PROPOSAL FOR RESEARCH IN PRENATAL BREASTFEEDING 1
Proposal for Research in Prenatal Breastfeeding Education
NURS 500 Liberty University
Author Note
This author has no known conflict of interest.
PROPOSAL FOR RESEARCH IN PRENATAL BREASTFEEDING 2
Abstract
The Healthy People 2030 goal for exclusive breastfeeding is 42.4%. Exclusive breastfeeding
provides the optimum nutrition and health protection in the infant for the first six months of life.
Fewer than 25% of infants born in 2015 were exclusively breastfeed to six months. (U.S.
Department of Health and Human Services, 2020). Breastmilk is perfect food for newborns and
infants, and it continually acclimates to what the infant needs. Finding ways to encourage and
educate new moms will need to begin before birth, during the prenatal period.
Keywords: prenatal, breastfeeding, initiation, duration, education
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Proposal for Research in Prenatal Breastfeeding Education
Breastfeeding has been thought of as a natural, biological behavior, yet many
women struggle with maintaining a feeding ritual with their newborn. The World Health
Organization (WHO) encourages mothers to breastfeed at least six months of life, yet many find
breastfeeding not as natural as expected (Breastfeeding, 2020). They may feel dejected and
regretful if breastfeeding is not successful. Where is the disconnect between the desire to
breastfeed, initiating and duration in breastfeeding? In her book Breastfeeding Uncovered, Amy
Brown identifies two challenges for women who are biologically capable of breastfeeding: lack
of knowledge and no societal support (Brown, 2016). How does knowledge about breastfeeding
affect the extent of breastfeeding? Does prenatal breastfeeding education prepare new moms
better for breastfeeding and encourage a longer duration as compared to those who didn’t receive
prenatal education?
Background
Breastfeeding benefits both mom and baby. For the newborn, breastmilk contains the
correct amount of nutrients an infant may need for growth and development. It is a perfect blend
that has been linked to lower rates of infections in the gastrointestinal, respiratory, and urinary
systems. Breastfeeding is related to a decrease in obesity and Type II diabetes (Wang et al.,
2017). For mom, when breastfeeding is initiated, postpartum hemorrhage declines. Breastfeeding
is also linked to a decrease in risk for both breast and ovarian cancers (Ross-Cowdery et al.,
2016).
While the World Health Organization recommends exclusive breastfeeding (EBF) until
six months of age, many countries are falling short of this goal. In the United States 25.6% of
PROPOSAL FOR RESEARCH IN PRENATAL BREASTFEEDING 4
infants born in 2017 were exclusively breastfed until six months of life (Center for Disease
Control [CDC], 2020).
New moms wanting to exclusively breastfeed have either: educated themselves during
their pregnancy by reading, watching videos, learning from their friends/family or they are
learning about breastfeeding for the first time when they put their newborn to their breast
immediately after delivery.
Education involving breastfeeding as a whole is not being utilized to its fullest. New
parents need to understand how breastmilk works, why it is the best form of feeding, what to
expect those first two days at the hospital and then at home. The new moms need to be aware of
resources, support groups, when to call their pediatrician. All of this information and more
cannot be given within a 24–48-hour period after delivery. Most importantly, a tired,
overwhelmed, emotional new mother will never be able to absorb this information during that
time frame. Breastfeeding rates decline because it is not the natural experience the mom was
expecting.
Interventions to help improve breastfeeding initiation and duration have included
hospitals instituting Baby Friendly Hospital Initiative (BFHI) standards which include rooming
in methods, extensive training for nurses, and round the clock lactation accessibility (Baby
Friendly USA, 2021). Baby Friendly is an example of the multitude of assistance that hospitals
and clinicians look to help engage and educate new moms.
Significance
The goal of this research is to identify methods that will increase a mother’s desire to
initiate breastfeeding in the immediate postpartum phase and exclusively breastfeed to at least
three months of life and beyond to six months as the WHO and CDC recommend. Breastfeeding
PROPOSAL FOR RESEARCH IN PRENATAL BREASTFEEDING 5
rates have not improved in the last two decades (Breastfeeding, 2020). By studying and brining
ways to the forefront will enable understanding of the best interventions to encourage exclusive
breastfeeding and how to best promote it. Coupled with the promotion of EBF, the health of the
infants and mothers are augmented when breastfeeding is chosen.
