236 BIRTH 28:4 December 2001

Postpartum Positioning and Attachment Education forIncreasing Breastfeeding: A Randomized Trial

Ann Henderson, RM, DipT, BEd, MEd Studies, Georgina Stamp, RM, MSc, PhD,and Jan Pincombe, RM, BA, MAppSc, PhD

ABSTRACT: Background: Although lactation experts suggest that a correct positioningand attachment technique reduces breastfeeding problems and enhances long-termbreastfeeding, evidence from randomized trials is lacking. The objective of this study wasto evaluate the effect of postpartum positioning and attachment education on breastfeedingoutcomes in first-time mothers. Method: A randomized trial was performed in a publichospital in Adelaide, South Australia, where 160 first-time mothers were randomly allocatedto receive either structured one-to-one education (experimental group) or usual postpartumcare (control group) within 24 hours of birth. The primary outcome was breastfeeding at6 weeks and 3 and 6 months postpartum; other outcomes were nipple pain and trauma inhospital and at 6 weeks and 3 and 6 months, and satisfaction with breastfeeding. Results:No significant differences occurred in breastfeeding rates between the groups at eachendpoint, although a trend in the direction of lower rates was seen at each endpoint in theexperimental group. This group reported less nipple pain on days 2 (p � 0.004) and 3 (p� 0.04), but this was not sustained on follow-up. No differences were observed in nippletrauma in hospital or in self-reported nipple pain and/or trauma at the three endpoints.Experimental group women were less satisfied with breastfeeding at 3 and 6 monthspostpartum when using a one-item measure; however, a multiple-item measure showed nosignificant differences at the three endpoints. Conclusions: The intervention did not increasebreastfeeding duration at any assessment time or demonstrate any differences between thegroups on secondary outcomes. The trend toward lower breastfeeding rates in the experimen-tal group suggests a need for a larger trial to evaluate whether or nor postpartum positioningand attachment education may negatively affect breastfeeding. (BIRTH 28:4 December2001)

Breastfeeding is promoted internationally as the rec- percent at 6 months (2). In a national breastfeedingsurvey conducted in 1995, 82 percent of women initi-ommended method of feeding infants for the first 6

months (1). Optimal target rates for the year 2000 and ated breastfeeding, and at 3 months 62 percent and at6 months 46 percent were either partially or exclusivelybeyond for exclusive breastfeeding in Australia are 90

percent at 6 weeks, 60 percent at 3 months and 50 breastfeeding (3). These rates are higher than thosereported in Scotland, the United States, New Zealand,and China but lower than Denmark, Norway, and Swe-den (3–8), but different timing of measurements make

Ann Henderson is a doctoral student in the School of Nursing and accurate comparisons difficult. Although many Austra-Midwifery, University of South Australia; Georgina Stamp is an

lian women initiate breastfeeding in common with in-adjunct Senior Research Fellow, School of Nursing and Midwifery,University of South Australia; and Jan Pincombe is Professor, ternational figures, many stop. Poor supply, socialSchool of Nursing and Midwifery, University of South Australia, pressures, nipple pain, and nipple trauma are reasonsAdelaide, Australia.

commonly cited in the literature (9,10).In Australia most women give birth in hospital, andAddress correspondence to Ann Henderson, Senior Lecturer in

Nursing and Midwifery Division of Health Sciences, University of midwives provide postpartum care in public, private,South Australia, GPO 2471, Adelaide SA 5001, Australia.

or community settings (11). The average length ofhospital stay after a vaginal birth is 2 to 3 days and� 2001 Blackwell Science, Inc.

