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Running head: ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 1

Attitudes About Breastfeeding and Continuing Exclusive Breastfeeding for 2 Weeks in First-

Time Breastfeeding Mothers in a Baby- Friendly Aspiring Hospital

by

Tamika Missouri

Coppin State University

A Thesis Paper Submitted to the Faculty of the School of Graduate Studies of Coppin State University in Partial Fulfillment of the Requirements for the

Degree of Master of Science in Nursing

Approvals

Advisor:_____________________________________ Date:______________

Chairperson:__________________________________ Date:______________

Area Dean:___________________________________ Date:______________

Dean, Graduate Studies:________________________ Date:______________

Format used: Publication Manual of the American Psychological Association, 6th edition

Running head: ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 2

Table of Contents

Acknowledgements....................................................................................................................................5

Abstract.......................................................................................................................................................6

Chapter One...............................................................................................................................7

Introduction...............................................................................................................................7

Significance of Study..................................................................................................................8

Statement of Problem................................................................................................................9

Purpose of the Study..................................................................................................................9

Research Question...................................................................................................................10

Assumptions.............................................................................................................................10

Theoretical Definitions.............................................................................................................11

Operational Definitions............................................................................................................11

Summary.................................................................................................................................. 12

Chapter Two..............................................................................................................................................13

Introduction............................................................................................................................. 13

Review of Literature.................................................................................................................13

Theory of Planned Behavior.....................................................................................................18

Influences of Attitudes.............................................................................................................18

Exclusive Breastfeeding for 2 weeks........................................................................................19

Nursing Theory.........................................................................................................................20

ATTITUDES ABOUT BREASTFEEDING AND CONTINUING 3

Major Concepts Identification..................................................................................................21

Summary.................................................................................................................................. 24

Chapter Three............................................................................................................................................25

Introduction............................................................................................................................. 25

Design of the Study..................................................................................................................25

Sample..................................................................................................................................... 25

Study Limitations......................................................................................................................25

Procedure.................................................................................................................................26

Protection of Human Participants............................................................................................26

Instrument............................................................................................................................... 26

Data Analysis............................................................................................................................27

Summary.................................................................................................................................. 28

Chapter Four..............................................................................................................................................29

Introduction............................................................................................................................. 29

Description of the Sample........................................................................................................29

Participant Responses..............................................................................................................30

Chapter Five..............................................................................................................................................43

Discussion................................................................................................................................ 43

Limitations................................................................................................................................46

Implications for Nursing Education..........................................................................................46


Implications for Nursing Practice.............................................................................................47

Implications for Nursing Research............................................................................................48

Conclusion................................................................................................................................48

References................................................................................................................................................50

exposure recall with breastfeeding intentions, initiation, and duration. Journal of Human.....................55

Lactation, 0890334413487256..................................................................................................................55

Appendix A................................................................................................................................................56

Tool Permission........................................................................................................................56

Appendix B................................................................................................................................................58

Site Permission.........................................................................................................................58

Appendix C................................................................................................................................................59

IRB Approval.............................................................................................................................59

Appendix D................................................................................................................................................60

Informed Consent.................................................................................................................... 60

Appendix E.................................................................................................................................................61

Tool.......................................................................................................................................... 61

APPENDIX F................................................................................................................................................65

Telephone Interview................................................................................................................65


Acknowledgements

Completion of this project could not have been possible without the continued support

and encouragement of my committee members. Dr. Nayna Philipsen (Committee Chair), Dr.

Joan Tilghman (Committee Member), and Dr. Warren- Dorsey (Committee Member/ Advisor). I

offer my sincere appreciation for the guidance and learning opportunities.

To my mother, Nina Hairston, there is no way that I could have gone through this journey

without you. Your continued encouragement and support kept me going. Your presence and

voice in the midst of stormy times was my comfort. Thank you for dedicating your time to help

care for my babies. I am grateful.

My deepest gratitude to my loving, caring, husband, Myron Missouri. Your dedication to

our boys and the management of activities “in” and “out” of our home does not go unnoticed. I

appreciate you.

I would also like to thank my children Malik, Myles, and Mason for giving me a moment

to concentrate on other things. You now have my undivided attention. I missed you.

Finally, I would also like to thank my fellow thesis classmates N. Lomax and C. Jackson

for keeping me focused. I appreciate your support throughout this entire time.


Abstract

Breastfeeding plays a pivotal role in societal health with major health benefits to the family. It is

the primary choice of nutrition that most mothers choose when they give birth. Although most

mothers breastfeed initially, various factors affect a mother’s decision to continue to breastfeed

her baby. This study, Attitudes About Breastfeeding and Continuing Exclusive Breastfeeding for

2 weeks in First- Time Breastfeeding Mothers in a Baby- Friendly Aspiring Hospital, sought to

examine the impact that attitudes of first- time breastfeeding mothers have on breastfeeding

initiation and duration of breastfeeding for 2 weeks. The study also sought to examine the

interplay of age, race, and education attainment in the dynamics of breastfeeding. The

Breastfeeding Attrition Prediction Tool (BAPT) was used to survey 30 first- time breastfeeding

mothers at a metropolitan pediatric office and measure their attitudes about breastfeeding and

factors associated with exclusively breastfeeding for 2 weeks. Ramona T. Mercer’s nursing

theory, “Maternal Role Attainment- Becoming a Mother”, provided the framework for this

research study, which highlights the process of becoming a mother and asserts that fore

knowledge about breastfeeding affects a mother’s breastfeeding intention. This study confirmed

that all mothers surveyed are aware that breast milk is healthy and more nutritious for their

babies. Nursing implications in education, practice, and research should target exclusive

breastfeeding in the Black community which was the greatest area of concern.


Attitudes About Breastfeeding and Continuing Exclusive Breastfeeding for 2 Weeks in First-

Time Breastfeeding Mothers in a Baby- Friendly Aspiring Hospital

Chapter One

Introduction

In the United States (U.S.), approximately 4 million babies are born each year (Center for

Disease Control [CDC], 2013). Many women are faced with the question of what form of

nutrition they will provide for their babies once they give birth. Variances effecting this

important decision include maternal age, educational attainability, race, and attitudes about

acceptable forms of feedings (Rossem, 2009). Throughout the history of human cultures, various

types of feedings have existed as normal practices for infant nutrition in that society. In the U.S.,

formula has been the primary source of infant nutrition since 1950’s. WIC (the Special

Supplemental Program for Women, Infants, and Children) purchases and distributes over half of

the infant formula used in the U.S. It is provided by the manufacturer at a discounted price, in

turn costing taxpayers approximately $627 million, which is equivalent to a $2 billion value in

the retail market (Ginty, 2011).

Human breast milk is the healthiest form of nutrition available for infants. In spite of

this, 59% of babies born in the U.S. are exclusively breastfed, and even fewer, 40% are still

breastfeeding at 3 months (CDC, 2013). In recent years, U.S. public health priority has been to

advance exclusive breast milk as the primary intake for babies up to 6 months of life and to be

used in combination with other foods up to 12 months of life (American Academy of Pediatrics

[AAP], 2012). Breast milk is beneficial as the primary source of nutrition because it has an

abundance of essential proteins, fats, carbohydrates, and vitamins. These are important for

newborn brain development, disease prevention, and prevention of ovarian and breast cancer in


women. Studies show, that babies who are breastfed have reduced comorbidities that greatly

impact health care costs [AAP], 2012). The concept of the importance of breastfed babies has

been an integral part of antenatal education for years. Healthcare facilities have the duty to

promote breastfeeding to encourage bonding of parent and child, cost effectiveness, and health

benefits of both mother and baby. Following Baby- Friendly hospital practices help mothers

achieve exclusive breastfeeding (Perrine, Scanlon, & Li, 2012). Women who breastfeed their

first baby for a continuum, are subsequently likely to breastfeed their other children. First- time

breastfeeding mothers’ attitudes related to breastfeeding directly impact initiation and

continuation of exclusive breastfeeding beyond the hospital stay (Persad & Mensinger, 2008).

Healthcare facilities should target first time breast feeders to increase the likelihood of starting

the traditions of breastfeeding in the family.

Significance of Study

Promotion of breastfeeding significantly impacts societal health. Healthier nations

prevail when mothers breastfeed. According to UNICEF, an increase of 90 percent of families

breastfeeding exclusively for 6 months would decrease infant mortality by 1,000 deaths per year

(2013). Medical costs in the U.S. would decrease by $13 billion per year for breastfed infants

when compared to formula fed babies. Health benefits of breast milk on children include

prevention of obesity, diabetes, asthma, necrotizing enterocolitis, childhood leukemia, atopic

dermatitis, and sudden infant death syndrome (SIDS). Mothers benefit from a reduction in

postpartum depression, ovarian/ breast cancer, and type 2 diabetes. Breastfeeding also has a

benefit of reducing weight gain associated with pregnancy (Chapman, 2009). Other newborn

benefits include infants with fewer sick visits, prescriptions, and hospitalizations. Healthier

infants prevent loss of work for parents, contributing to a more productive work force. Employer


medical costs are subsequently lower as a result. Breastfeeding contributes to a greener

environment by eliminating plastic and trash waste associated with formula and bottles.

