i

Abstract of dissertation entitled

“Evidence-based guideline of postnatal telephone lactation support

on duration of breastfeeding”

Submitted by

Wong Ho Yan

for the Degree of Master of Nursing

at The University of Hong Kong

in July 2016

In the recent decades, the benefits of breastfeeding to both the mothers and the infants have

gained increasing significance among the public. The breastfeeding rate on hospital discharge

showed remarkable increase from19% in 1992 to 85.8% in 2012. Despite the effort made by the

government as well as the NGOs, such as the Baby Friendly Hospital Initiative Hong Kong

Association, the current percentage of breastfeeding in 6 months after delivery in Hong Kong still

lags behind the recommendations of the World Health Organization (WHO).

Considering the traditional Chinese cultural belief, the Chinese mothers are usually expected

to stay at home in the first month of postnatal period. In order to provide continuous postnatal

breastfeeding support for them, telephone support intervention would be considered as a feasible

method in this situation. Even those mothers remain at home in the early postnatal period, they are

still able to access professional breastfeeding support with the use of telephone which is an easy

communication medium nowadays.

For the evidence-based guidelines, it is developed from five selected studies which indicated

that telephone breastfeeding support is effective in prolonging breastfeeding duration. To consider

the implementation potential of the innovation, the implementation plan and its evaluation would be

thoroughly discussed in the later part of this project.

ii

Evidence-based guideline

of postnatal telephone lactation support

on duration of breastfeeding

by

WONG HO YAN

School of Nursing

The University of Hong Kong

A thesis submitted in fulfillment of the requirements for

the Degree of Master of Nursing

at The University of Hong Kong.

July 2016

iii

Declaration

I declare that this dissertation represents my own work, except where due acknowledgment

is made. It has not been previously included in a thesis, dissertation, or report submitted to this

university or to any other institution for a degree, diploma, or other qualifications.

Signed……………………………………………………………………

WONG HO YAN

iv

Acknowledgements

I would like to express my sincere gratitude to my supervisor, Professor Elizabeth Hui, who

provides vulnerable advice, guidance as well as psychological support to me throughout my

dissertation. She did promote interactive atmosphere in the tutorials which facilitated us to

exchange our ideas. And she always provided constructive feedback for my dissertation work. Her

passion and enthusiasm deeply impresses me and drives me to pursuing evidence-based guidelines

related to breastfeeding.

In addition, I would like to give thanks to my supportive classmates. We did enjoy our

learning time in this programme. Not only did I gain knowledge, but also friendship.

Finally, I would like to show my appreciation to my beloved family, including my parents,

my husband and my upcoming new family member who always show understanding and

encouragement throughout my two-year master study.

v

Table of Contents

Abstract ……………………………………………………………………..……………………………………i

Cover page……………………………………………………………………..……………………………… ii

Declaration……………………………………………………………………………………..………………iii

Acknowledgements …………………………………………………………………………………………… iv

Table of contents ……………………………………………………………………………………………… v

Lists of appendices ……………………………………………………………………………………………vi

Chapter 1 - Statement of the Problem……………………………………………………………. 1

Background………………………………………………………………………………….………….1

Affirming the need……………………………………….…………………………………………..2-4

Objective and Research Question……………………..…………………………………….….………4

Significance of clinical issue…………………………………………………………………….……..4

Chapter 2 – Critical Appraisal .....……..………………..………………………………..………6

Search and appraisal strategy……………………………………………………….…………….….6

Table of evidence…………………………………………...…………………………………………7

Quality assessment………………………………………………………………………………….…9

Summary and Synthesis……………………………………………………………………………….12

Chapter 3 - Implementation Potential ………………………………………………………….. 18

Transferability of the findings …………………………………………………………………18-20

Feasibility of the innovation ………………………………………………………………………. 20

Cost-benefit ratio of the innovation ………………………………………………………..……….23

Conclusion ………………………… ………………………………………………………...........25

Chapter 4 – Implementation plan ………………………………..………………………………26

Communication plan …………………………………………………………………………...…..26

Pilot study plan ……………………………………………………………………………………..28

Evaluation plan ……………………………………………………………………………………..29

Outcomes measurement …………………………………………………………………………….31

Basis for effectiveness ……………………………………………………………………...………32

Conclusion …………………………………………………………………………………….32-33

References ……………………………………………………………………………………...34-36

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List of appendices

Appendix A: PRISMA diagram …………………………………………………………………….37

Appendix B: Table of Evidence ………………………..……………………………....……………38

Appendix C: Quality assessment using SIGN methodology checklists for RCTs ………..….…39-40

Appendix D: Timeframe for the innovation …………………………………………..……………41

Appendix E: Material and non-material costs of implementing the innovation …………………...42

Appendix F: Material costs of not implementing the innovation …………………………………..42

Appendix G Calculation of cost-benefit ratio: …………………………………………………..…42

Appendix H: Grades of Recommendations ……………………………………………..…….… 43

Appendix I: Levels of Evidence ……………………….…..………………...…………..…….… 43

Appendix J: Breastfeeding data collection form ……………………………..………………...…44

Appendix K: Telephone support checklist …………….…………………………...……..…….… 45

Appendix L: Questionnaire for the level of satisfaction among nurses …………………..…….… 46

Appendix M: Evidence-Based Practice Guideline …………………………………...…………47-48

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Chapter 1 - Statement of the Problem

Background

Breastfeeding is not only beneficial to infants but also to the mothers and the society. For

infants, breast milk is the best gift to nourish their growth. Its benefits are well recognized by the

public throughout the years. The components of breast milk uniquely satisfies the health needs of

infants in different stages of development and it provides the most ideal nutrients to promote the

growth and development of infants (World Health Organization [WHO], 2003). Unlike the artificial

milk, the constituents of breast milk vary in order to satisfy the health needs in different

developmental stages among the infants. Colostrum is produced during the first few days of

postpartum and it contains plenty of immune protective matters to provide the newborns with a

natural barrier against the pathological agents. Therefore, breastfeeding infants are less prone to

various infant illnesses, such as gastroenteritis, pneumonia, otitis media, eczema, asthma and

Sudden infant death syndrome (SIDS) (Kramer et al., 2001). Breastfeeding is proven to have dose

dependent protective effect on the health outcomes of infants. Evidence showed that there is a direct

cause-and-effect relationship between breastfeeding intervention and positive infant health

outcomes while reducing infant morbidity (Kramer et al., 2001). For the maternal benefits of

breastfeeding, oxytocin released during breastfeeding minimizes the risk of postpartum hemorrhage

by stimulating uterine contraction. There is also lower incidence of ovarian cancer and Type 2

diabetes among lactating mothers (Danforth et al., 2007; Jordan et al., 2010). It is worth promoting

breastfeeding to the public through breastfeeding support intervention.

Regarding to the local situation in Hong Kong, there was a continuous increasing trend of

breastfeeding initiation rate over the past decades. One of the reasons to explain this phenomenon is

that more women become more aware of the health benefits of breastfeeding and they tend to

choose breastfeeding for their infants. According to the latest statistics retrieved from Baby Friendly

Hospital Initiative Hong Kong Association (BFHIHKA), the breastfeeding initiation rate in 2014

2

and 2015 had slightly increased from 84.2% to 86.3% (BFHIHKA, 2015). However, the

breastfeeding rate substantially declines in the few months of postpartum. It implies that local

mothers may acknowledge the benefits of breastfeeding and the majority of mothers choose

breastfeeding for their infants.

In Hong Kong, there are both governmental and non-governmental organizations to promote

breastfeeding, such as Hospital Authority, Maternal Child Health Centres (MCHCs), BFHIHKA and

the La Leche League Hong Kong, via hotline services, educational talk and support groups to

support lactating mothers in breastfeeding concerns. They have greatly contributed in promoting the

duration and rate of breastfeeding. The breastfeeding rate on discharge showed remarkable growth

from 19% in 1992 to 85.8% in 2012 (BFHIHKA, 2015). Despite the efforts made by these

organizations, most mothers decide to stop breastfeeding especially after 1 month of postpartum and

only 32.7% mothers breastfed until 6 months postpartum (CHP, 2014).

Therefore, an evidence-based breastfeeding support intervention for mothers during

postnatal period is vital to provide effective breastfeeding intervention in prolonging duration of

breastfeeding.

Affirming the needs

According to the recommendation by the World Health Organization (WHO), exclusive

breastfeeding is recommended for infants up to 6 months of age, and it can be continued until two

years of age or beyond, accompanied with the introduction of complementary food (WHO, 2003).

