Breastfeeding has been shown to improve intellectual, neurological, psychomotor, and social development (Olang et al, 2009; Kronborg and Kok, 2011), and to provide all essential nutrients for the development of the infant brain and nervous system. It is also associated with decreased risk for many early life diseases (Olang et al, 2009).
The pattern of breastfeeding has been changing in recent years. The breastfeeding rate is declining and early cessation of breastfeeding is increasing (Kim et al, 2013), influenced by social, physiological, and psychological factors. The most commonly cited factors that lead to early cessation of breastfeeding are physiological (Banginwar et al, 2011), such as sore and cracked nipples, problems with attachment, and insufficient breast milk production (Abuidhail et al, 2014). The positioning and attachment of the newborn infant to the breast during breastfeeding have been the main causes of occurrence of nipple problems and insufficient milk supply (Banginwar et al, 2011). Insufficient milk supply causes lactation failure, which deprives the newborn infant of natural passive immunity, causes susceptiblity to hypoglycaemic seizures, and impairs sensory and cognitive developments (Tella et al, 2016).
McDonald et al (2008) found that breastfeeding problems, such as breast engorgement, an unsettled baby, nipple soreness, and poor attachment, caused early cessation of breastfeeding at 2 months after birth. All issues and their consequences (engorgement, mastitis, and breast abscess) were associated with poor position and attachment (Banginwar et al, 2011), and were classified in this study as breastfeeding problems. Postnatal breastfeeding education has been found to have a significant effect in preparing mothers for a positive breastfeeding experience, free of these problems (Tella et al, 2016).
McDonald et al (2008) conducted a randomised control trial to evaluate the effects of an extended midwifery postnatal support programme on Australian women who breastfed exclusively for 6 months. The results showed that extended midwifery support programmes did not cause an increase in breastfeeding rates, while a Jordanian study conducted by Khresheh et al (2011) found that increasing mothers' knowledge of breastfeeding in postnatal period did not increase the duration of breastfeeding. The effects of professional postnatal support have also been found to be inconsistent (Kronborg and Kok, 2011).
Successful breastfeeding practice has, however, been found to be partially influenced by developing an effective educational programme (Kim et al, 2013). Most postnatal education has focused on knowledge of breastfeeding rather than skills of breastfeeding practice, such as latch-on technique, which teaches position and attachment of the newborn infant to the breast during breastfeeding (Khresheh et al, 2011). This study therefore aimed to measure the effectiveness of postnatal breastfeeding education on improving Jordanian postpartum mothers' skills of latch-on technique. Postnatal education sessions focused on the best available approach to latch-on technique of breastfeeding, which would help mothers to prevent problems and continue breastfeeding.
Methods
Design
The authors hypothesised that postnatal breastfeeding education among Jordanian mothers would improve the mothers' latch-on skills. A quasi-experimental, non-equivalent control group before/after design was used in this study to measure the effectiveness of postnatal breastfeeding education among Jordanian postpartum mothers. This design was suitable for this study because the aim was to compare the effectiveness of the educational material, which required a comparison group. Randomisation was difficult to achieve because the participants were recruited from three hospitals in three different areas with high admission rate of women giving birth, meaning that there was no sample frame. The participants were also recruited on more than one occasion, so randomisation could not be achieved.
Sample
The sample in this study consisted of postpartum mothers who had been in the postnatal ward of the main governmental hospitals for a minimum of 24 hours, to be sure that the mothers had started breastfeeding. The inclusion criteria were: the participating postpartum mother should be aged 15-49 years (Department of Statistics (DoS) and ICF International, 2013), have given birth vaginally or via caesarean section to a healthy full-term infant, without any pregnancy-related health diseases. Women could be primi-or multiparous.
