van · dierdre waywell at the famiiy medicine centre, donna wood at the community midwives centre,...

Breastfeeding Confidence and Duration of Breastfeeding

Among Drop-In Mothers

by

LORI VAN MANEN

A thesis submitted to the School of Nursing

in conformity with the requirements for

the degree of Master of Science

Queen's University

Kingston, Ontario, Canada

September, 1998

copyright O Lori Van Manen, 1998

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B r d e e d i n n Confidence and Duration of Breastfeedine Amone D r o ~ I n Motbers

Abstract

Only 30% of mothers breastfeed until the recomrnended i&t age of six months. Many

mothers stop earlier than they planned for rasons that are amenable to professional intervention

Breastfeeding Drop-Ins were estabIished in Kingston, Ontario to provide support for

breastfeeding mothers It was hypothesized that support increases breastfeeding confidence,

which in turn increases breas tfeeding dura tion Bandura's self-efficacy theory ( 1 997) provides

theoretical support for this causal pattern However, empirical evidence regarding the relationship

between breastfeeding confidence and breastfeeding duration is incongruous.

-ose: The purpose of this study was to describe the extent to which mothers who

attended Breastfeeding Drop-lns in Kingston breastfed to inf'ant age of six months, and to

examine the relationship between breastfeeding confidence and duration among these mothers.

Met hods: A longitudinal descriptive design was emp loy ed with thirty-seven mot hers

recruited fiom four &op-in sites in Kingston A socio-demographic survey and an 18-item Iikert

scale of breastfeeding confidence (Morrow, 1994) were administered at fmt drop-in visit and by

telephone 4-6 weeks later. intended duration was assessed at fmt visit and extent of breastfeeding

was assessed at six months.

Analvsis: Percentages and bar graphs were used to describe the results. Kendall's tau, the

Mann-Whitney U, and Chi-squared tests were used to analyze the relationships among

breastfeeding confidence and duration. Factors that best predicted breastfeeding at six months

were explored through logistic regression

Results: Seventy-six percent of mothers were breastfeeding at infant age of six months.

Breastfeeding confidence was not significantly related to intended and actual duration, after

contro lling for the age of the infhnt at fîrst drop-in visit. Breastfeeding confidence increased over

tirne for the majority of mothers, but change in confidence was not significantly related to the

number of &op-in visits. Materna1 age was the best predictor of breastfeeding at six months in

this sample. The srnall sample size and homogeneity of this sample obscured potentially

signif~cant relationships between breastfeeding confidence and duration

Conclusion: Asking mothers their age and how long they intend to breastfeed would have

been an effective means of identiQing mothers at risk for stopping breastfeeding early. Expected

relationships between breastfeeding confidence and duration were not found.

Acknowledgements

1 have enjoyed working with the many wonderful people who have helped me to

complete this thesis and would like to express my sincere gratitude to the following:

My thesis supervisor, Dr. Sharon Burke, Professor of Nursing and Rehabilitation Therapy, who instilied in me a Iove for research. Thank-you for providing me with a rich learning environment, and for s haring your qualitative and quantitative research perspectives. Y our expertise and warm words of encouragement provided an invaluable support.

Dr. Kate O'Connor, Assistant Professor of Community Health and Epidemiology and Thesis Cornmittee Member. who spent countiess hours with me explainhg the iritricacies of the English language. Thank-you for your guidance and statistical knowledge, and for making my thesis writing experience an enjoyable one.

My thesis advisory cornmittee - Co-Supervisor Dr. Judy De Wolfe, Assistant Professor of Nursing, and Ms. Pam Carr, Lecturer of Commmity Health and Epidemiology, for their careful evaluation of several drafts and valuable feedback

The Kingston, Frontenac, Lennox, and Addington Health Unit for their generous fnancial support for this project, and to the public health nurses who helped me with my recruitment of subjects.

Dierdre Waywell at the FamiIy Medicine Centre, Donna Wood at the Community Midwives Centre, and Lindi Sibeko at the North Kingston Community Health Centre for your breastfeeding expertise and help in recnliting subjects. Thank-you also to the mothers who attended the Breastfeeding Drop-Ins, for without you 1 would have no study.

The Canadian Nurses Association and the Registered Nurses Association of Ontario Foundation for their generous financial support.

AI1 the members of my M l y for their love, support, and inspiration. A special thanks to my mother and fither for their warm words of encouragement. 1 would ako Iike to thank my dear fnends, many of whom live tar away but have provided me with much needed telephone breaks.

The Wowk fàmily for feeding and watering me at t h e s when 1 was glued to my chair.

Tim, for your love and support over the past year and a half The sun, the moon, and the stars.. .You saved me from thesis despair many times with your seme of humour. Thank-you for helping me with rny thesis, for proof-reading, for photocopying, and the countless other things.

iii

TABLE OF CONTENTS PAGE

ABSTRACT ................ .............,................................... i

. . * ACKNO WLEDGEMENTS ............................................................................... iii

................................................................................... TABLE OF CONTENTS iv

S.. ............ LIST OF TABLES ............................. ..... ... vui

.............................................................................. LIST OF FIGURES ...*...-.-n ic

.................................................... LIST OF APPENDICES .......................... ...... x

Chapter 1 : Introduction

... .................................... Study Purpose ... ... 5

Chapter 2: Literature Review

Background ..................... .. ..... .... ................................................ 6

Advantages of Breastfeeding ........................................................ ... 6

................................................................. Reasons for W eaning ... 7

Factors Influencing Breastfeeding Duration .................. ..... . ... .................. 8

Socio-dernographic Factors ................... .. ... .. ............................... 8 Breastfeeding Support ....................... ............... .................... 8

Support £kom health care professionais .................... .., ........... 10

Evidence Linking Support fiom Health Care Professionals and Breastfeeding Duration ...................................... .... ................................ 12

Evaluations of Support Interventions ............................................ ., 1 3

Studies of Breastfeeding Drop-In Centres or Clinics .............................. 19

Theoretical Frarnework Linking Support, Confidence, and Breastfeeding Duration: ............................................................... Bandura's Self Efficacy Theory 2 1

.................................... Description of Bandura's Self-Etficacy Theory 2 1

Level .......................................................................... 21

Generality ...................................................................... 21

Strength ......................... ......................................... 22

......................................................... Self-efficacy and Confidence 22

.................................... Sources of information to increase Confidence 22

............................................. Performance accomp lishrnents 22

.......................................................... Vicarious expenence 23

............................................................ Verbal persuasion 23

............................................................ Emotional arousal 24

.................... ... . ................ Breastfeeding Drop-Ins .. ..... ..... 24

............................. Confidence. Behaviour, and Outcornes ... ..... .. . 25

........ Empirical Evidence Linking Support, Codidence. and Breastfeeding Duration 28

........................... Support fkom Breastfeeding Drop-Ins and Confidence 28

........................................... Confidence and Breastfeeding Duration 29

Smdy Objectives ................................................................................. 33

Chapter 3 : Methods

Setting .................... -........... ............................................ ........... .... 35

Study Population and Sample .................................................................. 35

..................................... ....................... Data Collection Procechues ..... 36

.......................................................................... intake Protoc01 36

.......................................-.. . . .......... Follow-up Protocols .... .... .. 38

................................................................................ Snidy Instruments 39

...................................................... B r d e e d i n g Confidence Scale 39

.............................. .................... Breastfeeding Drop-ln Survey .,.. 42

............. DataCoding, Entry. and Cleaning ........ ................................... 43

............................................................... Sample Size Estimation 45

Ethicai Considerations .................... ................................................... 46

Chapter 4: Resufts

........ Objective 1 : Characteristics of Mothers Who Attended Breastfeeding Drop-Ins 47

...... .................... ................... Socio-demographic Characteris tics ... .. 47

Parity. Prenatal Class Attendance. and Smoking .................................. 47

..................................... Mothers' Current Breastfeeding Experiences 49

..................................................... Infànt Age at First Drop-In Visit 49

..................................... Mothers' Previous Breastfeeding Experiences 49

Objective 2: Rates of Breastfeeding at Six Months among Study Mothers ............., 51

Objective 3: Breastfeeding Confidence and Duration of Breastfeeding .................. 51

initial Breastfeeding Confidence Scores and Intended Duration ................ 51

Breastfeeding Confidence Four to Six Weeks after First Visit ................................. .............................. and Actual Duration .... 53

Post-Hoc Analyses ....................................... .. .................................... 58

Initiai Breastfeeding Confidence in Relation to Breastfeeding at Six Months ............................................................................... 58

initial Breastfeeding Confidence in Relation to Confidence Measured Four to Six Weeks Later ................... .....,................................. 60

................... ..... Intended Duration and Breastfeeding at Six Months ... .... 60

Objective 4: Change in Breastfeeding Confidence Over Time ............................. 62

Number of Drop-In Visits ............................... .. .............. 67

Objective 5: Exploratoxy Analysis . Predicting Breastfeeding at Six Months .......... 67

Bivariate Analyses ..................... .......... ..... .................... . . . . . 67 ................. Predictors of Breastfkeding at Six Months: Logistic Regression 72

Chapter 5: Discussion

............................................. Attendance at Breastfeeding Drop-Ins 75

Socio-dernographic Characteristics ................................ ., ................ 76

...................................................................... Intended Duration 77

infànt Age ............................................................................. 77

Initial Breastfeeding Confidence ..................................................... 78

Sample Limitations ............,.............................................. ... ...... 79

................................................................. Breastfeeding at Six Months ... 80

................................... Initial Breastfeeding Confidence and Intended Duration 83

initial and Four to Six Week Breastfeeding Confidence and Actual Duration ........... 87

................................ . . . Changes in Breastfeeding Confidence Over T h e .. 89

Change in Breastfeeding Confidence in Relation to the .................................................................... Number of Drop-lm 91

........................ Predicting Breastfeeding at Six Month .. .. .. .................... 92

................................. ........................ ........ Clinical Implications .... ... 94

................................................................... Future Research Suggestions 98

......................................................................................... Conclusion 99

............................................................................................ REFERENCES 100

............................................................................................ APPENDICES 108

CURRiCtlLUM VITAE ........................ .... ..................................................... 124

vii

LIST OF TABLES

Table

1

2

3

4

Title Page

Summary of Support Interventions and Findings .................................. 14

Socio-demographic Characteristics of Study Mothers ............................ 48

Characteristics of Mothers' Current Breastfeeding Expenences ............... , 50

................. Characteris tics of Mothers ' Previous Breas tfeeding Experiences 51

Relationships between Breastfeeding Confidence (BFC). Intended Duration, and

Breastfeeding at Six Months .......................................................... 54

Mothers with Younger Versus Older Infants and Intended Duration ........... 56

Breastfeeding Confidence at First Visit and at 4-6 Weeks after First Visit ..... 62

Relationships of Characteristics of Study Mothers with Breastfeeding

Duration ................................................................................ 69

Crosstabulation of Materna1 Age. Intended Duration., and Breastfeeding

at Six Months .......................................................................... 71

Logistic Regression Mode1 to Predict Breastfeeding to Six Months

... VUL

LIST OF FIGURES

Figure

1

Title Page

The Conditional Relationships between Eff~cacy Beliefs and Outcome ....................... Expectancies ........................... ............O.~........... 26

Diagrammatic Representation of the Relationships Between Infant Age, Breastfeeding Confidence (measured at first drop-in visit and 4-6 weeks

. later), Intended Duratios and Actual Duration (breastkding at six months).. 34

Examples of Physicai, Self-evaluative, and Social Items of the BCS ............ 40

Study Mothers Bottle feeding, Partially, and Fully Breastfeeding at Initial Drop-ln Visit and Enfànt Age of Six Months ....................................... 52

Part 1: Diagrammatic Representation of Study Constnicts - Bivariate Relationships benveen (a) Initial Breastfeeding Confidence and I&nt Age and

....................... (b) Initial Breastfeeding Confidence and Intended Duration 5 5

Part 2: Diagrammatic Representation of Study Constructs - Relationship between Breastfeeding Confidence Measured 4-6 After First Drop-In Visit and Breastfeeding at Six Months ...........................................,......... 57

Part 3: Diagrammatic Representation of Shidy Constructs - Bivariate Analyses of Relationships between (a) Infant Age and Initial BFC, (b) Infânt Age and Breastfeeding at Six Months, and (c) Initial BFC and Breasrfeeding at Six Months, and (d) initial BFC and BFC measured 4-6 weeks after f h t &op-in visit .................... .. ... ... .............................................. 59

Part 4: Complete Diagrammatic Representation of the Interrelationships of Smdy Constnicts, Controlling for &nt Age (n = 20) ..., ........................ 6 1

Distribution of Medium High, High, and Very High Breastfeeding Confidence Scores Measured at First Drop-In Visit and 4-6 Weeks after Initial Visit ...... 64

Changes in Breastfeeding Confidence Scores between First Drop-ln Visit and 4-6 Weeks Later for Mothers With Younger Mmts (n = 18) and Mothers with Older b t s (n = 17) ................................................................. 66

LIST OF APPENDICES

Appendix Title Page

Program Evaluation of Breastfeeding Drop-Ins:

.................................... information Sheet and Consent F o m 1 08

.................. .................... Breastfeeding Confidence Scale ..... 1 1 1

.............................................. Breastfeeding Drop-In Survey 114

Breastfeeding Drop-In Survey - Telephone FoIlow-up 4-6 Weeks

. ......... .... After Initial Drop-in Visit., .......- ...........,.. 1 17

Breastfeeding Drop-In Survey - Telephone Follow-up

................................................. BabyatSixMonths ofAge 119

Logistic Regression Model Number 2: Exciuding Infant Age fiom the

Mode1 ........................................................................ , 121

Breastfeeding Drop-In 1

CHAPTER 1

Introduction

Exclusive breastfeeding for the fmt 4-6 months of Iife is the o p h l source of infànt

nutrition (Canadian Paediatric SocietyDietitians of Canada/Health Canada. 1998:

WHO/üNICEF, 1990)- In Canada, of the approxirnately 80% of mothers who initiate

breastfeeding in hospital, only 30% continue to breastfeed for six months (Health and We&e

Canada, 1991). The latest results fiom the National Longitudinal Survey of ChiIdren and Youth

(NLSCY) (Ministry of Industry, 1996) reveal relatively unchanged initiation and miration rates of

breastfeeding in Canada over the past decade.

Across Canada, &ta from the NLSCY indicate that 24% of mothers continue to

breastfked for six months (Ministry of Industry, 1996). Statistics fiom various small-scale studies

across Canada parallel these findings. Of mothers who breastfeed, 15-20% stop within one month

(Chomniak & Hubay, 1992: Lynch, Koch, Hislop, & Coldman, L986: Sims-Jones & Bowes.

1997). 35% by three months (Lynch et al., 1986; Valaitis, Ciliska, Sheeshka & Sword, 1996). 40-

50% by four months (Isaacs & Li- 1996; Pastore & Nelson, 1997: Solway, 1992). and 60-

70% by six months (Lynch et al., 1986). Not only do the majority of mothers discontinue

breastfeeding before their inEants are six months 014 but many mothers stop breastfeeding sooner

than they had planned (Ferris, McCabe, Allen & Pelto, 1987; Hill, Humenick, Argubright &

Al&% 1997; Loughlin, CIapp-C hanning, Gehlbach, Pollard & McCutchen, 1 985: Rogers, Morris

& Taper, 1987) and express regret at doing so (Health Caoada, 1995: Rogers et al., 1987).

Early obstetrical discharge together with inadequate comtnunity follow-up is thought to

contribute to early breastfeeding cessation (O'Leary Quinn, Koepsell & Haller, 1997). in

Canada, most mothers are discharged fiom hospital24-72 h o m after giving b a ; some are

discharged as early as 12 hours (Health Canada, 1 994). Consequently. mothers have iimited time

to establish breasaeeding before they r e m home. S hortened obstenical stays in the absence of

adequate community follow-up have resulted in increased rates of newbom re-admiss ion for

dehydration and jaundice (Health Canada, 1994: Lee, Perlrnan, BaIlantyne, Elliot, & TG, 1995).

Not only are such re-admissions cost-intensive and burdensome on the hmlth care system. but

serious consequences result when feeding problems go unnoticeci, as in the Ontario case of an 11-

&y old breastfed infànt who died fi-om dehydration (Registered Nurses Association of Ontario,

1998).

