Breastfeeding is an important health promotion strategy that has widely accepted and documented benefits for mothers, infants, and society (Wieczorek et al, 2010; Ahluwalia et al, 2012; Kuyper et al, 2014). According to the World Health Organization (WHO) (The Partnership for Maternal, Newborn and Child Health, 2011), most of the infection-related deaths in children under 5 years old could be avoided by clean births, treating maternal infection, and exclusive breastfeeding. Approximately 5.6 million children under 5 years old died in 2016 (15 000 per day), and Jordan is ranked 96th in terms of deaths for children under 5 years' old. The mortality rate for children under 5 years old was 19% per 1000 live births, while the infant mortality rate was 17% per 1000 live births (Malkawi, 2016). Reducing these inequities and preventing child deaths are therefore important priorities (WHO, 2019).
WHO (2019) and the American Academy of Pediatrics (Section on Breastfeeding, 2012) recommended that breastfeeding should be initiated within the first hour of life and that infants should receive exclusive breastfeeding from birth to 6 months. This should continue alongside complementary feeding for 2 years. Despite these recommendations, the rate of exclusive breastfeeding remains low in both developed and developing countries (Imdad et al, 2011). Only about 45% of infants are put to the breast within the first hour of life, and the same proportion of infants are exclusively breastfed until 6 months (Malkawi, 2016). In Jordan, 95% of postpartum women initiate breastfeeding during the hospital stay; however, only 1% of women exclusively breastfeed for 6 months and the average duration of exclusive breastfeeding was 1 month (Abuidhail et al, 2014). A recent Jordanian study by Dasoqi et al (2018) found that the rate of breastfeeding initiation within the first 4 hours after birth was just 13%. The percentage of exclusive breastfeeding at 6 weeks and at 6 months were 25.5% and 2.1%, respectively (Dasoqi et al, 2018).
There are several barriers to successful breastfeeding, including social norms, embarrassment, lactation problems, returning to work, caring for other children, short periods between pregnancies, infants feeling hungry after breastfeeding, sore nipples, pain and dose of ergometrine during birth (Ahmed and El Guindy, 2011; Abuidhail et al, 2014; Watkins, 2015; Ruffin and Renaud, 2015; Dasoqi et al, 2018). Many of these barriers could be prevented by learning effective breastfeeding techniques (Ouyang et al, 2016); however, inadequate knowledge and training among health professionals is considered a barrier to teaching mothers (Abuidhail et al, 2014; Watkins, 2015). Evidence suggests that many health professionals have low level of confidence, clinical competence, knowledge, attitude and practice towards breastfeeding (Renfrew, 2006; Gavine et al, 2016); that their practices are not evidenced-based; and that they rely on their experiences rather than evidence (Ward and Byrne, 2011; Ayed, 2014). However, evidence also suggests that knowledge and support from well-trained health professionals, especially nurses and midwives, increases rates of breastfeeding initiation and continuation, which reduces neonatal mortality by 22% (Jana, 2009; Ward and Byrne, 2011). Accordingly, nurses and midwives need to be given appropriate knowledge about the methods of infant feeding, the process of lactation, problem management, communication, and advanced skills to support mothers to successfully initiate and continue breastfeeding (Gavine et al, 2017).
To overcome issues with breastfeeding, multifaceted and structured programmes—supported and sponsored by the UNICEF and WHO, such as the Baby-Friendly Hospital Initiative—were introduced. These programmes recommend that all health professionals should be trained to implement breastfeeding best practice through educational and training courses of at least 18 hours duration, including a minimum of 3 hours of supervised clinical practice (Gavine et al, 2017). Educating health professionals is a required component for the success of all breastfeeding interventions (Watkins, 2015). These are defined as programmes ‘that improve knowledge, skills, attitudes, or behaviour of health professionals towards the importance of breastfeeding, the physiology and management of lactation or counselling related to breastfeeding’ (Shealy et al, 2005:41). Improving health professionals' knowledge, attitudes and practices towards breastfeeding is considered a key strategy to influence mothers' decisions to breastfeed and improve overall rates of breastfeeding (Hunter et al, 2015; Spatz et al, 2015).