Research Question
How does prenatal breastfeeding education influence a mother’s decision to initiate
breastfeeding and exclusively breastfeed for three months compared to mothers who did not
receive prenatal breastfeeding education? The purpose of this study is to understand the impact
of early breastfeeding education with the mother’s confidence to initiate breastfeeding and
continue exclusively breastfeeding to three months of life. It is important to acknowledge the
need to educate mothers on the etiology of breastfeeding, the factors that could limit EBF and
encourage confidence to work through any barriers.
Demographic variables include age, race, marital status, education, and socioeconomic
status. Biological variables comprise inadequate milk supply, infant health, maternal health,
smoking, parity, and delivery experience. Social variables incorporate if the mother returns to
work, support from family or friends, and ability to pump while at work. Maternal variables
involve the desire to breastfeed, prenatal intention, self-efficacy.
Study Design
The research will be conducted using a quantitative measure by means of quasi-
experimental review using two groups: an intervention group who receives prenatal
breastfeeding education during weeks 32-36 of their pregnancy along with the routine
postpartum education in the hospital The control group will not receive any prenatal
breastfeeding education but will obtain the current postpartum education and lactation consultant
PROPOSAL FOR RESEARCH IN PRENATAL BREASTFEEDING 6
visits in the hospital. The prenatal education will come from healthcare professionals. Both
groups will have follow-ups at certain points postpartum up to three months. Follow-up will
include questionnaires and surveys via phone calls.
Literature Review
The choice of research studies reviewed began with the similarities of the samples and
methods to be used. Utilizing pregnant women in the 32-36 range of gestation is paramount in
the timeframe to understand how well prenatal breastfeeding education is matriculated during
postpartum. Some differences were within the approach to education, yet each collected the data
similarly.
Each of the studies evaluated the outcome of prenatal breastfeeding education on the
longevity of breastfeeding. One of the nurse-led classes compared to peer led had a significant
increase of 67% of breastfeeding at any stage (Wong et al., 2015) . Mean maternal ages were
between 28-32 and more than 50% reported their income as below average (Francis et al., 2021).
There did seem to be a correlation that with the prenatal breastfeeding education, most new
mothers felt empowered and knowledgeable about breastfeeding and more than 90% initiated
breastfeeding at birth (Abuidhail et al., 2019).
Studies of the relationship between education and breastfeeding indicates that women are
knowledgeable about breastfeeding, the health benefits and a desire to breastfeed for a significant
time. This signifies that the prenatal education and the initiation and duration of breastfeeding
are relational (Jasny et al., 2019). The understanding that prenatal breastfeeding education and
breastfeeding postpartum is a necessary element in meeting the recommendation of WHO and
how make it readily available to the practitioners is a vital next step in breastfeeding success
(Parry et al., 2018).
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Midwife or nurse led education seems to be the best route of instruction with the higher
rate of success (Iliadou et al., 2018) compared with online or web-based education (Lumbiganon
et al., 2016). This type of study is groundbreaking and needs more research, especially with
regards to studying the coupling of prenatal and postnatal breastfeeding education and assessing
the success of breastfeeding at the different intervals (Su et al., 2007).
Ethical Concerns
Informed Consent
Informed consent requires a transparency between researchers and potential
participants. The process of informed consent is ethically driven by autonomy, it allows the
participant the freedom of choice. They will have the choice to participate, and they also have the
choice to discharge themselves from a study if they deem it necessary (Burr & Gibson, 2017).
The subjects will know the reason behind the research, a time frame of participation, how the
education will be conducted, risks and benefits, how their privacy will be maintained and that
this is purely voluntary (Gray et al., 2017). It is also important that the women understand that
choosing not to complete the study will not cause harm. They will continue to receive quality
healthcare and education.
Privacy
Once the participants are chosen, a written consent will be acquired after they are
informed of the purpose of the study and what their involvement entails. The information will
also include how the results will be utilized and assuring the women that their privacy will be
upheld. Confidentiality will be maintained with only the researcher having access to their
information solely for the purpose of research. Privacy can be maintained by assigning a number
to each participant. Each outcome will then be labeled with the subject’s code, avoiding their
PROPOSAL FOR RESEARCH IN PRENATAL BREASTFEEDING 8
identity. This study will be based exclusively on volunteers who are considering breastfeeding
their infants after delivery. Infants will be monitored for weight gain and growth to avoid any
ethical dilemmas by promoting a culture of safety (American Nurses Association, 2015).
