Running head: ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 1
Attitudes About Breastfeeding and Continuing Exclusive Breastfeeding for 2 Weeks in First-
Time Breastfeeding Mothers in a Baby- Friendly Aspiring Hospital
Tamika Missouri
Coppin State University
Masters Thesis Guidelines
NURS 720
Dr. N. Philipsen
October 01, 2014
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 2
Attitudes About Breastfeeding and Continuing Exclusive Breastfeeding for 2 Weeks in First-
Time Breastfeeding Mothers in a Baby- Friendly Aspiring Hospital
Chapter One
Introduction
In the United States (U.S.), approximately 4 million babies are born each year (Center for
Disease Control [CDC], 2013). Many women are faced with the question of what form of
nutrition they will provide for their babies once they give birth. Variances effecting this
important decision include maternal age, educational attainability, race, and attitudes about
acceptable forms of feedings (Rossem, 2009). Throughout the history of human cultures, various
types of feedings have existed as normal practices for infant nutrition in that society. In the U.S.,
formula has been the primary source of infant nutrition since 1950’s. WIC (the Special
Supplemental Program for Women, Infants, and Children) purchases and distributes over half of
the infant formula used in the U.S. It is provided by the manufacturer at a discounted price, in
turn costing taxpayers approximately $627 million, which is equivalent to a $2 billion value in
the retail market (Ginty, 2011).
Human breast milk is the healthiest form of nutrition available for infants. In spite of
this, 59% of babies born in the U.S. are exclusively breastfed, and even fewer, 40% are still
breastfeeding at 3 months (CDC, 2013). In recent years, U.S. public health priority has been to
advance exclusive breast milk as the primary intake for babies up to 6 months of life and to be
used in combination with other foods up to 12 months of life (American Academy of Pediatrics
[AAP], 2012). Breast milk is beneficial as the primary source of nutrition because it has an
abundance of essential proteins, fats, carbohydrates, and vitamins. These are important for
newborn brain development, disease prevention, and prevention of ovarian and breast cancer in
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 3
women. Studies show, that babies who are breastfed have reduced comorbidities that greatly
impact health care costs [AAP], 2012). The concept of the importance of breastfed babies has
been an integral part of antenatal education for years. Healthcare facilities have the duty to
promote breastfeeding to encourage bonding of parent and child, cost effectiveness, and health
benefits of both mother and baby. Following Baby- Friendly hospital practices help mothers
achieve exclusive breastfeeding (Perrine, Scanlon, & Li, 2012). Women who breastfeed their
first baby for a continuum, are subsequently likely to breastfeed their other children. First- time
breastfeeding mothers’ attitudes related to breastfeeding directly impact initiation and
continuation of exclusive breastfeeding beyond the hospital stay (Persad & Mensinger, 2008).
Healthcare facilities should target first time breast feeders to increase the likelihood of starting
the traditions of breastfeeding in the family.
Significance of Study
Promotion of breastfeeding significantly impacts societal health. Healthier nations
prevail when mothers breastfeed. According to UNICEF, an increase of 90 percent of families
breastfeeding exclusively for 6 months, would decrease infant mortality by 1,000 deaths per year
(2013). Medical costs in the U.S. would decrease by $13 billion per year for breastfed infants
when compared to formula fed babies. Health benefits of breast milk on children include
prevention of obesity, diabetes, asthma, necrotizing enterocolitis, childhood leukemia, atopic
dermatitis, and sudden infant death syndrome (SIDS). Mothers benefit from a reduction in
postpartum depression, ovarian/ breast cancer, and type 2 diabetes. Breastfeeding also has a
benefit of reducing weight gain associated with pregnancy (Chapman, 2009). Other newborn
benefits include infants with fewer sick visits, prescriptions, and hospitalizations. Healthier
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 4
infants prevent loss of work for parents, contributing to a more productive work force. Employer
medical costs are subsequently lower as a result. Breastfeeding contributes to a greener
environment by eliminating plastic and trash waste associated with formula and bottles.
Healthcare personnel have the burden of educating women in the antepartum and
postpartum periods to promote breastfeeding as the primary source of nutrition for their babies.
Healthcare facilities have the responsibility of training staff members to ensure adequacy in
education for them to be effective communicators of pertinent information to patients. Hospitals
should exercise “Baby Friendly” practices to prepare staff members and patients for exclusive
breastfeeding (Brown & Isaacs, 2010). Intercepting women in this preliminary phase will impact
the course of breastfeeding throughout the continuum.