237BIRTH 28:4 December 2001

after a cesarean birth, 5 to 7 days. Midwives provide The researcher (AH) approached and invited eligiblewomen to take part in the trial in the postpartum wardin-home follow-up to some women, primarily those

who gave birth in the public health system (11), and area of the hospital within 24 hours of birth. An infor-mation sheet about the study was provided and writtentherefore they are the caregivers for women who are

initiating breastfeeding. informed consent was obtained from all participants.University and hospital Human Research and EthicsCorrect positioning and attachment play a crucial

role in the successful establishment and maintenance Committee approval was granted.A midwife who was not involved in the researchof breastfeeding (12). Positioning and attaching a new-

born at the breast is a learned and mostly manual skill organized randomized schedules by separate com-puter-generated balanced blocks of 20 in individuallythat is acquired through education, observation, and

practice (13,14). Since breastfeeding is less overt in sealed opaque envelopes that were sequentially or-dered from 1 to 200. After obtaining consent, the re-public and family environments in contemporary West-

ern culture, many women are deprived of the direct searcher telephoned an independent ward area to obtainthe randomized treatment allocation, where a midwifeexperience of observing breastfeeding (14,15).

Imaging techniques show that during correct posi- selected and opened the next sequentially ordered en-velope, and informed the researcher of the group allo-tioning and attachment the nipple is at the back of the

mouth in the soft palate area, protected from pressure cation. This method enabled the randomizationschedules to be concealed from the researcher andand friction (16,17), which can induce nipple inflam-

mation, skin damage, and pain, especially during the midwives on the postpartum ward, a factor consideredto be important in avoiding potential selection bias.first week postpartum (18–21). A Cochrane systematic

review of randomized trials on breastfeeding technique Women were randomized to receive postpartum posi-tioning and attachment education (experimental group)showed that poor positioning and attachment were asso-

ciated with low supply, nipple trauma, breast engorge- or to receive usual postpartum breastfeeding care (con-trol group). All women, irrespective of their treatmentment, and early weaning (22). The review concluded

that health professionals trained in breastfeeding tech- allocation, received the usual breastfeeding care pro-vided by the hospital midwives. In preparation for thenique should give women early practical advice on cor-

rect positioning and attachment to reduce problems and trial, four focus group discussions were conducted witha convenience sample of 18 midwives in the studyincrease breastfeeding duration.

Another Cochrane review reported that antepartum hospital to establish usual breastfeeding practices. Dis-cussions revealed considerable variation in informa-and postpartum interventions effective in increasing

breastfeeding duration include access to a breastfeeding tion provided and styles of assistance. Midwives mostoften provided hands-on assistance with the techniqueexpert, antenatal education, information and advice,

health professional and volunteer counseling, and post- of positioning and attachment: that is, the midwifeactively attached the infant for the woman. Formalpartum support. Face-to-face support from ‘‘expert pro-

fessionals’’wasassociatedwith increasedbreastfeeding education and assessment of positioning and attach-ment were not a focus of usual practice (25).duration, particularly in the first 2 months postpartum

(23). Published research is meager on early postpartumeducation by midwives for women planning to Procedurebreastfeed. No randomized trials on positioning andattachment education in the early postpartum period After allocation to the experimental group, and within

the first 24 hours of birth, the researcher, who was also(first 24 hours) were located in the literature. Ourrandomized trial was designed with sufficient power the educator (AH), provided a one-to-one standardized

education session lasting 30 minutes. She negotiatedto evaluate the effect of a standardized education inter-vention on breastfeeding and other outcomes. with the woman to conduct the session at the infant’s

next breastfeed. Visual, written, and verbal informationcovered simple breast anatomy, various positions ofMethodsthe infant at the breast, principles of correct attachment,and the three stages of suckling. A cloth breast modelStudy Population and Designwas used to explain breast anatomy and physiologyand the importance of positioning the infant’s jawsA 1:1, two-group randomized trial was conducted be-

tween June and September 1999 in a public hospital in behind the nipple so milk sinuses could be compressed.Advice and verbal assistance were given with position-Adelaide, South Australia, where approximately 4000

babies are born annually (24). First-time, English- ing and attachment during the breastfeed using a hands-off technique; that is, the educator did not physicallyspeaking mothers who planned to breastfeed and had

a singleton, term infant with an Apgar score of 7 or position or attach the infant. The technique of self-positioning and self-attachment by the woman and themore at 5 minutes were eligible to enter the trial.