Exclusive breastfeeding is defined as the practice of solely giving an infant breast milk for the first

6 months of life without any type of food or drink (WHO, 2003). In the regular survey conducted by

Family Health Service of the Department of Health in 2013, the exclusive breastfeeding rate even

drop from 22.1% at 1 month to 2.3% at 6 months which is far below the WHO recommendation

(CHP, 2014). In addition, the ever breastfeeding rate substantially drop after first month of

postpartum. It indicates that there is room for improvement on current breastfeeding support

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intervention.

The majority of mothers would attend MCHCs after discharged from hospital for a wide

range of child care services and postnatal support services, such as child immunization programme

and breastfeeding coaching service. MCHCs have implemented a new breastfeeding policy,

incorporating the 'Ten Steps to Successful Breastfeeding' and the International Code of Marketing

of Breastmilk Substitutes since 2000 in order to protect and promote breastfeeding (Leung, 2009).

Breastfeeding promotion has become a major component of current MCHCs services, targeting

from pregnant women to postnatal women through breastfeeding support group, breastfeeding

coaching service and education talk. Since MCHCs provides health promotion services to eligible

persons without any charges, it attracts many local women to utilize the services. Therefore,

MCHCs is an feasible place to implement the innovation of this study. For breastfeeding coaching

services, it is conducted by nurses who have completed professional breastfeeding training and they

are competent to provide hands-on demonstration and individual coaching for those lactating

mothers with breastfeeding concerns. Throughout the coaching service, mothers would learn about

the proper breastfeeding techniques, such as latching on and attachment, and it help minimize the

risk of breastfeeding complications. Although the coaching services are comprehensive, it requires

mothers to take their initiatives to seek for professional help at the first step. For the Chinese

culture, women during postnatal period should stay at home at the first month of postpartum to

promote their recovery. This is a major challenge for them to assess coaching services. Furthermore,

they are usually reluctant to seek help for their breastfeeding problems since they perceive it should

be managed by them. In view of providing effective breastfeeding support intervention among

Chinese mothers, telephone breastfeeding support would be considered as a feasible approach to

provide continuous support for lactating mothers even after discharge. For those lactating mothers

during the period of “sitting month”, they can be easily reached via telephone support. Unlike the

traditional hotline services that mothers take active role to make calls, telephone support is operated

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in a proactive approach which nurses take initiatives to contact the mothers. Telephone is chosen as

an ideal communication medium since it would not be influenced by geographical limitations and it

is a convenient, economical way compared to other kinds of breastfeeding support intervention,

such as home visit (Tahir & Al-Sadat, 2012).

For those researches including telephone breastfeeding support, the findings are

inconclusive. According to the research conducted by Pugh et al. (2010), the intervention group

received combined intervention (hospital visits provided by a breastfeeding support team, home

visits and telephone support) and their results indicated no increase in duration of breastfeeding.

This do not mean telephone breastfeeding support alone would not be effective to prolong duration

of breastfeeding. Therefore, an evidence-based protocol of telephone lactation support to prolong

duration of breastfeeding is required to provide standardized way to prolong duration of

breastfeeding.

Objective and Research Question

The objective of the dissertation is to prolong the duration of breastfeeding through

telephone support intervention during postnatal period. The proposed research question is

“Among breastfeeding mothers in the postnatal period, does telephone breastfeeding support

intervention prolong breastfeeding duration, compared to usual care?”

Significance of clinical issue

According to World Health Organization (WHO) and United Nations Children's Fund

(UNICEF), exclusive breastfeeding (EBF) is recommended for infants up to the first 6 months of

life and continued breastfeeding with appropriate complementary food can be provided up to 2

years of age or beyond (WHO, 2003). There are extensive evidences shown that the benefits of

breastfeeding is dose dependent, infants receiving longer duration of breastfeeding experience better

health outcomes (Kramer & Kakuma, 2004). Early cessation of breastfeeding not only increases the

risk of childhood obesity, gastroenteritis, necrotizing enterocolitis, lower respiratory infections,

5

Type 1 and 2 diabetes and sudden infant death syndrome (Kramer et al., 2001). It also associates

with adverse health impacts among mothers, such as breast and ovarian cancers, Type 2 diabetes

and postpartum depression (Kramer et al., 2001). In addition, breastfeeding is beneficial to our

society and the health care system. Nowadays, people become more aware of sustainable

development and environmental conservation. Compared to formula feeding, breastfeeding is more

environmental-friendly since mothers just directly feed their infants without extra preparation,

thereby reducing the environmental burden from disposal of artificial cans. For the health care

system, breastfeeding infants are less prone to common childhood illnesses, such as diarrhea and

pneumonia which are the primary causes of child mortality worldwide. Therefore, it reduces

hospital admission and duration of hospitalization, in which directly relieves financial burden on

health care system. In addition, telephone is a well-accepted medium of communication as it works

independent of neither geographical limitation nor physical barriers. And it is particularly beneficial

among Chinese mothers since most of them would “sit month” in the first month of postpartum

which is a delicate period of adaptation in both physiological and psychological way.

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Chapter 2 – Critical Appraisal

Although telephone lactation support is suggested as an effective intervention to prolong the

duration of breastfeeding, there are still lack of relevant guidelines that standardize nursing practice

among local institutions. Therefore, systematic review allows people to critically appraise the

quality of selected articles. The role of systematic review is to provide health care professionals

with updated and evidence-based clinical information which helps maintain quality of care. It also

assists in standardizing current nursing practice. In this study, our objective is to prolong

breastfeeding duration via professional telephone lactation support. To perform critical appraisal,

the first step is to select relevant articles by keyword searching. After the articles are filtered, the

table of evidence (TOE) would be used as a tool to appraise the articles and facilitate the

comparison among the selected articles in terms of intervention, effect size and so forth.

Search and appraisal strategy

Eligible criteria of study participants

To be eligible for study selection, participants have to meet the criteria shown as follows: (1)

Hong Kong Chinese women aged 18 or above; (2) without significant obstetric complications

during pregnancy, such as pre-clampsia or postpartum hemorrhage; (3) intended to breastfeed; (4)

no history of major medical or psychiatric diseases that may interfere breastfeeding; (5) term

delivery at 37 gestational weeks or beyond; (6) no physical anomalies of mothers and babies that

may contradict with breastfeeding.

For exclusion criteria, mothers who are multiple pregnancy would be excluded in this study

as it is regarded as high risk obstetric case. When their infants who are transferred to Special Care

Baby Unit (SCBU) or Neonatal Intensive Care Unit (NICU) during the study would also be

excluded.

The study search was conducted on 9 and 12 July 2015. Two electrical databases, PubMed

and CINAHL Plus were selected for searching articles. There was no filter used at the beginning of

7

article searching. Keywords used in the searching process include “breastfeed”, “breastfeeding”,

“telephone support”, “telephone breastfeeding support”, “telephone lactation support”, “telephone

support intervention”, “telephone intervention” , “telephone counseling”, “duration of

breastfeeding”, “breastfeeding duration”. After the searching result generated, additional filters

were applied to limit the results, including randomized control trial, English for article language.

There is no limitation of published year of the articles.

The flow diagram of articles searching is presented in PRISMA diagram (Refer to Appendix

A). A total of 587 articles were retrieved from these databases; 487 articles were retrieved from

PubMed and 100 articles from CINAHL. After removing the duplicated articles from the above

databases, there were remaining 494 articles. By screening the title and abstract, 478 articles were

excluded. There were 16 articles which were further screened for their eligibility. Finally, 5 relevant

articles were selected for critical appraisal. There was also 1 article retrieved by manual searching

through the above eligible studies. However, it was excluded after screening through the titles and

abstract since the intervention group received combined intervention support during postnatal

period, including home visit and telephone support (Pugh et al., 2010). Therefore, the effectiveness

of telephone support alone could not be evaluated.

Table of Evidence

Table of evidence provides quick reference of each selected article by clearly presenting data

in different columns. Table of evidence is used to present the summary of the 5 selected studies,

including citation, study design, level of evidence, sample characteristics, treatment received from

intervention and control group, outcome(s) measured and effect size.

Study design & Level of Evidence

All of the five selected studies are randomized controlled trials (RCT). According to the

grading system of Scottish Intercollegiate Guidelines Network (SIGN) in 2011 on the levels of

evidence, four out of these studies were 1+ (Carlsen et al., 2013; Dennis et al., 2002; Simonetti et

8

al., 2012; Tahir & Al-Sadat, 2013) while one study was categorized as 1++ (Fu et al., 2014). The

number of sample size from the above studies ranged from 114 to 1948. For the study with largest

sample size, it was 3 arms study, including 2 intervention groups and 1 control group.

