RESEARCH Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomised controlled trial Lin-Lin Su, associate consultant,1 Yap-Seng Chong, senior consultant,1 Yiong-Huak Chan, head, biostatistics unit,2 Yah-Shih Chan, assistant director of nursing,3 Doris Fok, research coordinator and lactation consultant,3 Kay-Thwe Tun, clinical project coordinator,4 Faith S P Ng, biostatistician,4 Mary Rauff, senior consultant1 1 Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119074 2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597 3 Department of Obstetrics and Gynaecology, National University Hospital, Singapore 119074 4 Clinical Trials and Epidemiology Research Unit (CTERU), Singapore 1699039
Correspondence to: Y-S Chong
[email protected] doi:10.1136/bmj.39279.656343.55
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ABSTRACT Objective To investigate whether antenatal breast feeding education alone or postnatal lactation support alone improves rates of exclusive breast feeding compared with routine hospital care. Design Randomised controlled trial. Setting A tertiary hospital in Singapore. Participants 450 women with uncomplicated pregnancies. Main outcome measures Primary outcomes were rates of exclusive breast feeding at discharge from hospital and two weeks, six weeks, three months, and six months after delivery. Secondary outcomes were rates of any breast feeding. Results Compared with women who received routine care, women in the postnatal support group were more likely to breastfeed exclusively at two weeks (relative risk 1.82, 95% confidence interval 1.14 to 2.90), six weeks (1.85, 1.11 to 3.09), three months (1.87, 1.03 to 3.41), and six months (2.12, 1.03 to 4.37) postnatally. Women receiving antenatal education were more likely to breast feed exclusively at six weeks (1.73, 1.04 to 2.90), three months (1.92, 1.07 to 3.48), and six months (2.16, 1.05 to 4.43) postnatally. The numbers needed to treat to achieve one woman exclusively breast feeding at six months were 11 (6 to 80) for postnatal support and 10 (6 to 60) for antenatal education. Women who received postnatal support were more likely to exclusively or predominantly breast feed two weeks after delivery compared with women who received antenatal education (1.53, 1.01 to 2.31). The rate of any breastfeeding six weeks after delivery was also higher in the postnatal support group compared with women who received routine care (1.16, 1.02 to 1.31). Conclusions Antenatal breast feeding education and postnatal lactation support, as single interventions based in hospital both significantly improve rates of exclusive breast feeding up to six months after delivery. Postnatal support was marginally more effective than antenatal education. Trial registration Clinical Trials NCT00270920.
INTRODUCTION Despite awareness of the many advantages of breast feeding, its rates often fall short of recommended practice. The World Health Organization1 and the American Academy of Pediatrics2 advocate exclusive breast feeding for six months and partial breast feeding thereafter for at least 12 or 24 months. In an effort towards achieving better breast feeding practices, UNICEF and WHO launched the baby friendly hospital initiative in 1991 to ensure that all maternity facilities support mothers in making the best choice about feeding. The initiative was introduced to the United Kingdom in 1993, but, although improvements have been reported,3 rates of breast feeding in the UK are still among the lowest in the world.4 5 Recent reports from the National Institute for Health and Clinical Excellence (NICE) urge NHS units to become baby friendly to improve rates of breast feeding and save money.4 6 Data from the millennium cohort study, however, show that though participating maternity units in the UK increased rates of initiation of breastfeeding, duration did not increase.5 Other strategies are therefore required to support mothers in the UK to breast feed for the recommended time. The challenge lies in implementing programmes that can effectively improve rates of short and long term exclusive breast feeding. A national survey in Singapore in 2001 found that only 21% of mothers were breast feeding at six months, with less than 5% of mothers exclusively breast feeding, despite the fact that nearly 90% of the mothers surveyed indicated that breast feeding was the best form of infant nutrition and 95% said they had attempted to breastfeed.7 It is evident that many mothers are unable to establish and maintain breast feeding successfully, despite wanting to do so. While antenatal education and counselling is helpful,8 68% of mothers said that early problems with breast feeding was the main reason they stopped nursing before two months postpartum.7 Other barriers were lack of knowledge about breast feeding and lack of support from health professionals.7 Women value being shown how to breast feed rather than being told how to.9 10 Evidence of effective interventions to improve exclusive breast page 1 of 7
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feeding for the recommended duration of six months is sparse. While there is evidence for the effectiveness of professional support in prolonging duration of breast feeding and increasing rates of initiation of breast feeding, the strength of its effect on the rate of exclusive breastfeeding is unclear.11 12 We used a randomised controlled study to compare the relative effectiveness of an antenatal breast feeding education protocol and a postnatal lactation support protocol versus routine care in improving rates of exclusive breast feeding in a tertiary hospital setting.
Definitions of types of breastfeeding Exclusive breast feeding—only breast milk given to baby. Medicines, vitamins, and oral rehydration solution may be given but no formula or water Predominant breast feeding—breast milk and water, sweetened water, and juices given without formula Partial breast feeding—breast milk and complementary food such as formula milk, gruel, semisolids, or solids are given No breast feeding—no breast milk given and only formula milk and other liquids or food given
METHODS Study population
Assignment and intervention
We recruited healthy pregnant women who were attending antenatal clinics at the National University Hospital, a tertiary hospital in Singapore. One research assistant, who is an experienced lactation consultant, recruited women from the outpatient obstetric clinic. Mothers were eligible for participation if they were more than 34 weeks’ gestation at the time of delivery, expressed an intention to breast feed, and had no illness that would contraindicate breast feeding or severely compromise its success. We excluded women with high risk and multiple pregnancies. Women who agreed to participate gave written informed consent.