This study was therefore a quasi-experimental design, and to maximise the probability of detecting significant findings, a statistical power of 0.9, at a level of significance 0.05 and medium effect size of 0.4, was used because the intervention in this study has not been previously tested in Jordan. A medium effect size has also been used in nursing studies (Polit and Beck, 2012). According to the power analysis, the sample size required for this study was 262 postpartum mothers, considering 20% missing and 20% attrition rate. This sample was divided into two groups (intervention and comparison) (Polit and Beck, 2012). The sampling method was consecutive sampling, which meant recruiting eligible participants until the sample size was completed for both groups (Figure 1).
Setting
Three major governmental hospitals in Jordan were selected: Albasheir Hospital in Amman, Prince Faisal Hospital in Zarqa, and Princesses Badee'a for Maternity and Gynecology Governmental Hospital in Irbid. These hospitals are the largest in Jordan with the highest capacity rate (Ministry of Health, 2012).
Ethical issues
The study was ethically approved by the Institutional Review Board of the Ministry of Health and the Hashemite University for data collection. The participants in the study voluntarily signed an informed consent form before their participation. The participants had the choice to withdraw from the study at any time. The researcher was the only person who could access participants' data. This information was anonymised after coding, then deleted after finalising the research study. The participants were contacted at a minimum of 24 hours after giving birth to make sure that they would be fully recovered and could understand and sign the consent form freely.
Data collection tool
Data was collected using the LATCH assessment tool and the Systemic Assessment of the Infant at Breast (SAIB) before and after the intervention.
The LATCH Breastfeeding Assessment Tool was developed by Jensen et al (1994) to identify the areas of intervention and to determine priorities in providing care for the mother and teaching content. The LATCH assessment tool measures five components of breastfeeding: latch, audible swallowing, type and shape of the nipple, comfort level, and hold positioning. The system assigns a numerical score (0, 1, 2) to five key components of breastfeeding for a positive total score of 10 (Jensen et al, 1994; Küçükoğlu and Çelebioğlu, 2014).
Turkish validity of the assessment tool was examined and it was found to be a reliable tool (Racine et al, 2009). The Cronbach's a value of the LATCH Breastfeeding Assessment Tool was found to be 0.95 by Yenal and Okumus (2003) and 0.93 by Küçükoğlu and Çelebioğlu (2014). In this study, the LATCH assessment tool had good internal consistency with 0.8 Cronbach's a coefficient, which is considered high reliability (Polit and Beck, 2012). Content validity of the LATCH assessment tool was also established by group of experts in the field of maternal and child health nursing.
The SAIB was designed to assess whether the infant could extract milk from the breast effectively, thereby indicating successful breastfeeding (Shrago and Bocar, 1990), and has been used to teach women how to breastfeed (Taha, 2009). The observational tool consists of a checklist of alignment, areolar grasp, areolar compression, and audible swallowing (Shrago and Bocar, 1990), although no scoring system is provided a scoring system (Howe et al, 2008). This was used as an educational tool so its validity was not measured.
Postnatal breastfeeding educational material
The researcher prepared the breastfeeding educational material that was used during the postnatal educational classes at hospitals. It had been developed after a literature review to select the information that covered breastfeeding problems and skills of latch-on technique. The information was then distilled to form handouts, with drawings that clarified the proper latch-on technique. It consisted of brief introduction to breastfeeding and breastfeeding problems, the normal ways of caring for the breast, how to deal with breastfeeding problems, and the proper positions of breastfeeding and latch-on technique which decrease the incidence of breastfeeding problems. Experts in the maternal and child health care department at the faculty of nursing established the content validity of the educational material after careful review. One iteration of modifications was completed.
Data collection procedure
Since most of the postpartum mothers might encounter breast problems related to improper latch-on technique in the immediate postpartum period, the best time to collect data and conduct educational sessions for the intervention group was 24 hours after giving birth. At that time, each participating mother would be starting breastfeeding and she would be completely recovered so she could comprehend the educational session.