The Ontario Minisûy of Health (1997), in its mandate to improve the health of chiidren

emphasizes the need to increase breastfeeding duration and to implement adequate community

foliow-up services for breastfeeding mothers, such as breastfeeding &op-in centres. One

objective is to increase the percentage of idànts breastfed up to six months to 50% by the year

20 10 (Ontario Minisûy of Health, 1997). To meet this objective, the Ministry recommends that

communities establish breastfeeding services, such as telephone help-lines, centres, clinics, drop-

ins, and peer support groups.

The current study was conducted with mothers who attended Breastfeeding Drop-lns in

Kingston, Ontario. Breastfeeding Drop-Ins are places where mothers can get professional help

with breastfeeding problems, meet other breastfeeding mothers, and have their babies weighed.

Several studies report that breastfeeding support intervent ions such as home vis it ing, telep hone

support, and support groups generally increase breastfeeding duration in the short term (Brent,

Redd, Dworetz, D'Amico, & Greenberg, 1995; Houston, Howie, Cook & McNeilly. 1981:

Jenner. 1988; Saunders & Caroll, 1988). However, these findine are questionable, as

methodological fiaws are inherent witbin these studies. As weli, it is not known if breastfeeding

drop-ins are associated with increased breastfeeding rates at infant age of six months.

Breastfeeding Drop-ln 3

Breastfeeding support services or programs Vary with regard to the type, intensity, and

combination of interventions used (Brent et al., 1995: Houston et al., 198 1: Jenner, 1988;

Saunders & Caroil, 1 988): nevertheless, they tend to share common characteristics. Most

interventions indude informational and emotional support components (Brent et al., 1995; Jenner,

1988: McNaa & Frestos 1992: Saunders & Caroll 1988). Informational nippon includes any

information or encouragement offered by heakh care professionals to breastfeeding mothers

(McNatt & Freston, 1992). Information is offered to breastfeeding mothers by telephone, home

visiting, breastfeeding drop-ins, or through dismiution of reading materials (Buckner &

Matsubara, 1 993). Emotional support and encouragement for breastfeeding mothers are also

offered by health a r e professionals (McNatt & Freston, 1992).

Informational and emotional support have been shown to positively influence

breastfeeding outcornes (McNatt & Freston, 1992: Sirnopoulos & Grave, 1984). Studies show

that the more support a mother perceives she has for breastfeeding, the longer she breastfeeds

(Cronenwett & Reinhardt, 1987; Isabella & Isabella, 1994; McNatt & Freston, 1992). This is tme

after controlling for confounding variables such as materna1 age, education. smoking status. and

pari ty -

How breastfeeding support influences breasfeedïng duration is not clearly understood.

One hypothesis is that support increases confidence, which, in tum, increases breastfeeding

duration. Findings from previous studies suggest that breas tfeeding support increases mothers '

confidence (Kearney, 1988; Minde, S hosenberg, & Thompson, 1983 ; Sims-Jones & Bowes.

1997; Stefiuk, 1997). However, findings regarding the relationship between breastfeeding

confidence and breastfeeding duration are conflicting.

Some studies show that breastfeeding confidence is related to breastfeeding duration

(Loughiin et al., 1985; O'Campo, Faden, Gielen, & Wang, 1992), but other research findings

Breas tfeeding Drop-In 4

indicate this is not so (Lawson and Tuiioch 1995). Discrepancies in fuidings may be attributed to

limited measures of breastfeeding confidence. Bandura (1997) maintains that in order to be

considered valid measues of self-eficacy, or confidence. should: (a) rneasure different levels of

task demand, (b) include enough items to i d e n t e upper and lower limits of capability, (c)

measure the abiiity to perform the same cisk in diffeient circumstances. and (d) be unipolar in

their ratings so that high scores indicate high confidence.

instruments used to measure materna1 confidence with breastfeeding, to date. have not

satisfîed aii of Bandura's (1997) cnteria. Most instruments contain too few questions for which a

rnother can assess her ability to perform different levels of tasks associated with breastfeeding

(Lawson & Tulloch, 1995; Loughin et al.. 1985; O'Campo et al., 1992). Morrow (1 994)

developed a more comprehensive s a l e that assesses several dimensions of breastfeeding

confidence and meets the cnteria specified by Bandura. However, she did not examine the

relationship between breastfeeding confidence and breastfeeding duration

Since mothers bring their own beliefs, experiences and expectations to breastfeeding, it

logically follows that the confidence a rnother feels in her ability to breastfeed rnay be related to

how long she actually breastfeeds. Given that previous measures of breastfeeding confidence may

not be valid, the next research step was to examine the relationship between brmtfeeding

confidence and duration using Morrow's ( 1994) Breastfeeding Confidence Scale. Examination of

this relationship within the fiamework of Bandura's (1997) self-efficacy theory may lead to a

clearer understanding of tàctors that influence breastfeeding duration Such knowledge could be

usefiil in planning, implementing, evaiuating or redesigning existing programs that aim to

increase duration.


S tu& Purpose

The purpose of the present study is two-fold:

1. to evaluate the extent to which mothers who attended Breastfeeding Drop-Ins located

in Kingston, Ontario meet the recommended guidelines of breasneeding to six rnonths, and

2. to examine the relationship between breastfeeding contidence and duration of

breastfeeding among mothers who atrended the Breastfeeding Drop-Iris.


C W T E R 2

Literature Review

Backmound

The importance of breastfeeding in developed countrks has been undermined as a result

of the low morbidity and mortaIity rates of formula fed inhts. improved infànt formulas and

higher standards of sanitation are, in part, responsible for decreased infiant morbidity and

mortality (Canadian Paediatric Society et al., 1998). Nevertheles, significant immediate and

long-term advantages exist for breastfed infants and mothers who breastfeed The following

findings lend support CO the m e n t recommendation of exclusive breastfeeding for the fmt 4-6

months of Me.

Advantages of Breastfeeding

Infaats experience both s hort-term and long-terrn benefits of breastfeeding. Breast milk is

more digestible than artificial formula and is associated with fewer allergic reactions,

gastrointestinal infections, respiratory illnesses. and vorniting episodes (Beaudry, Dufour, &

Marcoux, 1995: Lawrence, 1994; Wood, Isaacs, Jensen, & Hilton, 1988). Breastfeeding may

reduce the risk of sudden infant death syndrome (Ford et al., 1993; Klonoff-Cohen et al., 1995),

and is associated with better growth and fister motor developrnent over formula fed infants in the

fmt few months of age (Lucas et al., 1997; Martorell & O'Gara, 1985). Long-term cognitive

advantages have been linked CO breastfeeding. A study by Rogan and Gladen (1993) reports

increased intelligence, psychomotor skills, and school grades among children breastfed as infants.

Longer duration of breastfeeding was associated with higher scores of verbal memory,

quantitative, and general cognitive skills for cbildren aged two to five. This was especially so for

children breastfed two years or more after controiiing for confounding variables.


Mothers who breastfeed are Wely to benefit emotionally and physically. Breastfeeding

encourages matematinfant bonding (Dignam. 1995: Morse. 1990) and promotes uterine

contractions for mothers in the early postpartum penod, thus reducing the risk of hemorrhage

(Lawrence, 1994). Reports of rehced risk of breast cancer, ovarian cancer, and osteoporosis have

been Linked with breastfeeding (Canadian Institute of Child Health, 1996). although these

findings remain highly controversial.

Reasons for W eaning

Despite known benefits, the majority of infànts are weaned before three months of age.

Mothers discontinue breastfeeding for rnany reasons. Lack of confidence in the Fdce of adverse

circumstances and feelings of embarrassrnent contriiute to early breastfeeding cessation

(Feinstein, Berkelhamer, Gniszb, Wong, & Carey, 1986: Goodine & Fried, 1984, Health

Canada., 1995; O'Campo et al., 1992). Health Canada ( 1995) found that mothers who terminated

breastfeeding before four months expressed discomfort with breastfeeding "anythe, anywhere".

Most mothers indicated that they were uncornfortable breastfeeding in the presence of others,

including their partner and W l y .

Other fiequently mentioned reasons for discontinuing breastfeeding are: materna1

perception of insuficient milk supply. materna1 perception that her baby is hungry (Hanly,

Laundry, & MadiIl, 1993; Isaacs & Litwak, 1996; Solway, 1992; Stewart & Potter, 1990),

supplementation with formula (Hellings, 1985: Loughlin et al., 1985; 07Campo et al., I992),

matenial or intànt illness (Isaacs & Litwak, 1996: SoIway, 1992), r e m to work or school (Hanly

et al., 1993; Solway, 1992; Stewart & Potter, 1990)- materna1 perception that it is time to stop. or

i&t disinterest in breastfeeding (Solway, 1992; Stewart & Potter, 1990). The majority of these

problems are resolvable through professional intervention.


Factors Influencinp: Breastfeeding Duration

Socio-dernograuhic Factors

Mothers who breastfeed longer are more likely to be older (Isaacs & Li- 1996;

Solway, 1992; Stewart & Potter. IWO), married (Solway. 1992; Stewart & Potter, 1 99O), have

more formal education (Solway, 1992: Stewart & Potter, 1990). have breastfed a previous child

(Hanly et al., 1 993; Isaacs & Litw* 1996; Sirnopoulos & Grave. l984), be non-smoking

(Stewart & Potter, 1 WO), and have a higher income (So tway, 1992). These mothers are also more

iikely to have attended a premtal class (Isaacs & Li- 1996). stated prior to delivery their

intention to breastfeed (Isaacs & Litwak 1996; Solway, 1992). planned to breastfeed for a longer

period of time (Lawson & TuIloch, 1995; Loughlin et al.. 1985; O'Campo et al.. 1992), and had

larger, stronger support systems (Buckner & Matsubara, 1993: Isabella & Isabella, 1994:

Kaufinan & Hall, 1989; McNatt & Freston, 1992). The sources of support which rnothers access

and their effectiveness rnay be influence4 in part, by such socio-demographic variab1es as age.

education level ethnic identity, and economic status (Cronenwett & Reinhardt. 1987; Kaufman &

Hali, 1989).

Breastfeeding Sup~ort

The more support a mother perceives she has for breastfeeding, the longer she breastfeeds

(Cronenwett & Reinhardt, 1987). This is tnie even after such variables as materna1 age, marital

s tatus, race, education, income, prenatal class attendance, p lamed lengt h of breastfeeding

lactation problems, and infant condition are controlled (Katifman & Hall, 1 989: McNatt &

Freston, 1992).

Support is defined as ". . .any input directly provided by another person (or group) which

moves the receiving person towards goals which the receiver desires" (Caplan, Robinson, French,

Caldwell & Shinn, 1976, p. 39). House (198 1) identifid four types of support: emotionai,


instrumental informational and appraisal. Emotional support includa such qualities as empathy.

caring, love or trust; instrumental support includes helping behav iours, for examp le. helping

around the house; informational support is the provision of usehl information; and appraisal

support is information provided fiom another person with similar experiences (House. 198 1).

McNatt and Freston ( 1992) evaluated the structure of breastfeeding mothers' support

network to determine which types of support were offered for breastfeeding, as ciassified by

House (198 1)' and by whom each type of support was offered Also measured were mothers'

perceived amount of informational instnunental, and emotional support. Appraisal support was

not assessed Three general groups of support providers were identified: signifiant others. health

care providers, and society in general (McNatt & Frestos 1992). After examining the relations hip

between each type of support and various support providers. McNatt and Freston f o n d that

participants viewed health care providers as major sources of informational support, and to a

lessor degree, providers of emotional support. Significant others and society in generaI were

identified primarily as providers of emotional and instrumental support.

Mothers who perceive they have more emotional, instrumental, and informational support

providers for breastfeeding tend to breastfeed longer ttian mothers who perceive they have fewer

support providers (McNatt & Freston, 1992: Sirnopoulos & Grave, 1984). McNatt and Freston

(1992) found in their study of 45 fmt-time rnothers that those who felt satisfied with their

breastfeeding experience had &vice as many informational support providers than those who were

dissatisfied As a mother's total support network increased, informational support fiom health

care providers as well as emotional support f?om simcant others and society in general

significantly increased Mothers who felt dissatisfied with their breastfeeding expenence

expressed greater self-doubt in their ability to breastfeed, more discodort and inconvenience

with breastfeeding, and displayed more guilt feelings upon discontinuing breastfeeding than

Breastfeeding Drop-In 1 0

mothers who were satisfied (McNan & Freston 1992). Ka- and Hall (1989) examined the

influence of social network on the choice and duration of breastfeeding arnong 125 mothers of

pre-term infants. The authors found that mothers who identified themselves as having no sources

of support for breastfeeding were six times more likely to stop breastfeeding in the fmt nine

months postpartum than mothen with six sources of support (Kauûnan & Hall, 1989). As the

nurnber of social supports for breasneeding increased, the cumulative proportion of mothers

breasdeeding at one and two months increased significantly @ < .O00 1 ). and the ris k of stopp ing

breastfeeding decreased (Kaufman & Ha& 1 989).

Su~oort fkom health care orofessionals. Mothers seek informational support from health

care professionais in the early postparturn penod In a study of 1 1 1 breastfeeding mothers, Izatt

(1997) found that 47% of mothers obtained breastfeeding information fiom books during the

prenatal period, whereas 87% of mothers consulted nurses for information during the postpartum

period Lactation consultants are most often accessed for informational support in the early

postpartum period (Bucher & Matsubara, 1993).

Bryant (1982) found that approximately two-thirds of Cuban, Puerto Rican and Anglo

mothers reported health m e professionals were a major source of information about the

advantages of breastfeeding. Conversely, kin, fkiends, and neighbours were viewed as major

sources of information about coping with breastfeeding problems. Interestingly, fiends and

Family tended to discourage breastfeeding in the face of obstacles (Bryant, 1982).

However, information provided by health care professionals is not always beneficial. Izatt

( 1997) reponed that rnany mothers in her study did not receive supportive breastfeeding

counselling fiom physicians. Advice given by physicians in the hunediate postpartum period

centered on such medical issues as sore nipples. materna1 die^ and adequacy of infant intake of

breastmilk, yet limited advice was provided for maintenance of breastfeeding and management of

Breastfeeding Drop-ln 1 1

engorgement Advice given two months postpartuxn by physicians pertained mainly to feeding

issues and formula supplementation (hi& l 997), even though it is well known that early formula

supplementation is significantly related to decreased breastfeeding chation (Lawson & T d o c k

1995: Loughlin et al., 1985). lzatt (1997) suggested that although 'iasuficient milk' is a prirnary

concern for many mothers. supportive healtb teaching should encompass methods to increase

milk supply, use of a breast pump, and storing breast milk rather than encouraging formula

supplementation in the early postpartwn period

Mothers' perceptions of professional breastfeeding counselling differ h m providers'

perceptions (Coreil, Bryant, Westover & Bailey. 1995). Qualitative data were colIected fiom 35

f o m group discussions with clientele and health care professionals fiom public health

departments in five Southeastern U.S. States. While clients were interested in hearing about the

physiologicaI benefits of breasrfeeding for their infant, the majority were disappointed by the Iack

of information they received regarding mateml physioIogica1 and psychosocial benefits (Coreil

et al., 1995).

Receiving conflicting advice about breastfeeding fhstrates atternpts at breastfeeding and

undermines the confidence of mothers (Coreil & Murphy, 1988). Lack of consistent information

offered by health care professionals contributes to shortened breastfeeding duration Following a

qualitative study of attitudes on breastfeeding, Health Canada (1995) revealed that lack of

awareness of potential problems and solutions was the main issue affecting the duration of

exclusive breastfeeding. The report recommended that health care professionals provide clients

not only with consistent information regarding breastfeeding and associated benefits, but also

with information regarding potential problerns of breastfeeding and how to solve them (Health

Canada, 1995). Watters and Kristiansen (1995) concur with this recomrnendation and suggest that

support should include information about infant growth sputs and increases in feeding demands.


