BrEaSTfEEdiNg EducatioN EmpoweriNg Future HEalth Care ProvidErS Louise C. Miller, PhD, RN Jane T. Cook, MSN, RN, IBCLC Constance W. Brooks, PhD, RN, CS Anne G. Heine, MSN, RN Teresa K. Curtis, MPH, RD
rresearch shows that women s decisions of whether or not to breastfeed are influenced by information they receive from their health care providers. Yet, many health care providers lack sufficient knowledge surrounding breastfeeding. This article outlines how a team in Missouri developed online breastfeeding education modules for nursing and medical students. Breastfeeding is the preferred infant feeding method supported by many professional health care organizations, led by the American Academy of Pediatrics (AAP) position statement on breastfeeding. Breastfeeding provides clinically proven maternal and infant health benefits, as well as social and economic benefits to the nation (Gartner et al., 2005) (see Box 1). It has been included as a component of the U.S. Healthy People initiative since 1978. Despite the scientific evidence in favor of breastfeeding and endorsements from national health care organizations and the government, the United States fell short of achieving the goals set by Healthy People 2000, which were 75 percent of infants to be breastfed at birth and 50 percent at six months. The overall rates by 2003 were only 66 percent and 32.8 percent, respectively, with considerably lower rates for Women, Infants and Children (WIC) participants (Ross Products Division, Abbott Laboratories, 2003). Healthy People 2010 included a third breastfeeding goal for 25 percent of mothers continuing to breastfeed for one year (U.S. Department of Health and Human Services, 2000). In an effort to uncover the barriers to reaching these goals, researchers have directed significant efforts to assess how a mother determines whether she will breastfeed, the role of the health care provider (nurse or physician) in the decision-making process, and the knowledge and attitudes of health care professionals toward breastfeeding. ProvIderS INfluENceS on WomEN Arora, McJunkin, Wehrer and Kuhn (2000) have shown that women who choose to breastfeed are heavily influenced by personal choice and potential health benefits for the baby. In this study of women who chose to bottle- or combination feed, the primary influence was the husband or close family member, of- ten the infant s maternal grandmother. The reported extent to which the health care provider impacts a mother, regardless of her feeding decision, is consistently secondary to the influence of the father, infant s maternal grandmother or friends. However, the WIC infant feeding study found that physicians encouragement is associated with both initiation and frequency of breastfeeding (Bentley et al., 1999). Given that the health care provider has an important role in the mother s choice of infant feeding, not encouraging breastfeeding represents a significant missed opportunity to improve the health of both mother and child. The issue of encouragement is worth emphasizing Lu, Lange, Slusser, Hamilton and Halfon (2001) found that nearly two-thirds (74.6 percent) of women who were encouraged to breastfeed by either their physician or nurse did indeed initiate at birth, while less than half (43.2 percent) of women who were not encouraged initiated at birth. A study of participants in the Special Supplemental Nutrition Program for WIC found that 57 percent of women were not aware of their health care provider s opinion regarding infant feeding (Nazli, McCam, Williams, & Vesper, 1997). A review of seven randomized clinical trials that used educational interventions to promote initiation of breastfeeding were most often implemented by nonphysician providers, specifically lactation consultants and nutritionists (Dyson, McCormick, & Renfrew, 2006). FormS of ENcouragemeNt Due to the positive effect of encouragement on breastfeeding, it s worthwhile to examine forms of encouragement or endorsements. Mothers report being influenced by other sources of information, including books, magazines and pamphlets (Arora Women who choose to breastfeed are heavily infl u- enced by personal choice and potential health benefi ts for the baby. et al., 2000). Materials made available to mothers in offices of health care providers lead mothers to assume that the provider endorses these materials. If the expectant or new mothers find only formula-based information produced by formula companies in a health care provider s office, the assumption is that the office is giving implicit approval of formula products (Pletta, Eglash, & Choby, 2000). While nearly all obstetricians provide infant feeding information to patients, some of that material may be counterproductive http://nwh.awhonn.org Nursing for Women s Health 375