Characteristics of study participants

Participants were recruited from Hong Kong, Malaysia, Denmark, Canada and Italy (Carlsen

et al., 2013; Dennis et al., 2002; Fu et al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat, 2013).

Two studies focused on primiparous women in postnatal period (Fu et al., 2014; Dennis et al., 2002)

while Carlsen et al. (2013) targeted on whether telephone support prolongs the duration of

breastfeeding among the obese women as it was found that obese women are easier to have

breastfeeding difficulties. Among all of the selected studies, participants are intended to breastfeed

and without significant maternal illnesses. For their infants, all of them are term delivery, without

physical anomalies.

Intervention group

Four of the selected studies had telephone lactation support conducted by lactation

counselors (Carlsen et al., 2013; Tahir & Al-Sadat, 2013), nurses (Fu et al., 2014), midwives

(Simonetti et al., 2012). In Dennis's study (2002), telephone support was provided by peer

counselors. One of the studies was 3 arms studies which consisted of 2 intervention groups and 1

control group (Fu et al., 2014). In the study of Fu et al. (2014), the 2 intervention groups included

breastfeeding support session and weekly telephone support. For the qualification of health

professions, those lactation counselors had completed lactation management and counseling course

based on WHO module in the study (Tahir & Al-Sadat, 2013). In the study by Fu et al. (2014), the

intervention was delivered by nurses, who were either experienced midwives or certified lactation

consultants, with the completion of relevant program and extensive experience on lactation support.

For the peer counselors in those studies by Dennis et al. (2012), they had breastfeeding experience

for at least 6 months duration with completion of orientation session to ensure standardization of

intervention.

9

Control Group

In the control group, participants received standard of care or conventional postnatal care

without telephone breastfeeding support service in all of the above studies (Carlsen et al., 2013;

Dennis et al., 2002; Fu et al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat, 2013).

Outcomes measured

The primary outcome in the above studies was to assess the rate of breastfeeding in both

exclusive and any method (exclusive breastfeeding and partial breastfeeding) in different intervals,

such as 1, 3 and 6 months of postpartum. In the study conducted by Dennis et al. (2002), its

secondary outcome was maternal satisfaction of infant feeding.

Effect size

The detailed results of the above studies were shown in relative risk (RR) and odd ratio

(OR) (Refer to Appendix B). The effect size in 1 month ranges from 1.627 to 1.89 in terms of odd

ratio and from 1.1 to 1.8 in terms of relative ratio. For the effect size in 3 month, the range is wider

than 1 month, ranging from 1.2 to 2.45 (odd ratio) and from 1.21 to 1.9 (relative ratio).

Quality assessment

To assess the quality of each selected article, SIGN methodology checklist is chosen as the

appraisal tool. SIGN was established in 1993 and it aims at improving the quality of health care

system by standardizing the existing practice and thus maximizes health benefits among patients. It

is divided into 2 sections in the methodology checklist, including internal validity and the overall

assessment of the study. The details of each study are presented in the table of Quality Assessment

(Refer to Appendix C).

Appropriate and clearly focused questions

All of the above studies had clear and appropriate research question which contained all

elements of “patient-intervention-comparison-outcome” (PICO) format which covered the effectiveness

of telephone lactation support on rate of breastfeeding during postnatal period.

10

Randomization

Four studies used randomization for random assignment by different methods, such as random

allocation program, online randomization program (Carlsen et al., 2013; Dennis et al., 2002; Fu et al.,

2014; Tahir & Al-Sadat, 2013). In the study by Simonetti et al. (2012), randomization was

mentioned for study participants but the method was not specified.

Concealment

Only 2 studies achieved the criteria of allocation concealment (Fu et al., 2014; Tahir & Al-Sadat,

2013). In Fu's study (2014), the research nurses and study sites were informed of treatment allocation 48

hours prior to recruitment of study participants. Tahir and Al-Sadat (2013) used a list of random codes to

ensure adequate concealment. In the other 3 studies, no concealment method was mentioned (Carlsen et

al., 2013; Dennis et al., 2002; Simonetti et al., 2012).

Blinding

Since the intervention was conducted by either nurses or peer counselors, it was impossible to

blind either participants or those delivering the intervention. Nevertheless, it is possible to blind the

researcher enumerators who were responsible for data collection and analysis. Four studies succeeded in

blinding the researchers (Carlsen et al., 2013; Dennis et al., 2002; Fu et al., 2014; Tahir & Al-Sadat,

2013). In only one study, the presence of blinding was not clear since it did not mention whether the

researchers were blinded of treatment allocation (Simonetti et al., 2012).

Comparable group

For the baseline characteristics of both intervention and control group, there was no statistical

significance at the beginning of the study. Therefore, study participants in all five studies were

comparable (Carlsen et al., 2013; Dennis et al., 2002; Fu et al., 2014; Simonetti et al., 2012; Tahir &

Al-Sadat, 2013).

Difference between groups is the treatment under investigation

In all five studies, there was no key difference between the treatment groups and control groups

and the intervention was the only difference between two groups (Carlsen et al., 2013; Dennis et al.,

11

2002; Fu et al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat, 2013).

Valid and reliable outcome measures

All studies clearly mentioned their outcomes which were measured in a valid and reliable way

(Carlsen et al., 2013; Dennis et al., 2002; Fu et al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat,

2013).

Percentage of dropouts

In all five studies, the dropout rate did not exceed 20%, which was favorable. The detailed

figures of dropout rate in each group are shown in the table of quality Assessment (Refer to Appendix

C).

Intention–to-treat analysis

Only two studies adopted Intention-to-treat analysis (Fu et al., 2014; Tahir & Al-Sadat, 2013).

In the data analysis, they used the original number of participants in each group even though some

participants dropped out. In the remaining three studies, participants who dropped out were not

included throughout the study after randomization (Carlsen et al., 2013; Dennis et al., 2002;

Simonetti et al., 2012).

Results are comparable for all sites

Only 1 study involved multi-centre approach and the results were comparable among all sites

(Fu et al. 2014). For the remaining four studies, their study conducted in a single site only (Carlsen et

al., 2013; Dennis et al., 2002; Simonetti et al., 2012; Tahir & Al-Sadat, 2013).

Ratings of the studies

Two studies were categorized as high quality (++) as they showed adequate randomization

and allocation concealment (Fu et al., 2014; Tahir & Al-Sadat, 2013). In the other 2 studies, they

had randomization but no allocation concealment; therefore, their ratings were classified as

acceptable (+) (Carlsen et al., 2013; Dennis et al., 2002). In the pilot study conducted by Simonetti

et al. (2012), the randomization method was not clear and it did not have allocation concealment. It

was classified as low quality (-).

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Summary and Synthesis

Summary of study result

All of the five reviewed studies investigated the effect of postnatal telephone lactation

support on breastfeeding outcomes: the rate of exclusive and any breastfeeding at different intervals

in postnatal period.

Diversity of conclusions

In general, all studies showed that telephone lactation support provided by health

professionals was effective to increase the rate of both exclusive and any breastfeeding at various

postnatal periods. According to the result of each study, the intervention was statistically significant

at specific interval. In the study by Tahir & Al-Sadat (2013), it showed that telephone lactation

support was effective in increasing the exclusive breastfeeding rate at the first month postpartum,

but not effective at the fourth and sixth month of postpartum. Fu et al. (2014) showed similar

findings in their study. Professional telephone breastfeeding support significantly increased the rate

of exclusive and any breastfeeding in the early postnatal period: the first month of postpartum.

Carlsen et al. (2013) showed that telephone intervention by lactation consultant prolongs the

duration of both exclusive and any breastfeeding among obese women across the first 6 month of

postpartum. In the study by Dennis et al. (2002), it indicated that telephone support by peer

counselors was statistically effective in maintaining breastfeeding up to 3 months postpartum. In the

pilot study by Simonetti et al. (2012), structured telephone support was shown effective in prolong

duration of breastfeeding during the first 5 months postpartum.

Characteristics of participants

In all of the five studies, the target participants were assessed for their intention to breastfeed

during the recruitment process, only mothers intended to breastfeed would be eligible for the studies

(Carlsen et al., 2013; Dennis et al., 2002; Fu et al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat,

2013). Four studies reported that their study participants were of good past health without

13

significant obstetric and medical illness that may impair their ability to breastfeed (Carlsen et al.,

2013; Dennis et al., 2002; Fu et al., 2014; Tahir & Al-Sadat, 2013).