Evidence Linking SUDOOR fiom Health Care Professionals and Breastfeedinp: Duration

As ment ioned previous ly, mos t breastfeeding support provided b y health care

professionals includes infonrmtio~l and emotional support components. Postparnun

breastfeeding support is offered through a variety of means including telephone, home visiting,

pre- and postnatal classes, postnatal counselling, and breaçtfeeding support groups (Health

Canada, L994). Although support seems to be positively associated with increased breastfeeding

duration, whether or not specific interventions increase the proportion of mothers who meet the

current recommendation of exclusive breastfeeding to f i t age of four to six months is

unknown.

After reviewing several evaluations of breastfeeding support interventions and studies of

breastfeeding drop-in centres. a variety of methodological limitations were identified: (a)

breastfeeding rates were measured at different times in the postpartum penod, making it dificult

to compare the impact of various interventions on breastfeeding duration; (b) t e m used to

describe breastfeeding outcomes, such as 'full', 'exclusive', and 'partial' breastfeeding, were not

always defined, and when they were, lack of a standard definition complicated cornparison: (c)

interventions were usually complex and included several cornponents, thus it was difficult to

evaluate and compare individual program comp onents; (d) samp le s ize was O ften inadequate for

the type of design useci, and this reduced the statistical power to detect hue effects: (e)

generalizability was limited because of self-selection bias; (f) lack of controlled settings limited

the ability to draw causal inferences between the intervention and breastfeeding outcomes; (g) co-

intervention of other services diminished the effect of the interventions under study; and (h) lack

of controt groups reduced the ability to estimate the m e effect of the intervention

The findings elicited from the review of evaluations do not conclusively show that health

care interventions increase breastfeeding duration, as methodological inconsistencies and


limitations are inherent within these studies. Since breastfeeding support programs or services

vary with respect to the type, intensity, and combination of interventions used (Brent et al., 1995:

Houston et al.. 198 1 : Jenner, 1988; Saunders & Caroll, l988), the following section will review

each study independently. The critique of the following studies will focus on the effectiveness of

specific strategies emp Io y ed to increase breastfeeding duration and the methodological limitations

associated with each study. Six evaluations of support interventions and three studies of

breastfeeding drop-ins are reviewed

Evaluations of Support Interventions

The information gathered from the various evaluations of support interventions is

sumrnarized in Table 1. Detailed information regarding study findings is provided in the

following section

Houston, Howie, Cook, and McNeilly ( 1 98 1) compared breastfeeding duration for 28

mothers in an intervention group with 52 mothers in an historical control group, and found an

increase in breastfeeding duration for the intervention group. The intervention group received

more home visits by health visitors over a greater period of time in the postpartum period Each

mother in the intervention group received, on average. 12 more visits than mothers in the

historical control group during the fmt 24 week postparturn- No significant difierences were

found between the two groups with respect to age, par@, or social class distribution The sample

consisted of mothers who left hospital breastfeeding after delivenng a mature, n o m l birth-

weight baby. Eighty-six percent of the intervention group was still breastfeeding at 24 weeks

postpartum as opposed to 65% of the control group. Breastfeeding rates were higher for the

intervention group at ail times throughout the study, and differences were statistically significant

at 12 and 20 weeks @ < .01, p < .O5 respectively). An historical bias may be present, as an

historical control group was used; hence, events outside the study may have influenced findings.


Table 1

Sumrnary of Sumort Interventions and Findings

Authors Design Intervention Out corne

Houston, Howie, Cook & McNeiIly (1981)

Jenner (1 988)

Brent, Redd, Dworetz, D'Arnica. and Greenberg (1 995)

Lynch, Koch, Hislop, & Colciman ( 1986)

Quasi- Experimental with an Historical Conuol Group (N= 80)

Quasi- Experimental with an Historical Control Group (N = 155)

Randomized, control trial (N= 38)

Randomizd, nm-b1 inded clinical control trial (N = 108)

Randomized, conuoI trial (N = 343)

Randornized, control trial (N = 270)

Experimental Group (EG): 12 more home visits over a greater period of time in the postpartum than the Control Group (CG)

EG: Follow-up phone calls; BF Support class 2 w& postpart- CG received standard hospital care - no follow-up phone cails or BF support class

EG: Mare home visits pre- and postnatally; telephme support p -na ta l ly CG: One home visit in the prenatai and postnatal period; no telephone support

EG: Praiatal teaching sessions, inpatient follow-up, phonecall postslischarge, clinic visit at two weeks postpartum, and home visits until infant reached 1 year of age or was weaned CG: prenatal BF dasses, in- hospita1 BF instruction

EG: One postpartum counselling session, 8 phone caHs pst-discharge CG: Routine BF counselling in- hospi ta1

EG: PHN home visit p s t - discharge, one home visit by BF consultant; telephane support CG: One PHN home visit pst- dischargef no telephone suppxt

B r e a s t f h g (BF) at 6 Months: EG - 86% CG - 65% Differences significant at 12 we$cs@~.01)and20weeks @ < .OS), but not at 6 months

BF at 4 Months: EG - 67% " CG -47% Di fferences significant at 4 weeks @ = -001) and 16 weeks @ = .03).

BF at 3 Manths: EG - 68% CG-21% Difference significant at three months postpartum @ < .O 1 ).

BF at 6 Months of age: EG - 14% CG- 7?hb Differences significant at 2 weeks @ = .001) and 2 months @ < .O0 1 ), but not at 6 rnonths.

BF at 4 Months: EG - 63% CG-56% Differences significance at 2 months but not at 4 mmths

BF at 6 Months: EG - 40% CG - 42% No significant diffaence between groups

Note. The percent of mothers breastfeeding at 4 months out of 36 who received the complete intervention Eight mothers in the control group were excluded fkom this analysis for receiving lactation consultant advice in the outpatient unit.


Saunders and Caro11 (1988) snidied participants involved in the Special Supplemental

Food Program for Women Infants, and Children (WIC). They compared 80 WIC participants

who received an experimental protocol to 75 W C participants from an historical control group

who received standard care. The experimental intervention consisted of in-hosp ital visit., follow-

up phone calls after discharge, and a breastfeeding support class at two weeks postpartum

provided by a nutritionist. While a greater proportion of the experimental group were

breastfeeding at four and 16 weeh than the historical control group. this difTerence was not

statistically significant. Only 3 6 rnothers in the experimental group received the complete

intervention When compared to the historical control group of mothers who received standard

hospital care and no follow-up phone-calIs or breastfeeding class, a significantly greater

proportion of the complete intervention group (n = 36) was breastfeeding at 4 and 16 weeh @ =

.O0 1 and p = .03, respectively). Sixty-seven percent of the complete intervention group was still

breastfeeding at four months cornpared to 47% of the control group. Several limitations of the

study indicate that these fmdings should be interpreted cautiously: (a) lack of consideration of

possible confounding kctors, including materna1 smoking behaviour, pnor breastfeeding

experience, and patemal support, (b) inherent problems associated with the historie nature of

cornparison, and (c) the bias resulting from resiricting analysis to a subset of mothers who

received complete experimental interventions.

Jenner (1 988) studied breastfeeding dwation rates in a randomized, control trial of 38

primiparous, white, working class mothers. Al1 mothers received a prenatal visit. The

experimental group received two additional visits prenatally at which time an information

package was distributed Mothers in the experimental group were seen within the first five

postpartum days in hospital and were visited again upon their return home. Subsequently, advice,

home visiting, and telephone support were provided to these rnothers over a three-month period


The control group received one postpartum visit. Successful breastfeeding outcomes (defined as

the use of breastmilk only for infànt feeding in the fmt three months) were significantIy greater

for rnothers in the experimental group than for those in the control g r o g ( p < .O 1). At three

months, 68% of the experimental group was 'successfiilly breastfeeding' cornpared to 2 1% of the

control group. Senous bias may limit the validity of these finding, as the study was not blinded

The same person who delivered the experimental interventions also assessed the outcomes.

Mothers who worked closely with this person may have been reluctant to report weaning or

supplementation.

Brent, Red& Dworetz, D' Amico. and Greenberg ( 1995) conducted a randomized, non-

blinded clhical control tria1 with 108 Iow-incorne mothers in an inpatient maternity unit who

received investigational care or standard care. Investigational care consisted of pre- and postnatal

breastfeeding education and support in the form of individual prenatal teaching sessions, inpatient

follow-up by a lactation consultant, a telephone cal1 at 48 hours post-discharge. one visit to the

lactation clinic at two weeks postpa.rtum, and home visits performed by a lactation consultant

until the infant rcached one year of age or was weaned Standard care consisted of prenatal

breastfeeding classes, postpartum breastfeeding instruction by nurses and physicians in-hospital

and outpatient follow-up by nurses and physicians in the ambulatory deparmient (Brent et al..

1995). Eight mothers in the control group who received lactation consultation in the outpatient

unit were excluded from the analysis of duration of breastfeeding data. Brent et al, (1995) found

that the chtration of breastfeeding was significantly longer for mothers who received

investigational care than for those who received standard care at two weeks @ = .O0 1) and at two

months postpamim @ < .O0 i), but not at infànt age of six months.

One limitation identified concerns the exclusion of some of the controt patients who

received additional outpatient follow-up. Exclusions of this nature undennine randomization and

Brmtfeeding Drop-In 1 7

therefore violate the comparability of groups. As welL the study was not blinded, which leads to

uncertainty as to the validity of study findings. The lactation consultant, who was responsible for

conducting inpatient and home follow-up counselling visits, was also responsible for

administering the questionnaires that assessed outcornes. Mothers who worked closely with the

lactation consultant may have been reluctant to report weaning or supplementation.

Frank, Wirtz Sorenson and Heeren (19871, in a randomized control trial involving 343

multiethnic, low-income mothers, found that cornpared to routine breastfeeding counselling

provided by in-hospital nurses experimental breastfeeding counselling did not exert a statistically

signiflcant effect on breastfeeding duration at four months postpartum. Experimental

breastfeeding counselling was provided by a trained couns elor and cons kt ed of eight SC heduled

telephone cal& made over a three month post-discharge period Sixty-three percent of mothers in

the experimental group were breastfeeding at four months compared to 56% of rnothers in the

control group.

Nevertheless, Frank et al. (1987) reported that at two months postpartum experimental

counselling did exert a statistically significant effect on breastfeeding duration. However. they did

not report the Ievel of significance of this effect. Interestingly. of the eight telephone calls made

to the experimental group post-discharge, seven of the calls occurred within the fmt two mon&

of the study period. The lack of a significant relationship between experimental counselling and

breastfeeding duration at four months postpartum may be attributed to the fact that experimental

counselling may have been adrrjnistered too infrequently over too short a t h e period to

distinguish it fiom the impact of routine breastfeeding counselling post-discharge. The impact of

the intervention did not persist throughout the entire study period

Lynch, Koch, Hislop and Coldman (1986) found no significant relationship between

supportive interventions and breasaeeding duration Lynch et al. ( 1986) randomly assigned 270

breasdeeding mothers to an experirnental group and a control group. The experimental group (n

= 135) received the service of a breastfeeding consultant during the f m t six rnonths postparturn,

which included an initial contact with the counselor shortly after discharge, the use of an

answering service, and weekly then monthly phone calis, followed by home visits as necessary.

The control group (n = 135) received routine care, consisting of a home visit by a public health

nurse shortly after birth. No significant ciifferences with regard to breastfeeding duration were

found between the two groups, although materna1 age, education, and intended duration of

breas~eeding were found to be strongly associated with duration (Lynch et al.. 1986). OveralL

42% of subjects in the controt group and 40% of subjects in the experimental group were still

breastfeeding at six months. Forty-five percent of mothers in the experimental group reported that

a lactation consultant was the single most helpfùl support during breastfeeding-

Although subjects were randomly assigneci, the two groups were not equally matched

with respect to parity and plans to return to work Parity was significantly different between

groups @ = -02). with twice as many mothers in the control group having three or more children

than mothers in the experimental group. Significantly more multiparous mothers were

breastfeeding at each t h e penod throughout the study @ = .02). Likewise, more mothers in the

experimental group were planning to r e m ro work than mothers in the control group, and this

difference was significant ( p = -05). Both parity and intent to r e m to work have been proven to

be significantly related to breastfeeding chiration in other studies (Hanly et al. 1993; Isaacs &

Litwak, 1995; Sirnopoulos & Grave 1984: Solway, 1992; Stewart & Potter, 1990) but were not

controlled for in this study. The two experimental studies which show that breastfeeding

interventions lead to positive breastfeeding outcornes (Brent et al., 1995: Jenner, 1988) control for

work and parity.


Five out of six studies showed that various breastfeeding support interventions were

effective in increasing duration for experimental groups over standard-care control groups.

However, there are many limitations associated with each study which challenge these fmdings.

The one experimental study that showed no improvement in duration may have been affected by

methodological problems, which reduced the probability that statistically significant effects could

be detected

Studies of Breastfeeding Drop-In Centres or Clinics

The previous section reviewed studies that employ forma1 breastfeeding support

interventions to increase breasneeding duration while the present section discusses studies of

community breastfeeding support programs. These drop-in centres or clinics have been

implemented to enhance mothers' breastfeeding expenences and positively influence

breastfeeding duration Support groups. such as community breastfeeding support groups. may be

defined by their common characteristics. Most support groups: (a) focus on a single Iife event, (b)

function primarily to support persona1 change, (c) are based on voluntary attendance, and (d)

foster activities that improve the state of the condition of interest (Ryan, 1997). Several

community breastfeeding suppon programs have been implemented in North America, yet only a

few have been evaluated (Health Canada, 1994).

Pastore and Nelson (1997) used a telephone survey to evaluate a Breastfeeding Drop-ln

Centre (BDC) in Richmond, Brîtish Columbia. Fifty-seven BDC clients took part The supportive

intervention offered at the BDC was a 30-60 minute session provided by a lactation consultant or

community health nurse, and consisted of a complete individual breastfeeding assessrnent and

health teaching. Optional follow-up included referral back to the BDC or to another appropriate

community resource, such as a Family physician or La Leche League. Eighty-one percent of study

mothers breastfed for at least four months, but only 5 1 % of infants were exclusively or primarily


breastfed untii thk time (Pastore & Nelson 1997). Exclusive breastfeeding was defined as

breastmilk only, and primarily b r a s tfeeding was detined as breasmiilk plus no more than one

alternative milk feeding per week

Sims-Jones and Bowes ( 1997) camied out a descriptive study of 98 mothers who attended

Breastfeeding Drop-In Clinics in the Ottawa-Carleton region At the &op-ins, mothers received

information, emotional support and practical breastfeeding assistance fiom nurses, lactation

consultants and La Leche League leaders. A telephone survey was conducted six weeks afier the

initial &op-in visit. At this tirne. 84% of mothers were still breasfeeding versus 92% at two

weeks. Of those still breastfeeding, 49% were exclusively breastfeeding (Sims-Jones & Bowes,

1997). The rnajority of mothers felt that the c h i c made a difference to their breastfeeding

expenence by 'giving [them] confidence' (Sims-Jones & Bowes, 1997). The long-term impact of

this type of service on breastfeeding duration was not determined

Lactation consultants at a breastfeeding cenae in Saskatoon provided breastfeeding

support, advice and information to mothers via telephone, home visiting. and breastfeeding centre

visits (Stefiuk, 1997). Information regarding the impact of this program on breastfeeding duration

was not available, yet early process evahation results revealed that mothers were satisfied with

the care they received Most mothers felt that the breastfeeding centre helped them to resolve

problems and continue breastfeeding. S tefiuk ( 1997) suggested that enhanced feelings of

confidence might have motivated mothers to attain and surpass their intended breastfeeding

duration.

in summary, findings from evaluations of supportive interventions and studies pertaining

to breastfeeding drop-in centra suggest that breastfeeding support, including telephone support

breastfeeding counselling, and breastfeeding support groups, rnay increase breastfeeding duration

to some extent- How breastfeeding support influences duration is unknown One hypothesis is


that support increases confidence, which, in him increases breastfeeding duration. These

relationships are best understood within the framework of Banmira's (1997) self-eff~cacy theory.

Theoretical Framework L inkinn Sumort, Confidence. and Breastfeedinp; Duration:

Bandura's Self-Efficacv Theow

Descri~tion of Bandura's Self-Efficacv Theorv

Bandura's self-efficacy theory provides insight into the nature of the relationship between

support, confiidence, and duration. The following section will provide a definition of self-efficacy.

describe self-eficacy in relation to confidence, examine sources of information to increase self-

efficacy, and exp lore the proposed relations hips between self-effrcacy, b ras tfeeding behaviour.

and outcomes.