238 BIRTH 28:4 December 2001

cues she could use to determine that her technique was from 0 to10 as before, and to report any past or existingnipple trauma using the previously identified charac-correct were the main foci of the intervention.

During the session, and on each subsequent day teristics. Satisfaction with breastfeeding was addressed,first, with an overall rating question where ‘‘0’’ meantin hospital, the woman’s positioning and attachment

technique was assessed and immediate feedback given. verysatisfiedand‘‘10’’meantverydissatisfied.Second,statements expressing specific views about breastfeed-The LATCH tool was used for the assessment. This

measure was found to be valid (26) and reliable (27) ing were presented (29–31), and a 4-point Likert scalerated them as either ‘‘strongly agree,’’ ‘‘agree,’’ ‘‘dis-when providing feedback on a woman’s ability to posi-

tion and attach her infant. A recent study also reported agree,’’ ‘‘strongly disagree,’’ ‘‘always,’’ ‘‘often,’’‘‘sometimes,’’ and ‘‘never,’’ as appropriate. Responsesthat the use of this tool was positively correlated with

breastfeeding duration (28). Because of the nature of were scored as 4, 3, 2, or 1, respectively, and summedto produce the total score. The higher the score the morethe intervention, it was not possible to mask the woman

or the person who conducted the intervention. satisfied the woman was with breastfeeding. The re-searcher contacted all participants at 6 weeks, 3 months,and 6 months postpartum by telephone using theAnalysisquestionnaire.

Data were analyzed using a Student t test for contin-The trial was designed to test a primary hypothesis thatfirst-time mothers who receive postpartum positioning uous variables. For categorical variables we used chi-

square 2�2 contingency tables and relative risks withand attachment education will breastfeed their babieslonger than a matched control group who receive usual their 95% confidence intervals and p values, with 0.05

as significant. For a cell value of less than 5, a Fisherbreastfeeding care at 6 weeks and 3 and 6 monthspostpartum. A sample size of 150 would have the exact test was used. All data were analyzed as intention

to treat.power to detect a 20 percent difference in breastfeedingrates from 70 to 90 percent at 6 weeks postpartum; a23 percent difference from 55 to78 percent at 3 months Resultspostpartum; and a 24 percent difference from 42 to 66percent at 6 months postpartum (using two-tailed tests Of 184 eligible women approached, 160 consented and

were randomized to the experimental or the controlat the 5% level (� � 0.05). Secondary outcomes ofnipple pain and trauma and of satisfaction with group. One woman withdrew after randomization to

the experimental group but before the intervention tookbreastfeeding were assessed daily in hospital and againby telephone interview at 6 weeks and 3 and 6 months place. A high rate of return occurred in both arms of

the trial at each of the follow-up points: at 6 weeks,postpartum.A nipple visual analog scale measured the intensity 79/80 (99%) in each group; at 3 months 78/80 (98%)

in the experimental group and 76/80 (95%) in theof nipple pain in all participants. It has been reportedas a valid and reliable measure for nipple pain in control group; and at 6 months 75/80 (94%) in each

group. A total of 10 women (5 in each group) werebreastfeeding women (20). All women in the trial wereasked by the researcher (AH) to report nipple pain on lost to follow-up.

