ANGELES UNIVERSITY FOUNDATION

Angeles City
COLLEGE OF NURSING
Department of Nursing
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Evidenced-Based Journal: Exclusive Breastfeeding Duration and Perceptions of

Infant Sleep: The Mediating Role of Postpartum Anxiety

Submitted by:
Jan Camille C. Lenon
BSN 2-A | Group 3

Submitted to:
Mam Maria Fe M. Mallari, RN, RM, MAN

TITLE
Title: Exclusive Breastfeeding Duration and Perceptions of Infant Sleep: The Mediating
Role of Postpartum Anxiety
Authors: Davies, S.M.; Todd-Leonida, B.F.; Fallon, V.M. and Silverio, S.A.
Date of acceptance for Publication: 6 April 2022
Date of submission for the publication: 8 April 2022
Name of Journal: International Journal of Environmental Research and Public Health
(2022)
Journal details: 2022 Apr 8;19(8):4494. doi: 10.3390/ijerph19084494. PMID:
35457362; PMCID: PMC9029530.

INTRODUCTION

Previous studies reiterated that mental disorders increase among women,

including depression and anxiety after giving birth. It shows that postpartum anxiety is
rampant compared to postnatal. This condition impacts maternal and infant health
outcomes, such as weak ties between mother and child bonding, perceptions of difficult
infant temperament, reduced maternal self-efficacy, and poor infant feeding outcomes.
As the World Health Organization (WHO) recommended, exclusive breastfeeding for six
months of life has multiple benefits, like optimal growth and development. Although
supported by different studies, many from the UK National Health Service (NHS) stated
that approximately 81% of women in the UK experience this condition. However, these
rates drop to 34% by six months and 0.5% by twelve months. In addition, 90% of
women discontinue breastfeeding, ending it earlier than the recommended time. As it is
described by the study, an intention-behavior gap associated with sub-optimal mental
health outcomes like depression, anxiety, guilt, and shame, in terms of postpartum
anxiety and perceptions of infant sleep. It was described that there is a bi-directional
relationship between adverse maternal mental health and infant sleep that produces
cortisol and adrenaline that continues to deteriorate the mother's mental health. Many
studies show the intertwined connection of how a mother's stress and anxiety can affect
the child's sleeping pattern. Another lay belief is that breastfeeding is associated with
poor sleep due to breast milk digesting faster than formula. The research gap refers to a
notion not recognized by studies due to conflicting narratives that it is normal for a child
to have irregular sleeping patterns and night-wakings that limit them to conclusion.
Similar to the previously mentioned, this also appears to be bi-directional and dynamic,
which connects three constructs exclusive breastfeeding duration, postpartum anxiety,
and perceptions of infant sleep. The study's goal is to look simultaneously at postpartum
anxiety (PPA), breastfeeding duration (EBF), and infant sleep perceptions (ISP). A
secondary purpose of this study is to see if PPA mediates the relationship between EBF
duration and infant sleep perceptions. The results of this study will contribute to the
benefit of the mother, baby, and healthcare providers since it gathers the appropriate
information necessary for them to be aware of ways to reduce postpartum anxiety and
build a solid connection to the mother’s child. The researchers believe this study will
help mothers understand postpartum anxiety after labor and delivery. This study will
benefit healthcare workers because it will provide data on effectively reducing negative
effects on sub-optimal mental health, strengthening the bond, and attachment for
postpartum clients who underwent complex physiopsychological experience.

METHODOLOGY

The study's participants were 470 mothers who underwent screening. The criteria
must be a mother's age ranging from 19 years old and above with an infant of six to
twelve months. Another standard is that the baby is supposed to reach the term
gestation or above 37 weeks. Preterm infants were excluded because of the delays they
may experience during the development of function that may alter the results. Qualtrics
pioneered it through an online survey dominated by 92% white, 67% married, 46%
homeowners, 46% educated at the university level, and 30% professionals. The study
reports that 18% of mothers experience anxiety, and 13% for depression. A cross-
sectional online survey was administered, and it is appropriate because it is a method of
inquiry used in various academic disciplines, usually in the social sciences, but also in
market research and varied perspectives. It aims to gain a deeper awareness of human
behavior and the reasons that control such behavior. The qualitative method
investigates the why and how of decision-making, not just the what, where, and when.
Hence, smaller but focused samples are more often used than large samples.
Generally, qualitative methods only produce information on specific cases rather than
general conclusions. Applying this study design encounters options for data collection,
such as online surveys using a battery of questionnaires via Facebook and Twitter. This
questionnaire consists of the EBF duration item, the Brief Infant Sleep Questionnaire
(BISQ), and the Postpartum Specific Anxiety Scale (PSAS). As mentioned, the methods
used to measure were the demographics wherein it records the following: maternal age,
country of residence, marital status, occupational status, educational attainment,
household size, homeowner status, and current clinical diagnosis of anxiety and
depression. It also evaluated using Exclusive Breastfeeding Duration through a question
of how long have you exclusively breastfed this infant? And if not longer exclusively
breastfeed, for how many weeks did you exclusively breastfeed?

