Breastfeeding self-efficacy of women using second-line strategies for healthy term infants in the first week postpartum: an Australian observational study

Study design and setting

The study design was a quantitative, observational retrospective self-report survey. The research was conducted at one Australian metropolitan UnitingCare Health private birthing facility, located in Brisbane.

Participants

Participants were identified through systematic chart review of all current inpatients, from 1 November 2008 to 27 February 2009. Following the birth of their healthy term singleton infant, and initiating any breastfeeding, participants were invited to complete a questionnaire mailed to their home by day seven. Length of postnatal inpatient stay at this facility was four/five days. Figure 1 shows women screened for inclusion, reasons for exclusion, and response rate of both primiparous and multiparous women.

Ethics

Ethical approval was granted from UnitingCare Health Human Research Ethics Committee (200837), and Queensland University of Technology Human Research Ethics Committee (0800000784). No identifying information was contained on the questionnaires and consent was implied by return of the questionnaire[18].

Measures

Women were asked to respond to a range of questions regarding demographic, birthing, feeding variables, and the 14 item Breastfeeding Self Efficacy Scale - Short Form (BSES-SF), yielding nominal and interval data. Permission to use the scale was granted by the owner. International studies have measured BFSE, with repeated reliability and validity, including one Australian study[19–26]. The timing of BFSE measurement varies in the literature and includes antenatal, in-hospital, and up to six months postpartum measurement. The BSES-SF tool is designed for women to reflect on the previous 24 hours when choosing their responses. Whilst providing a precise snapshot of BFSE, it may not reflect day-to-day lactogenesis II changes, particularly during the first week postpartum. Therefore, data was collected at day seven, and all responses were the participant’s retrospective view of the first seven postnatal days. In this study, internal consistency of the BSES-SF with minor retrospective changes was confirmed with Cronbach’s alpha 0.93. The BSES-SF provided interval data with scores ranging from 14 (lowest) to 70 (highest). The eight second-line strategies were grouped together to form a single variable representing the number of women who used second-line strategies for the purpose of analyses. The group of second-line strategies was developed from the literature. A panel of 2 midwives and 2 mothers was requested to review the whole questionnaire to comment on its face validity (these mothers did not participate in the survey). Suggestions received from this panel were incorporated into the final questionnaire.

Data management and analysis

All questionnaires were checked for missing data. One respondent omitted a page, and two others had other missing data but this was minimal so their available data were included in the analysis. Seven respondents omitted an item in the BSES-SF, and these were not included in analysis. Data were analysed using SPSS version 16.0. Descriptive statistics were used to describe the demographic profile of the respondents, present the rates of use of second-line strategies and the reasons for their use. Due to large variances, the non-parametric Kruskal-Wallis Analysis of Variance[27, 28] was used to test median BSES-SF score for the two groups. The probability level chosen for significance testing was p-value < 0.05.

Demographic profile

The majority of infants weighed between 3000 g and 4000 g, and just over half the women were multiparous, with a history of breastfeeding a previous infant for more than six months (Table 1). Almost all (93%) women reported skin-to-skin contact with their infant at birth. Of 128 women who began breastfeeding, four ceased breastfeeding by seven days. More than three quarters of the women reported using spinal or epidural pain relief during the delivery. Forty-seven percent gave birth by Caesarean section (60/128), 97% of these were planned (58/60).

Use of second-line strategies

Knowledge and preference

Knowledge and preference was noted for all respondents. For each second-line strategy women indicated whether or not they previously knew of the strategy, and if not, to indicate if they would prefer to have known. As shown in Table 2, a high proportion of women already knew of bottles with regular and wide teats, and nipple shields. Variants of syringe feeding, cup, and supply line strategies were less well known. With the exception of nipple shields, women indicated very little preference for strategies they did not have previous knowledge of.

Key challenges

BFSE

Key challenges

The seven key challenges cited by women using second-line strategies in this study are consistently noted in the literature[2, 7, 16, 17, 36–38]. One of the most common challenges was nipple pain, with others being infant behaviour (‘baby would not settle’), perceived insufficient breast milk supply (‘not enough breast milk/colostrum’), and fatigue. The latter three suggest an interplay of challenges to breastfeeding occurring at night. This is consistent with one Canadian study reporting a high risk factor for supplementary feeding to be time of birth (7 pm to 9 am)[36]. In that study nurses reported breastfeeding problems, infant behaviour and maternal fatigue were reasons for supplementation also. Given that frequent feeding at night by the second/third night is considered normal[39], birthing facility practices such as lower level of staff at night may be an important factor that has been overlooked by breastfeeding advocates.

Implications

The Baby Friendly Health Initiative (BFHI) Ten steps to successful breastfeeding step nine is to “give no artificial teats or pacifiers to breastfeeding infants”[10]. Almost all the women in the sample who began breastfeeding continued to breastfeed at day seven, despite a high proportion of bottle and teat use. Although bottle and teat use, whether containing breast milk or non-breast milk is widely viewed as harmful to breastfeeding success, this has been challenged in the literature[1, 39, 40]. In this study more than half the second-line strategies used were BFHI preferred (non artificial teat).

Woman centred care revolves around the guiding principles of control, choice, and continuity[41]. In many settings breastfeeding education and guidance is a part of care provided by midwives. This key component of midwifery practice should therefore be based on the principles of woman centred care. That is, control of breastfeeding aspects in the first week postpartum including decision-making if challenges occur. At present in Australia, second-line strategies are often controlled by policies at birthing facilities[42, 43] and opportunities for women to engage in informed decision making about such strategies may be limited. There is some discussion in recent literature that control of breastfeeding should be ‘handed back’ to women[41, 44, 45]. Evidence of the success of this approach has been provided by Wan et al.[46], who found increased satisfaction in woman-centred postpartum care rather than task-centred postpartum care. In one Swedish study, Zwedberg and Naeslund[47] argue that the current midwifery approach was not entirely woman-centred. Instead they note care models can be family centred, infant-centred, and mother/infant dyad centred. They noted that midwives viewed the woman/midwife relationship from both subjective and objective viewpoints, with the objective viewpoint resulting in woman-centred care being impossible. Just as women birth their infants, not the attendants present at the birth, “the individual woman is responsible for the success of breastfeeding”[44]. Choice of second-line strategies by the woman should be based on her own values and beliefs (which form BFSE via vicarious learning and verbal/social persuasion), establishing a continuance of woman-centred care beyond birth. Where women have knowledge deficits, a continuity of care model facilitates education based on midwives prior knowledge of the woman[45].