Characteristics of the two groups were similar ateach day of the hospital stay where ‘‘0’’ meant no painand ‘‘10’’ the maximum pain possible. The researcher trial entry for mean age, mode of birth, timing of the

decision to breastfeed, planned length of breastfeeding,also observed all women in the trial for nipple traumaon each day in the hospital. Accepted characteristics private or public health insurance, smoking status, and

education background (Table 1).of nipple trauma, such as redness, peeling, blistering,bruising, bleeding, cracking, and scabbing, were in- No statistically significant differences occurred be-

tween the study groups for breastfeeding duration atcluded (20,21). A score of 2 was allocated if the charac-teristic was observed or a score of 1 if not observed. the three endpoints (Table 2). At 6 weeks, 60 of 79

women (76%) in the experimental group wereNo attempt was made to compare the severity of eachcharacteristic. In preparation for the trial, this measure breastfeeding compared with 65 of 79 women (82%)

in the control group (p � 0.3). At 3 months, 56 of 78was piloted with 17 women and 2 independent observ-ers, revealing excellent reliability (r � 0.97) and ac- women (72%) in the experimental group and 57 of 76

women (75%) in the control group were breastfeedingceptable face validity.A purpose-designed, self-report questionnaire that (p � 0.7). At 6 months, 42 of 75 women (56%) were

still breastfeeding in the experimental group comparedasked about breastfeeding or artificial feeding practiceswas used to collect data on the primary and secondary with 48 of 75 (64%) in the control group (p � 0.3).

Fewer women in the experimental group reportedoutcome measures. Women were also asked to casttheir minds back over their breastfeeding experience nipple pain in hospital than in the control group. On

day 2, nipple pain increased in both groups (Table 3).and report any past or existing nipple pain on a scale

239BIRTH 28:4 December 2001

Table 1. Characteristics of Groups

Experimental Group Control GroupCharacteristics (n � 80) (%) (n � 80) (%) RR (95% CI) p

Mean age (yr) 27.6 SD�5.6 27.2 SD�5.7 t � 0.5 0.6Mode of birth

Spontaneous 46 (58) 43 (54) 1.07 (0.81–1.41) 0.6Instrumental 13 (16) 17 (11) 0.76 (0.40–1.47) 0.4Cesarean section 21 (26) 20 (25) 1.05 (0.62–1.78) 0.9

Breastfeeding decisionBefore pregnancy 53 (66) 55 (69) 0.96 (0.78–1.19) 0.7During pregnancy 27 (34) 25 (31) 1.08 (0.69–1.69) 0.7

Planned duration6–11 wk 2 (2) 2 (2) 1.33 (0.79–2.26) 1.03–6 mo (24) (30) 18 (23) 1.00 (0.57–1.74) 0.37–12 mo 19 (24) 19 (24) 0.88 (0.33–2.30) 1.0>12 mo 7 (9) 8 (10) 0.92 (0.58–1.46) 0.8As long as I can 24 (30) 26 (32) 0.57 (0.17–1.88) 0.7Unsure 4 (5) 7 (9) 0.3

Health insurancePublic 72 (90) 74 (93) 0.97 (0.88–1.07) 0.6Private 8 (10) 6 (7) 1.33 (0.48–3.67) 0.6

Smoker 11 (14) 10 (12) 1.10 (0.50–2.44) 0.8Education

University 17 (21) 15 (19) 1.13 (0.61–2.11) 0.7Technical college 21 (26) 26 (33) 0.81 (0.50–1.31) 0.4Certificate 18 (23) 17 (21) 1.06 (0.59–1.90) 0.8Left school � 15 yr 5 (6) 4 (5) 1.0Left school > 15 yr 19 (24) 18 (22) 1.06 (0.60–1.86) 0.9

SD � standard deviation; RR � relative risk; CI � confidence interval.

Table 2. Breastfeeding at 6 Weeks, 3 Months, and 6 Months Postpartum

Experimental Group Control Group

Time Postpartum No. (%) No. (%) RR (95% CI) p

6 wk (n � 79) (n � 79)60 (76) 65 (82) 0.92 (0.79–1.08) 0.3

3 mo (n � 78) (n � 76)56 (72) 57 (75) 0.96 (0.79–1.16) 0.7

6 mo (n � 75) (n � 75)42 (56) 48 (64) 0.88 (0.67–1.14) 0.3

RR � relative risk; CI � confidence interval.