Statement of Problem
Attitudes about breastfeeding may contribute to mothers’ intent and continuation to
exclusively breastfeed for the first- time. Healthcare facilities must be held accountable for
educating first time mothers on the breastfeeding health benefits to the family. Baby- Friendly
hospital practices provide a blueprint for supportive practices that educate and assist mothers
who choose to breastfeed. Foundational knowledge and early support related to breastfeeding
influences a mother’s decision to opt for exclusive breast milk as a primary source of nutrition
for her newborn.
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 5
Purpose of the Study
The purpose of the study is to investigate the relationship between attitudes of first- time
mothers and their choosing to breastfeed and continuing to exclusively breastfeed their babies for
two weeks postpartum.
Hypotheses
Attitudes about breastfeeding among first time mothers is significantly related to the
decision to initiate and successfully continue to exclusively breastfeed for the first two weeks
postpartum.
Assumptions
Factors associated with women breastfeeding their babies include race, maternal age,
educational attainment, and attitudes regarding best feeding practices for newborns (Persad &
Mensinger, 2007). White mothers are more likely to exclusively breastfeed, whereas African
American mothers are more likely to breastfeed and formula feed interchangeably (Purdy, 2010).
In the U.S., women of lower socioeconomic backgrounds benefit from WIC, which decreases
financial considerations related to formula feeding. Until recently, WIC provided no incentive to
mothers choosing to breastfeed, thus unintentionally encouraging formula feeding (Jensen,
2012). Education limits pertaining to the true benefit of breastfeeding greatly inhibits a
women’s willingness to breastfeed her baby (Marrone, Vogeltanz- Holm, & Holm). Body image
disturbance, as well as attitudes about breastfeeding, have an impact on a woman’s ability to feed
her baby human milk (Persad & Mensinger, 2007). Also a woman’s age at delivery directly
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 6
correlates to educational attainment, which would limit the knowledge base of the benefits of
breastfeeding. Healthcare facilities that promote breastfeeding have an increased incidence of
women that choose to breastfeed their newborns.
Theoretical Definitions
Attitude- a cognition, often with some degree of aversion or attraction (emotional
valence), that reflects the classification and evaluation of objects and events
(Encyclopedia- Britannica, 2013).
Exclusive breastfeeding- when a newborn receives only breast milk and no other liquids
or solids except for drops or syrups consisting of vitamins, minerals, or medicines (WHO,
2014).
First- time breastfeeding mothers- Women who choose breastmilk feedings for their
newborn for the first time.
Antepartum- time period occurring before birth (Youngkin & Davis, 2013).
Postpartum- time period immediately after birth, until about 6 weeks after delivery
(Youngkin & Davis, 2013).
Comorbidities- two or more disorders or illnesses occurring in the same person
(Valderas, 2009).
Antenatal- during or relating to pregnancy; before birth (Youngkin & Davis, 2013).
Baby- Friendly Hospital Initiatives (BFHI)- a global programme developed by World
Health Organization (WHO) and UNICEF to improve maternity services role (UNICEF,
2014).
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 7
Operational Definitions
Attitudes- an opinion formed before having adequate knowledge about breastfeeding
Exclusive breastfeeding- when a newborn receives only breast milk and no
supplementation with formula.
First- time breastfeeding mothers- mothers who choose to use breast milk as a form of
nutrition for the first time.
Baby- Friendly Hospital Initiatives (BFHI)- Maternity/ Birthing facilities that implement
program of ten (10) step practice to support and promote breastfeeding.
Chapter One Summary
Healthcare facilities have a public health duty to mothers using their services. Promotion
and support of breastfeeding encourages healthier women and babies, and healthier populations.
Understanding that mothers have attitudes related to the best feeding methods for their babies are
an essential step in assessment for supporting mothers choosing to breastfeed for the first time.
New breastfeeding mothers need to be made aware of realistic expectations that come along with
the demands of breastfeeding. Education should be provided before, during, and after the
hospital stay to support mothers opting to breastfeed for the first time. Mothers that are
breastfeeding for the first time need access to resources to help them in the beginning stages of
breastfeeding, when the rates of reconsideration are so high. Adhering to BFHI, increases
compliance with exclusive breastfeeding during the hospital stay and also provides support for
the mother to continue to breastfeed for at least 2 weeks after discharge. Consideration of
contributing factors such as race, age, highest educational level completed, and foundational
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 8
knowledge determine the success of exclusive breast- feeding. If these hospital level changes are
followed, the success rate of first time breast feeders will increase.
