ABFAB : The effect of breastfeeding education in the middle of pregnancy on the duration of breastfeeding : a randomised controlled trial

Background: It has proven difficult to reach World Health Organization (WHO) recommendations that infants be exclusively breastfed from birth to six months of age [1,2], yet there is limited knowledge about interventions that are effective in increasing breastfeeding initiation and duration. Particularly lacking is evidence about how to maintain breastfeeding rates in countries which already have a high initiation of breastfeeding. This study aims to determine whether mid-pregnancy breastfeeding education, with a focus on either attitudes to breastfeeding or on technical aspects of breastfeeding, has an effect on rates of breastfeeding initiation and duration. Secondary aims of the study are to: explore what factors might affect the duration of breastfeeding and evaluate the interventions from the participant and childbirth facilitator perspectives. Methods/Design: A randomised controlled trial (RCT) design will be used. Women having their first baby, and planning to give birth as public patients at the Royal Women's Hospital (RWH), Melbourne, will be approached at 18–20 weeks of pregnancy and invited to participate in the study. Participants will be randomly allocated to a control group or one of two group interventions: a previously designed and trialled tool to teach practical aspects of breastfeeding or an exploration of family attitudes to breastfeeding. The latter was developed and piloted by the investigators in conjunction with the group facilitators, prior to trial commencement. The interventions are planned to take place at 20–25 weeks. Data will be collected by questionnaire at recruitment, at interview in hospital after the birth and by telephone interview six months later. Medical/obstetric outcomes will be obtained from the medical record. The sample size (972) was calculated to identify an increase in breastfeeding initiation from 75 to 85% and an increase from 40 to 50% in breastfeeding at six months. Published: 29 August 2003 BMC Pregnancy and Childbirth 2003, 3:5 Received: 15 May 2003 Accepted: 29 August 2003 This article is available from: http://www.biomedcentral. com/1471-2393/3/5 © 2003 Forster et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL. Page 1 of 12 (page number not for citation purposes) BMC Pregnancy and Childbirth 2003, 3 http://www.biomedcentral. com/1471-2393/3/5 Background It is widely accepted that breast milk is the ideal infant food and superior to all forms of artificial feeding. In acknowledgement of the benefits of breastfeeding, the WHO recommends that all infants should be exclusively breastfed from birth to six months of age. [1–3] In Australia this has been recognised by health policy makers who support the WHO recommendations. [4–6] Victorian breastfeeding statistics for 1994–95 show a dramatic decline from hospital discharge to six months after the birth. At discharge from hospital, 73.9% of new mothers are breastfeeding decreasing to 69.5% at two weeks, 53.9% at three months and 40% at six months. [7] Both State and RWH (Melbourne) data suggest that at hospital discharge, breastfeeding rates are close to the Commonwealth target initiation rate of 75%. [8] When the figures from the RWH are examined more closely, there is considerable difference by subgroup of women. The figures at discharge from hospital (fully breastfeeding or express breasted milk) at the time of the initial NHMRC grant application were greater than 90% for women delivering in the Family Birth Centre, 82% in the private postnatal units and 70% in the public units (Harris 1996, personal communication). An audit of 700 medical records was undertaken in 1998, excluding women who would be ineligible for ABFAB, that is non-English speaking, multiparous women and those whose babies had died, and found that the discharge breastfeeding rate (fully breastfeeding or feeding expressed breast milk) of publicly booked women who met ABFAB inclusion criteria was 75.3%. The RWH findings are consistent with reports that women who breastfeed are older, have more education, greater income and more social support. [9– 11] This is typical of the women accessing the family birth centre [12] and private units within the hospital. Public patients, including those of non-English speaking background and lower socioeconomic means have lower average breastfeeding rates than the State and hospital mean. There seems to be good rationale for paying more attention to breastfeeding promotion in this group of women. Although breastfeeding rates at discharge from hospital approximate Commonwealth target rates, [8] State figures reveal that breastfeeding rates decline rapidly after discharge. Anecdotal evidence suggests that this is also the case at the RWH (Harris 1996, personal communication) and is supported by other Australian [13] and international studies. [14,15] A