Subjects will be assigned a code number that only the researcher has access to. Once the study
has results, the review should be published in a way that the participants cannot be identified by
their responses (Gray et al., 2017) and the identifying information will then be destroyed.
Institutional Review Boards
Institutional Review Boards (IRB) provide protections for participants in research. IRB
sets ethical parameters that must be maintained when researching with human subjects. A
researcher for prenatal breastfeeding education will approach IRB with information about the
signed informed consent process and to gain approval for research and data collection. This
process will include the voluntary status of each individual and their agreeance to the study, the
information gained from the participants are for research and scientific purposes, only the
primary researcher will have access to the volunteers’ information, each person will be assigned
a code and the information will be recorded under the code number to maintain the subject’s
privacy, the volunteers have the right to discontinue the study and understand their prenatal and
postpartum health care will not be affected, and their identifying information will be removed
after the results of the study are final (Abuidhail et al., 2019).
Risk to Benefit Ratio
The risk benefit for exclusive breastfeeding have been extensively studied by the World
Health Organization. The benefits of breastfeeding for infants include enhanced immunity,
greater bonding with mother, ideal nutrition, decreased risk of ear infections, gastroenteritis,
respiratory illnesses, SIDS, allergies and obesity. Benefits for mother include decreased risk of
PROPOSAL FOR RESEARCH IN PRENATAL BREASTFEEDING 9
postpartum hemorrhage, uterine contraction and faster return to pre-pregnancy size, decreased
risk of ovarian and breast cancers, and decreased risk of postpartum depression (Ross-Cowdery
et al., 2016). Risks for exclusive breastfeeding can include infant dehydration, accidental
suffocation from unsafe sleep methods and increased anxiety for mother (Bass et al., 2016). This
study will begin a relationship with the woman in the prenatal time and follow her through
measured time frames up to the infant’s third month of life. With that monitoring, if these risks
are apparent interventions can be suggested to the mother to lessen any danger to the infant.
Therefore, benefits outweigh the risks.
Methods
Setting
The target population will be healthy women who are 18 years or older, 32-36 weeks
gestation. These women will be patients of an obstetric group located in Gainesville, GA. There
are eight physicians and eleven certified nurse midwives within the practice. This physician
group provides care to pregnant women who will deliver at the hospital located in the same city.
The hospital is a 557-bed facility which has sixteen delivery, eight antepartum, thirty postpartum
rooms and a Level III Neonatal Intensive Care Unit (NICU) within its Women and Children’s
Pavilion. The hospital healthcare team encompasses OB/GYNs, midwives, anesthesiologists,
CRNAs, staff nurses and techs. This facility delivers an average of 3600 babies annually.
Sample
The sample from the population will be women who have expressed a desire to
breastfeed. They will be free of high-risk pregnancies or any conditions that would impede
successful breastfeeding. High risk pregnancies will be defined according to American College
of Obstetricians and Gynecologists (ACOG) levels of maternal care ("Levels of Maternal Care,"
PROPOSAL FOR RESEARCH IN PRENATAL BREASTFEEDING 10
2019). Written informed consent will be obtained from the women after they are knowledgeable
of the intended research presented. This is a quasi-experimental study utilizing stratified random
sampling. The study sample will consist of 200 women: 100 in the intervention group and 100 in
the control group. The intervention group will be included in prenatal breastfeeding education
classes that is conducted via four one-hour classes offered by a certified lactation registered
nurse during 32-36 weeks of gestation. The control group will not receive breastfeeding
education prenatally but will receive the current education and follow-up process by a lactation
consultant in the hospital during the immediate postpartum time. Socio-demographics, age, and
ethnicity will be considered for representation within the sample population but must speak
English, have internet access via their phone or computer, and comfortable with daily technology
use. The use of technology will enhance the education by providing a means to review the
information.
To maintain privacy, each participant will be assigned a code number and only the
researcher will have access to personal, identifying information which will be stored on a
password protected database. Once the data is collected, summarized, and resulted the personal
information will be destroyed.
Data Collection
Baseline interviews for both groups will establish age of mother, education, marital
status, number of children, income, and ethnicity. Breastfeeding knowledge will be rated at this
time.