Jordanian mothers have been shown to rely on cultural beliefs and practices towards breastfeeding during the postpartum period (Abuidhail, 2014), while women who received breastfeeding education during pregnancy or after giving birth were more likely to initiate more before discharge from hospital (Dasoqi et al, 2018). Therefore, women need supportive educational services to enhance their level of knowledge (Abuidhail, 2014). There is a also a need to increase Jordanian health professionals' awareness of the factors that might negatively affect breastfeeding (Dasoqi et al, 2018) and to encourage their roles as educators and consultants in order to improve breastfeeding initiation and continuation among Jordanian mothers (Oweis et al, 2009; Dasoqi et al, 2018; Abuidhail et al, 2014). However, there is a lack of studies that included health professionals in their sample, as the majority of published studies from Jordan have assessed breastfeeding among women. To the researchers' knowledge, this is the first study that has evaluated the effectiveness of a breastfeeding educational workshop on nurses and midwives' knowledge, attitudes and practices.
Methods
Design
A quasi-experimental, pre- and post-test design in two groups was used to evaluate the effectiveness of an educational workshop on nurses and midwives' breastfeeding knowledge, attitudes and practices. The study design, with no randomisation, has been used widely by researchers because it is practical when full experimental rigour is not possible and when the random assignment of participants is difficult to achieve (Polit and Beck, 2014). The sample size was calculated using G* Power version 3.0.10, with a significance level of 0.05, a power of 80% and moderate-to-large effect size of 0.65, indicating that educational interventions were found to be effective in increasing nurses' level of knowledge. The adequate sample size for two independent samples was 39 nurses and midwives in each group; therefore, the total sample size required was 78 participants.
Participants
The study population included all nurses and midwives working with women during the antenatal, childbirth, postpartum periods and who were working with newborn babies. A convenience non-probability sampling strategy was used to recruit nurses and midwives from the relevant departments who had at least 1 year of experience. Nurses and midwives who had a workshop or specialty on breastfeeding were excluded. Participants were recruited from two major teaching hospitals, Jordan University Hospital in Amman and King Abdullah University Hospital in Ar Ramtha. The researcher had an access to 85 nurses and midwives in both hospitals, of whom 82 met the inclusion criteria, agreed to participate and completed all phases of the study. The two teaching hospitals were randomly assigned to either the experimental or the control group by flipping a coin. All nurses and midwives from King Abdallah University Hospital were randomly assigned to the control group while the Jordan University Hospital staff were assigned to the intervention group. This technique reduced the effect of intervention contamination and enhanced the internal validity.
Study intervention
Based on an up-to-date evidence, including recommendations from WHO (2019) and the National Institute for Health and Care Excellence (NICE) (2015), two educational materials were developed, addressing the importance of breastfeeding initiation and child growth and development from birth to 5 years old. The intervention group received a 2-hour, condensed educational workshop on breastfeeding, while the control group received a 2-hour, condensed workshop on child growth and development up to 5 years old. The researcher used a PowerPoint presentation, images, videos, and demonstration to educate participants about selected topics. The content was presented to both groups in English, which is the teaching language for nursing and midwifery students in Jordan. At the end of the educational session in the intervention group, small booklets containing all important material about breastfeeding were distributed to all participants. Participants in the control group also received the same booklets after they had completed the post-test questionnaire. The teaching materials consisted of different topics that nurses and midwives need to know about breastfeeding practices and child growth and development, and are displayed in Table 1.