Perceived seE-eficacy is concerned with judgements of persona1 capability. Self-efficacy

is the belief in one's own abilities to cany out certain behaviours required to bring about desired

outcomes (Banchira, 1977). Eficacy beliefk vary in levei, generality. and strength (Bandura,

1997).

Level, The level of self-eficacy refers to an individual's expected performance

attainments, and concerns the judgement of one's ability to overcorne various challenges or

irnpediments to perform a desired behaviour (Bandura, 1 997). The efficacy expectations of a

breastfeeding mother may be lirnited to simple tasks, for example learning how to position her

baby to breastfeed, extend to moderately dificuit ones, such as properly latching her baby ont0

the breast, or include even the most challenging aspects of a ta&, such as assessing whether or

not her baby is sucking correctly.

Generaliw. The generality of self-efficacy refers to the range of circumstances in which

people judge themselves to be eficacious. individuals may feel efficacious in their ability to

Breastf'eeding Drop-In 22

perfom an activity in one circumstance, but may feel less sure of their ability to perform the

same activity in different circumstances (Bandura 1997). A mother may feel eficacious

breastfeeding in private, but rnay feeI less efficacious breastfeeding in the presence of others.

Strenszth. The strength of self-efficacy expresses the confidence people have that they can

overcome impediments and attain expected levels of task performance (Bandura, 1997).

Individuais with weak expectations are likely to stop a desired behaviour when negative

experiences are encountered; individuais with strong expectations are likely to continue a desired

behaviour despite setbacks. Mothers with weak expectations of their breastfeeding abilities are

more likely to stop breastfeeding when dificulties arise than mothers with strong expectations of

their ability to breastfeed

Self-efficacv and Confidence

Confidence is one of the dimensions of self-eficacy, and refers to the strength of self-

eficacy, Both the affirmation of capability and the strength of that belief constitutes self-efficacy

(Bandura, 1997). Morrow's ( 1994) Breastfeeding Confidence Scale measures al1 three

dimensions of self-efficacy, even though she refers to it as a measure of confidence. Confidence

is often the term used in place of self-efficacy to fàcilitate understanding. Thus, for the purpose of

this paper, confidence and self-eficacy will be used interchangeably to depict the strength of

one's belief to produce given levels of attainment for a desired behaviour.

Sources of Information to Increase Confidence

Feelings of confidence are based on four sources of information as identified by Bandura

(1977): performance accomplishments, vicarious experiences, verbal persuasion, and emotional

arousal.

Performance accom~lishments. Performance accomplishments strongly influence

confidence because they are based on one's own personal experiences. Confidence increases


when one masters obstacles but decreases when one struggles with ongoing obstacles. Generally,

if obstacles are encountered and mastered early 0% then confidence is likely to be heightened and

the behaviour continued. If obstacles are encountered early and not mastered, confidence is

reduced and the behaviour likely terminated ( B a n h 1977). A raised sense of confidence will

ensue if an individual expenences periodic hiluces but continues to irnprove in performance over

tirne. An individual who experiences a steady improvernent in performance but then reaches a

plateau rnay demonstrate a subsequent decrease in self-efficacy, as reaching a plateau may be

interpreted as an indication of kilwe (Bandura, 1997).

Vicarious emenence. Vicarious experience involves watching others perform a certain

activity and feeling empowered to perform that same activity (Bandura, 1977). This can serve to

mise self-efficacy if one's performance surpasses another, or it can serve to lower self-efficacy if

others surpass one's performance. Vicarious expenence is most effective when one knows that

others achieved a certain outcome by overcoming difficulties rather than by easily attaining a

desired outcome (Bandura, 1 977). When one mother sees another mother rnaster breastfeeding

despite encounte~g dificulties, it instills in that rnother feelings that she too. can m t e r

breastfeeding if she persists in her efforts. The amount of confidence or self-efficacy that

vicarious experience instills depends on how closely the individual identifies with the person

whose behaviour is being emulated (Bandura, 1977).

Verbal persuasion, Verbal persuasion is a weak, though viable, source of information to

increase confidence (Bandura, 1997). Persuasion is often used to encourage people to persist with

a behaviour in the hce of obstacles. Positive verbal persuasion, if it is within realistic bounds, can

boister confidence. Persuasion without successful atterapts at overcoming obstacles does not lead

to persistence with a behaviour (Bandura, 1977). Persuasion that raises uruealistic expectations of

abilities rnay contribute to Mure and fiirther undermine belief in one's capabilities (Bandura,

Breas tfeeding Drop-In 24

1997). Studis show that 'verbal persuaders' are most truste. if they are skilled in the activity

under assessment have access to objective predictors of performance abiIities, or have a vast

source of knowledge gained fkom observing and comparing different people perfom the same

activity and knowing their outcornes (CrudaIl& Foddy, 198 1 ). Hence, credibility and

knowledge of health care professionals rnay play an important role in enhancing the impact that

verbal persuasion has on eficacy belie fS regarding breastfeeding.

Emotional arousal. Emotional arousal as a source of idormation to increase confidence

affects expectations of mastery. One is more likely to master a behaviour when one is not tense,

anxious, tireci, or highly stressed (Bandura, 1977). This is tme for mothers who breastfeed. Often

a mother will experience an inactive letdown reflex when she is overly anxious about

breastfeeding. A crying baby rnay increase the stress expenenced by the mother, which, in tum,

may affect breastfeeding performance and decrease a mother's confidence in her ability to

breastfeed (Kearney, 1988).

Breastfeeding Dro~-Ins. Breastfeeding Drop-Ins include aspects of verbal persuasion,

assessment of performance accornplishments, vicarious expenences, and emotional arousal.

These factors provide feedback to mothers about their breastfeeding capabilities. At

Breastfeeding Drop-111s. mothers can obmin information and support for breastfeeding. HeaIth

care professionals provide verbal and instructional feedback about physical concerns, such as

proper latch and positioning of the baby, as well as verbal and emotional support. Such feedback

indirectly enhances breastfeeding confidence if performance feedback is positive and

constructive. Knowledge that one is perfomiing correctly or incorrectly can improve and sustain

behaviour over an extended period of time (Banchua, 1977). Information and support also serves

as a motivator for breastfeeding. Mothers assess their own performance accomplishments while

receiving feedback from a health care professional.


Breastfeeding Drop-Ins are a place where mothers oui learn by sharing breastfeeding

experiences with other mothers. Breastfeeding volunteers, who are experienced breasneeding

mothers, are ofien available to offer support. Volunteer breastfeeding mothers share some of the

dficulties they encountered with breastfeeding, as well as some of the ways they resolved

problerns. Mothers leam chat they are not alone in experiencing difficulties, and that it is feasible

to overcome breastfeeding problems. Such knowledge instills in mothers feelings of confidence in

their ability to breastfeed

The state of emotional arousal of mothers at the drop-ins may affect their performance

behaviour. Mothers who attend the drop-ins who are anxious about breastfeeding are more Iikely

to experience an inactive letdown reflex and may demonstrate more difficulty breastfeeding. In

turn, the problem may dirninis h their feelings of confidence with breastfeediig. At the &op-ins.

health care professionals can offer information and reassurance to mothers that rnay subsequently

decrease anxiety and in tum, enhance performance and boost confidence.

Confidence. Behaviour, and Outcornes

How does confidence influence behaviour. and how does behaviour influence outcomes?

Figure 1 depicts the causal relationship between efficacy beliefs, behaviour. outcome

expectancies, and outcomes as illustrated by Bandura (1997). Eficacy beliefs determine if one

will ay a behaviour, how much effort is expended in maintainhg the behaviour, how long one

persists with the desired behaviour, and the level of accomplishrnent one realizes (Bandura,

1997). The greater one's self-eficacy beliefi, the higher one's eficacy expectations (Bandura,

1997). A rnother who feels very confident in her ability to breastfeed rnay expect that she will be

capable of breastfeeding in various circumstances despite obstacles, and intend to breastfeed for a

long period of tirne. Eficacy beliefs are a key fàctor of intention (Banduia, 1997). Thus, a mother

who feeIs more efkacious in her ability to breastfeed will more likely intend to breastfeed longer

Person b Behavior Outcome

Figure 1 . The conditional relationships between efficacy beliefs and outcome expectancies. In

given domains of functioning, efficacy beliefs Vary in leveL strength, and generahy. The

outcornes that flow fiom a given course of action can take the form of positive or negative

p hys ical social and self-evaiuative effects.

Note. From Self-Efflcacv: The Exercise of Control (p. 22), by A. Bandura, 1997, New York:

W.H. Freeman and Company. Copyright 1997 by W.H. Freeman and Company.

Reprinted with permission


than a mother who feels Iess eEcacious.

E fficacy beliefi also infiuence outcome expectations (see Figure 2). Outcome

expectatiom include physical, sociai, and seif-evaluative expectancies that are pos ihve or

negative (Bandura, 1997). A mother may expect that she will denve positive physical and

emotional benefits fkom breastfeeding. Outcome expectations act as motivators or inhibitors of

behaviour. Positive outcorne expectations provide incentives for pursing a behaviour, whereas

negative outcome expectations provide reasom not to perform a behaviour. Outcome expectations

that breastfeeding is a painfui experience, Ieads to social isolation, and causes low seif-worth are

not likely to encourage a mother to breastfeed On the other hand outcome expectations that

breastfeeding is cornfortable, is socially accepte4 and is beneficial to both mom and baby

encourages breastfeeding.

Efficacy beliefs indiredy affect performance (Ban- 1997). Individuais who possess

strong expectations of their ability to master obstacles tend to persevere with desired behaviours

despite negative circumstances. Efforts of individuais with weak expectations are easily

extinguis hed in the event of discouraging experiences (Bandura, 1 997). E fficacy beliefs influence

the level of performance attained Those with strong eficacy beliefs tend to set higher

performance standards. People who set higher performance standards tend to experience greater

performance attainments (Bandura, 1977). Therefore, it fo1Iows that mothers who dernonstrate

more confidence in their ability to breastfeed may deal more successfully with threatening

experiences, may intend to breastfeed longer, and may breastfeed longer than mothers with low

b r a s tfeeding confidence.

The difference between a performance and an outcome is an important distinction

According to Bandura (1997), performance is an accomplishrnent, whereas an outcome flows

fkom a performance. In other words. outcomes are consequences of behaviours (refer to Figure 2).


How Iong a mother breastfeeds is an example of a performance aminment rather thm an

outcome. One example of an outcome is the social approval or disapproval a mother receives in

reaction to her breastfeeding. Outcomes tend to be physicaf, social, and selfevaluative in nature.

Actual outcomes are often different from one's outcorne expectancies. For example, a rnother

who expects b r d e e d i n g to rerhice the possibility of her child getting ear infections may be

surprised if her chiId gets regular ear infections.

To surnmarize, Bandura's self-eficacy theory offers a theoretical understanding of the

relationship between breastfeeding confidence and breastfeeding behaviour. Supportive

interventions, such as Breastfeeding Drop-Ins, are likely to influence breastfeeding confidence.

They motivate mothers to continue breastfeeding and enable them to assess their efficacy in

breastfeeding. E ficacy beliefs influence behaviours and Vary on three dimensions : level

genmlity, and strength. How confident a mother feels in her ability to carry out difficult tasks

associated with breastfeeding and her perceived ability to breastfeed in vanous circumstances

determine her breastfeeding behaviour. Eficacy beliefs influence the effort put forth to sustain a

desired behaviour and the level of performance attained, such as how long a mother breastfeeds.

Positive or negative outcome expectancies act as incentives or inhibitors of behaviour. Actual

outcomes h t flow from behaviour are physical, social, and self-evaluative in nature. The present

study is most concerned with the part of Bandura's mode1 (Figure 2) that deals with the

relationship between person efficacy beliefs, and behaviour, rather than the physical and social

outcomes of behaviour.

Exmirical Evidence Linking Support, Confidence. and Breastfeeding Duration

Sup~ort fiom Breastfeeding D~oD-Ins and Confidence

Empirical evidence suggests that breastfeeding support interventions, in particular

Breastfeeding Drop-Ins, positively influence breastfeeding confidence. Sims-Jones and Bowes


( 1997) found that mothers who attended a drop-in c h i c reported <bar they gained confidence.

Stefiuk (1997) felt that mothers who attended a breastfeeding &op-in centre were more confident

in their breastfeeding capabilities. Breastfeeding support programs rnay aiso be associated with

longer breastfeeding duration In a qualitative study by Health Cana& (1995) some mothers who

exclusively breastfed their infànts for four months or greater mentioned that the single most

useful source in helping them overcome problems was attending a breastfeeding clinic. Other

reasoas attniuted to sustained breastfeeding included seeking help early and attending support

groups for new breastfeeding mothers (Health Canada, 1995). Of mothers who attended a

breastfeeding drop-in clinic in British Columbia most (95%) reported that their problems were

resolved and they were able to continue breastfeeding (Pastore and Nelson 1997).

Confidence and Breastfeedinn Duration

Ernpirical evidence for the relationship between breastfeeding confidence and

breastfeeding duration (intended and actual) is inconclusive. Some studies show that

breastfeeding confidence is significantly related to intended duration while other studies do not

confirm this finding. Lawson and Tulloch ( 1995) conducted a study of 78 first-tirne breastfeeding

mothers' prenatal intentions and postnatal breastfeeding practices. They found a significant,

though moderate, relationship between intended duration and coping confidence, noting that the

more confident a subject felt about coping with breastfeeding problems, the longer she intended

to breastfeed

Similady, a study of 44 breastfeeding mothers' prenatal intentions and postnatal practices

conducted by Coreil and Murphy (1988) showed that intended duration correlated signif~cantly

with confidence in breastfeeding. In a study of breastfeeding expenences of 94 mothers, Loughlin

et al. (1985) found that mothers who intended to breastfeed less than six months demonstrated

significantly lower levels of confidence than those who intended to breastfeed longer than six


months. However, Morrow (1994) found no significant relationship between breastfeeding

codidence and intended duration among 70 primiparous mothers.

Most researchers have found that mothers who had higher breastfeeding confidence

actually breastfed longer. Locklin and Naber (1993) used a grounded theory approach to study

breastfeeding experiences of ten low-incorne, minority mothers, who breastfed fiom six months

to over two years. Themes of 'personal motivation to continue' and 'confidence with

breastfeeding' emerged in this study. Problem solving and overcoming obstacles, combined with

personal motivation, gave mothers confidence and encouraged them to breastfeed longer (Locklin

& Naber, 1993). O'Campo et al. (1992) and Loughlin et al. (1985) noted that the more confident a

mother felt in her ability to breastfeed when faced with adverse circumstances, the longer she

breastfed However, Lawson and Tulioch (1 995) found no significant relationship beween

confidence and breastfeeding duration.

Morrow ( 1994) did not examine the relationship between breastfeeding confidence and

duration Instead, she looked at the relationship between breastfeeding confidence and various

socio-demographic characteristics. Morrow found that materna1 age, marital starus, &cation,

ethnicity, plans to return to work, prenatal class attendance and intended duration were not

significantly related to breastfeeding confidence. However, she did note that mothers with greater

social support demonstrated consistently higher breastfeeding confidence scores than mothers

who indicated they had little social support, although this dserence was not statistically

significant.

Discrepancy in fmdings between breastfeeding confidence and duration rnay be attributed

to the use of limited rneasures of breastfeeding confidence. Most scales used do not provide valid

measura of breastfeeding confidence. According to Bandura (1 997), a scale that accurately

measures efficacy or confidence should possess certain criteria:

1. masure people's judgement of their abilities to fulfil d~rerent levels of

imk demands within the domain under study,

2. includea widerangeoftuskdemands to identiQtheupperandlower

M t s of people's beliefk in their capabilities,

3. include items that pertain to people's judgement of their abilities to

perform ihe same task in d~jîcult circumstances, and

4. be unipolar in their ratings, so that a greater score indicates higher

eficacy in a11 cases. Individual items should be ranked so that the strength of efficacy beliefs can

be measured

Loughlin et al- (1985) asked only one question pertaining to mothers' judgemenn of their

breastfeeding confidence. Mothers were asked to rate how confident they felt about breastfeeding

on a 5-point s a l e ranging fiom very womed to very confident. This question was incorporated

within a Iarger survey instrument with questions regarding nurse's ratings of infant temperament

and mothers' ratings of level of support for breastfeeding. The measurement of breastfeeding

c ~ ~ d e n c e used in this case did not meet criteria 1.2, and 3 of Bandura's criteria.