Healthcare personnel have an obligation to educate women in the antepartum and

postpartum periods to promote breastfeeding as the primary source of nutrition for their babies.

Healthcare facilities have the responsibility of training staff members to ensure adequacy in

education for them to be effective communicators of pertinent information to patients. Hospitals

should exercise “Baby Friendly” practices to prepare staff members and patients for exclusive

breastfeeding (Brown & Isaacs, 2010). Intercepting women in this preliminary phase will impact

the course of breastfeeding throughout the continuum.

Statement of Problem

Attitudes about breastfeeding may contribute to mothers’ intent and continuation to

exclusively breastfeed for the first- time. Healthcare facilities must be held accountable for

educating first time mothers on the breastfeeding health benefits to the family. Baby- Friendly

hospital practices provide a blueprint for supportive practices that educate and assist mothers

who choose to breastfeed. Foundational knowledge and early support related to breastfeeding

influences a mother’s decision to opt for exclusive breast milk as a primary source of nutrition

for her newborn.

Purpose of the Study

The purpose of the study was to examine the attitudes of first- time breastfeeding mothers

who choose to breastfeed and continue to exclusively breastfeed for two weeks postpartum.


Research Question

What are the attitudes of first- time breastfeeding mothers toward breastfeeding?

Assumptions

Factors associated with women breastfeeding their babies include race, maternal age,

educational attainment, and attitudes regarding best feeding practices for newborns (Persad &

Mensinger, 2007). Attitudes about breastfeeding influence if a mother will breastfeed her

newborn (McCarter- Spaulding, 2002). White mothers are more likely to exclusively

breastfeed, whereas African American mothers are more likely to breastfeed and formula feed

interchangeably (Purdy, 2010). In the U.S., women of lower socioeconomic backgrounds benefit

from WIC, which decreases financial considerations related to formula feeding. Until recently,

WIC provided no incentive to mothers choosing to breastfeed, thus unintentionally encouraging

formula feeding (Jensen, 2012). Education limits pertaining to the true benefit of breastfeeding

greatly inhibits a women’s willingness to breastfeed her baby (Marrone, Vogeltanz- Holm, &

Holm, 2008). Body image disturbance as well as attitudes about breastfeeding, impact a

woman’s ability to feed her baby human milk (Persad & Mensinger, 2008). Also a woman’s age

at delivery directly correlates to educational attainment, which would limit the knowledge base

of the benefits of breastfeeding. Healthcare facilities that support BFHI have an increased

incidence of women that choose to breastfeed their newborns.


Theoretical Definitions

Attitude- a cognition, often with some degree of aversion or attraction (emotional

valence), that reflects the classification and evaluation of objects and events

(Encyclopedia- Britannica, 2013).

Exclusive breastfeeding- when a newborn receives only breast milk and no other liquids

or solids except for drops or syrups consisting of vitamins, minerals, or medicines (WHO,

2014).

First- time breastfeeding mothers- Women who choose breast milk feedings for their

newborn for the first time.

Baby- Friendly Hospital Initiatives (BFHI)- a global programme developed by World

Health Organization (WHO) and UNICEF to improve maternity services role (UNICEF,

2014).

Operational Definitions

Attitude- Attitudes about breastfeeding in this study will be a score on The Breastfeeding

Attrition Prediction Tool (BAPT) to evaluate factors affecting the duration of

breastfeeding in women. A positive or negative attitudinal score will determine its

influence on initiation and continuation of exclusive breastfeeding. The tool’s purpose is

to evaluate current patient beliefs as they relate to breastfeeding practices in the mother

(Janke, 2008). The tool determines information about breastfeeding knowledge to

determine its affect on beginning breastfeeding.

Exclusive breastfeeding- This study refers to a newborn receiving only breast milk and

no supplementation with formula during the initial two week period as exclusive

breastfeeding (WHO, 2014).


First- time breastfeeding mothers- This study refers to mothers who use breast milk as a

form of nutrition for the first time.

Baby- Friendly Hospital Initiatives (BFHI)- This study refers to Maternity/ Birthing

facilities that implement program of ten (10) step practice to support and promote

breastfeeding (UNICEF, 2014).

Summary

Healthcare facilities have a public health duty to mothers using their services. Promotion

and support of breastfeeding encourages healthier women and babies, and healthier populations.

Understanding that mothers have attitudes related to the best feeding methods for their babies are

an essential step in assessment for supporting mothers choosing to breastfeed for the first time.

New breastfeeding mothers need to be made aware of realistic expectations that come along with

the demands of breastfeeding. Education should be provided before, during, and after the

hospital stay to support mothers opting to breastfeed for the first time. Mothers that are

breastfeeding for the first time need access to resources to help them in the beginning stages of

breastfeeding, when the rates of reconsideration are so high. Adhering to BFHI, increases

compliance with exclusive breastfeeding during the hospital stay and also provides support for

the mother to continue to breastfeed for at least 2 weeks after discharge. Consideration of

contributing factors such as race, age, highest educational level completed, and foundational

knowledge determine the success of exclusive breastfeeding. If these hospital level changes are

followed, the success rate of first time breast feeders will increase.


Chapter Two

Introduction

The objective of this study was to investigate the relationship between attitudes of first-

time mothers and their choosing to breastfeed and continuing to exclusively breastfeed their

babies for two weeks postpartum. Ramona T. Mercer’s, “Maternal Role Attainment Theory”

provides the framework for this study.

Review of Literature

Breastfeeding is the most natural, nutritive choice of feeding for a newborn. Successful

support of breastfeeding is a public health imperative in the U.S. showing an incline from 60%

to 77% in the past 10 years (CDC, 2013). American society has spearheaded various

interventions aimed at informing and educating the public, especially new mothers, about the

healthiest choice that women can offer their newborns. This education has mainly targeted

informing new mothers about the benefits of breast milk. Breast milk is loaded with Lactoferrin

(limits iron availability for bacteria consumption in the gut), Lysozyme (aids in digestion),

Carnitine (fatty acid for energy), and DHA & ARA (for brain and retina development). This

information is conveyed to women to enlighten them to the newborn benefits of breastfeeding

(Mannel & Martens, 2012).

Nutrition for infants should be addressed as a public health concern and not simply as an

inconsequent maternal choice, as it has in the recent past. Influences of formula marketing can

directly affect a woman’s feeding choice. The World Health Organization’s International Code

of Marketing of Breast-milk Substitutes asserts the position to not market infant formula to the

public (2013). The U.S. has failed to follow these guidelines. Although the initiation and

duration of breastfeeding has been given lip- service in the U.S., formula is frequently suggested


as an equal choice. This practice is not helpful and can be even misleading for mothers with low

intentions of breastfeeding that are also influenced by subjective norms (Zhang, Carlton, Fein,

2013).

Infant mortality and morbidity of the target area should be considered when approaching

topics of breastfeeding. The impact of substituting a commercial formula for mother’s milk on

short- and long- term health is significant. Breastfeeding has been shown to decrease rates of

infant mortality and morbidity by 3% per year. Healthy People 2020 propose a decrease in

infant mortality to rates of 6.0 per 1,000 live births. Infant morbidity associated with otitis media,

gastroenteritis, childhood obesity, leukemia, type 1&2 diabetes, pneumonia, and SIDS all show

increased incidences in infants receiving formula instead of mother’s milk (American Academy

of Pediatrics, 2010). This alone should be a driving force of healthcare facilities urging of

breastfeeding as the primary source of infant nutrition.

The infants need for breast milk for healthy and optimum development is relayed to the

public, but health care agencies have an obligation to educate the pregnant woman about

breastfeeding as the healthy choice for her newborn. Educating new mothers on the long term

benefits to their newborns from breast milk would influence mothers desiring the best outlook

for their babies. The immunoprotective and nutritive value profoundly impact a newborns health

as compared to formula fed babies (Cramton et al, 2009). Direct patient education during the

antepartum period, postpartum period, and support after discharge play a critical role in the

process of initiating and continuing to breast feed for the first time. Educators should have a

sound knowledge base to provide mothers with proper information to make informed feeding

decisions, and to implement them, as few new mothers in the U.S. have extensive experience

with breastfeeding.


In 1991 with a revision in 2006, The United Nations Children’s Fund (UNICEF) and the

World Health Organization (WHO) launched the Baby- Friendly Hospital Initiative (BFHI) to

increase breastfeeding rates worldwide. According to Association of Women’s Health, Obstetric

and Neonatal Nurses (AWHONN), hospitals that trend with policies similar to Baby- Friendly

practices have an increase in breastfeeding initiation and compliance (2010). To be successful,

health facilities must take active steps and adhere to specific guidelines. Ten steps for Baby-

Friendly status achievement are standard, but variations exist between facilities. The primary

goal of any facility practicing these standards of care share a common outcome of optimal health

choice for mother and child.

The BFHI provides a framework that protects, promotes, and supports new mothers in

breastfeeding their babies. Specific interventions are outlined that highlight steps to follow that

proves beneficial in establishing and promoting successful breastfeeding patterns. Steps needed

to progress towards Baby- Friendly practices include:

1. Have a written Breastfeeding Policy that is routinely communicated to all health care

staff.