Qualifications of researchers who delivered intervention

In the four out of five studies, the telephone support was conducted by health professionals

who were certified lactation consultants, nurses or registered midwives (Carlsen et al., 2013; Fu et

al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat, 2013). Only one study reported that the

intervention was delivered by peer counselors (Dennis et al., 2002). To ensure the competency of

both health professions and peer counselors, lactation counselors (LC) had completed the lactation

management and counseling course prior to the study (Tahir & Al-Sadat, 2013). Counseling

guidelines and standard operation procedure booklet were issued to each lactation counselor (Tahir

& Al-Sadat, 2013). The research nurses were either experienced midwives or certified LC and they

possessed extensive experience in breastfeeding support and counseling skills (Fu et al., 2014).

They were provided additional training on study protocol before the study, in order to ensure the

evidence-based quality of study intervention (Fu et al., 2014).For the qualification of peer

counselors, they were provided with handbook and orientation session which aimed at developing

their skills in telephone support and referrals to increase standardization of the intervention (Dennis

et al., 2002). In the two studies, the intervention was performed by certified LCs (Carlsen et al.,

2013) and WHO-UNICEF licensed midwife (Simonetti et al., 2012) but it was not clear that

whether there was relevant training equipped for them prior to the study.

Duration & frequency of intervention

In the five studies, the duration of intervention varied from 3 to 6 month of postpartum.

Tahir & Al-Sadat (2013) reported that telephone support were delivered by LCs twice monthly until

6 month of postpartum, so participants in intervention group received 12 telephone calls at the end

of the study. Whilst Fu et al. (2014) reported that telephone support would be provided on weekly

basis up to 4 weeks postpartum or whenever mothers stopped breastfeeding. In Carlsen et al. (2013)

14

study, telephone support were provided for 3 times during the first month of postpartum, then

participants would be contacted every second week until 2 months postpartum, and monthly call

until 6 months of postpartum or whenever mothers stopped breastfeeding. Dennis et al. (2002)

reported that there was no standardized frequency of telephone contacts and it was provided based

on individual participant's need. In the pilot study by Simonetti et al. (2012), telephone support was

provided in the structured format. The timing of telephone calls were mutually agreed by both

mothers and midwives and the frequency of intervention was at least once per week.

Time of initial call

Three studies mentioned the timing of first call (Carlsen et al., 2013; Dennis et al., 2002; Fu

et al., 2014). The initial telephone call was made within 2 days after discharged from hospital

(Dennis et al., 2002); within 3 days after discharged from hospital (Fu et al., 2014) and within the

first 7 days (Carlsen et al., 2013).

Format of intervention (structured / patient-initiated)

Four studies provided their intervention based on their proposed frequency and it was

usually conducted on weekly basis (Carlsen et al., 2013; Fu et al., 2014; Simonetti et al., 2012;

Tahir & Al-Sadat, 2013). Dennis et al. (2002) reported that the intervention were participant-

initiated which participants determined the frequency of telephone call according to their individual

needs.

Content of telephone support intervention

Three studies described the content of telephone support intervention (Carlsen et al., 2013;

Fu et al., 2014; Simonetti et al., 2012). During each telephone support, participants were assessed

their breastfeeding knowledge and the well-being of mothers and infants, breastfeeding advice

would be provided accordingly (Carlsen et al., 2013). In Fu et al. study, its content focused on their

breastfeeding knowledge and emotional well-being. Guidelines on managing breastfeeding

problems, such as poor latching, would be provided on individual basis (Fu et al. 2014). Simonetti

15

et al. reported that relevant information and support on breastfeeding would be given in each

telephone call.

Synthesis

In accordance with the diversity of results among the five reviewed studies, the study design

and content of intervention would be compared and possible reasons would be provided to explain

the diversity.

Qualifications of health professions and peer counselors

In the five reviewed study, the intervention was mainly conducted by healthcare professions

(Carlsen et al., 2013; Fu et al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat, 2013) and it was

performed by peer counselors in one study (Dennis et al., 2002). Since both healthcare professions

and peer counselors received different type of training courses prior to the study, their competency

and qualification were not standardized, in which may impair the accuracy of study results.

Intention-to-treat analysis

Only two out of five reviewed studies adopted intention-to-treat analysis. In Carlsen et

al.(2013) study, the dropout rate was 13.6% in the control group and 2.78% in the intervention

group respectively. When the dropout rate is relatively high in this study, the accuracy of study

result would be impaired especially without intention-to-treat analysis.

Duration & frequency of intervention

Four studies provided telephone support on weekly basis throughout the studies and the

study results showed that the duration of intervention was positively correlated to duration of

breastfeeding (Carlsen et al., 2013; Fu et al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat, 2013).

Time of initial call

In order to provide continuous breastfeeding support after hospital discharge, the initial call

should be made within 2 days after hospital discharge. Breastfeeding mothers, especially the

primiparous mothers, may encounter breastfeeding problems, such as breast engorgement which is

16

commonly seen after day 3 of postpartum and it does require timely advice and management.

Content delivered via telephone support intervention

In the five reviewed studies, the content of telephone breastfeeding support mainly provided

mothers with breastfeeding knowledge, assessment of well-being of both mothers and infants and

advice of managing breastfeeding difficulties. In the early phase, lactating mothers may be

inexperienced and lack adequate breastfeeding knowledge. During this period, correct concepts and

basic principles of breastfeeding should be delivered, such as importance of correct attachment and

latching on. In addition, it is important to assess the psychological concerns of mothers during the

early postpartum period. In the later phase, some mothers need to return to work after maternity

leave. Therefore, storage of breast milk and use of milk pump can be taught.

Implications for innovation

In general, telephone breastfeeding support is shown effective to prolong the duration of

exclusive and any breastfeeding based on the result of five reviewed studies. And it should be

promoted among Chinese women due to cultural concerns. Most Chinese women sit month during

the first month of postpartum and they are often pressured by their relatives, such as mother-in-law,

to start formula feeding (Fu et al., 2014). Therefore, continuous breastfeeding support should be

provided via telephone intervention to ensure accessibility of these mothers as well as provide

timely breastfeeding advice. For the duration of intervention, it should be provided for at least 1

month since the first 1 month of postpartum is the critical period for mothers to adapt physically

and psychologically. The optimal timing of initial call would be 2 days after hospital discharge to

address mothers' concern and emotional needs timely. Prior to the innovation, the nurses who

deliver the intervention should complete certified refresher course organized by well-recognized

breastfeeding organization to ensure their competency and quality of intervention. For the content

of telephone intervention, it should be individualized as lactating mothers may have different

breastfeeding concerns. In addition, the content may be divided into several phases in the

17

postpartum period in order to best suit the needs of lactating mothers. Telephone breastfeeding

support should be provided for at least 1 month of postpartum since lactating mothers are the most

in need during the early period of postpartum.

18

Chapter 3 – Implementation Potential

Target setting and audience

The proposed setting of implementing the innovation would be the designated private

hospital. The target population is the local Chinese women who have no significant obstetric

complications throughout pregnancy, deliver term babies, intend to breastfeed and are willing to

participate postnatal lactation telephone counseling.

Transferability of the findings

Similarity of the settings and target population

The settings of the reviewed studies are local public hospitals with maternity service and our

proposed setting in the innovation is private hospital with maternity service as well. The nature of

maternity service in public or private hospitals in Hong Kong is generally similar and they

recognized the clinical significance of breastfeeding among both mothers and their infants.

Therefore, it is expected the innovation would be feasible in the proposed setting.

Compared to the target population of the reviewed studies and the innovation, the

characteristics of participants in these two groups are also similar and comparable. The target

population in the selected studies and the innovation are the local mothers who had term deliveries,

intended to breastfeed, no significant obstetric history during pregnancy.

Philosophy of Care of the designated private hospital

The designated private hospital is one of the local private hospitals with religious background.

Its mission is to ensure the physical, emotional and spiritual well-being of individuals for the Glory

of God by providing holistic healthcare. Care is its core business and value.

Philosophy of care underlying the innovation

To achieve holistic care, the maternity department of the private hospital advocates

breastfeeding which is regarded as the ideal nutrition for the newborn according to the World Health

Organization. The goal of the innovation is to prolong the duration of breastfeeding through

19

postnatal lactation telephone counseling as the mean of continuous postnatal support even after

hospital discharge. Current research evidences support that prolonging the duration of breastfeeding

would lead to positive health outcomes by reducing the risk of common infant illnesses, such as

gastroenteritis and pneumonia (Kramer et al., 2001).

The philosophy of care underlying the innovation is consistent with the private hospital, which

is to provide holistic care via continuous postnatal lactation support for those lactating women for

the sake of promoting their physical, emotional and spiritual well-being as well as health benefits

among newborns.