Single-item measures provide Little information about breastfeeding confidence; findings

tend to have IittIe predictive value and are of questionable validity (Bandura, 1997). According to

Bandura, efficacy rneasured on a single-item scale does not distinguish between two individuais

who judge thernselves to be completely eficacious for a particular task but ciiffer in their

perceived efficacy to accomplish higher levels of mculty of the task For example, two rnothers

who feel capable that they can hold their babies properly to breastfeed might differ in how able

they feel to properly latch their baby to the breast.

Coreil and Murphy (1988) incorporated questions pertaining to mothers' perceived

confidence in their ability to breastfeed within a general scale regarding mothers' breastfeeding


experiences. However, no other information was provided about the specifc questions asked nor

how their efficacy beIief5 were rateci

O'Campo et aL ( 1992) and Lawson and Tulloch (1995) measured mothers' judgements of

their ability to breastfeed in various stressfil circumstances. In both cases, mothers were asked to

rate ten different circumstances us ing a six-point Iikert s a l e ranging from very unsure to very

confident. The scales administered in each study were alrnost identical, differing only by three

items. Both scales met critena 3 and 4 of Bandura's criteria, but did not meet criteria 1 and 2- As

suck these scales provide limited measwes of breastfeeding confidence. Morrow ( 1994) provides

a more comprehensive measure of breastfeeding confidence that sufficiently meets Bandura's

(1997) criteria For a more in-depth discussion of Morrow's measure, refer to the section entitled

Breastfeeding Confidence S a l e in Chapter 3 of this thesis.

In summary. previous findings regarding the relationship between breastfeeding

confidence and breastfeeding dwation are inconclusive. Of those who have examined this

relationship, most show that these concepts are significantly related. However, the instruments

used to measure breastfeeding confidence are limited in their rneasurement of breastfeeding

confidence. Therefore, the relationship between breastfeeding confidence and breastfeeding

duration should be re-examined using Morrow's ( 1994) Breastfeeding Confidence Scale.

Bandura's self-eficacy theory (1997) will be used to provide a comprehensive Iink between

theoretical concepts and empirical relationships.

Based on information provided by Bandura's self-eficacy theory and previous empirical

findings, it is hypothesized that (a) the length of time a mother intends to breastfeed will be

significantly associated with breastfeeding confidence, (b) breastfeeding confÏdence scores will

be significantly associated with the length of time a mother actually breastfeeds, (c) breastfeeding

confidence will increase over t h e , and this increase will be positively associated with the nwnber


of visits mothers make to the breastfeeding &op-ins, and (d) breastfeeding confidence wilI be a

signifiaint predictor of breasôeeding at six months in this sampte.

Stu& Obiectives

The objectives of the study are to:

1. descnbe the characteristics of mothers who attend Breastfeeding Drop-Ins in

Kingston, Ontario:

2. descriibe rates of breastfeeding at infant age of six months among mothers who attend

Breastfeeding Drop-111s in Kingston, Ontario;

3. examine the relationship between breastfeeding confidence and duration of

breastfeeding among mothers who attend Breastfeeding Drop-Ins in Kingston, Ontario. This will

be done by examining the relationship between:

(a) initial breastfeeding confidence and intended chiration of breastfeeding, and

(b) breastfeeding confidence measured four to six weeks after initial &op-in visit and

breastfeeding at six months,

4. determine whether breastfeeding confidence changes over time and whether this

change is retated to the number of &op-in visits, controlling for infant age at f k t drop-in visit,

5. explore the factors that ba t predict breastfeeding to six months in this sample of

breastfeeding mothers.

Figure 2 shows a diagrammatic representation of the relationships among the variables

that wiii be studied in this thesis.


Figure 2. Diagrammatic represenîation of the relationships between infknt age, breastfeeding

confidence (BFC) (measured at first drop-in visit and 4-6 weeks Iater), intended duration, and

actual duration (breastfeeding at six months).


CHAPTER 3

Methods

Characteristics of study mothers, rate of breastfeeding at six months posrparturn, and the

relationship between breastfeeding confidence and duration of breastfeeding were investigated

among mothers who attended Breastfeeding Drop-Ins in Kingston, Ontario. A longitudinai,

descriptive study was designed to detennine whether there were changes in breastfeeding

confidence over tirne, and to describe the relationship between breastfeeding confidence and

breastfeeding at six months.

Setting

The study was conducted at four &op-in sites in Kingston, Ontario. Kingston has a

population of 1 12 605 and is geographically located in Southeastern Ontario between Montreal

and Toronto. Each &op-in was held once a week for a two-hour session. Health care

professionals, including public health nurses, midwives, dietitians, and lactation consultants.

staffed the &op-ios. Occasionally, experienced breastfeeding mothers volunteered at the drop-ins.

Al1 four sites had a common room designed to accornmodate group discussion and a private

section or room for individual consultation

Stuctv Population and S-le

The study population comisted of al1 mothers breastfeeding an infant four months of age

or younger, who attended a drop-in Mothers who met these cntena and who attended a drop-in

for the h t tirne between July 7Lb, 1997 and February 4h, 1998 were asked to participate in the

study. Forty-nine mothers attended the drop-ins during the data collection period Eleven mothers

were excluded fiom the study for the following reasons: four mothers had attended at Ieast one

drop-in before sampling began, five mothers had infimts who were too old, one mother fed her


premature infant breasnnilk solely by bottle, and one mother had not yet delivered Thirty-eight

mothers met the inclusion criteria. Al1 mothers were able to speak and understand English One

rnother refbsed to participate: therefore. the final sample size was 37.

Data Collection Procedures

Intake Protocol

Data intake began with mothers' initial visit to the &op-in (see Figure 3). After the

potential subjects had their immediate concems addressed by the professional at the &op-in, the

researcher approached the mothers (n = 3 l), explained the study. and detennined their interest in

participating. Subsequently, rnothers reviewed an information sheet (Appendix A) and written,

infonned consent was obtained

When the researcher was unable to attend the &op-in. a professional at the &op-in asked

mothers (n = 6) for permission for the researcher to contact them at home to explain the study.

The professional then gave the rnothers an information sheet along with the researcher's name

and contact number. The researcher contacted these mothers by telephone. as soon after their

&op-in visit as possibIe, to inform them of the study and to obtain verbal consent. A consent form

and a stamped r e m envelope were mailed to each mother to be signed and returned to the

investigator. Ali consent fonns were signed and returned to the investigator.

Once written or verbal consent was obtained, participants were asked to complete a

questionnaire including idormation about current and previous breasdeeding experiences. marital

status, education, and employment. A questionnaire was then administered to measure

breastfeediag confidence (see Figure 3). The researcher read the questions to mothers who were

being interviewed over the telephone. Completion of the questionnaires took five to ten minutes.


Time 1 Time2 Time 3 First &op-in visit 4-6 weeks later Infant at 6 months

-- - - - - - - -

Written Ouestionnaire " Telephone Survev Telahone S w e v

Demograp hics Number of drop-in visits Number of drop-in visits

Intended Duration of BF Intended Duration of BF

Breastfkeding Confidence Breastfeeding Confidence

Other BF Supports Other BF Supports

Breastfeeding Duration Breastfeeding Duration

Figure 3. Data collection protocol.

a Six mothers were read the questions over the phone. b For two older babies, Time 2 and Time 3 were collapsed.

Breastfeeding Drop-In

Pre-intervention breastfeeding confidence scores were considered desirable fkom a

theoretical and design perspective. However, obtaining these scores was not clinically or ethicaiiy

feasible. Most mothers who attended the drop-ins had specific concems or problems that they

wanted addresseci before they iadicated an interest in hearing about the study. The researcher felt

that it would be more sensitive to the needs of the mothers to tell them about the study once their

primary reasons for attending the &op-in were addressed.

Follow-UD Protocols

The participant was contacted by telephone four to six weeks after her first drop-in visit

and asked if she was currently breastfeeding (see Figure 3). I f she was breastfeeding to any

extent at that tirne, her breastfeeding confidence was assessed again by telephone using the

confidence questionnaire. The mother was also asked (a) how long she intended to breastfeed. (b)

the number of times she attended a drop-in, and (c) about any breastfeeding supports she may

have accessed For two mothers whose i h t s turned six months of age by the follow-up tirne of

four to six weeks after the fmt &op-in visit, questions asked at T h e 2 and T h e 3 were

combineci If the mother was not breastfeeding at this tirne, she was asked how old her baby was

when she stopped breastfeeding and her rasons for stopping breastfeeding, along with (b) and

(c). Those participants were then thanked and informed that their participation in the research

study was completed

A foilow-up period of four to six weeks was considered optimal to re-assess

breastfeeding confidence, as this gave mothers sufficient t h e to internalize what they Iearned at

the drop-in. A four to six week follow-up ako allowed enough tirne for mothers to experience a

change in bras tfeeding behaviour, for instance, to overcome breastfeeding p roblems, to

introduce formula supplements, or to stop breastfeeding altogether. Since confidence retains its

predictive power over follow-up periods only when measured in proximity to the initial penod of


uncertainty (Gulliver, Hughes, Solomon & Dey, 1995) a follow-up tirne any longer than six

weeks may have reciuced the chance that a relationship between breastfeeding confidence and

breastfeeding duration could be detected

At infànt age of six rnonths, participants who were breastfeeding at T2 (4-6 weeks after

their initial visit) were telephoned again and asked if they were still breastfeeding to some extent

(Figure 3). The number of &op-in visits was recorded along with the other breastfeeding supports

she accessed since her baby was born. For those who stopped breastfeeding, the age of their baby

at the time they stopped was recorded, as weil as their reasons for stopping.

S tu& Instruments

Two study instruments, the Breastfeeding Confidence Scale (Morrow. 1994). and the

Breastfeeding Drop- In Survey, were administered to mo thers a t different points during data

collection. The Breastfeeding Conf~dence Scale was administered to mothers at their fmt drop-in

visit and four to six weeks later. The Breastfeeding Drop-In Survey was administered in full at

mothers' fmt drop-in visit and, in part. four to six weeks after their fmt drop-in visit and at infant

age of six months.

Breastfeeding Confidence Scale

Morrow (1994) deveioped the Breastfeeding Confidence Scale (BCS) to specificalIy

masure breastfeeding confidence. Bandura's (1 997) self-efftcacy theory was the theoretical

framework that guided Morrow's research. The BCS was chosen for this study because it

represented a comprehensive assessrnent of breastfeeding codidence. Morrow's BCS sufficiently

met the critena specified by Bandura (1997): (a) it assessed mothers' abilities to fulfil different

leveis of task demands (cntenon l), (b) included a wide range of task dernands (criterion 2), (c)


assessed mothers ability to perforrn the same m k in difficult circumstances, and (d) was unipolar

in rating so that a p a t e r score indicated greater confidence.

The BCS developed by Morrow (1994) was adapted for use in this study (Appendix B).

In its original form, the s a l e contains 18 circumstantial i tem that pertain to physical, self-

evaluative. and social aspects of breastfeeding. These aspects reflect mothers' level and generality

of eficacy beliefs about breastfeeding. Exarnples of each aspect of breastfeeding c m be seen in

Figure 4. Morrow did not ascribe these category labels for individual items, and sub-sales were

not created for the three aspects. A Cronbach's alpha value of -85 indicated that the BCS had

suficient interna1 consistency in Morrow's study.

Each item was scored on a 5-point likert-scale fiom "strongly disagree" (1) to "strongly

agree" (5). Most statements were positively phrased, with agreement indicating a higher ievel of

confidence. Three items in the BCS were negativety worded These items were reverse scored

pnor to summing so that a higher score indicated an increase in confidence in al1 cases. Using

both positively and negatively phrased items lirnits response set bias (Roberts & Burke, 1989).

Physical "I know how to attach my baby to the breast"

"1 know how to hold my baby h i l e breastfeedingV*

Sel f-evaluative "1 feel that my baby is sucking correct1 y wfiile breastfeeding"

"1 h o w that 1 am capable of making enougti milk for my baby to grow well"

Social "My ffiends support my decision to breastfeed"

"1 have known mothers who have been successful witb breastfeeding"

Fimre 4. Examples of physical self-evaluative, and sociaI items on the BCS.

Minor variations to Morrow's (1994) BCS were made for use in the m e n t study. To

accommodate mothers without a partner or mother, a new 'not applicable' response category was


added for three items, and these were moved to the end of the scale. These items were "My

partner feeis embarrasseci about me exposing my breasts dunng feedings", "My partner supports

my decision to breastfeed". and "My mother supports my decision to breastfeed", Otherwise. the

wording of the items was not changed The BCS was pilot tested by two breastfeeding mothers

for clarity and worduig. No changes were made to the survey following pilot testing.

Breastfeeding confidence scores were calculated as a rnean of the 18 items. When a

response was missing or was coded as not applicable. the item(s) were dropped from the analysis.

and the mean was the average score of items answered. To ensure that the score was a full

description of breastfeeding confidence, no more than four out of the f m t 2 5 items could be

missing. If more than four items were missing, the data would be considered an inaccurate

estimate of breaseeeding confidence and would be dropped Corn the analysis. Since hvo mothers

were not breastfeeding four to six week after their fmt drop-in visit, 4-6 week BFC scores were

not obtained Subsequently, these mothers were dropped fiom fwther analyses of BFC scores

measured four to six weeks after fmt &op-in visit. Al1 items ranging fiom one to 15 were

answered at Time 1 and at Tirne 2 for the rernaining study mothers.

Al1 missing data values that occurred for subjects without a mother or partner were

replaced by the mean value for that variable for the purpose of reliability analysis. Misshg data

values were replaced for one mother at rime 1 and two mothers at T h e 2 who did not have a

partner, and for three mothers at both Time 1 and T h e 2 who did not have a mother.

Administered at the fmt &op-in visit, the BCS yielded a Cronbach's alpha value of .78;

administered four to six weeks Iater, the BCS yielded a Cronbach's alpha value .8 1. This

indicated that the BCS, even in its changed form, dernonstrated sufficient interna1 consistency for

this study. Lastly, change BFC scores were calculated by subtracting BFC scores measured at

fmt drop-in visit fiom BFC scores measured four to six weeks after initial &op-in visit.


Breastfeeding Droo-In Survey

The Breasaeeding Drop-In survey (BFDI nwey; Appendix C) was based on the Infant

Feeding Survey (WL&A Health Unit, 1997) and provided the following data: previous

breasdeeding exp enence: ext ent of breastfeeding; use of such breastfeeding support persons or

resources as public health nurses, doctors, fàmily, or books: prenatal class attendance: r e m to

work; intended duration of breastfeeding (any breastf'eeding): age of infant at fmt &op-in visit:

smoking status: matenial age; marital status: sources of household income: and mothers'

educational level.

Extent of breastf'eeding was recorded as full breastfeeding, partial breastfeeding, or

bottle-feeding. Fu11 breastfeeding means that breast milk is the main source of milk formula may

be use& but less than once a day. Partial breastfeeding means that both breast milk and formula

milk are used at least once a day. Bottle feeding means that infant formula is the main source of

milk; breastmilk may be used, but less than once a day (KFL&A Health Unit, 1997).

Only part of the BFDI survey (Appendix D) was administered at Time 2. Also,

information on the number of &op-ins the mother had attende4 use of support services, extent of

breastfeeding, intended duration of breastfeeding, and (if bottle-feeding) when and why mother

stopped breastfeeding was gathered

When the BFDI survey (Appendix E) wits administered at Mànt age of six months,

information on the variables collected at Time 2 were gathered again, with the exception of

intended duration of breastfeeding. Extent of breastfeeding was recorded If the mother was bottle

-feeding, the age of the infant at the time breastfeeding was stopped was also recorded

Three health care professionais reviewed the survey instrument for content validity.

Content validity is the degree to which items on an instrument represent the constnict to be

measured, as well as the instrument's appropnateness in measuring the constnrct within the

BrMeeding Drop-In 43

proposed study population (Roberts & Burke, 1989). It was determined that the s a l e had

sufficient content validity. The survey was subsequently pilot tested for clarity, wording, and

length by two breastfeeding mothers who were not part of the smdy. No changes were made to

the wording and the order of questions following pilot testing.