| Interventional group workshop | Control group workshop |
|---|---|
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Study instruments
Demographic variables were collected (Table 2), as well as eight questions about basic nursing and midwifery breastfeeding education (Hennessy, 2003) (Table 3). Two validated pre- and post-test questionnaires, developed by the American Academy of Pediatrics (Feldman-Winter et al, 2010), were used to collect data about breastfeeding knowledge and practices. The questionnaire consisted of 20 questions measuring knowledge and five for practice. Correct answers were recorded as a score of 1 and incorrect answers were recorded as a score of 0, thereby giving a maximum of 20 for knowledge and 5 for practice. A 7-item questionnaire (Hennessy, 2003) was also used to assess nurses and midwives' attitudes towards breastfeeding. A score of 1 was given for ‘yes’ answers (indicating a favourable attitude) and a score of 0 was given for ‘no’ answers (indicating an unfavourable attitude). The maximum possible score for the attitude questions was 7. The pre- and post-test questionnaires for knowledge and practice assessed the same information; however, the pre-test questions were different from the post-test questions to minimise bias. These questions were also in English. The questionnaires were reviewed by five experts in the field of maternal and neonatal health for face and content validity. Minor changes were made based on experts' suggestions. The study instruments were piloted on ten nurses before conducting the original study. Results of this pilot study were not included in the final sample. In this study, the Cronbach's alpha (a) for the knowledge scale was α=0.73, indicating that the questionnaire was a reliable measurement tool to test the study variables. The practice and attitudes scales scored α=0.50 and α=0.24, respectively and therefore items were analysed individually instead of using total scores.
| Variable | n | % | |
|---|---|---|---|
| Age (years) | ≤25 | 10 | 12.2 |
| 26–30 | 20 | 24.4 | |
| 31–35 | 21 | 25.6 | |
| 36–40 | 14 | 17.1 | |
| ≥41 | 17 | 20.7 | |
| Years of experience | ≤5 | 24 | 29.3 |
| 6–10 | 23 | 28.0 | |
| 11–15 | 14 | 17.1 | |
| 16–20 | 12 | 14.6 | |
| ≥21 | 9 | 11.0 | |
| Marital status | Single | 16 | 19.5 |
| Married | 61 | 74.4 | |
| Widow/separated | 5 | 6.1 | |
| Education | Diploma | 21 | 25.6 |
| Bachelor | 53 | 63.4 | |
| Master's/PhD | 7 | 8.5 | |
| Other | 2 | 2.4 | |
| Job title | Registered nurse | 48 | 58.5 |
| Paediatric nurse | 16 | 18.3 | |
| Midwife | 17 | 20.7 | |
| Nurse specialist | 2 | 2.4 | |
| Department | Labour ward | 27 | 40.9 |
| Postnatal ward | 14 | 21.2 | |
| Nursery | 9 | 13.6 | |
| Outpatients | 10 | 15.2 | |
| A&E | 3 | 4.5 | |
| Neonatal intensive care unit | 3 | 4.5 | |
| Breastfeeding her children* | Yes | 52 | 63.4 |
| No | 8 | 9.8 | |
| N/A | 22 | 26.8 | |
| Breastfeeding period (months)* | N/A | 9 | 13.3 |
| ≤6 | 14 | 25.0 | |
| 7–12 | 21 | 35.0 | |
| 13–18 | 9 | 15 | |
| ≥19 | 7 | 11.7 |
| Education item | Yes (%) |
|---|---|
| I was adequately trained in breastfeeding in nursing school | 42.7 |
| I received education about breastfeeding in my paediatric and/or maternity theory course(s) | 59.8 |
| I received experience with breastfeeding during my paediatric and/or maternity clinical rotation(s) | 58.5 |
| I counselled a woman about infant feeding choices during my clinical rotation(s) | 56.1 |
| I counselled a woman with breastfeeding problems during my clinical rotation(s) | 59.8 |
| I cared for a breastfed infant | 65.9 |
| I received education on the management/treatment of sore/cracked nipples | 70.7 |
| I received education on the management/treatment of breast engorgement | 65.9 |
Data collection
A total of 42 nurses and midwives from Jordan University Hospital were assigned to the intervention group and received the educational programme on breastfeeding, while 40 nurses and midwives from King Abdullah University Hospital received an educational programme about child growth and development (control group). Pre-test questionnaires were distributed to participants to complete before the start of the workshops and they were asked to return them in an envelope provided. Participants were given 25–30 minutes to complete the questionnaire before the workshops were held. The post-test questionnaires were distributed 2 weeks after the workshops for both groups. The data collection period lasted for 2 months from March–May 2018.