2. Train all health care staff in skills necessary to implement this policy. Mandatory

education via in services, supplemental education, and hands on practices should be

mandated.

3. Inform all pregnant women of the benefits and management of breastfeeding.

Prenatal packages with breastfeeding information should be made available to pregnant

mothers. Prenatal breastfeeding classes should be offered. Lactation consultants also

visit Women’s, Infant’s, and Children’s (WIC) sites to inform pregnant moms about


breastfeeding, inquire about future plans, and encourage expectant moms to visit the OB

offices. Mothers make up their minds to bottle or breast feed very early in their

pregnancy (Forster and McLachian, 2007).

4. Help mothers initiate breastfeeding within one hour of birth. Babies should be put to

breast as soon as possible in the delivery room, even following a c-section birth. The

assistance by a lactation consultant can be utilized at this time.

5. Discuss breastfeeding basics and techniques to mothers that are separated from their

newborns for medical reasons. Steps to initiate and maintain lactation, such as use of a

breast pump.

6. Only give newborns breast milk, unless medically indicated. An order by a nurse

practitioner or pediatric resident is required before any supplementation is provided.

7. Rooming- in practices should be encouraged. Mothers and babies are encouraged to

remain together 24 hours per day and staff is expected to perform as many infant daily

cares as possible at the mother’s bedside.

8. Encourage breastfeeding on demand. Breastfeeding times should be every two to

three hours to establish a good breastfeeding pattern and initiate good milk supply.

9. Give no artificial nipples or pacifiers to breastfeeding infants. Pacifiers can cause

nipple confusion for the infant because different mechanisms are used when sucking at

the breast as compared to sucking a pacifier. Parents are taught to syringe- feed to avoid

use of a nipple.

10. Encourage and educate mothers to utilize breastfeeding resources. Mothers are

instructed to call a resource telephone number to access a lactation consultant for help.

Breastfeeding groups that support new mothers should be offered, as well as follow- up


outpatient support by lactation consultants. Additionally, not offering gift bags containing

formula is strongly recommended. This practice puts a budgeting strain on the healthcare

facility because formula is usually given to the facility at no cost for advertising

purposes.

The Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN)

endorses the BFHI framework in helping maternity areas in hospitals progress forward with

promoting breastfeeding as the primary nutrition for newborns (2014). Hospitals should have

staff members that are active in the organization and understand AWHONN’s guidelines and

practices. According to AWHONN, when choosing breastfeeding as the most optimal form of

nutrition, women should receive proper education and support (2014). AWHONN’s standards

centers around the belief that it takes the entire health care team to successfully initiate and

sustain breastfeeding. This team of people supporting the breastfeeding process should include

physicians, nurses, and lactation consultants. Discussions with women concerning breastfeeding

should begin during the antepartum period, to assess preconceived knowledge about

breastfeeding and bridge any education gaps that may pose an obstacle to initiating and

continuing to breastfeed for an extended period of time. Healthy People 2020, set forth a goal to

increase the proportion of mothers who breastfeed their babies. This goal includes initiatives to

raise the rate of breastfeeding initiation in the early postpartum period to 81 percent, to increase

to 46 percent the proportion of women who continue exclusive breastfeeding until their infants

are three months of age, and to 25 percent the proportion of infants who are exclusively breastfed

until 6 months of age (2014).


Theory of Planned Behavior

Icek Ajzen proposed a “Theory of Planned Behavior” (TPB), which boasts an

understanding of human behavior. TPB asserts that intention is a prediction of behavior (Ajzen,

1987). Intention is a result of the attitude that controls the perception or idea. Behavior is

predicated by the attitude that is possessed about the idea. The attitude about the behavior links it

to an outcome. The outcome holds a subjective value, either making it a negative or positive

attitude about the idea. TPB highlights the notions outlined in this study by showing the

relationship that attitudes about breastfeeding have on intent and duration of breastfeeding.

Attitudes about breastfeeding influence breastfeeding intention in mothers (Bai, Middlestadt,

Peng, Fly, 2010).

Influences of Attitudes

Breastfeeding is not instinctual or natural for all women. In an effort to improve

breastfeeding rates in the U.S., identification of factors that influence initiation and continuation

of breastfeeding should be studied. A woman’s preconceived knowledge concerning

breastfeeding as a nutritive choice directly correlates with her decision to initiate breastfeeding,

whereas, the support offered in the postpartum period influences her decision to continue to

exclusively breastfeed (Perrine et al., 2012). Limited knowledge about the benefits of

breastfeeding for both the health of mother and baby affect a woman’s intent to breast feed;

however the attitude and subjective norms that these women possess play a role in intention as

well. This coincides with Sharps, El- Mohandes, El- Khorazaty, Kiel, & Walker’s study that

determined that maternal self motivation to breastfeed appears to supersede the perception of

influences around her (2003).


According to Ajzen’s Theory of Planned Behavior (TPB), attitudes and personal beliefs

effect intention and control behavior (1987). The foundational knowledge base that women

believe as truth concerning breastfeeding is a great determination of what her decision will be

concerning initiating breastfeeding. Personal attributes that are influenced by tradition, culture,

family, and social entities carry considerable weight when decisions about breastfeeding are

made before delivery (McCarter- Spaulding, 2002). Social norms of the woman’s environment,

without the influence of education, determine what feeding techniques will be chosen (Sharps et

al., 2003).

Foundational knowledge based on educational disparities play a role in a mother’s

decision to breastfeed. Women with higher education attainability are better informed about the

health benefits of breastfeeding for mother and child. Despite what is deemed normal feeding

methods for these groups of women, decisions can be individually based to provide optimal

health outcomes for the couplet. Implementing BFHI, with mothers desiring to breastfeed

imprints the same knowledge principles to first-time breastfeeding mothers, prompting initiation

of exclusive breastfeeding ( Difrisco et al., 2011).

Exclusive Breastfeeding for 2 weeks

Exclusive breastfeeding is when a newborn receives only breast milk and no other liquids

or solids except for drops or syrups consisting of vitamins, minerals, or medicines (WHO, 2014).

Inability to establish successful breastfeeding is a main culprit in mothers not continuing to

breastfeed. The U.S Preventative Services Task Force determined breastfeeding education as the

most effective intervention for increasing breastfeeding initiation and short- term continuation

(2014). The Joint Commission implemented the Perinatal Care Core Measure Set, a standardized

performance measurement that monitors care of “exclusively breastfed” term-babies to examine


practices for supplementation other than medical reasons (2014). In alignment with BFHI

guidelines, exclusive breastfed babies should not be offered supplementation of formula unless

medically necessary to optimize breastfeeding (Baby- Friendly, 2010). BFHI practices is

associated with increased rates of breastfeeding and a primary hospital practice associated with

discontinuing exclusive breastfeeding before discharge was babies receiving supplementation

(Perrine, Scanlon, & Li, 2012).

Lack of support from hospital staff is another strong indicator of early breastfeeding

cessation. Support during the hospital stay by educated health care staff members, including

Licensed Lactation Consultants (LLCs), are influential in increased rates of exclusive

breastfeeding rates for a short duration (Murray, 2007). Healthcare staff having evidence- based

breastfeeding knowledge combined with the expertise of LLCs, offers the mother essential

support with being successful with the breastfeeding process. The benefit of LLC’s offers an

irreplaceable advantage to mothers needing support during the early stages of breastfeeding.

Follow- up support via discharge telephone calls or postpartum group sessions post- discharge to

troubleshoot problems with breastfeeding is also important with continuation of breastfeeding

(DiFrisco, 2011).

Nursing Theory

Nursing theories offer structure by providing a foundational basis that nursing can use as

a guide to provide patient care. Ramona T. Mercer’s, “Maternal Role Attainment- Becoming a

Mother” was used as a guide for this research study. Recognizing the woman, the patient as the

primary focus served as a rationale for Mercer’s theory selection. Her theory uses the mother as

the focal point, with variables of social influences, nursing, health impacts of mom and newborn,

and role identity (Mercer, 1985). The process used in Mercer’s theory helps the mother develop


an attachment to the infant, which in turn helps the infant form a bond with the mother.

Breastfeeding facilitates this mother- child bond, which is enhanced as the infant grows

(Schwarze, Hellhammer, Stroehle, Lieb, & Mobascher, 2014). Mercer’s theory asserts

developmental and interactional change over a period of time. Throughout this process, the

mother bonds with the infant, acquires competence in breastfeeding, and then experiences

pleasure in her role as a mother. Many aspects of Mercer’s theory support this study. Her

theory predicts relationship between the concepts that are outlined in BFHI and their influence

on new mothers. Mercer’s theory provides support for the assertion that new mothers need

extensive psychological, social, and physical attention to make a healthy transition into

motherhood (Mercer, 1985). Nursing plays a major role in Mercer’s theory of helping new

mothers learn and grow in their new identities (Mercer, 1985).