Data C o d i n ~ Entrv. and Cleaning

Data collected from the BCS and the BFDI sumey were entered in separate databases

using the Statistical Package for the Social Sciences (SPSS) program, version 7.5. Each subject

received a code number and each variable was assigned a variable name. Data were assigned

labels and numeric values, and were then entered Value labek were created to fàcilitate

interpretation of data. To accommodate the skip patterns in die survey, a not applicable category

was created for skipped variables. Values assigned the labels of 'miss hg', 'don't know' or

'refuse' were treated as missing values. The data values entered were verified and cleaned

Reverse-scored values were checked twice for accuracy. Total BCS scores were calculated using

SPSS and verified against manual calculations.

Data Analvsis

Descriptive analyses (frequencies and crosstabulations) and simple associations

(correlations) were performed us ing the SPS S program:

1. Frequencies, percentages, and graphs were used to summarize the descriptive data.

2. The rate of breastfeeding was expressed as the number of mothers breastfeeding at

infant age of six months, as a proportion of the total number of participants breastfeeding at

intake. Percent of mothers partially and fùlly breastfeeding at six months was describeci.

3. Kendall's tau was used to descnbe the relationship between initial breastfeeding


confidence and intended duration Kendall's tau is appropriate when measuring the relationship

between an independent variable measured on an interval scale and a dependent variable

measured on an ordinal scaie Polit, 1996). Next, analyses to test for possible confounders of the

relationship were carrieci out. To test for confounding variables, the relationships beween

potential confounders and each of the two variables under study (breastfeeding confidence and

duration) were examined for signif~cance. Chi-square was used to test the significance of

relationships between crosstabulated variables. The Fisher's exact test was used to determine

signifrcance when the expected cell counts were less than five. Any variable which was

significantly related to the independent variable of initial breastfeeding confidence and the

dependent variable of intended duration, but not on the causal pathway, was classified as a

confounder (Schlessleman, 1982). The confounder was then controlled for accordingly.

The differences in breastf'eeding confidence scores at six weeks between mothers

breastfeeding and mothers not breastfeeding at six months was examined using a Mann-Whitney

U-test. The Mann-Whitney U-test is a non-paramemc analog of the independent-groups t-test

used to test the difference in the ranks of scores of two independent groups (Polit, 1996). The

independent variable is based on an ordinal scale, and the dependent variable is based on a

nominal scale. Similarly, this test was used to determine if initial BFC scores were significantly

different for mothers who intended to breastf'eed longer than six months and mothers who

intended to breastfeed les than six months.

Wilcoxin signed ranlcs test was used to determine if initial scores differed significantly

from scores measured at four to six weeks after mothers' fust drop-in visit. Wilcoxin signed ranks

test is a non-parametric analog of the paired t-test, and is used to test the difference in the rads of

scores of two related groups. Kendall's tau was used to examine the relationship between change

in breastfeeding confidence over time and the number of &op-in visits.


4. An exploratory logistic regression of factors predicting breastfeeding at six months

was conchrcted. Bivariate analyses were canied out beforehand to identifL potential predictors or

confounders of breastfeeding at six months. Potential predictors or confounders were classified as

those which demonstrated a relationship with the dependent variable (breastfeeding at six

months) at a liberal level of significance o f p = .25 or Iess. Refer to Figure 1 for a diagrammatic

representation of the relationships among the variables that will be studied in this thesis.

Using a -25 Ievel of significance as a screening criterion for seiection of potential

predictors was chosen because more stringent p-values (such as p = -05) often hi1 to identifi

variables which can become important in a multivariable mode1 (Fiosmer & Lemes how, 1989).

Certain variables may show weak association with an outcome variable in bivariate analyses, but

rnay become important predictors of an outcome when taken together with other variables

(Hosmer & Lemeshow, 1989). After potential confounders or predictor vanabtes were identifie4

logistic regrasion analyses were conducted using these variables. Backward stepwise logistic

regression was carried out manually to determine the factors that best predicted breastfeeding at

six mont&.

Samde Size Estimation

Targeted sample size was based on the objective of detecting a positive, significant

relationship between breastfeeding confidence and breastfeeding duration. An estimation of the

sample size was based on the number of observations needed to detect a statistically significant

correlation of at Ieast .4 (a modest effect size) between breastfeeding confidence and

breasifeeding duration. The investigator chose to set power equal to -80 and a level of

significance of -05. For Pearson's r, a sample size of 37 will have 80% power to detect a

correlation of r = .4 at a level of ~ i ~ c a n c e of .O5 (Cohen, 1988). When r = .4 ,2 = .16;


thaefore, f 6 percent of the variation in breastfeeding duration is attriiutable to breastfeeding

confidence at the .O5 levet of significance.

To use Pearson's r, at least two main assumptions of the test should be met: (a) subjects

should be randornly and independently sampled from the population of interest and (b) data

should be measured on at Ieast an interval s a l e (Poli& 1996). Since the subjects in the current

study were not randomly sampled and the variables of interest were measured on both interval

and ordinal scales, Kendall's a u was the more appropriate test to use in place of Pearson's r.

Efficiency of Kendall's Tau is approximately 90% that of Pearson's r (Siegel, 1956). Estirnated

sampie size was increased to 40 to maintain power at 80%. Subject recmitment was concluded

after obtaining 37 subjects because of t h e constraints associated with follow-up.

Ethical Considerations

The study m m e s and protocol were approved by Queen's University and AffXiated

Teaching Hospitak Health Sciences Htunan Research Ethics Board before data collection

cornmenced The study was explained to potential subjects after their breastfeeding concerns were

addressed by a BFDI professional and written informed consent was obtained Each participant

received a code number, and al1 answers were recorded on questionnaires identified only by this

code number. Consent forms with identifjring information were locked in a separate location from

the data collected Information collected fiom participants was stored in a locked cupboard at the

KFL&A HeaIth Unit according to the Ministry of Health Record Storage and Retention

Guidelines. Only the principal investigator, faculty thesis supervisor and thesis supervisory

committee members had access to the data.


CHAPTER 4

ResuIts

Results are presented by study objectiva: (a) characteristics of study mothers, (b) rate of

breas tfeeding at infant age of six months, (c) relationships between breasneeding confildence and

breastfeeding duration (d) changes in breastfeeding confidence over t h e , and (e) factors that

predict breastfeeding at six months.

Obiective 1: Characteristics of Mothers Who Attended Breastfeedina Drap-Ins

Socio-dernom~hic Characteristics

Thirty-seven mothers comprised the study group. The typical mother was well educated

mamed, between 30 and 34 years of age, and not currently working outside the home. Detailed

socio-demographic characteristics of BFD t participants are shown in Table 2.

Most mothers were between 30-34 y m of âge (43%). Few mothers were younger than

24 (1 1%) or older than 40 (3%). A h o s t al1 rnothers were married or lived in a cornmon-Iaw

relationship (95%). Nearly ail mothers had completed college or university (84%) and oniy two

mothers had less than post-secondary school education. With the exception of six mothers ( 16%)

who were already working outside the home, mothers were not working at the t h e of their first

&op-in visit (84%). Thirty-two percent of mothers were on maternity l a v e and an additional

24% planned to r e t m to work eventually. One in four mothers had no plans to retum to work

FulI-time employment provided the ptimary source of incorne in 84% of households (Table 2).

Paritv. Prenatal CIass Attendance. and Smoking

More than half of attendees were fmt tirne mothers (65%). Nearly al1 had attended at

Ieast one prenatal class (95%), either during the curent or a previous pregnancy. Almost al1

mothers were non-smokers (92%) (see Table 2).


Table 2

Socicxiemo~~aphic Characteristics of Studv Mothers (N = 3 7)

- -

Mother's age 20-24 25-29 30-34 35-39 4044

Marital status Manied a commm-law Single (includes separated)

Education level Hi& school or less Some col1 ege'universi t y Completed college/univertity

Currently working Ym No, on mat ernity leme No, plans to work eventually No, does not plan to work

Household incorne fiom al1 sources a

Full-time ernplayment Part-time anplaymen t Self-employment Seasonal employment Farnily or gaiad welfare assistance Employmen t insurance (includes rnatemïty benefits) Canada pension plan ûtha

First-time mother Yes No

Attended prtnatal class Yes No

Smoking status Smoker Non-moka

" Cat egories not mutually exclusive; mothers checked al1 items that applied.


Mothers' Current Breastfeeding Emeriences

Characteristics of study mothers' curent breastfeeding experiences are shown in Table 3.

Most mothers (92%) were fùlly breastfeeding at the tirne of their first &op-in visit. Mothers in

this sample planned to breastfeed for a long period of tirne, with just less than three quarters of

mothers (73%) intending to breastfeed for more than six months. A large percentage of mothers

(30%) pianned to breastfeed more thaa 12 months (see Table 3).

Study mothers used a variety of resources to help with breastfeeding (see Table 3). The

five most fiequent sources of help were books or pamphlets (82%). their partner (72%), hospital

staff (67%), public health nurses (6 1 %), and fàmily (44%). Only one mother indicated no support

for breastfeeding. More tfian half (57%) of mothers reported that they had used at least five

sources of breastfeeduig support. Approximately one mother out of every four mentioned that she

received help with breastfeeding from a doctor.

Infant Age at First Drop-In Visit

Infants ranged in age fiom less than one month to four month at the time of their fmt

&op-in visit. Fewer infânts (30%) than anticipated were one month of age or younger.

Approximately one quarter of infants (24%) were in their second month of life, fourteen percent

were in their third month, and an unexpectedly large percentage of infants were in their fourth

month of life ( 19%) or were more than four months of age ( 14%) at fmt drop-in visit (Table 3).

Mothers ' Previous Breastfeeding Experiences

Seventy percent (n = 26) of the mothers surveyed had no previous breastfeeding

expenence (Table 4). Of the 1 1 mothers who breastfed previously, six breastfed longer than six

months. Seven mothers indicated that their previous breastfeeding experience was sa& Qing, and

four mothers indicated dissatisfàction or uncertainty with their previous breastfeeding experience.


Table 3

Characteristics of Mothers' Current Breastfeeding Ex~e ia i ces (N= 37)

Extait of breastfeeding Fu11 Partial

intmded duration of breastfeeding: Longer than 12 months 1 O- 12 months 7-9 months 4-6 rnonths 1-3 rnonths

Help with breastfeeding ": Reading books or pamphlets Parmer Hospital staff Public health nurse FamiI y Friends Doc t or La Leche League Midwife mer

Nurnber of drop-in visits: One Two Three or more

Age of baby at first visit to BFDI: I 1 month > 1 SSmmths > 2 1 3 months > 3 14months >4<5mmths

Categories not mutually exclusive; mothers checked al1 items that applied.


Table 4

Characteris tics of Mothers ' Previous Breastfeeding Experiences

Previous breastfeeding experiaice (n = 37) No Yes

Longest period of time breastfd other chiIdren (n = 1 1) 5 Six rnonths > Six months

Satisfied with previous breastfeeding experience (n = I 1) Dissatisfied or sanewhat dissatisfied Nei ther satisfied nm dissatisfied Satisfied or sornewhat satisfied

Obiective 2: Rates of Breastfeeding at Six Months arnonp; Studv Mothers

Al1 study mothers were breastfeeding at their fmt drop-in visit; a h o s t a11 (92%) rnothers

were fully breastfeeding at this t h e . At infant age of six months, 76% of mothers were

breastfeeding; 86% of these mothers were fully breastfeeding. The percentage of mothers fully or

partially breastfeeding at initial visit and at infant age of six months is shown in Figure 5.

Nine out of 37 mothers were not breastfeeding at six months. Of the nine mothers who

stopped breastfeeding before six months. five stopped because of "return to work"; four of the

five mothers stopped when their infànt was approximately five months of age. Two mothers

stopped breastfeeding at infant age of two and four months because of "insufficient milK', and

two stopped because of materna1 or infant iIlness at approximately three months of age.

Obiective 3: Breastfeedinn Confidence and Duration of Breastfeeding

Initial Breastfeeding Confidence Scores and Intended Duration

Breastfeeding ~ o ~ d e n c e scores at fmt drop-in visit ranged from 3.67 to 5.00 with a

mean score of 4.42 (n = 37. SD = 0.36). As the possible range of scores was 1-5, most mothers

O Bottle Feeding

Partial Weastfèedmg

Hi Full k a s tfeedmg

Iriitial BFDI visit M b t at 6 m&

'Ilme

F i w e 5. Study mothers bonle feeding, partially, and !My breastfeeding at initial

drop-in visit and infant age of six months.


in this sample demonstrated relatively high initial breastfeeding confidence scores. As

hypothesized, rno thers who demonstrated higher breasneeding confidence scores at their first

&op-in visit iutended to breastfeed longer. initial breastfeeding confidence scores and intended

duration were significantly, but modestly, correlated: r (N = 37) = 0.29, p = .O 12 (Table 5: Figure

6). Initial breastfeeding confidence scores were also significantly, but modestly correlated with

the age of the infant at first &op-in visit: r (N = 37) = .28, p = .O08 (Table 5; Figure 6). Mothers

who had higher initial breastfeeding confidence scores had older infànts at first &op-in visit.

I&nt age was seen as potentially biasing the relationship between initial breastfeeding

confidence and intended duration. Mothers with older infants at the tirne of their fnst drop-in visit

expressed an intention to breastf'eed longer, since, by virtue of breastfeeding an older infant, they

already experienced longer duration. Mothers with younger i&ts at fmt &op-in visit, on the

other han& could intend to breastfeed for either a short or long period of rime. This is shown in

Table 6. To reduce the bias associated with i d t age. the relationship between initial

breastfeeding confidence scores and intended duration was explored within a subgroup of

mothers (n = 20) breasneeding infants two months of age or younger. No significant relationship

was detected between initial breastfeeding confidence scores and intended duration among

mothers with younger infants (see Figure 6).

Breastfeedinp; Confidence Four to Six Weeks after First Visit and Actual Duration

Breastfeeding confidence scores measured four to six weeks afier k t visit ranged fkom

3.39 to 5.00 with a mean score of 4.54 (n = 35, SD = 0.39). No significant relationship existed

between breastfeeding confidence scores measured at four to six weeks after first visit and

breastfeeding duration at six months (Table 5; Figure 7). Four to six-week breastfeeding

confidence scores for mothers who continued to breastfeed at infànt age of six months were not

significantly higher than 4-6 week breastfieeding confidence scores of mothers who did not


Table 5

Relationships between Breastfeedin~ Confidaice (BFC), lntended Duratim, and Breaafeedinn at Six

Months (N= 37)

lni tial BFC ( 2 ) Score Change intendeci Br east feeding BFC Score 4-6 weeks Score Duraticm at Six Months (BFC' ) d e r ls visit (BFC' - BFC')

BFC 4-6 weeks 'C = . ~ 4 " ~ after l0 visit p < .O01

Chan$ Score ns (BFC--BFC')

Mother's Age ns

Inbt 's Age s = . 2 g b at 1' drop-in p = .O08

Note. " Two mothers not breastfeeding 4-6 weeb afler initial &op-in visit; therefore, n = 3 5 Kendall's tau Mann Whitney U Chi-square (Fisher's Exact Test used for both)

' Not controlling for *nt age


~ o t Signifiant Backgrouad

Dura ti on - 'ne' "

Fimire 6. Part 1: Diagrammatic representation of study constructs - bivariate relationships

between (a) initial breastfeeding confidence and infant age and @) initial breastfeeding

confidence and intended duration

Note. ' Mothers breastfeeding i a t s two rnonths of age or younger. -


Table 6

Mothers with Younger Versus Older Infànts and Intended Duration (N = 37)

htended Duration p p p p p

n 1 6 Months > 6 Months

Mothers with k t s 20 1 2 months

Mothers with infànts 17 > 2 months


~ o t S ignificant 1 Background

Infant Age

A'

A'

,

\ 0

/ 0

' . / 0

0 /

/ Intended /

Durat ion n = 35" /

/ /

/ /

/ /

0

4-6 week BFC O F i w e - 7. Part 2: Diagrammatic representation of study constructs - relationship between

breastfeeding confidence (BFC) measured 4-6 weeks after first drop-in visit and breastfeeding at

six months.