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 9
Chapter 2
Review of Literature
Introduction
The objective of this study is to investigate the relationship between attitudes of first- time
mothers and their choosing to breastfeed and continuing to exclusively breastfeed their babies for
two weeks postpartum. Ramona T. Mercer’s, “Maternal Role Attainment Theory” provides the
framework for this study.
Breastfeeding is the most natural, nutritive choice of feeding for a newborn. Successful
support of breastfeeding is a public health imperative in the U.S. showing an incline from 60%
to 77% in the past 10 years (CDC, 2013). American society has spearheaded various
interventions aimed at informing and educating the public, especially new mothers, about the
healthiest choice that women can offer their newborns. This education has mainly targeted
informing new mothers about the benefits of breast milk. Breast milk is loaded with Lactoferrin
(limits iron availability for bacteria consumption in the gut), Lysozyme (aids in digestion),
Carnitine (fatty acid for energy), and DHA & ARA (for brain and retina development). This
information is conveyed to women to enlighten them to the newborn benefits of breastfeeding
(Mannel & Martens, 2012).
Nutrition for infants should be addressed as a public health concern and not simply as an
inconsequent maternal choice, as it has in the recent past. Influences of formula marketing can
directly affect a woman’s feeding choice. The World Health Organization’s International Code
of Marketing of Breast-milk Substitutes asserts the position to not market infant formula to the
public (2013). The U.S. has failed to follow these guidelines. Although the initiation and
duration of breastfeeding has been given lip- service in the U.S., formula is frequently suggested
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 10
as an equal choice. This practice is not helpful and can be even misleading for mothers with low
intentions of breastfeeding that are also influenced by subjective norms. (Zhang, Carlton, Fein).
Infant mortality and morbidity of the target area should be considered when approaching
topics of breastfeeding. The impact of substituting a commercial formula for mother’s milk on
short- and long- term health is significant. Breastfeeding has been shown to decrease rates of
infant mortality and morbidity by 3% per year. Healthy People 2020 propose a decrease in
infant mortality to rates of 6.0 per 1,000 live births. Infant morbidity associated with otitis media,
gastroenteritis, childhood obesity, leukemia, type 1&2 diabetes, pneumonia, and SIDS all show
increased incidences in infants receiving formula instead of mother’s milk (American Academy
of Pediatrics, 2010). This alone should be a driving force of healthcare facilities urging of
breastfeeding as the primary source of infant nutrition.
The infants need for breast milk for healthy and optimum development is relayed to the public,
but health care agencies have an obligation to educate the pregnant woman about breastfeeding
as the healthy choice for her newborn. Educating new mothers on the long term benefits to their
newborns from breast milk would influence mothers desiring the best outlook for their babies.
The immunoprotective and nutritive value profoundly impact a newborns health as compared to
formula fed babies (Cramton et al, 2009). Direct patient education during the antepartum period,
postpartum period, and support after discharge play a critical role in the process of initiating and
continuing to breast feed for the first time. Educators should have a sound knowledge base to
provide mothers with proper information to make informed feeding decisions, and to implement
them, as few new mothers in the U.S. have extensive experience with breastfeeding.
In 1991 with a revision in 2006, The United Nations Children’s Fund (UNICEF) and the
World Health Organization (WHO) launched the Baby- Friendly Hospital Initiative (BFHI) to
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 11
increase breastfeeding rates worldwide. According to Association of Women’s Health, Obstetric
and Neonatal Nurses (AWHONN), hospitals that trend with policies similar to Baby- Friendly
practices have an increase in breastfeeding initiation and compliance (2010). To be successful,
health facilities must take active steps and adhere to specific guidelines. Ten steps for Baby-
Friendly status achievement are standard, but variations exist between facilities. The primary
goal of any facility practicing these standards of care share a common outcome of optimal health
choice for mother and child.
The BFHI provides a framework that protects, promotes, and supports new mothers in
breastfeeding their babies. Specific interventions are outlined that highlight steps to follow that
proves beneficial in establishing and promoting successful breastfeeding patterns. Steps needed
to progress towards Baby- Friendly practices include:
1. Have a written Breastfeeding Policy that is routinely communicated to all health care
staff.