Women were randomised into three groups. Group 1 was the control group and women received routine antenatal, intrapartum, and postnatal obstetric care with no special intervention applied. At our hospital, this included optional antenatal classes, which did address infant feeding, and postnatal visits by a lactation consultant should any problems with breast feeding arise. Women randomised to group 2 received one session of antenatal breastfeeding education in which they were shown a 16 minute educational video entitled “14 Steps to Better Breastfeeding” (InJoy Videos, Boulder, CO), which introduced the benefits of breastfeeding, demonstrated correct positioning, latch on, and breast care, and
Eligible women (n=544) Randomised women (n=450)
Group 1: standard hospital care (n=151)
Group 2: one session of antenatal breastfeeding education (n=150)
Group 3: two sessions of postnatal lactation support (n=149)
Excluded (n=5): Withdrawn (n=2) Delivered in another hospital (n=3)
Excluded (n= 1) Delivered in another hospital (n=1)
Excluded (n=8): Withdrawn (n-5) Delivered in another hospital (n=2) Could not be contacted (n=1)
Analysed on intention to treat basis (n=151)
Analysed on intention to treat basis (n=150)
Analysed on intention to treat basis (n=149)
1st-2nd week Lost to follow-up (n=0) Dropped out (n=7)
1st-2nd week Lost to follow-up (n=7) Dropped out (n=5)
1st-2nd week Lost to follow-up (n=3) Dropped out (n=12)
6th-8th week Lost to follow-up (n=2)
6th-8th week Lost to follow-up (n=5)
6th-8th week Lost to follow-up (n=5) Dropped out (n=1)
At 3 months Lost to follow-up (n=2)
At 3 months Lost to follow-up (n=5) Dropped out (n=1)
At 3 months Lost to follow-up (n=6)
At 6 months Lost to follow-up (n=8)
At 6 months Lost to follow-up (n=5)
At 6 months Lost to follow-up (n=3)
Completed follow-up at 6 months (n=126)
Completed follow-up at 6 months (n=122)
Completed follow-up at 6 months (n=119)
Flow of participants through each stage of randomised trial page 2 of 7
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discussed common concerns. They were also given printed guides on breast feeding13 14 and an opportunity to talk to a lactation counsellor for about 15 minutes. They subsequently received routine intrapartum and postnatal obstetric care. Women randomised to group 3 were placed in a two session postnatal lactation support programme. They were visited by a lactation consultant within the first three postnatal days before discharge from hospital. They also received the same printed guides on breast feeding13 14 during this visit. A second support session was provided during their first routine postnatal visit one to two weeks after delivery. During these two encounters, the women received hands-on instructions in latching on, proper positioning, and other techniques to avoid common complications. Each encounter lasted about 30 minutes. We conducted our study in conjunction with the clinical trials and epidemiology research unit, which is an independent organisation funded by the National Medical Research Council. This unit performed the randomisation, sequence allocation, trial
coordination, site monitoring, data collection, and analysis for this study according to good clinical practice guidelines. The unit generated and maintained a list of random codes for participants, corresponding to the two interventions and the control assignment groups. Treatment assignment was generated with a computer programme. The clinical project coordination department of the Clinical Trials and Epidemiology Research Unit randomised women by means of telephone calls. Unit personnel would then log on to the password protected website to obtain the randomisation number and assign the study group. Backup envelopes were used if website randomisation failed. The sequence was therefore strictly concealed until the intervention was assigned. The research assistant ensured that appropriate interventions were carried out depending on the group to which the women were allocated. The trial data were collected on printed case record forms, and the unit performed data entry. Clinical project coordinators of the unit regularly monitored sites to ensure accuracy of recruitment and data collection as well as strict compliance to the study protocol. We
Table 1 | Baseline characteristics of women according to group allocation.* Figures are numbers (percentages) of women unless stated otherwise Group 1 (n=151)
Group 2 (n=150)
Group 3 (n=149)
Total (n=450)
28.6 (5.8)
29.5 (5.2)
29.9 (6)
29.4 (5.6)
Primiparous
60 (40)
59 (39)
59 (40)
178 (40)
Multiparous
91 (60)
91 (61)
90 (60)
272 (60)
Mean (SD) age (years) Parity:
Ethnicity: Chinese
46 (31)
62 (41)
65 (44)
173 (38)
Malay
82 (54)
65 (43)
69 (46)
216 (48)
Indian
16 (11)
20 (13)
12 (8)
48 (11)
Other
7 (5)
3 (2)
3 (2)
13 (3)
Higher than secondary
53 (35)
56 (37)
51 (34)
160 (36)
No qualification/primary
98 (65)
94 (63)
98 (66)
290 (64)
Highest educational qualification:
Employment: Student/housewife
86 (57)
86 (57)
69 (46)
241 (54)
Employed
65 (43)
64 (43)
80 (54)
209 (46)
Entitlement to >2 months maternity leave for employed women: Yes
27 (42)
26 (41)
31 (39)
84 (40)
No
31 (48)
31 (48)
40 (50)
102 (49)
Not applicable
7 (11)
7 (11)
9 (11)
23 (11)