Note. " Two mothers did not have 4-6 week breastfeeding confidence scores as they were no - longer breastfeeding 4-6 weeks after first &op-in vis it.


continue to breastfeed at infànt age of six months.

Since mothers with older i m t s were already more IikeIy to be breastfeeding at sir

months, infant age was seen as a potential bias of the relationship. Therefore, breastfeeding

confidence scores measured four to six weeks afier intake were examined in relation to

breastfeeding duration at six months among a subgroup of mothers (n = 20) breastfeeding i n h t s

two months of age or younger. The relationship remained non-significant among rnothers

breastfeeding younger hfànts.

Post-Hoc Analvses

initial Breastfeedine: Confidence in Relation to Breastféedinp, at Six Months

Initial breastfeeding confidence scores were significantly higher for mothers who were

breastfeeding at infant age of six rnonths than for mothers who were not breastfeeding at six

months (Mann-Whitney U test; z (N = 37) 1 -2.4 1, p = .O 16; Table 5; Figure 8). However, e t

age at fmt drop-in visit was identifred as a potential confounder of this relationship, as it was

significantly related to both initial breastfeeding confidence scores: t (N = 37)= .28, p = ,008

(Table 5), and breastfeeding at six months (Mann-Whitney U test: z (N = 3 7) 5 -2.30, p = -02 1 ;

Table 5). Mothers with older infimts at fmt drop-in visit demonstrated significantly higher initial

breastfeeding confidence scores than mothers with younger infants. Likewise, mothers with older

inf'ants were more likely to be breastfeeding at six months.

Therefore, to minimize the bias associated with infànt age, the relationship between

initial breastfeeding confidence scores and breastfeeding at six months was examined among a

subset of mothers (n = 20) breastfeeding infants two months of age or younger. ïnterestingiy,

mothers (with younger infmts) who were breastfeeding at six months did not demonstrate

signifrcantly higher initial breastfeeding confidence scores than mothers who were not

breastfeeding at six months (see Figure 8).


~ o t Significant 1 9z Background

Infint Age

r (N= 37) = .28,p = .O08 z (N= 37) 1 - 2 . 3 0 , ~ = .O21

F i m e 8. Part 3: Diagrammatic representation of shidy constructs - bivanate analyses of

relationships between (a) infant age and initial BFC, (b) infant age and breastfeeding at six

months, and (c) initial BFC and breastfeeding at six months, and (d) initial BFC and BFC

rneasured 4-6 weeks after fust drop-in visite

Note. ' Mothers breastfeeding infànts two rnonths of age or younger.


Initial Breastfeedinn Conf~dence In Relation to Confidence Measured 4-6 Weeks Later

The relationship between initial breastfeeding confidence and breastfeeding confidence

measured four to six weeks d e r first drop-in visit was explored. However, since two mothers

were not breastfeeding at the t h e of follow-up, four to six week confidence scores were not

obtained for al1 study mothers. The results of this analysis pertain to 35 of 37 mothers who were

breastfeeding at first visit and 4-6 weeks later. As illustrated in Figure 8, the relationship between

initiai breastfeeding confidence scores and breastf'eeding confidence scores measured 4-6 weeks

aRer first drop-in visit was significant; r (n = 35) = S4, p < -00 1 (Table 5). Mothers with high

breastfeeding confidence at their fmt drop-in visit tended to have high breastfeeding confidence

four to six weeks later.

Intended Duration and Breastfeeding at Six Months

Post-hoc analysis of the relationship between intended duration and breastfeeding at six

months was explored Intended duration was significantly correlated with breastfeeding at six

months; J? (1. N = 37) = 15.53. p < -001 (Table 5). Mothers who intended to breastfeed longer

than six months were more likely to be breastf'eeding at hfànt age of six months than mothers

who intended to breastfeed six month or less.

I d n t age was identified as a possible confounder of this relationship because mothers

who had oIder infants could only intend to breastfeed a longer period of Mie, while mothers with

younger &ts could intend to breastfeed for either a short or long period of t h e . Therefore, the

relationship between intended duration and breastfeeding at six months was examined among

mothers breastfeeding infants wo rnonths of age or iess. The relations hip between intended

duration and breastfeeding at six months remained significant when examined among mothers

with younger infants: g(1, n = 20) = 6.61, p < .O5 (Figure 9). Mothers who intended to

breastfeed for a long time were more likely to be breastfeeding at six months. Mothers who


Signif~cant m g = Not Significant - Background

Infant Age

t (N= 37) = .28, p = .O08 z (N= 37)s - 2 . 3 0 , ~ = .O21

n = 20" > œ œ œ - - 1 - ~ 1 ~ - - - 1 - 1 1

BF 6 months

A' 8 I

? ( l , n = 2 0 " ) = 6 . 6 1 , ~ <.O5 /

I f

Duration r ( n = 3Sb)=.54.p c.001

\ I

8 I

f I

I I

4-6 week BFC O F i m e 9. Part 4: Complete diagrammatic representation of the intenelationships of study

constmcts, controlling for infint age (n = 20).

Note. a Mothers breastfeeding infdnts two months of age or younger. - Two mothers did not have 4-6 week BFC scores as they were no longer breastfeeding at

4-6 week after their fmt drop-in visit.


intended to breastfeed a shorter period of time tended not to be breastfeeding at six months. Ten

mothers intended to breasdeed for six months or les. Of these, seven mothers stopped

breastfeeding two mothers were partidy breastfeeding at six months. and one mother was fûiiy

breastfeeding at infant age of six months.

Obiective 4: Change in Breastfeeding Confidence Over Tirne

Table 7 contains the summary information for breas tfeeding confidence scores measured

at two time periods for study mothers. The sample mean breastfeeding confidence score rneasured

at four to six weeks after the mothers initial drop-in visit was slightly higher than the samp le

mean breastfeeding confidence score measured at mothers fust drop-in visit (4.54 and 4.42,

respectively). The range of breasrfeeding confdence scores at four to six weeb after intake was

also slightly larger (3.39 to 5.00) compared to initial breastfeeding confidence scores (3.67 to

5.00).

Table 7

Breastfeedina Confidence at First Visit and at 4-6 weeks after First Visit

Time n Mean Score S . M inirnurn Maximum

First Visit 37 4.42 .36 3.67 5.00

Given the possible range of scores between one and five (where one represents low

breastfeeding confidence and five represents high breastfeeding confidence) aii mothers

demonstrated medium high to very high breastfeeding confidence at both fmt drop-in visit and 4-


6 weeh later (mean scores = 4.42 and 4.54, respectively: see Table 7). Baseci on the pattem of

their distriiution, breastfeeding confidence scores were logically gmuped into the three categories

of similar size. namely : (a) medium hi& (b) hi& and (c) very high When scores were groupe4

as shown in Figure 10, initial breastfeeding confiidence scores measured at mothers fmt drop-in

visit were very evenly distributed However. b r a s tfeeding confidence scores rneasured four to six

weeks after mothers initial visit showed a marked shift in distribution, with the niajority (54%) of

scores hiling within the very hi@ range.

A smalL but significant difference between initial breastfeeding confildence scores and

breasneeding confidence scores measured four to six weeks later was detected (Wilcoxin signed-

ranks test, two-tailed, r (n = 35)= 1.62: p < .OS). The breastfeeding confidence scores measured

four to six weeks after intake were significantly higher than initial breastfeeding confidence

scores. Change breastfeeding confidence scores are the dflerences between breasdeeding

confiidence scores rneasured at first drop-in visit and breastfeeding confidence scores rneasured

four to six weeks later. Just over half of mothers ( 5 1%) experienced an increase in breastfeeding

confidence over time, whereas a small percentage of mothers (1 1%) showed no change in

breastfeeding confidence. and a moderate percentage of mothers (37%) experienced a decrease in

breastfeeding confidence over the .

Mothers with older infhts at fmt drop-in visit had higher breastfeeding confidence to

begin with. Therefore, l a s change in breasrfeeding confidence was perceived to occur over time

among these mothers. To ver@ this, changes in breastfeeding confidence over time were

examined separately for mothers breastfeeding older infants and mothers breasrfeeding younger

infànts. For mothers breastfeeding infants older than two months of age (n = 17), no statistically

signifiant difTerence was detected between initiai breastfeeding confidence scores and

breastfeeding confidence scores measured four to six weeks later.

Breastfeeding Drop-in 64

First drop-in visit

4 - 6 weeks afker 1st visit

Medium hi& H igh V e ry high (3.39-4.1 1) (4.12-4.56) (4.57-5.00)

Mean Breastfeeding Confidence Scores

Fimire 10. Distribution of medium high, high, and very high breastfeeding

confidence scores measured at first drop-in visit and 4-6 weeks after initial visit.


Nexc changes in breastfeeding confildence were examùied among rnothers b r e e e d i n g

i&ts two month of age or younger (n = 20) at the time of their fint &op-in visit. Two mothers

in this subset were not breastfeeding at the 4-6 week foliow-up and the breastfeeding confidence

scale was not admiaisterd for these two mothers. For this subset of mothers with younger infànts

(n = 18), a statistically significant difference between initial and 4-6 week breastfeeding

confidence scores was detected (Wilcoxin signed-ranks test, two tailed: T (n = 18) = 38, p < .OS).

However, the changes in breastfeeding confidence over time (increases. decreases. and no

change) appeared to be similar for mothers breastfeeding older inhts (n = 1 7) and mothers

breastfeeding younger infànts (n = 18). Approximately the same percentage of mothers

breastfeeding older infànts experienced an increase, decrease or no change in breastfeeding

confidence compared to rnothers breastfeeding younger infknts. A difference between the two

groups did not occur in the direction of change experienced, but rather with the amount of change

experienced. The dif5erence in amount of change (increase or decrease) is displayed graphically

in Figure 1 1. Mothers with younger infants appeared to experience greater increases in

confidence than mot hers with older infants. T hey also appeared to experience smaller decreases

in confidence as well.

Change in breastfeeding confidence scores (4-6 week breastfeeding confidence scores

minus initial breastfeeding scores) was not significantly related to initial breastfeeding confidence

scores, meaning that mothers with Iower or higher breastfeeding confidence at first &op-in visit

did not necessarily have lesser or greater changes in breastfeeding confidence. However, change

breastfeeding confidence was signifrcantly related to breastfeeding confidence scores at six

weeks, t (n = 35) = .3 1, p = -006, meaning that mothers who experienced a greater change in

breastfeeding confidence had higher breastfeeding confidence scores at six weelcs than mothers

who experienced no or slight change (Table 5). This supports the fmding that mothers with

Breastfieeding Drop-In 66

Individual Mothers

0.8

Figure 1 1 . Changes in breastfeeding confidence scores between fist drop-in

visit and 4-6 weeks later for mothers with younger infants (n = 18) and rnothers

with older infants (n = 17) at first drop-in visit.

-- % (n= 18)

X Younger Infants X X


younger infants had lower initial breastfeeding confidence and experienced a greater increase in

confidence over tirne, whereas mothers with older i-ts had high breastfeeding confidence

initially and continued to have high breastfeeding confidence 4-6 weeks later. Mothers with pior

breastfeeding experience did not demonstrate statistically higher breastfeeding conf~dence scores

at either tirne penod, nor did they experience statistically significant changes in breastfeeding

confidence over tirne when compared to mothers wit h no pnor breastfeeding experience.

Number of Droo-In Visits

More than half (57%) of study mothers visited the BFDI only once. A small percentage

(8%) came to the drop-in twice during the study period, and a moderate percentage of rnothers

(35%) attended three or more times (Table 3). The number of drop-in visits was not significantly

related to changes in breastfeeding confidence over rime, regardless of whether i-t age at fmt

&op-in visit was controlled (Table 5).

Obiective 5: Ex~loratorv Analvsis - Predicting Breastfeeding at Six Months

Logistic regression was conducted to develop a multivariable mode1 of characteristics of

study mothers that best predicted breastfeeding to six months. In order to identiQ potential

predictors or confounders for inclusion in the logistic regression model bivariate analyses were

performed. The following section will provide an overview of the results of bivariate analyses.

and the results of the logistic regression analysis.

Bivariate Analyses

To reiterate, potential predictors or confounders were classified as those which

demonstrated a relationship with the dependent variable (breastfeeding at six months) at a level of

significance o f p < .25 (Hosmer & Lemeshow, 1989). The variables marital status. education,

working statu, income, parity (having only one child versus tiaving two or more children),

previous prenatal class attendance, sources of support for breastfeeding, previous breastfeeding


expenence, and number of drop-ios attended were tested and found not to be related to

breastfeeding at six months at p S -25. These variables were not identified as potential predictors

or confounders of breasneeding at six months among this sample of breastfeeding mothers, and

were not included in the logistic regression

The following section identifies variables tested and found to be related to breastfeeding

at six months a tp 5 -25. Extent of breastfeeding at fmt drop-in visit (full or partial) and smoking

status were identified as potential predictors of breastfeeding at six months, as they were

associated with the dependent variable at a level of significance ofp s .25: x' (1. N = 37) = 3.8 1.

p = .14 1, for both (Table 8). These variables were selected for inclusion in the logistic regression

Initial and four to six week breastfeeding confidence scores were identified as potential

predictors of breastfeeding at six months, as both were associated with the dependent variable at a

level of significance of p 5.25; z (37) 5 -2.41, p = .O 16, and z (35) 5 - 1.16, p = .247, respectively

(Table 8). However, only one measure of breastfeeding confidence was incIuded in the logistic

regression Initial breastfeeding confidence scores, rather than 4-6 week breastfeeding confidence

scores, were selected for the following reasons: (a) initial breastfeeding confidence scores were

available for al1 study participants. whereas 4-6 week breastfeeding confidence scores were

availabte for only 35 of 37 participants, (b) initial breastfeeding confidence scores were more

s trongly correlated with breastfeeding at six months than 4-6 week breastfeeding confidence

scores, and (c) initial breastfeeding confidence scores were measured irnrnediately after the

mother received help at the drop-in; therefore they represented a closer approximation of baseline

breastfeeding confidence than breastfeeding confidence measured 4-6 weeks later.

M n t age at first drop-in visit was significantly associated with breastfeeding at six

months, z (37) < -2.30, p = .O2 l(Tab1e 8), and was identified as a potential confounder of

breastfeeding at six months. Mothers with older a n t s at first drop-in visit were more Iikely to


Table 8

Relationships of Characteristics of Stuciy Mothers with Breastfeeding Duration (N= 37)

Charact erist ic Breastfeeding at Six Months Test Statistic

No (n = 9 ) Yes (n = 28) Number (%) Number (%)

initiai BFC Score (mean score)

Mother's Age <30 >30

34 days 75 days

4-6 week BFC score (mean score)

Extent of BF at 1" visit Partial Fu1 1

Smoking No Yes

a Fkhers Exact Test

Note. The following variables were tested and found not to be related to breastfeeding at six

months at p I .25 and were not included in this table: marital status, education, working status,

income, parity, previous breastfeeding expenence, previous prenatal class attendance, sources of

support for breastfeeding, and number of &op-ins anended

be breastfeeding at six months than mothers with younger idants, Infant age was identified as a

potential confounder of breastfeeding at six months because the target of breastfeeding to six

months was more proximal for mothers with older infànts at the time of their first drop-in visit,

infànt age was included in the logistic regression as a potential confounder.

Matemal age was strongly correlated with breastfeeding at six months, 2 (1. N = 37) =

6.84, p = .O 17 (see Table 8), and was identified as a potential predictor of breastfeeding at six

month. Older mothers (2 30) were more likely to be breastfeeding at infant age of six months

than younger mothers (< 30). Therefore, materna1 age was included in the logistic regressions.