Mercer’s revision of the language contained in her theory based on more recent research

parallels the premise of the research study. She highlights “becoming a mother” as an ongoing

process rather than an endpoint (Mercer, 1985). In the study, the consideration of breastfeeding

over a 2 week duration closely mimics this framework’s idea of the research being a process over

time rather than reflecting the initiation of breastfeeding only. Mercer asserts that a mother’s

attitude predicts the behavior that she will exhibit when caring for her newborn (Mercer, 1995).

Implications of Mercer’s theory in this study suggests that breastfeeding knowledge before

delivery predicts breastfeeding tendencies once delivery takes place.

Major Concepts Identification

Mercer pinpoints major concepts that coincide with the theory that she portrays. These

focus areas directly correlate with the ideas of the research study. Maternal role attainment,

which is the mother bonding and confidently grasping her new role as a parent is one concept


(Mercer, 1985). Mothers have to possess confidence with the challenges that breastfeeding

proposes. Role attainment in breastfeeding is a process, happening over a period of time. The

process initially starts with the mother recognizing herself as the primary nurturer for her

newborn. Adaptation to the breastfeeding experience, then fosters psychological bonding

between the mother and her newborn (Liu, Leung, & Yang, 2013). The more accustomed a new

breastfeeding mother becomes with her role in the process, her confidence increases, thus

increasing the duration of breastfeeding (Thulier & Mercer, 2009). A mom’s perception of her

birth experience is another insightful concept that correlates with a mother’s sense of self while

breastfeeding. Mothers rate their birth experience based on what took place during the whole

experience. Challenges of breastfeeding can force mothers to rate their experiences negatively if

everything didn’t go as planned. Negative breastfeeding experiences impact success of exclusive

breastfeeding (Declercq & Labbok, 2009). Mercer points out self –regard as another concept

(Mercer, 1985). Self- regard incorporates self- esteem, self- acceptance, and self- satisfaction.

Mothers with a high self- concept have a tendency to exclusively breastfeed their newborns for a

longer duration (Britton & Britton, 2008). Another concept, flexibility, is discussed by Mercer.

New moms must not have a rigid approach to the breastfeeding experience. Allowances for

situations that are not ideal is a needed attribute. Merging the new role of being a breastfeeding

mother with new and old responsibilities in life, requires flexibility. Adaptation to new

situations, improve breastfeeding duration (Hegney, Fallon, & O’Brien, 2008). Childrearing

attitudes and beliefs is a concept proposed by Mercer. A mother’s belief about what is best for

her newborn is one of the single most important characteristics that influence a mother’s decision

to breastfeed (Persad & Mensinger, 2008). The idea of providing the best nutrition for her

newborn, perpetuates the intention to breastfeed. Her attitude not only affects the initiation of


breastfeeding, but impacts the duration of breastfeeding. A mother’s knowledge about the

concept of breastfeeding and her willingness to introduce breastfeeding into the family unit,

improves her chances of breastfeeding for a continuum. In addition, Mercer identifies infant

health status as a concept (1985). Breastfeeding plays an instrumental role in improved

newborn health. Attitudes related to the benefits of breast milk associates with this concept.

Improved health status for newborns related to breast milk consumption spearheads the

recognition of breastfeeding as the primary source of nutrition for babies. This is identified in

Mercer’s theory and correlates with this study. Another concept discussed by Mercer, role strain

is the difficulty that mothers feel in fulfilling their maternal role (Mercer, 1985). Taking hold of

breastfeeding and the demands associated with breastfeeding, is a challenging process for new

mothers. Once the obstacles that come along with breastfeeding are conquered, the pleasures

associated with breastfeeding settles in. The reward and pleasure of the bonding experience gives

a breastfeeding mother great satisfaction, which closely associates with Mercer’s gratification-

satisfaction and attachment concept (1985). The discussion of infant temperament, infant

characteristics, and infant cues all are congruent concepts discussed by Mercer that parallels the

research study. Mercer asserts that all three infant exhibitions illicit a maternal response

(Mercer, 1985). Breastfeeding initiation and duration is based on maternal responses to innate

infant cues that guide the breastfeeding experience (Guillain, Wijndaele, Clark, Acerini, Hughes,

Dunger, Wells, & Ong, 2012). Finally, social support is the most important concept that

Mercer proposes that ties into the study (1985). The support that is incorporated in BFHI

influences the duration of breastfeeding. Support is a necessary component for breastfeeding and

directly correlates with increased breastfeeding rates (Declercq & Labbok, 2009).


Summary

Breastfeeding rates in the U.S. continue to incline. Health disparities that continue to

plague populations commit governmental agencies, community agencies, and healthcare

facilities to spearhead initiatives to target breastfeeding as a public health concern. Recognizing

barriers that impede most mothers that deliver newborns to exclusively breastfeed will warrant

closer examination as goals set to increase breastfeeding further continue. It has long been a

predictor that age, education level, and race have posed disparities that interfere with mothers

choosing to breastfeed. A mother’s attitude about breastfeeding influences her decision to

initiate and continue breastfeeding. BFHI practices adapted by healthcare facilities, can serve as

an educational blueprint to expose the same knowledge to mothers choosing to exclusively

breastfeed. This study supports Mercer’s “Maternal Role Attainment” Theory assumption by

recognizing that a mother’s sense of self is determined by influences that affect her attitude about

real life situations (Mercer, 1986). In support of Mercer’s maternal role attainment theory, this

study proposes that breastfeeding is an overlapping process that is altered overtime. The process

is dependent on maternal and infant behaviors that impact the overall outcome for mother and

child. This correlates with the TPB, which reinforces the influence of a mother’s attitude about

breastfeeding on intention to breastfeed.


Chapter Three

Introduction

Chapter three will describe the study design. The hypothesis, sample, and study

limitations will be examined. Procedures for the study, protection of human rights, and

instruments for measurement will be discussed as well.

Design of the Study

A quantitative descriptive study was conducted to evaluate the relationship between

attitudes about breastfeeding and its influence on initiating and continuing to breastfeed. This

particular study was chosen because of its affiliation with current practices and naturally

occurring situations.

Sample

Convenience sampling was selected to be used in this study. Once consent was obtained,

a selection of 30 first- time breastfeeding mothers were used for the convenience sampling.

Diffusion of sampling eliminated breast feeders that are new versus experienced. Biases were

identified to wean all breastfeeding mothers from first time breastfeeding mothers. There was

no restriction to age, socioeconomic status, or ethnicity. The mothers were surveyed at a

pediatric office in the metropolitan area during initial newborn doctor’s visits. The babies were

born at surrounding metropolitan hospitals that are influenced by BFHI practices.

Study Limitations

A limitation of this study was choosing first- time breastfeeding mothers at one facility

of reference to provide the sampling. Losing participants for follow-up two weeks after delivery

was also a limitation.


Procedure

Participation in the study was limited to first time breastfeeding mothers. Special

attention was given to not eliminate mothers who have had prior formula fed babies. Permission

was obtained from the metropolitan pediatric office to conduct the study. Then, approval

to conduct the study was obtained from Coppin State University’s IRB Committee prior to

conducting the study. Each participant was surveyed about the initiation of breastfeeding.

Additional data collection continued over a 2 week period, by telephone interview to

evaluate the duration of breastfeeding. The data collection ended with the last information

obtained from the last initial newborn visit. Assessment of attitudes about breastfeeding

and the initiation and continuation of breastfeeding was then analyzed.

Protection of Human Participants

Respecting the dignity and health of individuals is an ethical responsibility. While

conducting research, the rights to self- determination, privacy, confidentiality, fair treatment, and

protection from harm was considered. Anonymity was safe guarded and anonymity was

reiterated with consent to participate in the study and with telephone follow-up 2 weeks after

initial data collection. The demographics of the patient was secured and kept anonymous for

purposes of evaluating the data after the study was complete. Participation was voluntary and

confidential. Compliance with the protection of participants’ rights, will comply with the

regulations set forth by the United States Department of Health and Human Services Protections

of Human Subjects Regulations, the Office for Human Research Protection , and the code of

Federal Regulations (CFR), Title 45, Part 46, Protection of Human Subjects (HHS, 2009).

Instrument


The instrument selected for this research study was The Breastfeeding Attrition

Prediction Tool (BAPT), based on Theory of Planned Behavior (TPB).

This tool has proven reliable in evaluating breastfeeding trials in the past. It was

developed by Jill Real Janke to evaluate factors affecting the duration of breastfeeding in

women. The tool’s purpose was to evaluate current patient beliefs as they relate to breastfeeding

practices in the patient. The tool goes further to determine information of breastfeeding

knowledge to determine its affect on starting breastfeeding. A modified version of the tool using

37 questions that evaluates the mother’s perceptions on breastfeeding as well as demographic

data was used. A 6 point Likert scale was used to measure questions. The BAPT tool boasts a

73 % rate of obtaining breastfeeding data and has a reliability coefficient of 0.80%. The study

proposes to use the tool to evaluate a mother’s attitude about breastfeeding and the

association that age, race, and educational levels have on a mother’s decision to breastfeed. A

numerical rating style survey will be used with a pencil to fill in the appropriate data.