Expected number of clients benefited from the innovation.

There are average 2,500 deliveries per annual in the designated private hospital. By

excluding those complicating pregnancies and foreign pregnant mothers which do not satisfy the

inclusion criteria of the innovation, there are approximately 1,500 mother-infant pairs per year (125

mother-infant pairs per month). According to the hospital statistics, nearly 90% mothers intended to

breastfeed. It is supposed that all of the mothers who meet the inclusion criteria would participate

the innovation. By calculation, it is estimated that there are around 110 mother-infant pairs fulfill

the inclusion criteria and would be benefited from the innovation per month.

Projected timeframe for implementing and evaluating the innovation

The total duration of this innovation is 12 months. Prior to the implementation of innovation, it

will take 6 months to establish the protocol of the innovation, implement the pilot test as well as

obtain approval from the stakeholders of the hospital. It includes the arrangement of nurses’

manpower for telephone counseling, preparation of orientation and refresher programme for all

participated nurses and required equipment to implement the innovation. It takes 3 months to

implement the innovation. There are several stages, including recruiting participants,

implementation of the innovation (postnatal lactation breastfeeding counseling performed by

qualified nurses) and data collection. The final part would be data analysis and evaluation based on

20

the collected data (Refer to Appendix D).

Feasibility of the innovation

For those participated nurses, they are provided with orientation and refresher programme

prior to the innovation, for the sake of ensuring their competency of telephone counseling skills and

consolidating their breastfeeding knowledge. They have freedom to implement the innovation based

on their clinical judgment as long as it would not violate the protocol of the innovation or cause

harm to the participated mothers. Under the circumstance that the nurses consider as undesirable,

they possess their choice to terminate the innovation.

In order to avoid excessive workload for the participated nurses during implementing the

innovation, extra manpower would be provided to share their routine workload. During the

implementation of innovation, there would be additional 3 relieving nurses from the nursery service

in every work shift. Therefore, the current staff function and workload would not be significantly

interfered during the innovation.

The administration had started advocating the importance and benefits of breastfeeding for

both mothers and their newborns for years since the existing clinical evidence showed that

breastfeeding babies would have less risk of common infant illnesses, such as pneumonia (Kramer

et al, 2001). The purpose of innovation perfectly matches with the direction of present clinical

practice since our aim is to prolong the duration of breastfeeding via postnatal lactation telephone

support, in order to promote positive health outcomes for the infants. The organizational climate is

conducive to research utilization. As a result, the implementation of the innovation would be highly

supported by the administrators and stakeholders of the hospital.

Consensus between the administrators and the staff

Since the administrators has advocated for the benefits of breastfeeding for both lactating

mothers and their infants via a series of baby-friendly activities. For example, those mothers who

prefer breastfeeding would be provided with early skin to skin contact with their newborns soon

21

after delivery. In addition, nurses also conduct breastfeeding education for those lactating mothers

so as to equip them with correct techniques and minimize risk of undesirable outcomes of

ineffective breastfeeding. Thus, the staff had well understood the significance and advantages of

breastfeeding and the majority of them have positive attitude towards the innovation. As the

implementation of this innovation would lead to change in their current workflow, it is anticipated

that the minority of staff may be reluctant to change. The most common reason is that they perceive

they do not possess sufficient knowledge to handle the cases and they feel incompetent to perform

telephone counseling. Some of them are worried about the unknown situation and dare stick on the

existing practice. To resolve these possible resistances, the orientation and refresher programme

would be provided prior to the implementation, to ensure that they have good understanding of the

innovation and facilitate their cooperation and support. These interventions are expected to

minimize the staff’s concern and rectify their attitudes.

Under the circumstance that the telephone counseling work impairs the daily routine operation

in the clinical setting, it may cause friction within the organization. To minimize the risk of possible

disturbance to the daily operation, there would be maximum 15 telephone call limits for each

participated nurse in every shift. For the sources of extra manpower support, there are additional 3

registered nurses designated from the nursery department which is within the nursing department.

According to the expected number of eligible mother-infant pairs, there are approximately 110

breastfeeding mother-infant pairs per month. To calculate the nurses’ workload, they have to handle

about 30 cases per week. Ideally, assuming that all the eligible mothers participate the innovation

and the dropout rate is zero, the accumulating cases would increase by 30 cases per week. The

maximum duration of each telephone call would be allowed for 20 minutes and special

consideration for time allocation is available if additional referral or support is required for those

mothers when necessary.

22

Skills required for participated staff

For all participated staff, they are required to complete the orientation and refresher

programme prior to the implementation of innovation. The programme would be delivered in 2

sessions and each session last for 3 hours. Working hour compensation would be provided for all

attending staff. The first session would be the orientation session and introduce our aims and

purposes of innovation to the staff. And the second session would mainly cover breastfeeding

knowledge and basic skills of telephone counseling by inviting guest speakers and experts. After the

completion of this programme, certificates will be given to each participated staff to qualify their

clinical competency on breastfeeding skills and fundamental counseling techniques.

Hardware required during implementation

Besides of preparation for participated staff, there is also essential equipment to run the

innovation, including sufficient number of telephone for use of breastfeeding counseling, logbook

and learning materials distributed to nurses during orientation and refresher programme. Extra five

telephones are required for this innovation. The relevant expenditure would obtain financial support

from the department and stakeholders of the hospital.

Special arrangement for participated staff

To minimize the possibility of disturbance to daily operation in the clinical setting, the

orientation and refresher programme will be arranged after the staffs are off their duty. Therefore,

the number of staff in each work shift would not be affected, ensuring the quality of care and

service.

Evaluation tool for measuring the outcomes

A tailor-made breastfeeding evaluation form would be used to collect the data which is

reported by postnatal mothers via telephone counseling at scheduled frequency during the

implementation of innovation.

23

Potential benefits and risks for participated mothers during the implementation

Our innovation relies on telephone as communication tool to deliver breastfeeding message

and psychological support to those participated mothers during implementation. The major

advantage of this innovation is to provide continuous support to those breastfeeding mothers even

after discharged from hospital. Since there is not sufficient time for mothers to learn breastfeeding

techniques within short period of hospitalization after delivery, they may not be competent to

manage breastfeeding problems themselves at home. Through telephone breastfeeding support,

mothers are allowed to raise their concern about breastfeeding and they can obtain correct

breastfeeding knowledge from nurses sooner. Existing research evidence has already shown that

prolonging breastfeeding duration reduce risk of common infant illness and shorten the duration of

hospitalization in which help reduce medical expenditure for the community and the Government

(Kramer et al., 2001). There is no side effect or potential hazard that mothers would be exposed.

Risks of maintaining current practice

In the Chinese cultural practice, postnatal women are expected to stay at home during the

first month of postpartum to promote enough rest and recovery. Without telephone breastfeeding

counseling, those breastfeeding mothers may be reluctant to seek for professional support due to

their cultural concern. In addition, their relatives may advise them to start formula feeding when

they have breastfeeding problems, such as insufficient breast milk supply, thus increasing the

likelihood of terminating breastfeed.

Material costs of implementing the innovation

These include expenditure for fixed assets, including extra telephones; learning materials used

in the orientation and refresher programme and logbooks for nurses to record mothers’ concern and

breastfeeding problems during telephone counseling (Refer to Appendix E).

Material costs of not implementing the innovation

If there is without telephone breastfeeding counseling for those mothers, they are prone to

24

encounter breastfeeding problems after discharged from hospital and early cessation of

breastfeeding would likely occur. For those infants without breastfeeding, they are exposed higher

risk of common infant illnesses, such as pneumonia and gastroenteritis (Ball, Thomas & Anne,

1999). It would directly increase the financial burden of healthcare expenditure. On the other hand,

purchasing formula milk would also contribute to additional expenditure of infant care compared to

breastfeeding which is more economical and eco-friendly (Refer to Appendix F).

Potential non-material costs of implementing the innovation

Since the innovation implies change in existing practice, it is expected that few number of

staffs who are opposed to the innovation even after the orientation and refresher programme, it may

impair staff morale. Participated staffs are also required to attend the programme after their work;

therefore it may reduce their leisure time and cause physical fatigue after attending the programme.

Potential non-material benefits of implementing the innovation

Prolonging the duration of breastfeeding is beneficial to both infants and lactating mothers.