to an outcome of encouraging breastfeeding. Howard, Schaffer and Lawrence (1997) found that almost all of obstetricians surveyed (98 percent) provided infant feeding education information to patients. Most of the obstetricians provided written information, slightly more than a third (39 percent) used videotapes, and a large proportion of obstetricians used information produced by formula companies, specifically infant feeding literature (41 percent), pregnancy literature (57 percent) and various other materials with free formula offers (61 percent). These findings can create questions for new mothers, such as why would health care providers supply information created by formula companies unless these companies are the authority on infant feeding? Wellstart International provides insight into A study of participants in the Special Supplemental Nutrition Program for WIC found that 57 percent of women were not aware of their health care provider s opinion regarding infant feeding. Based on the shortcomings of medical training with regard to breastfeeding, it would stand to reason that health care providers would increase their ownership of breastfeeding promotion if they felt more prepared to do so. This sentiment echoes the 2005 policy statement from the AAP on Breastfeeding and the Use of Human Milk, which states that obstacles to the initiation and continuation of breastfeeding include lack of guidance and encouragement from health care professionals, misinformation, insufficient prenatal breastfeeding education [and] inappropriate interruption of breastfeeding, (Gartner et al., 2005, p. 498). Hillenbrand and Larsen (2002) studied the effect of a breastfeeding education intervention on the knowledge, confidence and behaviors of pediatric resident physicians and found that not only did these attributes increase, but their clinical performance did also. Thus, part of the solution to encourage breastfeeding would be to strengthen the education of health care providers. EducatiNg ProviderS To respond to these issues, clinical leaders at University of Missouri Health Care developed a breastfeeding educational Box 1 Major Benefi ts of Breastfeeding this problem: Lack of knowledge of lactation management among health care providers is one contributing factor of failure to reach breastfeeding rates set by the U.S. government for the Year 2000/2010 National Health Objectives. An important reason for this lack of knowledge is that schools of medicine, nursing, and nutrition are not integrating lactation management education into their curricula (Wellstart International, 2004, p. 1). PhySiciaNS ReluctaNcE A review of the literature shows consistent signs that physicians are reluctant to take responsibility for educating patients about breastfeeding, as evidenced by the lack of encouragement to mothers, the provision of information produced by formula companies and, finally, believing that infant feeding education is the responsibility of a related specialty (Freed, Clark, Curtis, & Sorenson, 1995; Freed, Clark, Lohr, & Sorenson, 1995; Freed, Clark, Lohr, Sorenson, et al., 1995). Louise C. Miller, PhD, RN, is an assistant professor of clinical nursing; Constance W. Brooks, PhD, RN, CS, is an assistant professor of clinical nursing; Anne G. Heine, MSN, RN, is a clinical instructor; and Teresa K. Curtis, MPH, RD, is a consultant; all are affiliated with the University of Missouri Columbia, Columbia, MO. Jane T. Cook, MSN, RN, IBCLC, is a director of nursing at Taylor Regional Hospital, Campbellsville, KY. DOI: 10.1111/j.1751-486X.2007.00193.x Benefits to infants Benefits to mothers Social and economic benefits Decreased SIDS rate Decreased incidence of infection Reduction in postneonatal infant mortality rates in the United States Decreased incidence of overweight and obesity in adulthood Earlier return to prepregnancy weight Decreased postpartum bleeding Decreased risk of breast and ovarian cancers Decreased costs for public health programs, for example, WIC Decreased environmental burden for disposal of formula cans and bottles Source: Gartner et al. (2005). 376 2007, AWHONN Volume 11 Issue 4
If the expectant or new mothers fi nd only formula-based information produced by formula companies in a health care provider s offi ce, the assumption is that the offi ce is giving implicit approval of formula products program targeting maternal-child nurses to overcome common misconceptions held by the staff (Box 2). The assumption was that if staff nurses had correct information about breastfeeding, then they would strongly encourage breastfeeding in mothers delivering at the facility. After working with nurses, it became apparent that physicians had the same misconceptions and needed to be educated about optimal breastfeeding outcomes for mothers and babies. These nursing and physician issues were not unique to our institution; instead, these were common among health providers and health care facilities across the state. To this end, the Missouri Department of Health and Senior Services sponsored the creation of an easily accessible online curriculum created by the University of Missouri Columbia Sinclair School of Nursing. The purpose of this curriculum was twofold: (1) to improve the lactation competencies of health care professionals and students and (2) to positively impact the attitudes of health care professionals and students regarding