Data Analysis

Variables and descriptive statistics were described. The relationship between attitudes

about breastfeeding and the influence on the initiation and continuation of breastfeeding for 2

weeks was analyzed. Questions 1-29 of the BAPT served as the basis for data collection. Most

of these questions pertained to the mother’s subjective data of perceptions related to

breastfeeding. Questions surrounded the mother’s knowledge base of breastfeeding, convenience

of breastfeeding, comparison to formula feeding, and health benefits of breastfeeding for mom

and baby. There was a range of numbers 1-6, correlating with strongly disagree to strongly

agree, respectively. Other questions pertaining to demographics were analyzed from another


subset of the tool as well. The International Business Machines (IBM) Statistical Package for the

Social Sciences (SPSS) version 22.0 was used to implement statistical analysis.

Summary

Attitudes related to breastfeeding directly impact a mother’s decision to choose this

optimal method of feeding for her newborn. Societal views of the importance of breastfeeding

weigh heavily on a mother’s decision to choose nutrition for her newborn. Perspectives vary;

however, breastfeeding as the healthiest feeding option for moms and their babies is

indisputable. Recognition of mothers’ attitudes about breastfeeding helps prepare education

platforms that assist mothers who consider exclusive breastfeeding as a feeding option. The ten

steps outlined in (BFHI) provide consistent, structured recommendations for educating, assisting,

and supporting new mothers who breastfeed their infants. It serves as a global framework that

can be applied to any maternity area in any country. Increases in infant morbidity and mortality

among formula fed infants should be a primary motivator associated with prioritizing breast milk

as the nutritive choice for newborns. Instituting practices associated with BFHI will increase

education among mothers that will influence proper nutritive choices. Following these

guidelines and evaluating the efficacy of their implementation will result in increased exclusive

breastfeeding rates among first time breastfeeding mothers.


Chapter Four

Introduction

The purpose of this thesis was to examine the breastfeeding attitudes of first- time

breastfeeding mothers’ and their decision to initiate breastfeeding and continue breastfeeding for

two weeks postpartum. This chapter reports data collection and summarizes results of statistical

analysis of the study participants’ responses on the Breastfeeding Attrition Prediction Tool

(BAPT). The BAPT was developed to evaluate factors that impact a mother’s willingness to

breastfeed. Chapter Four also describes the study participants and details their responses to the

survey. Thirty questionnaires were completed at a private pediatrician’s office that serves as the

primary care provider for newborns born in hospitals in the metropolitan area. Assessment of the

attitudes that breastfeeding has on initiating and continuing breastfeeding was analyzed using

The International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS)

version 22.0.

Description of the Sample

The sample was comprised of 30 first- time breastfeeding mothers that had given birth in

surrounding metropolitan hospitals. Demographic variables used in the study included race, age,

and education attainability. 70% (n= 21), of the mothers included in the study were Black.

16.7% (n= 5), of the mothers were White. 3% (n= 1), of the mothers identified themselves as a

Native American (n= 1). While 10% (n= 3) identified themselves as other and chose not to

specify an ethnic origin. The ages of the mothers were categorized from 16-45 years of age in

the survey. 26-30 years of age was the largest group identified comprising of 50% (n= 15) of the


mothers. Both age groups 16-20 years and 36-45 years accounted for 6.7% (n= 2) of the mothers

surveyed. Mothers in the 21-25 age group range accounted for the second largest group, 23.3%

(n= 7). While mothers in the 31-35 age group range accounted for 13.3% (n= 4). Education

attainability identified most mothers as college graduates accounting for 53.3% (n= 16) of the

participants. 26.7% (n= 8) were high school graduates. 16.7% (n= 5) of the mothers completed

graduate school. Only 3.3% (n= 1) of the mothers reported grade school as the highest grade

level completed.

Participant Responses

For the question on the survey, “Have you ever breastfed before?” All of the participants

100% (n= 30), reported “no”.

The item on the survey, “Breastfeeding is more convenient than formula feeding.” Of the

study participants, responses were 0% (n= 0) strongly disagree, 6.7% (n= 2) slightly disagree,

13.3% (n= 4) disagree, 6.7% (n= 2) agree, 36.7% (n= 11) slightly agree, 36.7% (n= 11) strongly

agree.

The item on the survey, “Breastfeeding is painful.”, (Graph,1). Of the study participants,

responses were 20% (n= 6) strongly disagree, 16.7% (n= 5) slightly disagree, 13.3% (n= 4)

disagree, 13.3% (n= 4) agree, 26.7% (n= 8) slightly agree, 10% (n= 3) strongly agree.


The item on the survey, “Formula feeding allows the mother more freedom.”, (Graph 2). Of

the study participants, responses were 10% (n= 3) strongly disagree, 10% (n= 3) slightly disagree,

3.3% (n= 1) disagree, 6.7% (n= 2) agree, 46.7% (n= 14) slightly agree, 23.3% (n= 7) strongly agree.

Cross tabulations show that 66.7% (n= 10) mothers within the age range of 26-30 years slightly

agreed (Graph 3).



The item on the survey, “Infant formula can cause allergies.” Of the study participants,

responses were 16.7% (n= 5) strongly disagree, 3.3% (n= 1) slightly disagree, 26.7% (n= 8) disagree,

16.7% (n= 5) agree, 26.7% (n= 8) slightly agree, 10% (n= 3) strongly agree.

The item on the survey, “Breast milk is healthy for the baby.” Of the study participants,

responses were 0% (n= 0) for strongly disagree, slightly disagree, and disagree. Most of the

participants, 80% (n= 24) strongly agree. 16.7% (n= 5) slightly agree, 3.3% (n= 1) agree (Table 1).

Cross tabulations related to perceptions of infant well being and education attainability show that all

mothers agree that breast milk is healthy regardless of education level (Graph 4).


Breastmilkishealthyforthebaby

Frequency Percent Valid Percent Cumulative Percent

Valid

agree 1 3.3 3.3 3.3

slightly agree 5 16.7 16.7 20.0

strongly agree 24 80.0 80.0 100.0

Total 30 100.0 100.0

The item on the survey, “No one else can help feed the baby when you breastfeed.” Of the

study participants, responses were 26.7% (n= 8) strongly disagree, 16.7% (n= 5) slightly disagree,

10% (n= 3) disagree, 10% (n= 3) agree, 16.7% (n= 5) slightly agree, 20% (n= 6) strongly agree.


The item on the survey, “It is difficult to breastfeed in public.” (Graph 5). Of the participants,

responses were 20% (n= 6) strongly disagree, 13.3% (n= 4) slightly disagree, 10% (n= 3) disagree,

6.7% (n= 2) agree, 36.7% (n= 11) slightly agree, 13.3% (n= 4) strongly agree.

The item on the survey, “Formula fed babies tend to get sick.” Of the study participants,

responses were 23.3% (n= 7) strongly disagree, 6.7% (n= 2) slightly disagree, 10% (n= 3) disagree,

16.7% (n= 5) agree, 26.7% (n= 8) slightly agree, 16.7% (n= 5) strongly agree.

The item on the survey, “Breast milk is more nutritious than infant formula.” Most of the

participants 90% (n= 27) strongly agree. 6.7% (n= 2) slightly agree, 3.3% (n= 1) agree.


The item on the survey, “Breastfeeding makes your breasts sag.” Of the study participants,

responses were 23.3% (n= 7) strongly disagree, 16.7% (n= 5) slightly disagree, 16.7% (n= 5)

disagree, 10% (n= 3) agree, 23.3% (n= 7) slightly agree, 10% (n= 3) strongly agree.

The item on the survey, “Formula feeding is easier than breastfeeding.” Of the study

participants, responses were 30% (n= 9) strongly disagree, 13.3% (n= 4) slightly disagree, 10% (n=

3) disagree, 13.3% (n= 4) agree, 30% (n= 9) slightly agree, 3.3% (n= 1) strongly agree.

The item on the survey, “Formula fed babies are more fussy than breastfed babies.” (Table 1)

Most participants 36.7 (n= 11) strongly disagree. 10% (n= 3) slightly disagree, 13.3% (n= 4)

disagree, 10% (n= 3) agree, 20% (n= 6) slightly agree, 10% (n= 3) strongly agree.


The item on the survey, “Breastfeeding makes you closer to your baby.” Most of the

participants 76.7% (n= 23) strongly agree, 20% (n= 6) slightly agree, 3.3% (n= 1) agree. None of the

participants (n= 0) disagree, slightly disagree, or strongly disagree.

The item on the survey, “Breastfeeding makes returning to work difficult.” Of the study

participants, responses were 10% (n= 3) strongly disagree, 13.3% (n= 4) slightly disagree, 6.7% (n=

2) disagree, 10% (n= 3) agree, 23.3% (n= 7) slightly agree, 36.7% (n= 11) strongly agree.

The item on the survey, “Formula fed babies are easier to satisfy than breastfed babies.” Of

the study participants, responses were 20% (n= 6) strongly disagree, 23.3% (n= 7) slightly disagree,

13.3% (n= 4) disagree, 16.7% (n= 5) agree, 13.3% (n= 4) slightly agree, 13.3% (n= 4) strongly agree

The item on the survey, “Formula fed babies tend to be overweight.” Of the study

participants, responses were 16.7% (n= 5) strongly disagree, 26.7% (n= 8) slightly disagree, 13.3%

(n= 4) disagree, 16.7% (n= 5) agree, 13.3% (n= 4) slightly agree, 13.3% (n= 4) strongly agree.