For those infants, Pokhrel et al. (2014) showed that supporting mothers to continue breast feeding

until 4 months are expected to reduce the incidence of common infant infectious diseases and thus

saving at least £11 million annually. Besides of substantial health outcomes of infants resulting from

prolonging the duration of breastfeeding, lactating mothers also benefit from this innovation. Since

oxytocin would be released during breastfeeding, it helps promote uterine involution and reduce

risk of postpartum hemorrhage. Studies also showed that lactating mothers are less prone to breast

and ovarian cancer later in life (Danforth et al., 2007; Jordon et al., 2010). For nurses, they can

enjoy higher job satisfaction by helping mothers in prolonging duration of breastfeeding.

The cost-benefit ratio is 14.2% and the detailed calculation is shown in Appendix G. It is

calculated by cost of innovation minus actual cost (without innovation), the result is divided by

actual cost. Although the result is a positive number, the potential benefits of implementing the

innovation are not taken into account in the calculation. Both the lactating mothers and the infants

25

have positive health outcomes when prolonging the duration of breastfeeding. Therefore, the

innovation is worth implementing in the hospital.

Conclusion

In conclusion, this innovation is transferable and feasible to implement. Apart from

improving health outcomes of both mothers and infants, the innovation also help reduce medical

expenditure by shortening duration of hospitalization. Breastfeeding is more economical and eco-

friendly than formula feeding without the concern of formula powder can disposal.

26

Chapter 4 - Implementation plan

The implementation plan is composed of several parts, including communication plan, pilot

study plan, evaluation plan as well as the basis for implementation.

Communication plan

The major function of the communication plan is to get the stakeholders involved, and to

provide communication channel among them to ensure that they can obtain the latest information

simultaneously. In addition, the detailed process of establishing communication plan would be

described.

Identifying the stakeholders

“Stakeholder” in the communication plan refers to a person who has interest or concern to

the innovation. Stakeholders can have influence on the implementation’s outcomes. In this study,

the stakeholders include hospital administrators, the Department of Manager (DOM), Nurse

Officers (NOs), as well as frontline nurses who participate in the innovation.

Establishment of the communication team

Followed by identifying the stakeholders, a communication team would be established in

order to facilitate sharing of updated information among the stakeholders, which helps the

implementation of the communication plan. One of the functions of the communication team is to

educate the frontline staffs through emails, circulars or information seminars, which equip them

with knowledge about the potential clinical advantages of the innovation and the required skills for

implementation. The communication team consists of a total of six team members, including one

lactation consultant (LC), two nurse officers (NOs), the innovation author and two frontline nurses.

There would be one link person in each work position. It ensures that comprehensive feedback from

different levels of staff would be collected. And the frontline nurses would be responsible to

implement the innovation.

27

Detailed process of communication plan

The initial step of communication plan is to prepare the details of innovation and send the

proposal to the responsible hospital administrators via email 4 weeks prior to the formal meeting, in

order to obtain their approval and support for the innovation. The details of innovation would be

presented in PowerPoint format and it includes the objectives, proposed workflow of the program,

implementation potential in terms of transferability and feasibility, potential clinical benefits and

risks, as well as estimated material and non-material costs. The background information for

supporting the innovation is the five selected studies and they will be attached as appendix in the

proposal. During the formal meeting with the hospital administrators, a brief presentation about the

general workflow of the innovation would be presented by the innovation author. After that, they

are welcome to raise their concerns and inquiries in the Question & Answer session. Their feedback

would be also collected for modifying the details of innovation if necessary.

A meeting with the LC and the NOs will be arranged 2 weeks after obtaining approval from

hospital administrators, to allow sufficient time for the innovation author to modify the innovation

based on the feedback obtained from hospital administrators. This meeting aims at discussing

allocation of manpower and resources during the implementation. Since the innovation requires

additional nurses’ manpower to perform telephone counseling during the implementation stage,

comprehensive workflow of innovation and staff allocation must be mutually agreed to maintain

quality of care of existing nursing service. It also ensures the workload of frontline nurses is

acceptable during implementation.

Prior to the implementation of innovation, it is necessary to ensure all participating staff are

familiarized with the program details and possess sufficient clinical competency to implement the

innovation. All participating nurses need to attend two orientation sessions conducted by guest

speakers in the hospital prior to the implementation. During the orientation session, all of the details

28

of the innovation including the objectives, workflow of the program, potential clinical benefits and

manpower allocation would be clearly stated in order to obtain understanding and support from all

participating staff. It is expected that some nurses will be reluctant to change their current practice

and that is why a clear explanation and manpower support is crucial to ease their concern. In

addition, all participating staff are also encouraged to raise their opinions at the end of the

orientation session and supportive measures would be provided accordingly if possible. Regular

meetings will also be provided in order to facilitate their real-time feedback during the

implementation. Besides, they are also encouraged to provide their feedback via email.

Pilot Study Plan

Pilot study is defined as a small-scale research study conducted before the intended study.

Its purpose is to test the feasibility of the innovation in the reality and therefore it is also named as

“feasibility study”. Although the pilot study cannot eliminate all systematic errors, it can help

reduce the likelihood of type I & type II errors which would result in wastage of manpower and

resources. It also provides a way to identify potential problems of the innovation and allow the

innovation author to look for solutions before implementation. In terms of cost effectiveness,

conducting a pilot study provides a preliminary result about the efficacy of research protocol with

minimal resources input (Hilla, Christa & Gisela, 2006). It can also identify implementation

strategy and relevant facilitators to the innovation.

Timeline of pilot study

The duration of the pilot study is 4 weeks. It is divided into 4 parts: subject recruitment,

implementation, data collection and data evaluation. Subject recruitment will be performed in the

first week. Implementation will follow in the 2 weeks thereafter. Data collection and data evaluation

will be performed in the last week after the implementation. The pilot study aims to recruit 20

postnatal women who delivered their babies within one week and fulfilled our recruitment criteria

29

as stated in the actual innovation. It provides a reasonable number of subjects for frontline nurses to

practice their telephone support skills while not causing excessive workload to them. Verbal

consent is obtained from each eligible participant after recruitment.

All the frontline nurses have to complete the orientation session prior to the implementation of

pilot study to ensure their competency fulfilling our clinical standard. During the orientation session,

they will be equipped with fundamental telephone counseling skills and breastfeeding knowledge

which promotes those postnatal women to successfully breastfeed even after discharge from

hospital. A telephone support checklist (Refer to Appendix K) would be provided for nurses as

simple tips to deliver common telephone support methods to the clients.

After the implementation of the pilot study, the communication team is responsible for data

collection and evaluation, which can tell the feasibility of the innovation. For the part of data

collection, we will collect data including types of intervention delivered by nurses, average time of

each telephone counseling and duration of breastfeeding reported by mothers. Besides, regular

meeting with frontline staff would be conducted to collect their feedback about the pilot study

which helps to modify the innovation if necessary. Expected feedbacks from them include issues

like whether they encounter any difficulties during implementation or whether the telephone

counseling checklist is suitable or adequate for them to carry out their counseling.

Throughout the evaluation, the communication team would examine the overall workflow of

the pilot study, identify any risk factors that may impair the implementation or outcomes and

suggest possible solutions accordingly. The workload of frontline nurses would be assessed to

ensure adequate support to them and maintain good staff morale. After the completion of pilot study,

the results and suggested amendment, if any, of the innovation would be reported to the hospital

administrators in form of a written report.

Evaluation Plan

The evaluation plan is used to assess the effectiveness of the innovation by evaluating the

30

identified outcomes. In the innovation, the primary outcome is the breastfeeding rate in all forms,

including exclusive breastfeeding and partially breastfeeding in different intervals (1 month and 2

months after delivery) in postnatal period. And the secondary outcome is the level of satisfaction

among frontline nurses.

Primary outcome

The breastfeeding rate in all forms, including exclusive breastfeeding and partially

breastfeeding at 1 month and 2 months after delivery in postnatal period would be the primary

outcome (client outcome) of the innovation. Nurses would use standardized breastfeeding form and

telephone support tips card to collect breastfeeding data which is verbally reported by eligible

participants in each telephone call. To determine the effectiveness of the innovation, these collected

breastfeeding data would be compared with other clients who do not participate in the innovation in

the hospital.

Secondary outcome

For the outcome of health care professionals, the satisfaction level among the frontline

nurses would be considered. They are provided with regular meeting during the innovation to

express their feedback and concerns with regard to the innovation. In addition, a tailor-made

questionnaire form (Refer to Appendix L) would be used to assess their satisfaction level about the

innovation.

Characteristics of clients

During the recruitment process, only those local mothers who choose to breastfeed at the

first registration would be invited for the innovation. For their eligibility, they are required to have

good past health without significant obstetric history during pregnancy which may impair their

capability to breastfeed.