2. Train all health care staff in skills necessary to implement this policy. Mandatory
education via in services, supplemental education, and hands on practices should be
mandated.
3. Inform all pregnant women of the benefits and management of breastfeeding.
Prenatal packages with breastfeeding information should be made available to pregnant
mothers. Prenatal breastfeeding classes should be offered. Lactation consultants also
visit Women’s, Infant’s, and Children’s (WIC) sites to inform pregnant moms about
breastfeeding, inquire about future plans, and encourage expectant moms to visit the OB
offices. Mothers make up their minds to bottle or breast feed very early in their
pregnancy (Forster and McLachian, 2007).
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 12
4. Help mothers initiate breastfeeding within one hour of birth. Babies should be put to
breast as soon as possible in the delivery room, even following a c-section birth. The
assistance by a lactation consultant can be utilized at this time.
5. Discuss breastfeeding basics and techniques to mothers that are separated from their
newborns for medical reasons. Steps to initiate and maintain lactation, such as use of a
breast pump.
6. Only give newborns breastmilk, unless medically indicated. An order by a nurse
practitioner or pediatric resident is required before any supplementation is provided.
7. Rooming- in practices should be encouraged. Mothers and babies are encouraged to
remain together 24 hours per day and staff is expected to perform as many infant daily
cares as possible at the mother’s bedside.
8. Encourage breastfeeding on demand. Breastfeeding times should be every two to
three hours to establish a good breastfeeding pattern and initiate good milk supply.
9. Give no artificial nipples or pacifiers to breastfeeding infants. Pacifiers can cause
nipple confusion for the infant because different mechanisms are used when sucking at
the breast as compared to sucking a pacifier. Parents are taught to syringe- feed to avoid
use of a nipple.
10. Encourage and educate mothers to utilize breastfeeding resources. Mothers are
instructed to call a resource telephone number to access a lactation consultant for help.
Breastfeeding groups that support new mothers should be offered, as well as follow- up
outpatient support by lactation consultants. Additionally, not offering gift bags containing
formula is strongly recommended. This practice puts a budgeting strain on the healthcare
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 13
facility because formula is usually given to the facility at no cost for advertising
purposes.
The Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN)
endorses the BFHI framework in helping maternity areas in hospitals progress forward with
promoting breastfeeding as the primary nutrition for newborns (2014). Hospitals should have
staff members that are active in the organization and understand AWHONN’s guidelines and
practices. According to AWHONN, when choosing breastfeeding as the most optimal form of
nutrition, women should receive proper education and support (2014). AWHONN’s standards
centers around the belief that it takes the entire health care team to successfully initiate and
sustain breastfeeding. This team of people supporting the breastfeeding process should include
physicians, nurses, and lactation consultants. Discussions with women concerning breastfeeding
should begin during the antepartum period, to assess preconceived knowledge about
breastfeeding and bridge any education gaps that may pose an obstacle to initiating and
continuing to breastfeed for an extended period of time. Healthy People 2020, set forth a goal to
increase the proportion of mothers who breastfeed their babies. This goal includes initiatives to
raise the rate of breastfeeding initiation in the early postpartum period to 81 percent, to increase
to 46 percent the proportion of women who continue exclusive breastfeeding until their infants
are three months of age, and to 25 percent the proportion of infants who are exclusively breastfed
until 6 months of age (2014).
Influences of Attitudes
Breastfeeding is not instinctual or natural for all women. In an effort to improve
breastfeeding rates in the U.S., identification of factors that influence initiation and continuation
of breastfeeding should be studied. A woman’s preconceived knowledge concerning
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 14
breastfeeding as a nutritive choice directly correlates with her decision to initiate breastfeeding,
whereas, the support offered in the postpartum period influences her decision to continue to
exclusively breastfeed (Perrine et al., 2012). Limited knowledge about the benefits of
breastfeeding for both the health of mother and baby affect a woman’s intent to breast feed;
however the attitude and subjective norms that these women possess play a role in intention as
well. This coincides with Sharps et al., study that determined that maternal self motivation to
breastfeed appears to supersede the perception of influences around her (2003).
According to Ajzen’s Theory of Planned Behavior (TPB), attitudes and personal beliefs
effect intention and control behavior (1987). The foundational knowledge base that women
believe as truth concerning breastfeeding is a great determination of what her decision will be
concerning initiating breastfeeding. Personal attributes that are influenced by tradition, culture,
family, and social entities carry considerable weight when decisions about breastfeeding are
made before delivery (McCarter- Spaulding, 2002). Social norms of the woman’s environment,
without the influence of education, determine what feeding techniques will be chosen (Sharps et
al., 2003).