Ethical consideration
Before data collection, ethical approval was obtained from the Jordan University of Science and Technology Institutional Review Board, Jordan University Hospital and King Abdullah University Hospital. If nurses and midwives agreed to participate, they were asked to sign a written informed consent and complete the study questionnaire. All participants were assured that their participation was voluntary and that they could withdraw at any time without giving a reason.
Data analysis
Descriptive analysis was used to evaluate the effectiveness of the educational workshop on nurses and midwives' knowledge, attitudes and practice towards breastfeeding. Independent sample t-tests were used to compare knowledge between groups at baseline and after the workshops. Paired sample t-tests were used to compare knowledge within groups before and after the workshops. Practice and attitudes scales were analysed item by item using chi-square (χ2) tests between intervention and control groups and McNemar's tests to compare items on the pre- and post-test results for each group.
Results
A test of normality showed that the study sample was normally distributed. Table 2 shows the distribution of participants in terms of age, years of experience, marital status, education, job title, department, whether she breastfed her own children and her own breastfeeding period (if the participant was a mother).
Knowledge of breastfeeding at baseline
A Pearson test to assess associations between baseline knowledge and continuous variables such as age, breastfeeding education and years of experience revealed no significant results. Spearman's rho tests for associations between baseline knowledge and level of education, department, work experience, and length of breastfeeding (if applicable) also showed no significant correlations.
Participants' breastfeeding education
Nurses and midwives' education about breastfeeding was tested using eight items in the questionnaire. No significant correlations were found between level of education about breastfeeding and age, years of work experience and periods of breastfeeding, nor between breastfeeding education and baseline knowledge of breastfeeding. Table 3 displays the percentage of ‘yes’ responses as reported by nurses and midwives in relation to the received education about breastfeeding.
Participants' knowledge after the workshop
Independent samples t-tests were used to compare knowledge before and after the workshop, and to compare this between groups (Table 4). The results showed no significant difference in the means and standard deviations of the intervention group (n=42; M=8.14; SD=1.88) and the control group (n=40; M=8.98; SD= 2.31) at baseline (t=-1.79; P>0.05), which indicates homogeneity of variance. The results showed a significantly higher mean and standard deviation in the intervention group (M=11.73; SD=2.6) compared to the control group (M=8.38; SD=2.59) after the workshop (P=<0.001), indicating that the workshop was beneficial in improving participants' knowledge of breastfeeding.
| Intervention Mean (SD) | Control Mean (SD) | T | P | |
|---|---|---|---|---|
| Pre-test | 8.14 (1.88) | 8.98 (2.31) | -1.79 | 0.077 |
| Post-test | 11.73 (2.60) | 8.38 (2.59) | 5.82 | 0.000*** |
Paired samples t-tests were used to compare knowledge before and after the workshop within groups (Table 5). There was a highly significant improvement in the intervention group's knowledge after the workshop (M=11.73; SD=2.6) compared to baseline (M=2.12; SD=1.9; t=-7.11; P<0.001). However, there was no significant difference in the results of the control group (M=8.98; SD=2.31). The post-test score was (M=8.38; SD=2.59; t=1.09; P>0.05), indicating that the workshop improved breastfeeding knowledge.
| Group | Before workshop Mean (SD) | After workshop Mean (SD) | T | P |
|---|---|---|---|---|
| Study | 8.12 (1.90) | 11.73 (2.60) | -7.11 | 0.000 |
| Control | 8.98 (2.31) | 8.38 (2.59) | 1.09 | 0.281 |
Differences in participants' practices and attitudes towards breastfeeding
To compare group differences in the pre-test and post-test practices and attitudes, χ2-tests were conducted for each practice and attitude item. Table 6 shows the group differences in the pre-and post-test practice and attitude scores. The results revealed no significant differences on the item level at the baseline between the intervention and control groups; however, significant differences were revealed on the post-test comparisons between the two groups, in which practice items 1, 2, and 4 were significantly improved after the study intervention.