After delivery, interviews will be conducted via telephone at two and four weeks and at
two, four and six months postpartum. Standardized questions during the interviews regarding
infant feeding will be utilized. The first phone call will question if the infant received any
PROPOSAL FOR RESEARCH IN PRENATAL BREASTFEEDING 11
formula during the immediate postpartum period at the hospital. Two weeks is an optimum time
to assess breastfeeding due to high rate of developing difficulties (Abuidhail et al., 2019). At
each time interval the mother will be asked if she is direct breastfeeding or bottle-feeding
expressed breastmilk and if supplementation with formula is being offered. For those who have
discontinued breastfeeding, the date of discontinuation and contributing factors that led to
cessation of breastfeeding will be noted. Breastfeeding will be rated on exclusivity,
predominance, partial or none.
The two scales that will be used for data collection are the Breastfeeding Self-efficacy
Scale (BSES) (Dennis, 2003) and the Iowa Infant Feeding Attitude Scale (IIFAS) (Mora et al.,
1999). Both scales utilize the five-point Likert-type scale. The Breastfeeding Self-Efficacy Scale
is a reflective questionnaire that measures self-efficacy and predictive of those mothers who may
discontinue breastfeeding before the six-month mark. The scores are added together and the
higher the score the higher the level of self-efficacy. This is indication of confidence and
potential longevity of breastfeeding. It can be used not only in the postpartum period but during
pregnancy as well to use as a mode of prediction for breastfeeding outcomes (Iliadou et al.,
2018). According to a study conducted in 2018, this scale is a valid and reliable tool that can be
used by healthcare teams for developing and evaluating how supportive interventions are in
breastfeeding (Uyar Hazar & Uzar Akca, 2018)
The Iowa Infant Feeding Attitude Scale measures the mother’s attitudes of breastfeeding.
Like the BSES, it can be used as a predictive tool. Scores are added together. The higher the
score the better the outcome for greater breastfeeding time (Mora et al., 1999). This scale has
been customized and validated by several countries and has shown prediction capability and
reliability (Abdulahi et al., 2020).
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Data Analysis
The process of analysis will be through independent samples t-test. The groups are
independent from each other, one being the intervention group the other the control group (Main,
2016). Measurement analysis of variance (ANOVA) will be used to evaluate any changes
observed among the two groups pre and post intervention. Use of SPSS statistical software will
be utilized, and statistical significance is set at p<0.05 (Iliadou et al., 2018). Demographically
there will be minimal differences between the two group therefore the results will not be skewed
(Abuidhail et al., 2019). Using a binary logistic regression model, the dependent variable will be
how long breastfeeding lasted and the independent variable will be sociodemographic. This will
show that breastfeeding duration along with mother’s level of knowledge, residence and
education are independent to each other (Jasny et al., 2019).
Strengths
A strength in this study is that information is fairly easy to obtain from the subjects. They
all attend the same obstetric group and will deliver at the same hospital making gathering the
initial interview, informed consent and education classes easier to schedule. Focusing on the one
intervention, prenatal breastfeeding education, decreases unrelated variables. Due to the nature of
gathering information, the women will be contacted and questioned at two, four and six weeks,
and two and three months postpartum. This not only allows for the interview to be conducted but
also benefits the new mother to ask questions and to be directed to their provider if medical
intervention is needed.
Weaknesses
A key weakness to this study is that the control group did not receive the breastfeeding
education in the weeks leading up to delivery which if this study is correct will jeopardize the
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success of breastfeeding and duration in the control group. Another limitation will be that the
interviews will be conducted via phone and not face to face. Participants come from one OB
group and hospital which could limit the generalizability of the results (Iliadou et al., 2018). This
study did not explore breastfeeding outcomes among race or ethnicity. A study conducted as
such may prove to be useful to determine need for interventions and allow planning if the need is
apparent (Su et al., 2007).
Children are a gift from God. Finding a means to help new mothers be successful in
feeding their newborns and decreasing infant mortality allows Christian practitioners to be the
hands, feet and voice of God. God holds each of us as valuable, especially the most vulnerable
and those that cannot speak for themselves. Helping women nourish their children and find
success in breastfeeding bonds mom and baby and establishes a healthier future for the newborn
(Francis et al., 2021). Establishing if prenatal breastfeeding education is key to increasing
breastfeeding rates and where support may be needed to help new mothers feel empowered and
successful in feeding their infants.
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