Foundational knowledge based on educational disparities play a role in a mother’s
decision to breastfeed. Women with higher education attainability are better informed about the
health benefits of breastfeeding for mother and child. Despite what is deemed normal feeding
methods for these groups of women, decisions can be individually based to provide optimal
health outcomes for the couplet. Implementing BFHI, with mothers desiring to breastfeed
imprints the same knowledge principles to first-time breastfeeding mothers, prompting initiation
of exclusive breastfeeding ( Difrisco et al., 2011).
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 15
Exclusive Breastfeeding for 2 weeks
Exclusive breastfeeding is when a newborn receives only breast milk and no other liquids
or solids except for drops or syrups consisting of vitamins, minerals, or medicines (WHO, 2014).
Inability to establish successful breastfeeding is a main culprit in mothers not continuing to
breastfeed. The U.S Preventative Services Task Force determined breastfeeding education as the
most effective intervention for increasing breastfeeding initiation and short- term continuation
(2014). The Joint Commission implemented the Perinatal Care Core Measure Set, a standardized
performance measurement that monitors care of “exclusively breastfed” term-babies to examine
practices for supplementation other than medical reasons (2012). In alignment with BFHI
guidelines, exclusive breastfed babies should not be offered supplementation of formula unless
medically necessary to optimize breastfeeding (Baby- Friendly, 2010). BFHI practices is
associated with increased rates of breastfeeding and a primary hospital practice associated with
discontinuing exclusive breastfeeding before discharge was babies receiving supplementation
(Perrine et. al, 2012).
Lack of support from hospital staff is another strong indicator of early breastfeeding
cessation. Support during the hospital stay by educated health care staff members, including
Licensed Lactation Consultants (LLCs), are influential in increased rates of exclusive
breastfeeding rates for a short duration (Murray, 2007). Healthcare staff having evidenced-
based breastfeeding knowledge combined with the expertise of LLCs, offers the mother essential
support with being successful with the breastfeeding process. The benefit of LLC’s offers an
irreplaceable advantage to mothers needing support during the early stages of breastfeeding.
Follow- up support via discharge telephone calls or postpartum group sessions post- discharge to
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 16
troubleshoot problems with breastfeeding is also important with continuation of breastfeeding
(DiFrisco, 2011).
Nursing Theory
Nursing theories offer structure by providing a foundational basis that nursing can use as
a guide to provide patient care. Ramona T. Mercer’s, “Maternal Role Attainment- Becoming a
Mother” was used as a guide for this research study. Recognizing the woman, the patient as the
primary focus served as a rationale for Mercer’s theory selection. Her theory uses the mother as
the focal point, with variables of social influences, nursing, health impacts of mom and newborn,
and role identity (Mercer, 1985). The process used in Mercer’s theory helps the mother develop
an attachment to the infant, which in turn helps the infant form a bond with the mother.
Breastfeeding facilitates this mother- child bond, which is enhanced as the infant grows
(Schwarze et al., 2014). Mercer’s theory asserts developmental and interactional change over a
period of time. Throughout this process, the mother bonds with the infant, acquires competence
in general caretaking tasks, and then comes to express joy and pleasure in her role as a mother.
Twelve of Mercer’s concepts are evident in this study. Many aspects of Mercer’s theory support
this study. Her theory predicts relationship among the concepts that are outlined between
hospital practices and procedures and their influence on new mothers. Mercer’s theory provides
support for the assertion that new mothers need extensive psychological, social, and physical
attention to make a healthy transition into motherhood (Mercer, 1981). Nursing plays a major
role in Mercer’s theory helping new mothers learn and grow in their new identities (Mercer,
1985).
Mercer’s revision of the language contained in her theory based on more recent research
parallels the premise of the research study. She highlights “becoming a mother” as an ongoing
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 17
process rather than an endpoint (Mercer, 1985). In the study, the consideration of breastfeeding
over a 2 week duration closely mimics this framework’s idea of the research being a process over
time rather than reflecting the initiation of breastfeeding only.