breastfeeding. CurrIculum DeSigN and CoNteNt One way to increase breastfeeding rates among women is to increase the knowledge and confidence of health care providers, particularly physicians and nurses, to ensure promotion of breastfeeding practices. In 2002, expert nurses at University of Missouri Health Care and the Sinclair School of Nursing conducted a needs assessment of current breastfeeding knowledge, attitudes and caregiving behaviors of faculty from the Schools of Nursing and Medicine and undergraduate nursing students and medical students who completed their obstetrics rotations. Based on the results of this baseline survey, an IBCLC nurse professional created a Web-based educational project intended for use by all health professions across the state. Graduate nurse practitioner students conducted personal interviews with newly delivered mothers about their child feeding decision at the University s Women s Health Clinic to validate conclusions from the literature and assure that the curriculum had the correct client focus. These interviews served as a learning opportunity for the graduate students by challenging them to identify client needs about breastfeeding in addition to using their knowledge of best breastfeeding practices to answer questions and assure a supportive nurse-patient relationship. FEEdbacK from MotherS Of the 31 breastfeeding mothers interviewed, all reported an overall positive breastfeeding experience. Barriers to breastfeeding that were identified were similar across women, including confusing, negative or unsupportive feedback from providers and family members. Despite these barriers, all women stated that they would choose to breastfeed again. Common challenges to breastfeeding as expressed by the mothers included learning proper breastfeeding technique, infant compliance, time constraints and societal constraints. One mother underscored the importance of her determination to breastfeed in order to overcome negative comments from extended family, physicians not being educated, [problems with] stimulation of nipples, and getting baby to latch on. According to mothers surveyed, when the challenges became troublesome enough, they sought help for difficulties with breastfeeding technique and consequent physiologic problems. The most common situations in which mothers required Box 2 Common Breastfeeding Misconceptions of Nursing and Medical Providers Mother s milk supply increases by length of feed, not frequency of feed Babies should feed only about every four hours Maternal fatigue prevents mothers from breastfeeding after delivery Inability to measure breast milk intake is a challenge for infant care Physiologic jaundice is best treated by interruption of breastfeeding Infant formula needs to be introduced to increase the baby s intake and subsequent stooling August September 2007 Nursing for Women s Health 377
Box 3 State of Missouri s Lactation Education Breastfeeding Modules Anatomy and Physiology of the Breast Overview of Breastfeeding and American Academy of Pediatrics Standards Nutrition for Infants and Mothers Breastfeeding Statistics and Talking with Mothers Regarding Decision to Breastfeed Latch on and Techniques for Assisting Mothers with Breastfeeding Pumping and Storage of Breast Milk Challenges of Lactation: Provider s Guide to Common Questions from Breastfeeding Mothers Economics of Breastfeeding assi stance were proper latch-on, positioning the infant, waking the infant and nipple pain. Mothers reported that nurses provide the necessary help most often, but they also reported having received help from their families for less bothersome problems. The mothers questions about individual breastfeeding experiences follow thematically with breastfeeding challenges they identified. These women asked nurse interviewers questions about the physiology (e.g., when milk will come in, nipple soreness), technique (e.g., latching on, feeding positions, waking infant), and benefits (e.g., cost savings, nutritive value, bonding experience) of breastfeeding. When asked by the interviewers, What information did you get about feeding your baby and where did you get it? mothers listed a variety of information. Public media sources including books, magazines, Internet sites, videos and brochures were reported as most often used resources. Less often, women reported physicians, other health care providers and family as information sources. As supported by the literature, these women overwhelmingly agreed that they made an individual choice to breastfeed regardless of their sources of information (Arora et al., 2000). ProvIder EducatioNal ExpErIeNce and CliNical PreparEdNeSS Baseline survey data collected from nursing and medical students revealed a low incidence of clinical experience with breastfeeding mothers and babies. Of the 45 undergraduate nursing students who were surveyed, 43 of them had observational experience with breastfeeding mothers. However, this was limited to one to two hours of observation for more than 80 percent of the students. Medical students described on average a half-hour of breastfeeding