| Practice item (pre) | Pre-test of proper practice (%) | Post-test of proper practice (%) | ||||||
|---|---|---|---|---|---|---|---|---|
| Test (n=42) | Control (n=39) | χ2 | P | Test (n=42) | Control (n=40) | χ2 | P | |
| 1. When do you usually schedule the first postnatal office visit for an infant discharged to home? | 62.0 | 43.6 | 2.724 | 0.099 | 90.2 | 45.0 | 19.016 | 0.000*** |
| 2. When discussing feeding options with parents of healthy full-term infants in your practice, which of the following do you usually recommend for the first month of life? |
88.1 | 79.5 | 1.112 | 0.292 | 100.0 | 70.0 | 14.439 | 0.008** |
| 3. For approximately what length of time do you recommend exclusive breastfeeding? | 50.0 | 51.3 | 0.013 | 0.908 | 65.9 | 72.5 | 0.419 | 0.517 |
| 4. How frequently do you usually recommend that infants be breastfed during the first week of life? | 38.1 | 30.8 | 0.48 | 0.488 | 78.0 | 45.0 | 9.361 | 0.002** |
| 5. How frequently do you usually recommend that infants be breastfed during the first month of life? | 31.0 | 30.8 | 0.00 | 0.986 | 70.7 | 52.5 | 2.849 | 0.091 |
Both groups had higher positive attitude scores than negative attitude scores at baseline; therefore only item 5 showed a significant improvement after the study intervention (Table 6). Moreover, it can be seen from Table 7 that conducting McNemar's test to compare the practice items before and after the workshop showed a significant improvement in the scores of three items (1, 4 and 5) in the intervention group. For the control group, McNemar's test to compare attitude items before and after the workshop showed significant improvement in item 5 alone (Table 7).
| Practice item (pre) | Intervention group (n=41) | Control group (n=39) | ||||
|---|---|---|---|---|---|---|
| Pre-test (%) | Post-test (%) | P | Pre-test (%) | Post-test (%) | P | |
| 1. When do you usually schedule the first postnatal office visit for an infant discharged to home? | 61.0 | 90.2 | 0.004** | 43.6 | 46.2 | 1 |
| 2. When discussing feeding options with parents of healthy full-term infants in your practice, which of the following do you usually recommend for the first month of life? |
87.8 | 100.0 | 0.063 | 79.5 | 69.2 | 0.344 |
| 3. For approximately what length of time do you recommend exclusive breastfeeding? | 48.8 | 65.9 | 0.118 | 51.3 | 71.8 | 0.057 |
| 4. How frequently do you usually recommend that infants be breastfed during the first week of life? | 39.0 | 78.0 | 0.000*** | 30.8 | 43.6 | 0.267 |
| 5. How frequently do you usually recommend that infants be breastfed during the first month of life? | 29.3 | 70.7 | 0.001** | 30.8 | 51.3 | 0.039* |
Discussion
Workshops are one of the most used interventions to improve health professionals' capabilities (Seighali et al, 2015); however, there is a lack of high-quality evidence to determine if breastfeeding education alone for health professionals will improve health professionals knowledge, attitudes and practices towards breastfeeding (Gavine et al, 2016). Fortunately, this study's findings proved the positive effects of short educational breastfeeding workshops on participants' knowledge, attitudes and practices. Previous research findings have shown that breastfeeding educational programmes significantly increased participants' knowledge scores (Feldman-Winter et al, 2010; Ward and Byrne, 2011; Holmes et al, 2012; Wallace et al, 2018). Kwah et al (2018) reported that clinicians benefitted greatly from workshops that improved their knowledge, confidence and practice related to breastfeeding and supporting parents to be involved in their baby's care. Bhutta et al (2013) also found that educational programmes improved nurses' skills helped them to change their practice based on up-to-date evidence. This knowledge can then assist clinicians in providing appropriate care.
In this study, most respondents agreed that the promotion of breastfeeding by health professionals resulted in higher rate of breastfeeding, even though their breastfeeding practice varied. There was also a relationship between knowledge of breastfeeding and participants' attitudes and practices. Seighali et al (2015) agreed that knowledge, attitudes and practices improved significantly for their study participants after implementing workshops. They reported that didactic methods improved participants' knowledge immediately, but not enough to change participants' practice in the long-term. Weddig (2011) conducted a study using an 8-hour online course and found that it changed participants' knowledge of breastfeeding, but it did not change their behaviours. Hospital policy and work environments might make it difficult to change practice even if knowledge scores were improved (Weddig, 2011). In this study, the inability to change practice might be because the selected hospitals were not accredited by the UNICEF Baby-Friendly Hospital Initiative and did not have policies to support breastfeeding practices, or might be because the scale used was not sensitive enough and needed refinement.