Major Concepts Identification
Mercer pinpoints major concepts that coincide with the theory that she portrays. These
focus areas directly correlate with the ideas of the research study. Maternal role attainment,
which is the mother bonding and confidently grasping her new role as a parent is one concept
(Mercer, 1985). Mothers have to possess confidence with the challenges that breastfeeding
proposes. A mom’s perception of her birth experience is another insightful concept that
correlates with a mother’s sense of self while breastfeeding. Mothers rate their birth experience
based on what took place during the whole experience. Challenges of breastfeeding can force
mothers to rate their experiences negatively if everything didn’t go as planned. This can impact
success of exclusive breastfeeding. Mercer points out self -esteem as another concept (Mercer,
1985). Mothers’ perception of what others think about them plays an important role in mothers
choosing to initiate and continue to breastfeed. Another concept, flexibility, is discussed by
Mercer. New moms must not have a rigid approach to the breastfeeding experience.
Allowances for situations that are not ideal is a needed attribute. Childrearing attitudes and
beliefs of what is best for the newborn is one of the single most important characteristics that
influence a mother’s decision to breastfeed. In addition, Mercer identifies health status as a
concept (1985). Breastfeeding plays an instrumental role in improved maternal and newborn
health. Attitudes related to the benefits of breast milk associates with this concept. Anxiety is
discussed throughout Mercer’s theory, and is closely associated with the stress that all new
breastfeeding mothers exhibit. Role strain is another concept mentioned by Mercer. Taking hold
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 18
of breastfeeding and the demands associated with breastfeeding, proves to be a challenge for
new mothers. Once the obstacles that come along with breastfeeding are conquered, the
pleasures associated with breastfeeding settles in. The reward and pleasure of the bonding
experience gives a breastfeeding mother great satisfaction. This closely associates with Mercer’s
gratification- satisfaction and attachment concept (1985). The discussion of infant temperament,
infant characteristics, and infant cues all are congruent concepts discussed by Mercer that
parallels the research study. Finally, social support is the most important concept that Mercer
proposes that ties into the study (1985). Hospital policies and practices that support the
mother’s decision to breastfeed help to spearhead the mother’s initiation and continuation of
nursing her newborn.
Conclusion
Breastfeeding rates in the U.S. continue to incline. Health disparities that continue to
plague populations commit governmental agencies, community agencies, and healthcare
facilities to spearhead initiatives to target breastfeeding as a public health concern. Recognizing
barriers that impede most mothers that deliver newborns to exclusively breastfeed will warrant
closer examination as goals set to increase breastfeeding further continue. It has long been a
predictor that age, education level, and race have posed disparities that interfere with mothers
choosing to breastfeed. A mother’s fore knowledge of breastfeeding influences her decision to
initiate and continue breastfeeding, as well. BFHI practices adapted by healthcare facilities, can
serve as an educational blueprint to expose the same knowledge to mothers choosing to
exclusively breastfeed.
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 19
Chapter Three
Introduction
Chapter three will describe the study design. The hypothesis, sample, and study
limitations will be examined. Procedures for the study, protection of human rights, and
instruments for measurement will be discussed as well.
Design of the Study
A quantitative descriptive study will be conducted to evaluate the relationship between
attitudes about breastfeeding and its influence on initiating and continuing to breastfeed. This
particular study was chosen because of its affiliation with current practices and naturally
occurring situations.
Sample
Convenience sampling was selected to be used in this study. It’s considered an
accidental approach because subjects are considered until the desired sample size is reached.
This type of sampling is cost effective, and easier to obtain when compared to other sampling
selections (Burns & Grove, 2009). For this study, once consent is obtained, a selection of 25
breastfeeding women will be placed into the convenience sampling for the study. Diffusion of
sampling will eliminate breast feeders that are new versus experienced. Biases will be identified
to wean all breastfeeding mothers from first time breastfeeding mothers. These women will be
surveyed at Mercy Medical Center in Baltimore City, Maryland during the postpartum period.
Typical delivery capacity at this facility is well over 2,000 per year, so the sample size is
obtainable. Breastfeeding rates are above 70%, which further allows a decent sample size.
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 20
Study Limitations
A limitation of this study is choosing first- time breastfeeding mothers at one facility of
reference to provide the sampling. Dedication of time of the participants is another barrier.
Getting accustomed to the new role of motherhood is taxing enough without the demands of
doing any extra activities. Losing participants for follow-up two weeks after delivery may also
be a limitation.
Procedure
Participation in the study will be limited to first time breastfeeding mothers. Special
attention must be given to not eliminate mothers who have had prior formula fed babies.