observation experience and no hands-on assistance training. Similarly, lead School of Medicine faculty from Obstetrics, Pediatrics and Family Medicine departments reported little clinical time devoted to breastfeeding issues. The majority of nursing students reported that they would choose breastfeeding for themselves (96 percent) or recommend it to a friend (91 percent). When asked if as a health provider they would recommend breastfeeding to a client, 98 percent reported they would suggest their clients breastfeed, while only 7 percent would recommend bottle-feeding to a client. Physicians expressed the idea that providing handouts to mothers as well as referring mothers to nurses and lactation consultants for breastfeeding consultation are helpful for their practices. This supports the literature that recognizes a lack of physician ownership regarding breastfeeding issues. Because it s difficult to change current provider practice, the lactation project was designed to target future providers, that is, students. This strategy addressed barriers to breastfeeding as identified by the AAP, physician apathy and misinformation and insufficient prenatal education, and present breastfeeding as normal physiology rather than a medical model of disease that requires treatment. If all health care providers and medical specialists have a basic knowledge of breastfeeding and an understanding of its benefits, they will be better able to manage lactation appropriately and less apt to recommend its discontinuation. Despite overwhelming evidence supporting breastfeeding, health care providers still give conflicting messages to new mothers about breastfeeding. The education of students in the health sciences about breastfeeding was theorized to increase ownership of this knowledge and increase efficacy in informing new mothers about the benefits of breastfeeding. 378 Nursing for Women s Health Volume 11 Issue 4
Part of the solution to encourage breastfeeding would be to strengthen the education of health care providers. ONliNe EducatIoN ModuleS The Web-based education modules (available at http:// www.dhss.mo.gov/breastfeeding/lactation_ed.html) address basic breastfeeding topics (see Box 3). Modules were designed to be downloaded quickly and easily so as to maximize the health care provider s time; therefore, only the most pertinent information and applicable pictures were included. Modules were customized to needs of nurses, physicians and students as determined by the baseline survey. Specifically, material included in the modules was chosen on the basis of being evidence based, thorough, efficient and necessary in terms of breastfeeding knowledge. For example, the AAP guidelines were included to outline specific standards of care; information on pumping and storage of milk was included to satisfy a gap in knowledge as identified by physicians; the Economics of Breastfeeding module was aimed to show that investing time in breastfeeding education is an investment in the success of a practice; and the Breastfeeding Statistics and Talking with Mothers module was developed to provide strategies for conversation initiation. Participants from the Schools of Nursing and Medicine used the Web-based educational modules to gain a better knowledge base of breastfeeding benefits. After studying the modules and taking the pre- and posttests, nursing students were able to anticipate positive health outcomes for mothers and babies. In their clinical experiences, nursing students felt confident in their ability to communicate correct information about breastfeeding to mothers and were able to help mothers begin breastfeeding after delivery. Based on survey data from the medical students, changes were made to the standard medical curriculum, such as inclusion of a module on case studies for problembased learning (PBL) to reinforce breastfeeding issues. To design this module, the nurse expert from our project worked with the curriculum committee from the School of Medicine to revise an existing PBL case study. Recommended changes to the PBL case study included shifting the breastfeeding scenario from the mother who stopped breastfeeding as a result of problems to a positive approach in which the care provider worked through normal physiologic changes associated with breastfeeding. The new PBL case study addressed topics commonly asked about by new breastfeeding mothers (e.g., engorgement, adequate milk supply) within the first 14 days. Emphasis was placed on the first 7 to 10 days of breastfeeding due to the very high cessation rate during this period, and the mother was depicted as someone who enjoyed breastfeeding and wanted to continue. Other PBL case studies having some components related to breastfeeding were also problematic. These cases represented mothers who initiated breastfeeding and then abruptly stopped. The nurse expert was concerned that this would send an indirect message to students that short-term breastfeeding was the norm. Creating a breastfeeding-specific PBL case study provided both the medical students as well as the medical school