Table 3. Self-reported Nipple Pain in Hospital

Experimental Group Control Group

Hospital Day No. (%) No. (%) RR (95% CI) p

Day 1 (n �79) (n � 80)No pain 75 (95) 73 (92) 0.58 (0.18–1.90) 0.4Pain 4 (5) 7 (8)

Day 2 (n � 79) (n � 79)No pain 48 (61) 30 (38) 0.63 (0.46–0.87)* 0.004*Pain 31 (39) 49 (62)

Day 3 (n � 76) (n � 74)No pain 37 (49) 24 (32) 0.76 (0.58–0.99)* 0.04*Pain 39 (51) 50 (68)

* Statistically significant.RR � relative risk; CI � confidence interval.

240 BIRTH 28:4 December 2001

A significant difference was observed between the two with breastfeeding, confidence in their breastfeedingability, belief that breastfeeding calmed an upset infant;groups for nipple pain on day 2 (39% vs 62%, p �

0.004) and day 3 (51% vs 68%, p � 0.04). These and observing that her infant derived satisfaction frombreastfeeding.differences were not present on any other postpartum

day or at 6 weeks, 3 months, or 6 months postpartum(Table 4). A high incidence of nipple trauma was ob- Discussionserved in both groups in the first few days in hospital,predominantly related to nipple redness, but no signifi- Correct positioning and attachment are promoted as

being vital components of successful breastfeeding incant differences were noted between the groups on anyday in hospital or at the three endpoints (Table 4). the literature (15–18); nevertheless, many women find

these skills hard to achieve (32). In Australia, midwivesNo difference occurred in mean satisfaction withbreastfeeding scores, using the verbal analog scale, at are the primary providers for support to breastfeeding

women in the early postpartum period (11).6 weeks postpartum; however, women in the experi-mental group were significantly less satisfied with To the best of our knowledge, this study is the first

randomized trial to evaluate the effect of postpartumbreastfeeding at 3 months (p � 0.03) and at 6 months(p � 0.03) (Table 5). From 22 specific statements, positioning and attachment education by a midwife on

breastfeeding outcomes in first-time mothers. Thus itwomen in the experimental group were also less satis-fied with some aspects of breastfeeding, namely, ease contributes to the small number of randomized trials

Table 4. Self-reported Nipple Pain and Trauma at 6 Weeks, 3 Months, and 6 Months Postpartum

Experimental Group Control GroupStatus and TimePostpartum No. (%) No. (%) RR (95% CI) p

Pain6 wk (n � 79) (n � 79) 0.7

No pain 58 (73) 60 (75) 1.11 (0.65–1.89)Pain 21 (30) 19 (25)

3 mo (n � 78) (n � 76) 0.7No pain 64 (82) 64 (84) 1.14 (0.56–2.30)Pain 14 (18) 12 (16)

6 mo (n � 75) (n � 75) 0.4No pain 66 (88) 62 (83) 0.69 (0.32–1.52)Pain 9 (12) 13 (17)

Trauma6 wk (n � 79) (n � 79) 0.7

No trauma 65 (82) 63 (80) 0.88 (0.46–1.67)Trauma 14 (17) 16 (20)

3 mo (n � 78) (n � 76) 0.8No trauma 67 (86) 67 (87) 1.09 (0.49–2.41)Trauma 11 (14) 10 (13)

6 mo (n � 75) (n � 75) 0.5No trauma 67 (89) 64 (85) 0.73 (0.31–1.71)Trauma 8 (11) 11 (15)

RR � relative risk; CI � confidence interval.