Approval to conduct the study will be obtained from Coppin State University’s IRB Committee
prior to conducting the study. Permission will then be sought from the Director of the Maternal/
Child Unit and Mercy Medical Center’s Hospital IRB Committee to conduct the study at the site.
Surveys will be conducted by the nursing staff on the Mother/ Baby Unit to obtain initial results
surrounding the initiation of breastfeeding. Continued data collection to evaluate the
continuation of breastfeeding over a 2 week period, will be conducted by telephone. The data
collection will end with the last information obtained from the last delivered patient. Assessment
of attitudes about breastfeeding and the initiation and continuation of
breastfeeding will be analyzed at that time.
Protection of Human Participants
Respecting the dignity and health of individuals is an ethical responsibility. While conducting
research, the rights to self- determination, privacy, confidentiality, fair treatment, and protection
from harm are all considered (Burns & Grove, 2009). Anonymity will be safe guarded. The
participants will be inpatients and are already protected Health Insurance Portability and
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 21
Accountability Act (HIPPA); however, their rights under that protection will be reiterated with
consent to participate in the study and with telephone follow-up after discharge. The
demographics of the patient will be secured and kept anonymous for purposes of evaluating the
data after the study is complete. Participation will be voluntary and confidential. Compliance
with the protection of participants’ rights, will comply with the regulations set forth by the
United States Department of Health and Human Services Protections of Human Subjects
Regulations, the Office for Human Research Protection , and the code of Federal Regulations
(CFR), Title 45, Part 46, Protection of Human Subjects (HHS, 2009).
Instrument
The instrument selected for this research study is The Breastfeeding Attrition Prediction
Tool (BAPT), based on Theory of Planned Behavior (TPB) is the chosen instrument for this
study. This tool has proven reliable in evaluating breastfeeding trials in the past. It was
developed by Jill Real Janke to evaluate factors affecting the duration of breastfeeding in
women. The tool’s purpose is to evaluate current patient beliefs as they relate to breastfeeding
practices in the patient. The tool goes further to determine information of breastfeeding
knowledge to determine its affect on starting breastfeeding. A modified version of the tool using
46 questions that evaluates the mother’s perceptions on breastfeeding as well as demographic
data will be used. A 5 point Likert scale is used to measure questions. The BAPT tool boasts a
73 % rate of obtaining breastfeeding data and has a reliability coefficient of 0.80%. The study
proposes to use the tool to evaluate a mother’s pre- conceived ideas on breastfeeding and the
association that age, race, and educational levels have on a mother’s decision to breastfeed. A
bubble in survey style will be used with a pencil to fill in the appropriate data.
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 22
Data Analysis
Variables and descriptive statistics will be described. The relationship between attitudes
about breastfeeding and the influence on the initiation and continuation of breastfeeding for 2
weeks will be analyzed. Questions 1-29 of the BAPT will serve as the basis for data collection.
Most of these questions pertain to the mother’s subjective data of perceptions related to
breastfeeding. Questions surround the mother’s knowledge base of breastfeeding, convenience of
breastfeeding, comparison to formula feeding, and health benefits of breastfeeding for mom and
baby. There is a range of numbers 1-6, correlating with strongly disagree to strongly agree,
respectively. Other questions pertaining to demographics will be analyzed from another subset
of the tool as well. The International Business Machines (IBM) Statistical Package for the Social
Sciences (SPSS) version 22.0 will be used to implement statistical analysis.
Summary
Attitudes related to breastfeeding directly impact a mother’s decision to choose this
optimal method of feeding for her newborn. Societal views of the importance of breastfeeding
weigh heavily on a mother’s decision to choose nutrition for her newborn. Perspectives vary;
however, breastfeeding as the healthiest feeding option for moms and their babies is
indisputable. The ten steps outlined in (BFHI) provide consistent, structured recommendations
for educating, assisting, and supporting new mothers breastfeed their infants. It serves as a
global framework that can be applied to any maternity area in any country. The increase in infant
morbidity and mortality among formula fed infants should be a primary motivator associated
with prioritizing breast milk as the nutritive choice for newborns. Instituting practices associated
with BFHI will increase education among mothers that will influence proper nutritive choices.
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 23
Following these guidelines and evaluating the efficacy of their employment will result in
successful breastfeeding rates among first time breastfeeding mothers.
ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 24
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