The study's data was retrieved using the Brief Infant Sleep Questionnaire (BISQ),
which contains 29 questions correlated with the Likert scale. Meanwhile, the
Postpartum-Specific Anxiety Scale (PSAS) was administered to determine the
prevalence of maternal and infant-focused anxiety during the previous seven days. It
has 51 items with four subparts, 15 on maternal competence and attachment anxieties,
11 on infant safety and welfare anxieties, 7 on practical infant care anxieties, and 18 on
psychosocial adjustment to motherhood. The highest score one can have is 204, and
those who scored 112 above suggest anxiety. Correlation analyses were initially
performed to investigate the relationships between EBF duration, PPA, and infant sleep
perceptions. Following that, a simple mediation analysis was performed using the
PROCESS macro for SPSS 24 to investigate the mediating role of PPA. The
bootstrapping procedures were used to test the significance of the indirect effects. The
95% confidence intervals for unstandardized indirect effects were computed for each of
the 5000 bootstrapped samples.
RESULT

This section states that descriptive statistics and Pearson's correctional analyses
were applied to examine the relationship of the predictor, which is the exclusive
breastfeeding duration, the mediator known as postpartum anxiety, and the outcome
that refers to perceptions of infant sleep. The demographic profile such as the maternal
age, SES, birth order, and marital status were utilized to determine their relationships. It
shows that postpartum anxiety is related to breastfeeding of p < 0.05. Meanwhile,
exclusive breastfeeding duration was significantly associated with perceptions of infant
sleep (p < 0.001). Also, it exhibits that breastfeeding duration was interrelated with
perceptions of infant sleep (p < 0.001). Since a simple mediation was conducted, which
revealed that EBF's model manifested a total of (B = - 0.029 (0.010), p < 0.05), in terms
of direct (B = - 0.035 (0.009), p < 0.001), and as for EBF's indirect (B = 0.007, SE =
0.003, 95% CI = 0.000 to 0.014) wherein postpartum anxiety has an effect on infant's
sleep perception. Therefore, learning about this theory corresponds to nursing
interventions that can alleviate postpartum anxiety, suggesting WHO's exclusive
breastfeeding of six months and positive effects on maternal’s sub-optimal status and
infant sleep.

DISCUSSION
The research indicated that the relationship between variables positively
influenced the mother's psychological and emotional well-being after labor. Therefore,
conducting this study responds to the mother's anxiety since it is supported by needed
interventions that significantly affect breastfeeding, which is proven beneficial to a
child's growth and sleep. In line with this, healthcare providers were able to gain insights
on how to create a safe and healthy environment both for the postpartum mother and
the newborn that can accelerate the mother's recovery and the baby's adjustment. The
study has revealed that relationship of EBF duration and PPA, and PPA and
perceptions of infant sleep are interrelated that fills in the gaps in knowledge, and
changes the understanding of the nursing research since it increases mother's and
infant bonding, an attachment which enhances overall variable because it fosters a
healthy environment that can lower the risk of postpartum hemorrhage, excess
bleeding, and gains trust towards the nurse that equates to a holistic delivery of
services. Furthermore, adding this to the curricula and practice promotes a healthy
lifestyle appropriate for the mother's redefining roles; doing this also prevents disease
and validates women's experience on reproductive health that results in quality
postnatal care. One of the strengths of this study is the exploration of different
relationships utilized on childbearing-specific maternal mood measures due to the vast
knowledge presented. However, its weakness is its reliability, as it was described as
average, for it lacks evidence about sleep measures.

CONCLUSION AND RECOMMENDATION

Gaining information from this study offers interesting findings to nursing practice
since it classified PPA as a mechanism that affects the EBF and infant sleep. This
insight can prevent and promote optimal health for both parties as it covers supporting
measures to reduce anxiety in the mother that can increase the said variables leading to
better infant feeding and maternal bonding. Also, the nurses improve the physical,
emotional, and well-being of the patient, boost communication, create conducive
environments that lessen stress workload, and constant monitoring of patients while
providing a high-quality services. Integrating this journal increases patient safety
because it validates the feelings and emotions of the mother that only needs a simple
intervention like therapeutic communication that does not require a fortune and renders
greater comfort compared to overlooked postpartum moms. Therefore, this expands the
base knowledge of the nurse and patient that can be applied to their own experiences.
For example, as a first-time mom knowing what to do after giving birth can benefit her
and the baby because it creates established ties and a healing environment that may
have long-term benefits. As for nurses, it is an effective strategy to rejuvenate in
preparing to conquer their jobs' stressful and heavy workload. This method promotes
healing to the mother, allowing the nurse to boost social connection, reduce medication
review, and meet patient satisfaction. Unlike the different techniques, practicing this
maximizes the nurse's performance, improving patient safety. Delivering services like
this in education can positively impact current nursing education. Combining theoretical
advancements and discoveries can help nurses and future healthcare providers to
integrate holistic healthcare delivery. The journal can be applied to future related studies
with modification of filtered items from the BISQ from mothers with infants 6–12 months
and new literature measuring infant sleep. Prospective researchers are encouraged to
conduct similar research in a Philippine setting that contains more than one mechanism
to see if the findings are identical.
Reference:

Davies, S. M., Todd-Leonida, B. F., Fallon, V. M., & Silverio, S. A. (2022).

Exclusive breastfeeding duration and perceptions of infant sleep: The
mediating role of postpartum anxiety. International Journal of Environmental
Research and Public Health, 19(8), 4494.
https://doi.org/10.3390/ijerph19084494

AUF Honor Code

As an Angelenean who lives by the core values of pagiging mabuti, magaling at may
malasakit sa kapwa, I hereby commit that I complete my academic work with integrity.
This means that I shall accomplish my academic work without receiving or giving
unauthorized assistance. My work also observes scholarly and intellectual standards,
rules on proper citation of sources, and appropriate collection and use of data