Data in this study were collected by trained research assistants, who were registered nurses working at the faculty of nursing as teaching and research assistants. At the postnatal ward of each selected hospital, research assistants gave the recruited postpartum mothers the information sheet about the study and the consent form to be signed. At the same time, each participating postpartum mother was asked to provide contact details for later communication after discharge during follow-up interviews. She was then assessed before educational intervention using LATCH and SAIB assessment tool. After that, the participating mother was assigned to one of the two groups (intervention and comparison). This was done alternatively, the first mother who agreed to participate was assigned to the intervention group, and the second was selected to comparison group. This process was followed until the desired number for both groups was completed. To minimise potential bias due to non-randomisation, a sample was drawn from a homogeneous population, who were postpartum mothers at governmental hospitals.
The research assistants conducted the breastfeeding educational session for the intervention group, using the pre-prepared educational material about effective breastfeeding. The session lasted around one hour, and was conducted through several methods of teaching, such as discussion, explanation, and demonstration. At that time, the comparison groups—made up of women from the same hospitals—were not exposed to the educational material; however, they received the postnatal care that was followed at each selected hospital. At the end of educational sessions, participating mothers of both groups were reassessed using LATCH and SAIB, then were given handouts about effective latch-on technique and how to manage breastfeeding problems. A follow-up phone interview was conducted by the research assistants, who collected the data with each participating mother in both groups at the end of the fourth week after giving birth. These interviews were conducted to find the incidence of breastfeeding problems such as nipple soreness, cracked nipples, breast engorgement, mastitis, or abscess. Data were collected between March and September 2014.
Data analysis
Data were analysed using SPSS version 17. Descriptive statistics were used to describe sample characteristics. Independent t-test and multivariate analysis of variance (MANOVA) were used to determine the differences between the two groups, to indicate the effectiveness of postnatal breastfeeding education.
Results
The total sample of this study was 216 postpartum mothers who completed the study protocol (Figure 1). This was because 15 participants from the intervention group and 20 participants from the comparison group dropped out because of early discharge from the hospitals without post test. The total sample in the intervention group was 116 (51%) and in comparison group was 111 (49%) before intervention. However, during assessment after intervention, three mothers from the intervention group and eight mothers from the comparison group were waiting for discharge and declined to do the assessment after intervention. The total sample in the intervention group was therefore 113 (51%) and in comparison group was 103 (49%) after intervention.
The mean age of the participants was 26.5 years (SD=5.86), and their ages varied between 16 to 43 years old. Most of the participants were multiparous (n=180, 79%) and 47 were primiparous (21%). The household income of the participants ranged between $70–1050 (mean=$231.4; SD=$112) per month. Around two-thirds of participants were educated to secondary level (n=146, 64%), and 95% of them were housewives (n=215). Some 80% of the sample (n=181) gave birth through normal vaginal birth. The maximum number of antenatal visits was 20 visits over the entire pregnancy period with (mean=9.2; SD=3.2) (Table 1).
| Characterstic | n | % |
|---|---|---|
| Level of education | ||
| Illiterate | 11 | 4.3 |
| Primary | 34 | 15 |
| Secondary | 146 | 64.3 |
| Diploma | 19 | 8.4 |
| Bachelor's degree | 17 | 7.5 |
| Mother's employment status | ||
| Employed | 11 | 5 |
| Housewife | 217 | 95 |
| Parity | ||
| Primiparous | 47 | 21 |
| Multiparous | 180 | 79 |
| Planning of current pregnancy | ||
| Planned | 109 | 48 |
| Not planned | 116 | 52 |
| Mode of birth | ||
| Normal vaginal birth | 181 | 80 |
| Caesarean section | 46 | 20 |
After 4 weeks postpartum, mothers were interviewed by phone at the end of the fourth week postpartum to find out the incidence of breastfeeding problems. Descriptive statistics showed that 87% (n=158) of the participating mothers continued breastfeeding, and 81% of the participants (n=134) used complementary feeding while breastfeeding. Breastfeeding problems were cited in 9% (n=10) of the intervention group and 33% (n=30) of the comparison group.