Sample size calculation

The sample size calculation of the innovation is performed by the Piface Application version

31

1.76 (Lenth, 2011). To determine whether the breastfeeding rate is improved after the

implementation of the innovation, two-tailed z-test statistical method is used for testing one

proportion. Taking the level of significance at 5% and the power at 80%, the calculated sample size

is 194 when setting null value as 0.4 and actual value as 0.5. According to one of the selected

studies (Fu et al., 2014), the dropout rate is set as 5%, the required sample size is 204.2 (rounding

up to 205). It is estimated that there are 55-65 eligible participants recruited each week. As a result,

the recruitment period lasts for 4 weeks to acquire sufficient number of sample size in the

innovation.

Outcomes measurement

Primary outcome (Breastfeeding rate)

A standardized breastfeeding data collection form (Refer to Appendix J) would be used to

assess clients’ feeding method in each telephone counseling. Nurses would assess the infant’s age

and their feeding method as verbally reported by the clients. Whenever a client claims that she

would stop breastfeeding, telephone counseling will no longer be provided. The total duration of

breastfeeding would be calculated from the day of starting breastfeeding to the day that the client

stops breastfeeding.

Secondary outcome (Level of satisfaction among nurses)

It is worth considering the level of satisfaction among nurses since the participating nurses

are required to handle additional workload during the innovation. Nurses may provide precious

feedback towards the innovation. A tailor-made questionnaire (Refer to Appendix L) would be used

to assess their level of satisfaction. It would be distributed to all participating nurses after the

completion of the innovation. The questionnaire adopts 10-point Likert scale (1= totally disagreed,

10= totally agreed) which allows nurses to rate each statement according to their perception.

Data analysis

The aim of outcomes measurement is to determine if the breastfeeding rate is improved after

32

the innovation by comparing to those mothers who do not participate the innovation in the hospital.

The two-tailed z-test statistical method is used for testing one proportion in this innovation. For the

analysis of the level of satisfaction among the frontline staff, the two-tailed paired t-test would be

used to compare with the results before implementing the innovation.

Basis for effectiveness

There are some criteria to determine if the innovation is effective to improve the

breastfeeding rate and the level of satisfaction among nurses.

Primary outcome (Breastfeeding rate)

In accordance with the local breastfeeding statistics conducted by Department of Health in

2012 (Ching, 2014), the breastfeeding rate in all forms (including exclusive breastfeeding & partial

breastfeeding) at 1 month after delivery is 68.6%. The innovation is therefore considered effective if

the breastfeeding rate in all forms in 1 month is higher than the above percentage.

Secondary outcome (Level of satisfaction among nurses)

A successful innovation is not only supported by statistically significant figures, but also

welcomed by frontline nurses’ recognition. Nurses’ feedback can be reflected via the questionnaire

that assesses their level of satisfaction. The overall expected percentage is 70% of nurses would rate

at least 7/10 for more than 5 statements in the questionnaire.

Conclusion

In the past several decades, the public has become more aware of the benefits of

breastfeeding to both mothers and infants. Despite of the effort of the Government and the local

organizations, the overall breastfeeding rate in Hong Kong (including exclusive breastfeeding and

partial breastfeeding) still lags behind WHO recommendations. Therefore, it is proposed telephone

support to those breastfeeding mothers after hospital discharge would help them maintain longer

duration of breastfeeding and thus improve breastfeeding rate in 1 month.

There are various ranges of supportive measures for mothers to maintain breastfeeding, such

33

as postnatal breastfeeding peer support group, breastfeeding talk and breastfeeding coaching. With

consideration to Chinese traditional culture, postnatal mothers tend to “sit month” for 1 month after

delivery. Nevertheless, the first month after delivery is the most crucial period for them since they

need professional assistance to overcome the difficulties of breastfeeding, such as management of

breast engorgement, and desired breastfeeding position for those mothers with post-operative

wound pain. All of the results in the selected studies showed that telephone support had positive

outcomes on breastfeeding duration. Telephone support is therefore chosen as an ideal

communication tool to provide continuous breastfeeding support in the early postnatal period. After

the implementation of pilot study and its evaluation, postnatal telephone support with evidence-

based guidelines is recommended to prolong duration of breastfeeding in Hong Kong.

34

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37

Appendices

Appendix A: PRISMA diagram

Records identified through

PubMed searching

(n=487)

Additional records identified

through CINAHL

(n=100)

Records of duplicates removed

(n=93)

Records screened

(n=494) Records excluded

(n=478)

Full-text articles

assessed for eligibility

(n= 16 )

Full-text articles excluded

with reasons (n=11)

Reasons of excluded:

(1) combined intervention,

containing telephone

support and other

intervention; (2) outcome

measured not match with

our study

Number of reviewed

articles included (n=5)

38

Appendix B: Table of Evidence

Sample characteristics Intervention Control Outcomes Effect size

1

2

3

4

5

Citation/ Design/

Origin of country/

Level of Evidence

Tahir, N. M., &

Al-Sadat, N.

(2013) / RCT,

Malaysia (1+)

(1) 88.2% Malay women ;

(2) uncomplicated

pregnancy: singleton & term

delivery; (3) intended to

breastfeed; (n=357)

Telephone lactation counseling

given by lactation counselors

via telephone twice monthly

(n=179)

Received standard care, such as

breastfeeding talks and

breastfeeding advice

(n=178)

Rate of exclusive breastfeeding at

1,4 & 6 month after delivery

1 month: OR 1.627

4 month: OR:1.173

6 month: OR: N/A

Fu, I. C. Y.et al.

(2014) / RCT,

Hong Kong (1+

+)

(1) Hong Kong Chinese

primiparas;

(2) intended to breastfeed;

(3) without major obstetric

or medical complications;

(4) term pregnancy

(n=722)

2 intervention arms:

(1) In-hospital group: 30mins BF

support sessions for 3 times

(n= 191);

(2) Telephone group: weekly

telephone support for up to 4

weeks postpartum or until

breastfeeding had been completely

stopped

(n=268)

Received standard postnatal care

such as routine group postnatal

lactation education & post-

discharge followup

(n=263)

Rate of any and exclusive

breastfeeding at 1, 2, and 3

months.

Telephone VS Control (any

BF)

1 month: OR 1.63 P=0.01

2 month: OR 1.48 P=0.03

3 month: OR 1.37 P=0.08

Telephone VS Control

(exclusive BF)

1 month: OR 1.89 P=0.003

2 month: OR 1.43 P=0.12

3 month: OR 1.20 P=0.45

Carlsen, E. M. et

al. (2013)/ RCT,

Danmark (1+)

(1) women who participated

in the Treatment of Obese

Pregnant study;

(2) intended to breastfeed;

(3) without history of breast

surgery

(n=226)

(1) received telephone support, by

lactation consultant during first 6

months

(n=108)

(1) provided standard

breastfeeding support during

hospitalization;

(2) received routine follow up

(n=118)

Rate of any and exclusive

breastfeeding at 3 & 6 months of

postpartum.

Exclusive BF

3 month: OR 2.45 P=0.003

Partial BF

6 month: OR 2.25 P=0.008

Dennis, C. L. et

al. (2002)/ RCT,

Canada (1+)

(1) aged 25-34 women

intended to breastfeed;

(2) Acquired college or

undergraduate university

education level;

(3) without significant

maternal illness that may

impair breastfeeding

(n=359)

(1) Telephone support conducted

by peer volunteer, no standard

frequency of telephone contact as

mother requested

(n=132)

Received conventional in-hospital

care & community postpartum

support services

(n=126)

Primary outcome: rate of

breastfeeding;

Secondary outcome: maternal

satisfaction of infant feeding

1 month: RR 1.10 P= 0.03

3 month: RR 1.21 P=0.01

Simonetti et al,

(2012)/ RCT,

Italy (1-) Pilot

study

(1) Italian healthy

primiparous mothers;

(2) term delivery;

(3) Intended to

BF (n= 114)

Received structured telephone

support by licensed midvives;

timing of phone calls are agreed by

participants and midvives.