faculty the impetus to find and become familiar with credible resources on breastfeeding. An answer guide was provided to medical school faculty who supervised the rotation in which the PBL was used (facilitators) to aid them in directing students to appropriate resources. After the Web-based educational modules were finalized and suggestions for standard breastfeeding curriculum improvement collated, the Department of Health disseminated the breastfeeding training to health professions education programs, local health departments and providers across the state using the department s Web site. CoNcluSioNS According to the literature and interview data from new mothers, women are consulting public media to gather information about infant feeding. Therefore, a multipronged approach to August September 2007 Nursing for Women s Health 379
promoting breastfeeding to women needs to focus on what a woman hears about breastfeeding from her provider, what she learns from family and friends, and what she sees on television, reads in magazines and brochures and finds on the Internet. In our project, nursing and medical students who participated in the online education were able to more effectively articulate benefits of breastfeeding and assist mothers in the clinical setting to establish successful breastfeeding. With this success, these students report that they are much more likely to become advocates of breastfeeding in the future. Programs to increase breastfeeding education and experience for health care students and providers, coupled with promotion of positive media messages, might be the best new approach for increasing breastfeeding rates among American women. NWH Acknowledgments: The authors acknowledge assistance from the Missouri Department of Health and Senior Services: Division of Community Health, Section for Chronic Disease Prevention and Health Promotion, and from the WIC and Nutrition Services Unit for their financial and technical support of this Get the Facts Centers for Disease Control and Prevention http://www.cdc.gov/breastfeeding/ La Leche League http://www.lalecheleague.org/ State of Missouri Department of Health and Senior Services http://www.dhss.mo.gov/breastfeeding/ lactation_ed.html Womenshealth.gov http://www.4woman.gov/breastfeeding/ index.cfm?page=home project, and Pam Evans-Smith, RN, MS, FNP, for incorporating this pilot project into her course curriculum when teaching undergraduate baccalaureate nursing students. references Arora, S., McJunkin, C., Wehrer, J., & Kuhn, P. (2000). Major factors influencing breastfeeding rates: Mother s perception of father s attitude and milk supply [electronic version]. Pediatrics, 106(5), e67. Bentley, M. E., Caulfield, L. E., Gross, S. M., Bronner, Y., Jensen, J., Kessler, L., et al. (1999). Sources of influence on intention to breastfeed among African-American women at entry into WIC. Journal of Human Lactation, 15(1), 27 34. Dyson, L., McCormick, F., & Renfrew, M. J. (2006). Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews, 2, 1 32. Freed, G. L., Clark, S. J., Curtis, P., & Sorenson, J. R. (1995). Breastfeeding education and practice in family medicine. Journal of Family Practice, 40(3), 263 269. Freed, G. L., Clark, S. J., Lohr, J. A., & Sorenson, J. R. (1995). Pediatrician involvement in breastfeeding promotion: A national study of residents and practitioners. Pediatrics, 96(3, pt. 1), 490 494. Freed, G. L., Clark, S. J., Lohr, J. A., Sorenson, J. R., Cefalo, R., & Curtis, P. (1995). National assessment of physicians breastfeeding knowledge, attitudes, training and experience. JAMA, 237(6), 472 476. Gartner, L. M., Morton, J., Lawrence, R. A., Naylor, A. J., O Hare, D., Schanler, R. J., et al. (2005). Breastfeeding and the use of human milk. Pediatrics, 115(2), 496 506. Hillenbrand, K. M., & Larsen, P. G. (2002). Effect of an educational intervention about breastfeeding on the knowledge, confidence and behaviors of pediatric resident physicians. Pediatrics, 110(5), e59. Howard, C. R., Schaffer, S. J., & Lawrence, R. A. (1997). Attitudes, practices and recommendations by obstetricians about infant feeding. Birth, 24(4), 240 246. Lu, M. C., Lange, L., Slusser, W., Hamilton, J., & Halfon, N. (2001). Provider encouragement of breast-feeding: Evidence from a national survey. Obstetrics & Gynecology, 97, 290 295. Nazli, B., McCam, M., Williams, R., & Vesper, E. (1997). The WIC infant feeding practices study. Alexandria, VA.: Department of Agriculture. Pletta, K. H., Eglash, A., & Choby, K. (2000). Benefits of breastfeeding: A review for physicians. Wisconsin Medical Journal, 99(2), 55 58. Ross Products Division, Abbott Laboratories. (2003). Breastfeeding trends. Retrieved July 16, 2006, from http://www.ross.com/ images/library/bf_trends_2003.pdf U.S. Department of Health and Human Services. (2000). Healthy People 2010 (2nd ed.). Washington, DC: U.S. Government Printing Office. Wellstart International. (2004). Lactation Management Self-Study Modules, Faculty Guide (2nd ed.). San Diego, CA: Wellstart International. 380 Nursing for Women s Health Volume 11 Issue 4