When comparing between primiparous mothers and multiparous mothers in relation to incidence of breastfeeding problems at the end of the fourth week postpartum, 88% (n=32) of primiparous mothers did not complain of breastfeeding problems, while 76% (n=110) of multiparous mothers did not complain of breastfeeding problems.
Multivariate analysis of variance
Since the aim of this study was to find the effect of the postnatal breastfeeding education material on latch-on technique, MANOVA was used in this study. This was because there was more than one dependent variable, namely total LATCH assessment scores before intervention and total LATCH assessment scores after intervention. The intervention was either to receive postnatal breastfeeding education material (intervention group), or receiving hospital postnatal care (comparison groups). The advantage of using MANOVA is that it reduces the risk of Type 1 error. MANOVA was performed to investigate the effect of educational material about breastfeeding on the latch-on technique.
Preliminary assumption testing was conducted to check for normality, linearity, univariate and multivariate outliers, homogeneity of variance/covariance matrices, and multicollinearity, with no serious violation noted. There was a statistically significant difference between intervention group and comparison group in relation to total LATCH score: F(2, 210)=6.21, P=0.002; Wilks' l=0.94; partial h2=0.056. When the results for the dependent variables were considered separately, the only difference to reach statistical significance, using a Bonferroni adjusted a level of 0.025, was the total LATCH scores after introducing education material to the intervention group (P=0.001). An inspection of the mean scores indicated that the mothers of intervention group had higher total LATCH scores after being introduced to the educational material on breastfeeding (mean=9.4; SD=1.25) than the mothers of comparison group after receiving hospital postnatal care (mean=8.7; SD=1.45).
Independent t-test
The independent samples t-test was used as an additional analysis, designed to compare between the intervention group and the comparison group. The continuous variable was the total LATCH scores before and after intervention among postpartum mothers in the comparison and intervention groups. The results of the analysis, as well as means and standard deviations, are presented in Table 2.
| Variable | Total LATCH assessment tool score | n | Mean | Standard deviation | t | Df | Sig. (2-tailed) |
|---|---|---|---|---|---|---|---|
| Before intervention | Intervention group | 116 | 8.27 | 1.95 | 0.26 | 222 | 0.8 |
| Comparison group | 111 | 8.20 | 1.89 | ||||
| After intervention | Intervention group | 113 | 9.35 | 1.30 | 2.9 | 205.7 | 0.004 |
| Comparison group | 103 | 8.80 | 1.45 |
There was no significant difference in mean LATCH scores before intervention between the intervention (mean=8.27; SD=1.95) and comparison groups (mean=8.2; SD=1.89; t(222)=2.9, P=0.8). However, there was a significant difference in mean LATCH scores after intervention between the intervention (mean=9.35; SD=1.3) and comparison groups (mean=8.8; SD=1.45; t(205.7)=2.6, P=0.004).
The independent t-test was used as an extra analysis to compare between primiparous and multiparous mothers. The continuous variable was the total LATCH score before and after intervention in the comparison and intervention groups. There was no significant difference in mean scores of the total score of LATCH assessment tool before intervention between primiparous mothers (mean=8.06; SD=1.75) and multiparous mothers in the of the intervention group (mean=8.3; SD=1.97; t(222)=-6.45; P=0.5). Similarly, there was no significant difference in mean total LATCH scores after intervention between primiparous mothers (mean=8.6; SD=1.97) and multiparous mothers (mean=9.2; SD=1.2; t(50)=-1.8, P=0.07) in the comparison group.