Table 5. Overall Verbal Analog Mean Score for Satisfaction with Breastfeeding

Experimental Group Control GroupTime Postpartum Mean (SD) Mean (SD) t p

6 wk (n � 79) (n � 79)2.65 (2.80) 2.00 (2.22) 1.62 0.1

3 mo (n � 78) (n � 76)2.37 (2.70) 1.49 (2.18) 2.22 0.03*

6 mo (n � 75) (n � 75)2.35 (2.77) 1.47 (2.16) 2.17 0.03*

* Statistically significant.SD � standard deviation.

241BIRTH 28:4 December 2001

on interventions to increase breastfeeding rates. This thema and edema of the nipple appeared common,peaking on the third to seventh day (21).trial was appropriately designed with power calcula-

tions to allow for a clinically relevant increase in Finally, although not measured in this study, a pos-sible unintended consequence of the emphasis on in-breastfeeding rates. The return rate was high, and the

randomization ensured that groups were similar in im- struction and assessment of positioning and attachmentmay have been to raise anxiety in first-time mothers.portant characteristics that may affect breastfeeding.

The results revealed that postpartum positioning The early postpartum period, particularly, is a timewhen mothers have many skills to learn in addition toand attachment education is ineffective in increasing

breastfeeding duration. Not only did we find that breastfeeding. The physical and psychological eventsof childbirth may also influence the amount of informa-breastfeeding and other related outcomes for the exper-

imental group were no better than those for women in tion a new mother can process (34). Therefore thisintervention may have contributed to a feeling thatthe control group, we could not rule out the possi-

bility that the intervention may have contributed to breastfeeding was too difficult for women in the exper-imental group. It was also of concern that women inlower breastfeeding rates and less satisfaction with

breastfeeding. the experimental group were overall less satisfied withbreastfeeding. Further research could include a rangeThe primary limitation of the study relates to the

significant involvement of the researcher (AH) in the of psychosocial outcomes not addressed in this study.Study power calculations allowed for statisticallystudy. This researcher conducted the intervention and

was therefore aware of group allocation, thus creating significant and clinically relevant increases inbreastfeeding associated with the intervention, but aa source of potential bias. The researcher also con-

ducted the pain assessment in hospital. It is possible trend toward a decline occurred. Given the importanceaccorded to positioning and attachment in the literaturethat, as a result, women who received the supportive

intervention may have been more hesitant to admit and the lack of any controlled trials of interventions,these predictions were appropriate. The 8 percent trendpain to her. In addition, a bias was possible in the

visual assessment of nipple trauma that was conducted detected at 6 months is also of clinical relevance. Forthis study to have sufficient power to detect an 8 per-by this researcher. The likelihood of this possibility

may have lessened with the passage of time at the 6 cent difference (at the 5% level), a sample size of1,224 would have been required.weeks and 3 and 6 months assessments.

In relation to blinding, since the breastfeeding This research contributes new evidence aboutbreastfeeding care offered to women in the postpartumwomen were aware of their group allocation, it is

possible they may have talked about the study to each environment in Australia. As a small trial conductedin one setting, it should perhaps be viewed as a pilotother. Midwives also may have been able to determine

group allocation by noting the time taken by the re- study. On the basis of the results of the study, we areunable to recommend that this intervention be adoptedsearcher on activities with each woman. Since a ran-

domized trial about positioning and attachment as usual practice. A larger trial conducted in multiplesettings, possibly using cluster randomization to mini-education was being conducted in their unit, the mid-

wives may have become aware of it and have modified mize the problem of masking, is needed to adequatelyanswer this question adequately.their usual practices, that is, the so-called Hawthorne

effect (33). A possibility also exists that the amountof attention given to nipple assessment in both groups Acknowledgmentsin this trial may have raised expectations of pain andtrauma. If so, given that all women received the same

The authors wish to acknowledge midwives and seniorassessment, the raised expectations should have been

staff at the Adelaide Women’s and Children’s Hospitalequally distributed between the groups.

for their support during the study, and all women whoThe prevalence of nipple pain and trauma for both

willingly participated.groups in this study is consistent with other observa-tional research findings. Most women in both groups

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