-efficacy, infant feeding improving infant feeding status at 12 weeks postpartum in
practices at hospitals may need to be reformed as a pre- either hospital type. One possible explanation for this is
requisite for an effective intervention targeting breast- related to the timing of the intervention. In this study, the
feeding women. self-efficacy workbook was provided to women in their
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third trimester. Additional intervention after mothers ini- lead to a different magnitude of effectiveness. Therefore,
tiate breastfeeding may be required to enhance the impact before clinical use of the workbook, best ways to increase
of the intervention to improve exclusive breastfeeding rates utilization of the workbook should be explored.
after 4 weeks postpartum. This study has several limitations. First, although the
The intervention in this study was to provide an edu- results indicated a clear difference in the impact of the self-
cational workbook; the utilization of the workbook was not efficacy intervention between BFHs and nBFHs, the study
considered. Following the principle of intention-to-treat, did not directly measure the influence of hospital infant
even a mother who did not read the workbook at all was feeding practices on the impact of the intervention. Thus,
still included in the intervention group in all analytical some unknown factors may possibly have contributed to
processes. In this study, about one fourth of women in the the difference in the impact of the intervention between the
intervention group did not read the workbook at all. In two types of hospitals. Second, the four study sites were
clinical setting, the utilization of the workbook may be not systematically selected. However, hospital practices
different from that observed in this study in ways that may reported in the two nBFHs were similar to the results of a
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Step 3. Given enough information about the benefits and management of breastfeeding 132 58.7 195 46.8 0.002
Step 4. Helped to initiate breastfeeding within a half-hour of birth 194 88.2 233 54.8 \0.001
Step 5. Enough instructions on how to breastfeed 193 85.8 331 77.3 0.010
Step 6. No supplementation to infants, unless medically indicatedc 181 80.8 36 8.4 \0.001
Step 7. Rooming-in for 24 h a day 138 62.2 12 2.9 \0.001
Step 8. Breastfeeding on demand 217 96.4 271 63.3 \0.001
Step 9. No artificial teats or pacifiers 183 81.7 131 30.7 \0.001
Step 10. Having information on breastfeeding peer support 35 15.6 64 15.0 0.838
a
Practices listed as steps 3 to 10 refer to the Ten Steps to Successful Breastfeeding recommended by WHO/UNICEF
b
Chi square test was used
c
Numbers presented represented those who reported receiving supplementation. Relevance of the medical reasons was not assessed
nationwide survey in 2002 [24]. In addition, the results separation of mother and infant are common practices.
suggest that the practices in the two BFHs followed the When breastfeeding self-efficacy interventions are imple-
recommendations outlined by the Baby-Friendly Hospital mented to improve breastfeeding exclusivity, hospital
Initiative [3]. Thus, the four hospitals in this study closely practices may need to be optimized beforehand. Additional
reflected the general tendency of hospital practices in both studies are warranted to directly measure the influence of
BFHs and nBFHs in Japan. The characteristics of the hospital practices on the impact of a self-efficacy inter-
participants were also not remarkably different from those vention on breastfeeding outcomes. Furthermore, supple-
found in a previous national survey among mothers mental intervention may be required to improve exclusive
with infants aged 6 months [29]. Finally, contamination breastfeeding for longer than 4 weeks even in BFHs.
between intervention and control groups cannot be totally
ruled out. Although a month interval was set between the Acknowledgments This study was funded by the St. Luke’s Life
Science Institute. The authors are most grateful to the women who
recruitment of the two groups, participants might have had participated in the survey at a particularly busy time in their lives, and
the opportunity to observe and influence each other. to the staff members of the hospitals who distributed and collected the
Since the intervention was not a double-blinded, ran- questionnaires. We also thank the following researchers who con-
domized controlled study, several additional issues should tributed to the development of the research protocol and analytic
strategy: Colin Binns, Andy Lee, Toshinori Kitamura, Krishna Pou-
be considered when implementing the results. First, the del, Junko Yasuoka, and Akira Shibanuma. Finally, we acknowledge
characteristics of participants were adjusted statistically; the contribution of the following researchers in the conduct of the
therefore, there might be differences in unmeasured factors survey: Xiu-Fang Wang, Sumiyo Okawa, Yuko Matsuoka, and Ka-
between the intervention and control groups. Moreover, yoko Yoshikawa.
intentional and unintentional influence from hospital staff Open Access This article is distributed under the terms of the
also cannot be excluded because they had the option to Creative Commons Attribution License which permits any use, dis-
know their clients’ intervention group status if they so tribution, and reproduction in any medium, provided the original
chose. Despite these limitations, this is an important study author(s) and the source are credited.
for maternal and child health, as it is the first to show that
the impact of a breastfeeding self-efficacy intervention for
women can differ according to the practices followed in References
different hospital settings.
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(2012). Breastfeeding and the use of human milk. Pediatrics, 129,
efficacy and exclusive breastfeeding at 4 weeks postpartum
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only in BFHs. However, no positive effect was observed in 3. WHO & UNICEF. (2009). Baby-Friendly Hospital Initiative-
nBFHs, where supplementation to breastfed infants and Revised, Updated, and Expanded for Integrated Care, 2009.
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