Systematic assessment of the infant at the breast
SAIB, which was used as an educational tool, focuses on the holding and approaching techniques used with the newborn: latching to nipple, areolar compression and audible swallows. Its purpose is to evaluate suction movements and swallow by observation (Macías and Meneses, 2011). SAIB was completed twice during this study for all participating mothers, before and after the intervention. Frequencies have been calculated twice (before and after the intervention) for each step of the checklist (Table 3).
| Variable | Systemic assessment of the infant at breast (SAIB) category | Intervention Group | Comparison Group | ||
|---|---|---|---|---|---|
| pre-intervention | post-intervention | pre-intervention | post-intervention | ||
| n (%) | n (%) | n (%) | n (%) | ||
| Alignment | Infant is in flexed position, relaxed with no muscular rigidity | 87 (75) | 99 (90) | 87 (78) | 81 (79) |
| Infant's head and body are at breast level | 82 (71) | 106 (96) | 80 (73) | 71 (70) | |
| Infant's head is aligned with trunk and is not turned laterally, hyperextended, or hyperflexed | 84 (72) | 106 (96) | 81 (73) | 75 (73) | |
| Correct alignment of infant's body is confirmed by an imaginary line from ear to shoulder to iliac crest | 95 (82) | 106 (96) | 89 (80) | 77 (76) | |
| Mother's breast is supported with cupped hand during first 2 weeks of breastfeeding | 69 (60) | 104 (95) | 72 (65) | 63 (62) | |
| Areolar grasp | Mouth is open widely; lips are not pursed | 81 (70) | 105 (96) | 89 (80) | 83 (82) |
| Lips are visible and flanged outward | 84 (72) | 107 (97) | 92 (84) | 87 (85) | |
| Complete seal and strong vacuum are formed by infant's mouth | 64 (55) | 103 (95) | 65 (59) | 66 (65) | |
| Approximately half an inch of areolar tissue behind the nipple is centered in the infant's mouth | 49 (42) | 104 (95) | 58 (52) | 57 (56) | |
| Tongue covers lower alveolar ridge | 72 (62) | 105 (96) | 85 (77) | 83 (81) | |
| Tongue is troughed (curved) around and below areola | 69 (60) | 102 (93) | 82 (74) | 81 (79) | |
| No clicking or smacking sounds are heard during sucking | 83 (72) | 105 (96) | 98 (88) | 92 (90) | |
| No drawing in (dimpling) of cheek pad is observed during sucking | 88 (76) | 104 (95) | 97 (87) | 88 (87) | |
| Areolar compression | Mandible moves in a rhythmic motion | 92 (79) | 107 (98) | 94 (85) | 91 (89) |
| If indicated, a digital suck assessment reveals a wavelike motion of the tongue from the anterior mouth toward the oropharynx | N/A | N/A | N/A | N/A | |
| Audible swallowing | Quiet sound of swallowing is heard | 93 (81) | 107 (97) | 92 (83) | 88 (86) |
| Sound may be preceded by several sucking motions | 80 (69) | 98 (89) | 84 (76) | 80 (78) | |
| Sound may increase in frequency and consistency after milk ejection reflex | 84 (72) | 98 (89) | 83 (75) | 78 (77) | |
There was an increase in the number of postpartum mothers in the intervention group who demonstrated skills of latch-on technique after they were given educational material. These skills were related to alignment, areolar grasp, areolar compression, and audible swallowing. However, the number of mothers in the comparison group who demonstrated skills of latch-on technique did not change or decreased in some skills after receiving the postpartum care at the selected hospitals.
Discussion
In this study, the authors hypothesised that postnatal breastfeeding education would improve mothers' skills of latch-on technique. The results revealed that the mothers' skills were improved after receiving postnatal breastfeeding educational material. However, mothers in the comparison group did not show any improvement in their skills after receiving the postnatal care in the selected hospital. This improvement in the mothers' skills would decrease the incidence of breastfeeding problems that contribute to early cessation of breastfeeding (Abuidhail et al, 2014). Furthermore, this improvement reflects the importance of health education to mothers, and how breastfeeding skills can be used to enhance the health of newborn infants (Kronborg and Kok, 2011). The education and training that were offered also have positive effects on mothers' desire to breastfeed (Racine et al, 2009).