(n=55)

Provided conventional counselling

program consisting of periodical

visits with the physician

(n=59)

Rate of exclusive breastfeeding at

1,3 & 5 month after delivery

1 month: RR 1.8

3 month: RR 1.9

5 month: RR 2.1

39

Appendix C: Quality assessment

Quality assessment using SIGN Methodology Checklist for RCTs

Section 1: Internal Validity

Tahir & Al-Sadat (2013) Carlsen et al.(2013) Dennis et al.(2002) Simonetti et al. (2012)

Clearly focused question

Randomization Can't say

Allocation concealment

Blinding Can't say

Comparable group

Treatment is the only difference

Valid & reliable outcome measures

Drop-out rate IG 10.6%; CG 11.2% IG 2.78%; CG 13.6% IG 0%; CG 1.59% N/A

Intention-to-treat analysis

Comparable results from all sites N/A N/A N/A N/A

Section 2: Overall Assessment

Risk of bias minimized High quality (++) High quality (++) Low quality (-) Low quality (-) Low quality (-)

Overall effect due to intervention alone Not sure Not sure

Result applicable to target group

Notes

Level of Evidence (1+) (1++) (1+) (1+) (1-)

Fu et al.(2014)_

IG(1) 0.52%; IG(2) 2.6%;

CG 1.14%

Intention-to-treat analysis is

not clearly mentioned.

Conclusion: The benefit of

telephone support in

prolonging the duration of

breastfeeding was shown

across the first 6 months

postpartum in this study.

Therefore, professional

support should be initiated

soon after birth and

continued for at least 1 month

postpartum.

Comments: Further study

should explore why the rate

of exclusive breastfeeding is

persistently low in the early

postnatal period.

Conclusion: The telephone-

based intervention by a

lactation consultant

prolongs exclusive and

partial breastfeeding in

obese women during the

first 6 month postpartum.

Comments: No allocation

concealment and intention-

to-treat analysis is

mentioned.

Conclusion: Telephone-based

peer support, in conjunction

with professional support may

help new mothers continue to

breastfeed.

Comments: Future research

may explore the role of peer

volunteers who may act

connection between mothers

in the community and health

care professionals.

Conclusion: . The structured

telephone support

conducted by WHO–

UNICEF licensed midwives

showed its effectiveness on

breastfeeding duration

during the first 5 months on

Italian primiparous women.

Comment: This study show

some findings which are

different from previous

studies, they found a

positive association between

job resuming after childbirth

and continuing full

breastfeeding.

40

Footnotes:

: Yes

: No

IG: Intervention group

CG: Control group

N/A: Not applicable

41

Appendix D: Timeframe for the innovation

Month 1 2 3 4 5 6 7 8 9 10 11 12

Establish the protocol for the innovation

Manpower arrangement

Preparation of orientation and refresher programme

Obtain approval from the hospital

Implement the innovation

Recruit participants

Perform postnatal telephone lactation breastfeeding

counseling by qualifies nurses

Data collection.

Data analysis

Evaluation

42

Appendix E: Material and non-material costs of implementing the innovation

Items Estimated cost (HKD $) per month

Printout of learning material for the training programme $3,000.00

Cost of buying 5 telephones $2,500.00

Cost of buying logbooks for nurses $1,000.00

Cost of inviting guest speakers and expert for training programme $10,000.00

Cost of standard care (Nurses’ working salary) $30,000.00 (average monthly salary of each nurse)x 10 (total number of

participated nurses)= $300,000.00

Work hour compensation of nurses to attend the training programme $200 (Hourly nurses’ salary) x6hrs (3hr per session)x 30 (no. of participated

nurses)=36,000

Total $342,500.00

Appendix F: Material and non-material costs of not implementing the innovation

Items Estimated cost (HKD $) per month

Cost of standard care (Nurses’ working salary) $30,000.00 (average monthly salary of each nurse)x 10 (total number of

participated nurses)= $300,000.00

Total $300,000.00

Appendix G: Calculation of cost-benefit ratio

Cost-benefit ratio

= (cost of implementing the innovation – cost of not implementing the innovation)/ cost of not implementing the innovation x100%

= (342,500-300,000)/300,000 x100%

= 14.2% (correct to 3 significant figures)

43

Appendix H: Grades of Recommendations (SIGN, 2004)

Grades Statements

A

At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A body

of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall

consistency of results

B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall

consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+

C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall

consistency of results; or Extrapolated evidence from studies rated as 2++

D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+

Appendix I: Levels of Evidence (SIGN, 2004)

Level of evidence Evidence statements

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort or studies. High quality case control or cohort studies with a very

low risk of confounding or bias and a high probability that the relationship is causal

2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the

relationship is causal

2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not

causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

44

Appendix J: Breastfeeding data collection form

Breastfeeding data collection form

Client’s label

Date: ___________

Age of infant*: 1 month/ 2 month/ Others:____________

Feeding history

Type of feeding*:

Exclusive breastfeeding/ Partial breastfeeding/ Formula feeding

Time stopping breastfeeding: _________

Remarks: If client stops breastfeeding, nurses are not required to assess the following data.

Frequency of feeding/day: ____ times per day

Duration of each feed: ____ mins Fed with (one / both) breast(s)*

Any concerns raised by client?

_________________________________________________________________

Advice given: _________________________________________________________________

Nurse’s name & signature: __________________

*Please circle for the appropriate column.

45

Appendix K: Telephone support checklist

Telephone support tips card

Tips: Nurses can implement the following telephone support tips to the clients according to their

individual needs.

1. Actively listen to the client’s concern(s) and identify their needs on

breastfeeding.

2. Provide fundamental breastfeeding knowledge, such as common types of

positioning, signs of correct latch on.

3. Identify any barrier(s) of breastfeeding and provide appropriate management

accordingly, such as management of breast engorgement.

4. Assess client’s emotional status. Whether their family members support

breastfeeding.

46

Appendix L: Questionnaire for the level of satisfaction among nurses

Please circle the number which indicates your feelings about the innovation the most.

Strongly disagree ----------------------> Strongly agree

Preparation stage

1. The duration of orientation program is

appropriate to me. 1 2 3 4 5 6 7 8 9 10

2. The content of orientation program is

appropriate to the innovation. 1 2 3 4 5 6 7 8 9 10

Implementation stage

3. The content of breastfeeding form facilitates

me to record the data efficiently. 1 2 3 4 5 6 7 8 9 10

4. The manpower arrangement is acceptable and

reasonable. 1 2 3 4 5 6 7 8 9 10

5. I am competent to handle telephone support

and deliver breastfeeding knowledge to clients

accordingly.

1 2 3 4 5 6 7 8 9 10

6. The communication team is helpful and

supportive. 1 2 3 4 5 6 7 8 9 10

Evaluation stage

7. I am overall satified with the innovation. 1 2 3 4 5 6 7 8 9 10

8. I think the innovation is helpful in supporting

breastfeeding among mothers. 1 2 3 4 5 6 7 8 9 10

47

Appendix M: Evidence-Based Practice Guideline

Evidence-Based Practice Guideline

Title of the guidelines

Telephone breastfeeding counseling for lactating mothers after discharged from hospital.

Objectives of the guidelines

The objectives of this Protocol are to:

- Provide continuous psychological support for those mothers via telephone counseling;

- Deliver breastfeeding knowledge and skills to those mothers based on the existing evidence,

- Prolong the duration of breastfeeding among those lactating mothers after discharged from

hospital.

Target group of the guidelines

The target population is those mothers who had no significant obstetric history during

pregnancy and had term delivery, intend to breastfeed, are willing to participate telephone

breastfeeding counseling after hospital discharge.

Evidence-based recommendations

There are some recommendations developed from the 5 selected articles. The grading of

recommendations is based on the SIGN guidelines in Appendix D.

1. Participated nurses are required to complete the relevant breastfeeding training

programme prior to conducting telephone breastfeeding counseling (Grade B)

Available evidence: In order to maintain uniformity and quality of care, the participated nurses

should be qualified by relevant training or refresher courses on breastfeeding management and

counseling skills (1+ Tahir & Al-Sadat, 2013).

2. The willingness of breastfeed must be assessed during the selection process. Only

those mothers who meet the inclusion criteria and declare to intend for breastfeeding would be

eligible for the innovation. (Grade A)

48

Available evidence: The intention to breastfeed is assessed and only those mothers who plan to

breastfeed will be recruited (1+ Fu et al., 2014).

3. The timing of telephone support should be mutually agreed by both nurses and

mothers. (Grade B)

Available evidence: Timing of telephone calls are commonly agreed by nurses and mothers to

minimize the possible interruption of their daily family routines (1+ Fu et al., 2014; 1-

Simonetti, 2012).

4. The content in telephone counseling should focus on delivering breastfeeding

knowledge, assessing their breastfeeding concerns and emotional health. In addition, cultural

issues should be also addressed. (Grade A)

Available evidence: The telephone counseling with well-organized content can help mothers to

resolve their breastfeeding concerns and psychological needs (1+ Fu et al., 2014). Chinese

mothers may need to deal with family pressure to stop breastfeeding since they worry

breastfeeding is unable to satisfy infants’ needs.