The item on the survey, “Breastfeeding is more economical than formula feeding.” Most of

the participants 76.7% (n= 23) strongly agree, 20% (n= 6) slightly agree, 3.3% (n= 1) agree. None of

the participant (n= 0) strongly disagree, slightly disagree, or disagree.

The item on the survey, “When you breastfeed you never know if the baby is getting enough

milk.” Of the study participants, responses were 26.7% (n= 8) strongly disagree, 26.7% (n= 8)

slightly disagree, 3.3% (n= 1) disagree, 13.3% (n= 4) agree, 13.3% (n= 4) slightly agree, 16.7% (n=

5) strongly agree.

The item on the survey, “Mothers who formula feed get more rest than breastfeeding

mothers.” Of the study participants, responses were 16.7% (n= 5) strongly disagree, 16.7% (n= 5)

slightly disagree, 6.7% (n= 2) disagree, 13.3% (n= 4) agree, 26.7% (n= 8) slightly agree, 20% (n= 6)

strongly agree.


The item on the survey, “Breastfeeding is natural.” Most of the participants 70% (n= 21)

strongly agree, 23.3% (n= 7) slightly agree, 6.7% (n= 2) agree. None of the participants (n= 0)

strongly disagree, slightly disagree, or disagree.

The item on the survey,” Breastfeeding is more time consuming than formula feeding.”

(Graph 6) Of the study participants, responses were 6.7% (n= 2) strongly disagree, 13.3% (n= 4)

slightly disagree, 13.3% (n= 4) disagree, 16.7% (n= 5) agree, 23.3% (n= 7) slightly agree, 26.7% (n=

8) strongly agree.

The item on the survey,” Formula feeding lets the father become close to the baby.” Of the

study participants, responses were 13.3% (n= 4) strongly disagree, 20% (n= 6) slightly disagree,

3.3% (n= 1) disagree, 30% (n= 9) agree, 26.7% (n= 8) slightly agree, 6.7% (n= 2) strongly agree.


The item on the survey,” Infant formula can cause constipation.” Most of the participants 30%

(n= 9) strongly agree and equally 30% (n= 9) slightly agree. 20% (n= 6) agree, 6.7% (n= 2) disagree,

6.7% (n= 2) slightly disagree, 6.7% (n=2) strongly disagree.

The item on the survey, “Breastfeeding is best for the baby”, the most common answer was

strongly agree at 83.3% (n= 25). 10% (n= 3) slightly agree, 3.3% (n= 1) agree, 3.3% (n= 1) slightly

disagree. None of the participants (n= 0) disagree or strongly disagree.

The item on the survey,” Breastfeeding is personally satisfying”, the most common answer

was strongly agree at 66.7% (n= 20). 30% (n= 9) slightly agree, 3.3% (n= 1) strongly disagree. None

of the participants (n= 0) agree, disagree, or slightly disagree.

The item on the survey, “Breastfeeding is messy”, the most common answer was strongly

disagree at 56.7% (n= 17). 20% (n= 6) slightly disagree, 10% (n= 3) disagree, 10% (n= 3) agree,

3.3% (n= 1) slightly agree.

The item on the survey, “Breastfeeding ties you down.” Of the study participants, responses

were 30% (n= 9) strongly disagree, 13.3% (n= 4) slightly disagree, 16.7% (n= 5) disagree, 6.7% (n=

2) agree, 20% (n= 6) slightly agree, 13.3% (n= 4) strongly agree.

The item on the survey,” Breastfeeding helps you bond with your baby”, the most common

answer was strongly agree at 66.7% (n= 20). The remaining 33.3% (n= 10) slightly agree. None of

the participants agree, disagree, slightly disagree, or strongly disagree.

The item on the survey, “Mothers who formula feed get back into shape sooner”, the most

common answer was strongly disagree at 53.3% (n= 16). 30% slightly disagree (n= 9), 16.7% (n= 5)

disagree. None of the participants agree, slightly disagree, or strongly disagree.

For the survey question, “What is the PRIMARY method of infant feeding you are using with

your new baby?” All participants in the survey 100% (n= 30) answered breastfeeding.


For the survey question, “How long do you intend to breastfeed?” (Graph 7) Participants

answered in a range from 6 weeks to 4 years. 3.3% (n= 1) 6 weeks, 3.3% (n= 1) 2 months,

33.3% (n= 10) 6 months, 3.3% (n= 1) 7 months, 46.7% (n= 14) 12 months, 6.7% (n= 2) 18

months, 3.3% (n= 1) 4 years.

For the survey question, “When did you decide you were going to breastfeed?” Most

participants 80% (n= 24) answered, “Before you became pregnant.” 13.3% (n= 4) answered,

“During the first three months of your pregnancy (1st trimester).” 6.7% (n= 2) answered,

“During the middle three months of your pregnancy (2nd trimester).” None of the participants (n=

0) answered, “During the last three months of your pregnancy (3rd trimester)” and “After the

baby was born.”


For the survey question, “How soon after the birth did you breastfeed your infant?”

Most participants 56.7% (n= 17) answered, “1 hour”. 23.3% (n= 7) 2 hours, 6.7% (n= 2) 4

hours, 3.3% (n= 1) 6 hours, 10% (n= 3) 24 hours.

For the survey question, “Did you receive breastfeeding support from staff while you

were hospitalized?” (Table 2) All of the participants, 100% (n= 30), answered “yes.”

Didyoureceivebreastfeedingsupportwhileyouwerehospitalized


Valid Yes 30 100.0 100.0 100.0

For the survey question, “Were you offered resources to support breastfeeding after you

were discharged? (Table 3) Most participants 66.7% (n= 20), answered “yes”. 33.3% (n= 10),

answered ‘no”.

Wereyouofferedbreastfeedingsupportafteryouweredischarged


Valid

Yes 20 66.7 66.7 66.7

No 10 33.3 33.3 100.0

Total 30 100.0 100.0

For the survey question, “Are you feeding your baby breast milk only?” 50% (n=15),

answered “yes”. 50% (n= 15), answered “no”.

For the survey question, “If you are not feeding your baby breast milk only, why?” 50%

(n=15), did not answer because they continued to exclusively breastfeed for 2 weeks. 20% (n=

6) Insufficient milk supply, 13.3% (n= 4) Medically necessary, 6.7 % (n= 2) Pain, 3.3% (n= 1)

Lack of sleep, 3.3% (n= 1) Baby is not satisfied, 3.3% (n= 1) Return to work/ school. Cross

tabulation of race was used to show differences among race for discontinuing breastfeeding.



Chapter Five

Discussion

This chapter discusses the implications of the findings and the conclusion of the study.

The purpose of this study was to examine the breastfeeding attitudes of first- time breastfeeding

mothers’ and their decision to initiate breastfeeding and continue breastfeeding for two weeks

postpartum. Previous studies support the idea that a woman’s attitude is a strong indicator of

initiating breastfeeding, a woman’s will to breastfeed supersedes perceptions around her, and

support of staff as outlined in BFHI guidelines have a positive influence on promoting exclusive

breastfeeding. This study supports those findings of previous studies by determining that a

woman’s before knowledge surrounding breastfeeding plays an integral role in initiating

breastfeeding. The findings in this study also supported several of Mercer’s, “Maternal Role

Attainment Theory- Becoming a Mother” (Mercer, 1985).

Results of the analysis reveal that the majority of mothers have a positive attitude about

breastfeeding before initiating, which coincides with the literature support of theories of planned

behavior (Azjen, 1987). All of the mothers (100%) agree that breast milk is more nutritious

than formula and (100%) of the mothers agree that breastfeeding makes you closer to your baby.

All of the mothers (100%) agree that breast milk is healthy for the baby, as well as (100%)

agreeing that breast milk is more economical. Most mothers (93.3%) surveyed reported making

a decision about breastfeeding before pregnancy or in the first trimester of pregnancy. 80.1% of

the mothers agree that breastfeeding is more convenient than formula feeding. The majority of

mothers (96.6%) agree that breast milk is the best choice for feeding their babies.


In support of a study by Sharps, El- Mohandes, El- Khorazaty, Kiel, & Walker’s (2003),

survey results report that most mothers’ dedication to breastfeeding surpassed perceptions that

could have been influential.

Most mothers (63.4%) initiated breast feeding despite the idea that formula feeding

promoted a closer bonding experience for the father and baby. The study also reveals that most

mothers (66.7%) initiated breastfeeding despite the perception that breastfeeding required more

of their time versus formula feeding. Also, (76.7%) mothers perceived that formula feeding

allowed mothers more freedom. (70%) of the mothers’ reported that breastfeeding makes

returning to work more difficult, but chose to initiate breastfeeding.