Similarly, the mothers of the intervention group showed a greater improvement in the skills of SAIB tool after receiving postnatal breastfeeding education material than the mothers in the comparison group. These skills are related to alignment, areolar grasp, areolar compression, and audible swallowing, which indicate proper position and latch-on technique. The enhancement was shown by the increased number of the mothers in the intervention group who practised the skills correctly after receiving postnatal education material. This improvement meant that the mothers in this study did not originally have the skills of proper positioning and latch-on technique, even though most Jordanian mothers breastfeed their infants (DoS and ICF International, 2013). This was an indication that the SAIB tool was an effective method of education for postpartum mothers.
It was reported in the Jordan Population and Family Health Survey that only 13% of infants aged 0-5 months old were not breastfed (DoS and ICF International, 2013). This, however, was not exclusive breastfeeding as recommended, and only 23% of mothers exclusively breastfed their infants during the first 6 months of life (DoS and ICF International, 2013). The survey did not investigate or discuss the causes of the previous percentages of exclusive breastfeeding; however, Abuidhail et al (2014) found that breastfeeding problems were the most common barrier for successful (and exclusive) breastfeeding. So, the improvement that the participating mothers, whether primi-or multiparous, achieved in this study was an indicator of the effectiveness of the postnatal education material in enhancing the mothers' skills in latch-on breastfeeding technique and the proper position of the newborn infant to the breast (Banginwar et al, 2011).
These results have been supported by other studies that have demonstrated the success of postnatal breastfeeding education and its relation to breastfeeding practice. Studies have emphasised that the education on breastfeeding had positive effects on mothers' breastfeeding skills and their ability to manage themselves (Racine et al, 2009; Kronborg and Kok, 2011). At the same time, postnatal education helped to reduce problems associated with painful breastfeeding. This was clear in this study from the results of MANOVA and t-test after education sessions for the intervention group. Furthermore, the percentage of breastfeeding problems among the participating mothers in the intervention group was less than the percentage of breastfeeding problems among participating mothers in the comparison group. Such a result proved that postnatal education about breastfeeding skills was beneficial, although most of the participants were not highly educated. A possible explanation might be that latch-on technique could be mastered by demonstration and re-demonstration if midwives would do it, as opposed to mothers having to spend try to comprehend scientific materials or to search out information about health practices (Wen et al, 2009; Abuidhail et al, 2014).
Limitations
The main limitation in this study was the inability to meet the mothers after 1 month postpartum to assess their breastfeeding skills. The women were met at the hospitals when they gave birth and were enrolled in this study, but after this, the mothers were scattered to different maternal and child health centres for follow-up, which made it difficult to meet them again. The women were followed-up by phone interviews, but this may have led to the twin problems of recall bias and inaccurate information about breastfeeding skills. Secondly, the quasi-experimental design might have been limited due to non-randomisation, although an attempt was made to minimise this by the homogeneity of the population and the sample. Using a homogenous sample is easy and offers considerable control, but the limitation of this approach is that research findings cannot be generalised outside of the participants in the study. Lastly, the SAIB tool had no defined and determined scoring system, and the psychometric properties were not measured, meaning that this tool could only be used as an educational tool not as measurement tool.
Conclusion
Postnatal breastfeeding education is an effective method for the promotion and implementation of breastfeeding and exclusive breastfeeding. This was clear in the improvement of latch-on techniques and breastfeeding skills of the intervention group in this study. The effect of postnatal breastfeeding education programmes in this study led to enhanced breastfeeding skills among the mothers. It is necessary to increase midwives' awareness about breastfeeding education in the postnatal wards and to include it in the discharge planning for the mothers.
Implications for midwifery practice
Midwives who are breastfeeding trainers can enhance breastfeeding rates and duration by conducting sessions for postpartum mothers before they are discharged from hospital. Nursing policymakers in the Jordanian Ministry of Health should include a training programme on breastfeeding education for nurses and midwives working in maternal and child health care settings. It is important to include a policy of teaching breastfeeding skills to enhance the level of breastfeeding awareness among health care professionals in hospitals.