These findings demonstrated that the educational workshop for nurses and midwives had a positive effect on their attitude towards breastfeeding, although it was not significantly different from the baseline scores. This might be because of respondents' high baseline attitude scores or due to the cultural factors identified by Weddig (2011). This finding is consistent with many studies from the Middle East that reflect the positive attitudes towards breastfeeding among Arab and Muslim populations (Oweis et al, 2009; Ahmed and El Guindy, 2011; Zahid et al, 2017). Because Islam is not just a religion, but a way of life that covers all aspects of being human, the culture in Muslim countries adheres to the Quran and Sunna by following instructions regarding breastfeeding, which affects attitudes positively (Zahid et al, 2017).
This study also showed that none of the demographic variables including age, work experience or personal breastfeeding experiences had an effect on participants' knowledge, attitudes or practices. In contrast, Seighali et al (2015) suggested that personal breastfeeding experience, age, and having children were considered significant affecting factors on participants' knowledge. For example, participants who have had children may believe that breastmilk was preferred and healthier than formula (Henssey, 2003; Spear, 2004). Likewise, Henssey (2003) reported a positive correlation between participants' years of experience, length of personal experience of breastfeeding and age with participants' breastfeeding promotion, confidence and practices. Parker (2015) also reported that health professionals' attitudes were influenced positively by knowledge and personal experience. In contrast, Cantrill et al (2003) found that midwives who were more than 30 years old and who had more than 3 months of breastfeeding experience showed the negative effects of their experience and offered conflicting advice to breastfeeding mothers. With regards to our study, this might be because work or personal experiences do not always provide the clinician with the evidence-based information needed to counsel mothers and, therefore, the information may not be consistent among staff members, which may expose mothers to many different opinions and suggestions.
Similar to a previous study (Henssey, 2003), many participants were dissatisfied with the breastfeeding education provided in nursing school and maternity or paediatric courses. It is therefore advisable that nursing schools re-evaluate their curricula in order to integrate more breastfeeding education to maximise the benefits for future health professionals and mothers. Approximately 60% of participants reported receiving sufficient education about breastfeeding, yet they showed poor knowledge of the physiology, management, and complications of breastfeeding. This could be explained by the limitations of self-reporting scales, or by the length of time in the workplace—as the majority of respondents had been working for 10 years and more, they may have forgotten what education they received. Nurses and midwives should therefore receive continuous professional development (CPD) and use evidence to maintain high-quality practice. Feldman-Winter et al (2010) reported inadequate education in obstetric and paediatric residency programmes. As a result, nurses and midwives are needed to help fill this gap.
Limitations
The generalisability of these findings is uncertain as two settings were included. Using convenience sampling (as applying randomisation was difficult in these settings due to shift demands and workload) may have also limited the study findings. In addition, the use of self-reported measures to assess practice instead of using observational methods or a checklist limited the time to follow them up and may have affected the practice scores.
Implications and recommendations
These findings will encourage policy makers to implement CPD workshops for breastfeeding, which, in turn, will improve breastfeeding practices in Jordan. The educational content from this study can be used by nursing and midwifery educators and in-service educational departments to increase health professionals' knowledge of breastfeeding and improve their practice. Workshops can increase health professionals' knowledge, awareness and practices, which will enable them to practise as breastfeeding consultants, educators, and advocates for mothers. Breastfeeding education workshops are recommended to all maternal and child health professionals at all levels and should be updated frequently. Education and training should also cover practice-based learning.
Conclusion
This study revealed insufficient knowledge, attitudes and practices among Jordanian nurses and midwives and proved that a 2-hour workshop was enough to improve the knowledge of the participants. The study results were compared with other studies and it can be concluded that educational programmes increase health professionals knowledge, which may lead to improvements in practice and better breastfeeding outcomes.