The results and findings related to support of nursing staff using BFHI guidelines, reports

that all of the mothers (100%) were offered assistance while an inpatient. The survey also

highlighted that most mothers (56.7%) breastfed their babies within the 1 hour period after birth

and most mothers (66.7%) were offered supportive resources after delivery. The study also

reveals that of the 50% of mothers that were not exclusively breastfeeding, (13.3%) of the

mothers were supplementing for medical reasons. Although mothers in the sample delivered in

different healthcare facilities, these findings show the consistency of following BFHI guidelines

(UNICEF, 2014).

All of the mothers (100%) reported that they were going to breastfeed by at least the 2nd

trimester of pregnancy. Conversely, only 50% were exclusively breastfeeding at 2 weeks after

delivery. Most mothers (80%), decided on breastfeeding before becoming pregnant, which implies

some fore knowledge and a positive attitude about breastfeeding. The implication is that there is an

education gap because (20%) of the mothers discontinued exclusive breastfeeding because of

attitudes about insufficient milk supply. There’s a strong indication of an education gap in the black


community with 5 out of the 6 mothers that reported insufficient milk supply being black. Cross

tabulations with babies not getting enough milk with breastfeeding indicate, that (52.3%) of blacks

surveyed reported agreeing with this idea. These findings support a study by Purdy (2010), that

indicate African American (Black) mothers breast and bottle feed their babies.

This study’s findings support Azjen’s Theory of Planned Behavior (1987), that attribute

positive attitudes concerning breastfeeding as indicators that mothers would initiate

breastfeeding. All of the mothers (100%) agree that breast milk is more nutritious than formula

and (100%) of the mothers agree that breastfeeding makes you closer to your baby. Most

mothers (93.3%) surveyed reported making a decision about breastfeeding before pregnancy or

in the first trimester of pregnancy. All of these are contributors to mothers deciding to

breastfeed.

Findings support recommendations to exclusively breastfeed for the first 6 months of life

(AAP, 2010). One third (33.3%) of mothers reported an intention on breastfeeding for first 6

months of life. Many mothers (46.7%) reported intentions up to 12 months. This is an

indication that mothers are aware of recommended guidelines as pointed out in the literature.

The studies’ findings validate Mercer’s theory concepts of bonding, self- regard,

flexibility, childrearing attitudes and beliefs, infant health status, role strain, and support

(Mercer, 1985). Reported findings in the study reveal that most mothers (100%) report that

breastfeeding promotes a positive bonding experience between mother and child. Most mothers

(96.7%) reported that breastfeeding was personally satisfying, which supports Mercer’s self-

regard concept. Flexibility, another one of Mercer’s concepts, was depicted in the study with

reference to the finding that most mothers (76.7%) initiated breast feeding despite thinking that

formula feeding was more convenient. All of the mothers (100%), decided to breastfeed before


they became pregnant or very early in the pregnancy, which supports Mercer’s theory that child-

rearing attitudes and beliefs influence mothers actions. Mercer’s concept of the importance

infant health status is indicated in the findings by all of the mothers (100%) agreeing that breast

milk is healthy for the baby and breast milk is more nutritious than infant formula. This concept

is furthered supported by most mothers (96.6%) reporting breastfeeding is the best feeding

method. Mercer’s concept of role strain is evident in the study by (60%) of mothers reporting

that mothers who formula feed get more rest. Role strain is also depicted by (70%) of mothers

reporting difficulty returning to work while breastfeeding. The concept of support is evident in

this study by all of the mothers (100%) reporting that breast feeding support was offered in the

hospital. Also (66.7%) of the mothers reported supportive resources being offered after

discharge. This finding also depicts BFHI evidence- based practice that highlights supportive

measures as an intervention to increase breastfeeding rates (UNICEF, 2014).

Limitations

A limitation of this study that impacted results was sampling first- time breastfeeding

mothers from one facility. Future studies should seek samples from multiple locations to capture

a more diverse population. The sample was homogenous with many of the mothers having the

same demographics, which controlled generalizability of the data. As a result, variances to age,

race, and education levels were not obvious.

Implications for Nursing Education

Maternal/ Child Nursing and Pediatric Nursing are especially affected by the findings.

Education of Obstetrical Nursing staff is critical because they play a pivotal role in breastfeeding

in the early stages of decision making. Findings in this study imply feeding methods are chosen

most times before a woman conceives. The woman’s attitude surrounding the feeding method


affects what method she chooses. For mom’s that choose a method other than breastfeeding,

education about the benefits of breastfeeding would be influential in decision making.

Preparation of nursing staff with evidence- based knowledge is a prerequisite for educating 1st

time breastfeeding mothers about breastfeeding.

Pediatric Nursing would be most influential in mothers continuing to breastfeed. Their

knowledge base should incorporate the benefits of breastfeeding along with supportive measures

that increase the likelihood of mothers remaining steadfast with breastfeeding. Pediatric nursing

staff should embody standard breastfeeding knowledge to educate mothers. Teaching nursing

staff standard guidelines that are outlined in BFHI, allows the staff to transfer globally accepted

knowledge to mothers that have been tested and proven effective in exclusive breastfeeding

rates. Breastfeeding education that follow BFHI guidelines allow mothers to benefit from a

consistent stream of knowledge that is widely accepted. Following BFHI guidelines educates

staff with the same global objectives that can be taught to mothers across different age, race, and

educational backgrounds to meet the learning needs of every mother.

Implications for Nursing Practice

Most healthcare facilities that offer maternity services are moving toward practices that

encourage breastfeeding. In keeping with the Healthy People 2020 projection on breastfeeding,

healthcare facilities have spearheaded efforts to meet breastfeeding goal objectives. Facilities

have implemented evidence- based interventions for staff to practice that have proven effective

in increasing exclusive breastfeeding rates. The study’s findings report that most mothers are

receiving inpatient and discharge support with breastfeeding which coincide with nursing

moving towards practices that encourage continuing exclusive breastfeeding. According to the

study 13.3% of mothers supplemented because of medical necessity, this supports nursing


practice that follow BFHI guidelines of offering supplementation only when there is a medical

indication. Practicing under these standards, increase facility costs because the facility does not

receive kickbacks from formula companies for promoting particular brands of formula (Ginty,

2011). Reimbursement; however, should be for promoting breastfeeding and healthier outcomes

and not for promoting unhealthy outcomes.

Implications for Nursing Research

The evolution of healthcare increases the demand that the nursing profession keep

up with the most innovative approaches to meet the needs of the population. Based on research,

breastfeeding is the best feeding option to advance health for mom and baby (AAP, 2010).

Nursing has an obligation to implement the best practices to ensure that breastfeeding, as the best

feeding method, is conveyed to mothers for their babies. Based on findings in this study, 100%

of mothers are aware that breastfeeding is more nutritious than formula for their babies. So it is

evident that this knowledge is prevalent to most mothers, the missing link is the reason that

mothers are not giving their babies the best feeding option. Nursing research should expand to

include what barriers prevent mothers from instituting breastfeeding for their babies. The

research should go a step further in evaluating how to eliminate these barriers so that

breastfeeding for the duration is more widely accepted. Demographics of race, age, and

educational level should be considered so that the direct needs of a population could be targeted.

Conclusion

Breastfeeding continues to be a public health initiative and will be catapulted to the

forefront of the U.S. healthy objectives until goals are met. Great strides have been made with

increasing breastfeeding rates but with health expenditure increasing per year, initiatives will

continue to target breastfeeding rates based on evidence- based findings that the benefits of


breastfeeding promote healthier outcomes. This study supports the data that show breastfeeding

initiation rates are inclining and that healthcare facilities have assisted with getting those rates

increased (CDC, 2013). This study also shows that while Black mothers were well educated

about breastfeeding and infant health, there is a need in educating Black mothers about basic

physiological patterns of breastfeeding. Future studies should target factors associated with

cessation beyond the two week duration. Focus should be on implementing measures to help

meet 6 month breastfeeding goals (AAP, 2012).