recent Australian study using the 1995 National Health Survey data estimated the proportion of children breastfed at discharge from hospital, three and six months of age during the period 1992–1995. The findings indicate that 82% of mothers are breastfeeding when they leave hospital, but by three months only 57% of infants are breastfed and by six months only 46% of infants are continuing to breastfeed, either exclusively or partially. [16] Breastfeeding duration rates are not reaching set goals as stated by Lund-Adams & Heywood [17] and are unlikely to meet those targets by the year 2000. This highlights the need for action to support the promotion of continued breastfeeding. Several studies have identified maternal characteristics that are associated with increased breastfeeding duration. These factors include attitudes to breastfeeding such as prenatal intention to breastfeed, [10,18–20] maternal commitment to breastfeeding, [20,21] beliefs about breastfeeding, [22] planned duration of breastfeeding [9,21–23] and social learning. [22] Cox and Turnbull [24] identified that women who knew their own breastfeeding history and were themselves breastfed were more likely to breastfeed than women who were unaware. Other factors were related to maternal confidence [10,22,25] and social support. [18,22] Some of these factors may be amenable to change through an antenatal intervention. [18,22] Randomised controlled trials have been used to evaluate antenatal interventions that aimed to promote breastfeeding. [11,26,27] Two of these studies [11,26] utilised an antenatal intervention providing information about the health benefits and technical aspects of breastfeeding in either one antenatal class or a one on one education session. The interventions were evaluated in small randomised controlled trials, with samples drawn from specific ethnic and low-income groups identified as having low breastfeeding rates. The women participating in these trials had all indicated that they intended to breastfeed. Kistin et al., [11] concluded that additional prenatal support increased the breastfeeding initiation rate in lowincome urban black women, although the effect on breastfeeding duration was unclear. Wiles [26] measured maternal perception of the infant and perception of breastfeeding success and concluded that the intervention contributed to a successful breastfeeding experience. Neither of these studies could answer the question of whether an antenatal intervention could increase the duration of breastfeeding. However, an antenatal hands-on breastfeeding skills group provided to 59 primiparous Chilean women resulted in an increase in breastfeeding rates at six months postpartum to 94% compared with 67% in the control group, who attended an educational breastfeeding promotion session. [27] A recent Australian randomised controlled trial involving 70 primiparous women [28] has also reported an increase in breastfeeding duration following an antenatal intervention with a hands-on focus teaching technical breastfeeding skills. Redman et al [29] trialled a combination of antenatal and postnatal interPage 2 of 12 (page number not for citation purposes) BMC Pregnancy and Childbirth 2003, 3 http://www.biomedcentral. com/1471-2393/3/5 ventions (using alternate allocation), in Newcastle (NSW), and found that although the women liked the interventions, and although most women received all components of the intervention, there was no difference in breastfeeding duration. Other studies aiming at increasing women's knowledge of the benefits of breastfeeding did not increase breastfeeding duration. [30] Dix, [10] for example, reported that whilst most women agreed that breastfeeding is better for their baby than artificial feeding, this knowledge is not a strong incentive to breastfeed when compared with their own needs and responsibilities. Researchers have also examined the effect of postpartum interventions on breastfeeding duration, although the findings of these studies are not consistent. Grossman et al., [9]and Schy et al., [23] did not have the statistical power to demonstrate a difference in duration of breastfeeding with in-hospital lactation counselling. Frank et al., [32] combined in-hospital lactation counselling with ongoing telephone counselling, and again found no effect, although this study too was underpowered. Jones & West [31] reported an increase in breastfeeding at four weeks with a lactation visit and support in-hospital and at home. A trial is underway in Perth, Western Australia, comparing routine postnatal care with increased breastfeeding support during and after the postnatal hospital stay. [33] A recent systematic review of the effectiveness of interventions to promote breastfeeding initiation concluded that breastfeeding initiation rates in developed countries were increased by "informal, small group.education delivered during the antenatal period" and "one to one health educatio