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Appendix A

Tool Permission

RE: Permission to use toolDELETEREPLYREPLY ALLFORWARDMark as unread

Jill R Janke <[email protected]>Mon 9/15/2014 3:51 PMInboxTo:Broadnax, Tamika;Cc:Jill R Janke <[email protected]>;You replied on 9/16/2014 3:45 PM. 2 attachments

SCORE BAPT 2013.pdf 62 KB TOOLBAPT 2013.doc 49 KB

Download allDear Tamika,I do give you permission to use the BAPT as long as you follow-through on the conditions of your letter. As an aside, tell Dr. Tilghman I said Hi. Jill Janke From: Broadnax, Tamika [mailto:[email protected]] Sent: Monday, September 15, 2014 6:48 AMTo: Jill R JankeSubject: Permission to use tool Dear Ms. Janke,My name is Tamika Missouri, a Coppin State University, second year nursing graduate student. I am writing my thesis tentatively titled, "Preconceived Ideas About Breastfeeding and Continuing Exclusive Breastfeeding for 2 Weeks in First-time Breastfeeders in a Baby- Friendly Aspiring Hospital." I will be working under the direction of committee members, Dr. Nayna Philipsen (chair), Dr. Joan Tilghman, and Dr. Warren- Dorsey. My site for this study will be Mercy Medical Center in Baltimore, MD. I would like permission to use a modified version of the Breastfeeding Attrition Prediction Tool (BAPT) in my research study that will be administered to first- time breastfeeding postpartum women. In doing so, I will use the instrument solely for this study and will not be compensated for its use. I will include copyright statements with all pages utilizing the survey. I will also send the completed research study to you with any additional reports pertaining to the use of the tool.

https://pod51042.outlook.com/owa/service.svc/s/GetFileAttachment?id=AAMkADM0N2VmZjRmLThiNDktNGVlOC04Y2M5LTNmOTk4YzlmZjk3NABGAAAAAADtXj391O9SSLOAkAJeWL%2BOBwDMGJjYLlq3Qq8R2ZQ2kZyhAAAAdG%2BWAADvkteHFUm2RZurtx%2Fe1FTMAAERt73tAAABEgAQAGQ68E%2BYTMtDuACAC3zEmRI%3D&X-OWA-CANARY=BwXkpe7OGEKjF2Ig0twzARbx7Gp50dEIedlhs2fhEYL7XMwZWuiJ0pDmAYHd9i_88dHDiiNcBTg.

https://pod51042.outlook.com/owa/service.svc/s/GetFileAttachment?id=AAMkADM0N2VmZjRmLThiNDktNGVlOC04Y2M5LTNmOTk4YzlmZjk3NABGAAAAAADtXj391O9SSLOAkAJeWL%2BOBwDMGJjYLlq3Qq8R2ZQ2kZyhAAAAdG%2BWAADvkteHFUm2RZurtx%2Fe1FTMAAERt73tAAABEgAQAPrAAu0LRNJDoyTfMGQDvOs%3D&X-OWA-CANARY=BwXkpe7OGEKjF2Ig0twzARbx7Gp50dEIedlhs2fhEYL7XMwZWuiJ0pDmAYHd9i_88dHDiiNcBTg.

https://pod51042.outlook.com/owa/service.svc/s/GetFileAttachment?id=AAMkADM0N2VmZjRmLThiNDktNGVlOC04Y2M5LTNmOTk4YzlmZjk3NABGAAAAAADtXj391O9SSLOAkAJeWL%2BOBwDMGJjYLlq3Qq8R2ZQ2kZyhAAAAdG%2BWAADvkteHFUm2RZurtx%2Fe1FTMAAERt73tAAABEgAQAPrAAu0LRNJDoyTfMGQDvOs%3D&X-OWA-CANARY=BwXkpe7OGEKjF2Ig0twzARbx7Gp50dEIedlhs2fhEYL7XMwZWuiJ0pDmAYHd9i_88dHDiiNcBTg.


If these are satisfactory terms and conditions, please notify me by email giving me permission to use the BAPT. Thank you in advance for considering.

Tamika [email protected]

mailto:[email protected]


Appendix B

Site Permission


Appendix C

IRB Approval


Appendix D

Informed Consent

Coppin State University

Attitudes About Breastfeeding and Continuing Exclusive Breastfeeding for 2 Weeks in First- Time Breastfeeding Mothers in a Baby- Friendly Aspiring Hospital

The purpose of this research study is to examine the relationship between first- time breastfeeding mothers’ attitudes about breastfeeding and the influence these attitudes have on mothers choosing to breastfeed. A potential benefit of this study is to increase breastfeeding rates. Although the Principal Investigator does not anticipate any significant risks associated with your participation in this study, there is the possibility that you may experience intrusiveness from disclosing personal information while participating in the study. At the conclusion of your participation, you will have an opportunity to discuss your experience with the Principal Investigator, and receive information and referral, as appropriate.

Your personal identity and privacy, and the confidentiality of any personal information that is disclosed, will be protected. All information that is gathered will be kept in a locked file that is accessible only to the Principal Investigator, or in a password-protected electronic database. All individual records will be destroyed within 30 days of the conclusion of this research. The results of this research will only be reported in the aggregate for the total group of participants. The personal identity of any participant will not be revealed at any time.

Your participation in this research study is voluntary, and you may withdraw from participation at any time, without penalty.

By your signature below you confirm that you understand this agreement, that you have had an opportunity to have any questions answered in advance of your participation, and that you may contact the Principal Investigator, Dr. Nayna Philipsen 410-951-2630, email: nphilipsen @coppin.edu at any time if you have an additional question(s) regarding this study.

I, _______________________________ consent to participate in this research study.

______________________________ _____________________________ __________ Name (printed) Signature Date

______________________________ _____________________________ ___________ Principal Investigator Signature Date


Appendix E

Tool

BREASTFEEDING ATTRITION

PREDICTION TOOL

(BAPT)

© Jill Janke RNC, DNScUniversity of Alaska Anchorage


School of Nursing and Health Sciences3211 Providence Drive

Anchorage, Alaska 99508June 2008


PLEASE CIRCLE THE NUMBER THAT MOST CLOSELY DESCRIBES HOW YOU FEEL ABOUT EACH STATEMENT.

Strongly Strongly

disagree agree

1. Breastfeeding is more convenient than formula feeding. 1 2 3 4 5 62. Breastfeeding is painful. 1 2 3 4 5 63. Formula feeding allows the mother more freedom. 1 2 3 4 5 64. Infant formula can cause allergies. 1 2 3 4 5 65. Breastmilk is healthy for the baby. 1 2 3 4 5 6

6. No one else can help feed the baby when you breastfeed. 1 2 3 4 5 67. It is difficult to breastfeed in public. 1 2 3 4 5 68. Formula fed babies tend to get sick. 1 2 3 4 5 69. Breastmilk is more nutritious than infant formula. 1 2 3 4 5 610. Breastfeeding makes your breasts sag. 1 2 3 4 5 6

11. Formula feeding is easier than breastfeeding. 1 2 3 4 5 612. Formula fed babies are more fussy than breastfed babies. 1 2 3 4 5 613. Breastfeeding makes you closer to your baby. 1 2 3 4 5 614. Breastfeeding makes returning to work difficult. 1 2 3 4 5 615. Formula fed babies are easier to satisfy than breastfed babies. 1 2 3 4 5 6

16. Formula fed babies tend to be overweight. 1 2 3 4 5 617. Breastfeeding is more economical than formula feeding. 1 2 3 4 5 618. When you breastfeed you never know if the baby is getting enough milk. 1 2 3 4 5 619. Mothers who formula feed get more rest than breastfeeding mothers. 1 2 3 4 5 620. Breastfeeding is natural. 1 2 3 4 5 6

21. Breastfeeding is more time consuming than formula feeding. 1 2 3 4 5 622. Formula feeding lets the father become close to the baby. 1 2 3 4 5 623. Infant formula can cause constipation. 1 2 3 4 5 624. Breastfeeding is best for the baby. 1 2 3 4 5 625. Breastfeeding is personally satisfying. 1 2 3 4 5 6

26. Breastfeeding is messy. 1 2 3 4 5 627. Breastfeeding ties you down. 1 2 3 4 5 628. Breastfeeding helps you bond with your baby. 1 2 3 4 5 629. Mothers who formula feed get back into shape sooner. 1 2 3 4 5 6

PLEASE CIRCLE THE CORRECT ANSWER OR FILL IN THE BLANKS FOR THE FOLLOWING QUESTIONS:

30. What is the PRIMARY method of infant feeding are you using with your new baby?

a. Breastfeeding b. Formula feeding

31. How long do you intend to breastfeed? _________________

32. When did you decide you were going to breastfeed?

a. Before you became pregnantb. During the first three months of your pregnancy (1st trimester)c. During the middle three months of your pregnancy (2nd trimester)d. During the last three months of your pregnancy (3rd trimester)e. After the baby was born


33. How soon after the birth did you first breastfeed your infant? _______________

34. Have you ever breastfed before?

a. Yes b. No

35. What is your age? ___________

36. What is your ethnic origin?

a. Black b. Asian c. White d. Hispanic e. Native americanf. Other (please specify):_____________________

37. Circle the highest grade completed:

Grade school: 1 2 3 4 5 6 7 8 High school: 9 10 11 12 College: 13 14 15 16 Graduate School: 17 18 19 20

This is the end of the questionnaire. If you have further comments, please write them on the back of this


APPENDIX F

Telephone Interview

Hello, Ms. /Mrs._____________. My name is Tamika Missouri, a Coppin State Graduate

Nursing Student. I was calling today to follow-up with you after the breastfeeding survey that

you completed at your pediatrician’s office. I’ll ask you a few questions pertaining to your

breastfeeding experience over the past 2 weeks. This is a follow-up telephone interview to

review your breastfeeding experience now that your baby is about 2 weeks old. As previously

explained to you before you completed the first survey, your participation is voluntary and

confidential. You can opt to not continue to participate in this study at anytime without penalty.

1. Did you receive breastfeeding support from staff while you were hospitalized?

2. Were you offered resources to support breastfeeding after you were discharged?

3. Are you feeding your baby breast milk only?

4. If you are not feeding your baby breast milk only, why?

This concludes your participation in this study. I appreciate your willingness to participate. Are

there any questions that you have?

Thank you. Have a good day.


Documents

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