Intended duration was strongly correlated with breastfeeding at six months. x' (1. N = 37)

= 15.53, p < -00 1. (Table 8), and was conceptualized as a variable in the pathway between

confidence and breastfeeding duration Bandura ( 1997) ahdes to a causal relationship between

confidence, intention, and behaviour, where the level of attainment one strives for is the result of

perceived confidence in the ability to perform a behaviour. How long a mother intends to

breastfeed is influenced by the confidence she feels with breastfeeding and is a predictor of

breastfeeding behaviour. These attributes suggest that intended duration acts as a pathway

variable which, when entered in the logistic regression, may obscure the relationship between

other independent variables (such as breastfeeding confidence) and the outcome of interest

(breastfeeding to six months). Therefore, intended duration was not included in the logistic

regress io n

The strength of intended duration as a pathway variable is revealed by a cross-

tabulation of materna1 age, intended duration, and breastfeeding at six monrhq (Table 9). This

table should be interpreted with caution because five of the eight cells had less than five subjects.

Nonetheless, the cross-tabulation shows two important fïndings:

1. Most mothers (32/37) breastfed as long as they intended to breastfeed. Seven out of


Table 9

Crosstabulation of Materna1 Age. Intended Duratioa and Breastfeeding at Six Months (N= 37)

Breastfeeding at Six Months - -- - -

tntended Dutation n No Yes

Mothers Younger Than 30 Years of Age (n = 15)

PIan to Breastf'eed 6 Months or Less 5 5

Plan to Breastf'eed Longer than 6 Months 10 2 "

Mothers 30 Years of Age or Older (n = 22)

Plan to Breastfeed 6 Months or Less 5 2 3 b

Plan to Breastfeed Longer Than 6 Months 17 - 17

Note. Y w o mothers under 30 planned to breastfeed longer than six months, but did not. Three - mothers older than 30 yean of age planned to breastfeed six months or less. and were still

breastfeeding at infànt age of six months.


ten rnothers intended to breastfeed six months or less and had stopped breastfeeding before six

months. Twenty-five out of 27 mothers intended to breastfeed longer chan six m o n t h and were

breaslfeediig at infant age of six months. As a pathway variable, it is understandable that

intended duration is strongly related to breasaeeding at six months for this sample of mothers.

2. Matemal age was another important predictor of breastfeeding to six months. The

three mothers who breasâed longer than they intended were older than 30 years of age. The NO

mothers who breastfed for a shorter period of rime than they intended were younger than 30 years

of age.

In summary, four potential predictors (extent of breastfeeding at fmt drop-in visit

smoking satus. initial breastfeeding confidence scores, maternal age). and one potential

confounder (infant age at fmt drop-in vûit) in this data set were identified for entry into the

logistic regression

Predictors of Breastfeeding at Six Months: Loaistic R e ~ e s s ion

Stepwise logistic regression using backward deletion was used to develop the model. A

major concem was the age of the infant at first drop-in visit and the possibility of bias introduced

by this factor. Therefore. infant age was included in the model as a confounder and could not be

removed. The independent variables: extent of breastfeeding at first drop-in visit, smoking statu,

initial breasâeeding confidence scores, and maternal age were entered into the model (Table 10).

Materna1 age (c 30 versus z 30) was the only significant predictor of breastfeeding at six

months @ = .03) in the fmt step of the model and smoking status was the least significant (Table

10). In step 2 of the rnodel the independent variable, smoking statu, was removed from the

equation. Again, maternal age remained significant @ = -03). In step 3 of the mode4 extent of

breastfeeding (which was the least significant predictor of breastfeeding at six months in step 2)


Table 10

Lozistic Remession Model to Predict Breastfeeding to Six Months (N = 37)

Initial Model Final Mode1

b SE p Odds Ratio b SE p Wds Ratio

Maternai Age

I n b t Age in Days at First Drop-in

Initial BFC Score

Smoking Status

Constant

Model Chi Square


was elirninated from the equation with approximately the same results. Finally. initial

breastfeeding confidence score was removed f?om the equation, leaving the final and best mode1

(Table 10).

Matemal age cornprised the b a t modei, accurately predicting 86% of mothers in this

sample who breastfed to six rnonths, after controlling for the effect of infant age. Materna1 age

was identified as a signifiant predictor @ = .02) of breastfeeding at six mon& for the total

sample (N = 3 7) of breastfeeding mot hers in this data set. The chance of breastfeeding to infant

age of six months was almost one and one half times greater for mothers older than age 30 than

for mothers younger than age 30 (odds ratio = 1.4). The overall model was statistically

significan~ model x' (2. N = 37)= 15.14. p c -00 1.

A second logistic regression model was conducted purely for exploratory purposes. The

resula of this model and accompanying discussion are located in Appendix F. Both models reveal

essentially the same fmding. In both cases, materna1 age. rather than breas tfeeding confÏdence.

was the best predictor of breastfeeding to six months for this sample of breastfeeding mothers.


CHAPTER 5

Discussion

Major study fuiding will be diswsed kt Chaiacteristics of the sample are provided

followed by a aitique of sample limitations. Breastfeeding rates at six months, the relationship

between confidence and duration, change in confidence over t he , and the results of the logistic

regression are discussed in light of the identified sample liniitations. Curent study findings are

cornpared and contrasted with previous research fmdings and examined for fit with Bandura's

seKXEcacy theory. The section concludes with the consideration of c l in id implications.

Suggestions for future research are offered

S q l e Characteristics

Attendance at Breastfeeding Drop-las

The attendance at the &op-ins remained minimal throughout the course of the study

penod, despite extensive newspaper and radio advertking. During the seven-rnonth recruitment

period, only 38 mothers were eligible for the study. Only one rnother refùsed to participate:

therefore, study mothers were representative of mothers who attended the Breastfeeding Drop-Ins

in the Kingston area dunng the course of the study.

It is important to note that other services were avaiIable to breastfeeding mothers in the

Kingston community at the tirne that the Breastfeeding Drop-In initiative was introduced These

services may have infIuenced the number of mothers who attended the drop-ins, a s well as the

characteristics of mothers seea Breastfeeding mothers in the Kingston community may have had

their needs aiready addressed by a public health nurse, a midwife, a physician, or other existing

services such as La Leche League, the health unit's Babytalk line (a telephone information line)

and Breastfeeding Buddies. One of the drop-ins was held in a iow-income region of Kingston


already served by a CO-existing organization caiied Better Beginnuigs for Kingston Children

Among other things, this organization addresses the breastfeeding concems of many rnothers

living in the Better Beginnings area by providing prenatal careV home-visiting and lactation

consultant acivice for mothers who request help

Moreover, low attendance might be attn'buted to other hctors: inconvenient location of

the drop-ins for some mothers, cost associated with getting to the drop-ins, Iack of child m e for

older siblings, mothers' lack of awareness of the drop-ins. and other undetermined reasons. As

these reasons are onIy speculative, they should be investigated further.

Socio-demom~hic Characteris tics

It was hoped that the Breas~eeding Drop-Ins would attract a diverse group of

breastfeeding mothers, but this was not the case. Study mothers were predominantly college or

university educated, marrie4 between 30 and 34 years of age, non-smoking, and fmt-tirne

mothers. Most mothers had attended a prenatal class, and alrnost al1 mothers identified full-tirne

income as a source of househotd income. This socio-demographic profile paraleis sample

characteristics for mothers who attended other breastfeeding &op-in centres and clinics in British

Columbia and Ontario (Pastore & Nelson, 1997: Sirns-Jones & Bowes, 1997).

Very few single rnothers, mothers without post-secondaq education, or young mothers

attended the drop-ins. Nevertheless, it is well documented that mothers who choose to breastfeed

tend to be better educated, have higher incomes, are more Iikely to be married (or CO-habitating),

and are generally older than mothers who do not breastfeed (Beaudry & Aucoin-Larade, 1989;

Health Canada, 1995; K a u h & Hall 1989; Maclesin, 1998). Therefore, it is possible that the

mothers who attended the drop-ins may have been representative of breastfeeding mothers in

general.

Breas tfeeding Drop-in 77

intended Duration

Most mothers in this sarnple intended to breastfeed longer than six rnonths, Pastore and

Nelson (1997) found that mothen who attended the drop-in center in British Columbia intended

to breastfeed for a long period of time as weli, with most mothers indicating an intent to

breastfeed for at least six months.

Infknt Age

The mothers came to the drop-ins initialiy with older infànts. Almost three-quarters of

Wts were older than one month of age at their first drop-in visit. The average age of infants in

this study (two months) was almost Nvice the average age of infknts seen in other studies of

breastfeeding &op-in centres (Pastore & Nelson, 1997: Sims-Jones & Bowes, 1997). Pastore &

Nelson (1997) and Sims-Jones & Bowes (1997) found that rnothers who attended their &op-in

clinics had iIlfants who were, most comrnonly, two weeks of age or younger at the t h e of their

first visit.

The ages of infants seen at fmt drop-in visit were surprisingly low, since mothers often

encounter breastfeeding problerns within the first two weeks of initiating breastfeeding (Canadian

Institute of Child Health, 1996), and the majority of mothers who stop breastfeeding early do so

between two and six weeks of infant age (Feinstein, Berkelhamer, Gruszka, Wong, & Carey,

1986; Health and Welfkre Canada, 1991). It was not known why more mothers wiîh younger

infànts were not seen at the &op-ins. Initially it was thought that since the drop-ins were new to

the Kingston community at the time of the study mothers may not have been aware of them until

theu infants were older. This would create a backlog effect of older infants seen at fmt &op-in

visit. However, since mothers with older infants continued to attend the &op-ins during the entire

tint year of operation (Pam C m , personal correspondence), it is unlikety that this trend was the

result of a backlog effect.


It is possible that home visiting and telephone support were more appealing to mothers

with very young -6 since these services do not require rnothers to leave their home to get

help with breastfeeding. Two KFL&A Health Unit initiatives, Breastfeeding Buddies and

Babytallc. were in operation at the tirne that the drop-ins were introciuced and the study conducted

Both of these services offer breastfeeding support to mothers by telephone. In addition public

health nurses f?om the health unit cary out home visits to mothers identified as 'high-risk' for

breastfeeding problems upon discharge fiom hospital, or who have dficulty breas tfeeding once

returning home. This may partty expiain the low number of mothers with younger infànts seen at

the drop-ins. However, M e r research is needed to test this hypothesis.

Initial Breastfeedina Confidence

The mothers in this study had rnoderately high to very high brmtfeeding confidence at

their first drop-in visit. This finding was in contrast to Morrow's (1994) fmding that mothers of

newbom demonstrated oniy moderately high breastfeeding confidence. Morrow examined fmt-

time mothers' breastfeeding confidence before hospital discharge. Initially it was thought that the

difference might be attributed to the parity of the mothers. Mothers in the current study were

primparous (having oniy one child) or multiparous (having more than one child), whereas al1

mothers in Morrow's study were fmt-time mothers. However, initial breastfeeding confidence

was not significantly different for primiparous and multiparous mot hers.

Previous breastfeeding experience was aiso examined and found not to be related to

initial breastfeeding confidence. Mothers in the current study ranked their previous breastfeeding

experience on a s a l e from 1-5, where one represented dissatishction and 5 represented

satishction No difference in satisfàction with previous breastfeeding expenence was detected

among mothers with higher or lower initial breastfeeding confidence. However, this finding must

be interpreted cautiously as the small sample size may have obscured a potentially signifiant


relationship between extent of satisfiction with previous breastfeeding experience and

breastfeeding confidence.

Moîhers in Morrow's study had newborns at the time h t BFC was measured This

finding is believed to explain most of the differences in breastfeeding confidence between

mothers in the current study and mothers in Morrow's study, and is consistent with Bandura's

(1997) self-eficacy theory. According to Banbura, the more experience a person has on which to

base her judgements, the more information that person will have to assess her efficacy beliefh. By

virtue of attending a Breastfeeding Drop-In when their infànts were older, most mothers had

likely encountered and overcome initial breastfeeding difficulties already. T hose with lower

breastfeeding confidence may have discontinued breastfeeding. Since overcoming challenges or

impediments increases one's confidence in one's ability to perform that behaviour (Bandura,

I997), it is not unusual that mothers at the drop-ins ail had moderately to very high breastfeeding

confidence upon their fmt &op-in visit. Dflerences in breastfeeding confidence and the age of

the infknt will be discussed M e r in relation to intended and actual breastfeeding duration

The current study's breastfeeding confidence scores were not directly comparable with

Morrow's findings because of computational dflerences. In the current study, a 'not-applicable'

response category was added for mothers without a partner or mother. When a score was coded as

missing or not applicable, the item was dropped fkom the analysis and the average score of the

remainder of items answered was calculated. Morrow calculated total scores by summing the

responses over the 18 items and substituting the sample mode for missing scores of individual

items. The current study had a possible range of tom1 BFC scores of 1 - 5, whereas Morrow's

study had a possible range of total BFC scores of 18 - 90.

S a r d e Limitations

A major Iimitation of this study was the small sample size. These results are based on a


smali, self-selected sample and therefore, cannot be generalized The hornogeneity of the sample

is also of concern The sample cons isted mainly of older, well-educated, mmied mothers who

had older infants at the time of their fmt drop-in visit, intended to breastfeed for a long period of

tirne, and had hi@ initial breastfeeding confidence. Both srnall sample size and the homogeneity

of the sample were seen as limitations for several reasons: (a) they limited the extent to which the

researcher could contrast the differences between mothers breastfeeding at six months and

mothers not breastfeeding at six months by such sample characteristics as marital status and

education level, (b) they hindered the cesearcher's ability to adequately explore the relationship

between breastfeeding confidence and duration among this sample of breastfeeding mothers

because of a limited range in both variables, and (c) they limited the extent to which the study

findings could be generalized to populations outside this sample. These limitations will be

discussed in relation to their impact on specific study objectives.

Breastfeeding at Six Months

Approximately three-quarters of mothers in the current study cont inued to breastfeed

their Uifant to six months of age. Furthemore, almost al1 mothers who were breastfeeding at six

months were exclusively breastfeeding. The m e n t recommendation suggests that mothers

exclusively breastfeed their h f h t s for at least the fmt four to six months of life (CPSDietitians

of CanaMealth Cana& 1998; WHOKJNICEF, 1990). Compared to national statistics,

breastfeeding rates at six months were very high for this sample. According to the latest national

statistics, only 24% of mothers in Canada continue to breastfeed to six months of age (Ministry of

Industry, 1996). As other breasaeeding drop-in evaiuations report breastfeeding rates at only six

weeks (Sims-Jones & Bowes, 1997) and four months (Pastore & Nelson, 1997), it is not known


how these six-month rates compare to simiiar groups of mothers who attended breastfeeding

clinics or centres in Canada.

The high rate of breastfeeding at infant age of six mon& could be amibutable to the

socio-demographic characteristics of study mothers. Previous research shows that mothers who

breastfeed longer tend to be oIder, marrie& have more education, have breastfed before, are non-

smoking, have a higher income, intended to breastfeed for a longer period of the, and bave more

support for breastfeeding (Isaacs (e Linmk, 1995: Isabella & Isabella, 1994: Lawson & Tulloch

1995; Solway, 1992: Stewart & Potter, 1990). Most mothers were breastfeeding older infànts at

h t drop-in visit which may have contributed to the high number of mothers breastfeeding at six

months. Whether or not the drop-ins themeIves had any influence on the rate of breasrfeeding at

six months is not known due to the lack of a control group.

Mothers breastfeeding at six months differed fiom mothers who were not breastfieeding at

six months. Those who were breastfieeding at six months tended to be older, had older &ts at

the time of their fûst drop-in visit, and intended to breastfeed longer. These findings concur with

several other research studies (Matthews, Webber, McKim, Banough-Baddour, & L q e a , 1995:

Health and Welfkre Canada, 1991: Loughlin, et al., 1989: O'Campo et al., 1992).

Parity, previous breastfieeding experience, education, marital status, working status,

income, previous prenatal class attendance, number of sources of support for breastfeeding, and

the number of drop-uis attended did not differ between mothers who were breastfeeding at six

months and mothers who were not breastfeeding at six months. However, these results m u t be

interpreted with caution, as the homogeneity of the sample and the small sample size may have

limited the extent to which significant relationships could be detected Hill, Humenick

Argubright, and Aldag ( 1 997) found that previous breastfeeding experience, rather tban parity,

signifcantly influenced breasaeeding duration Infant age was a confounder of the relationship


between breastfeeding confidence and breastfeeding at six months. When the bias of infant age

was removed, breastféeding confidence did not differ between mothers breastfeeding at six

months and mothers not breastfeeding at six months. This will be discussed M e r in the section

pertaining to conftdence and duration.

Previous research suggesa that many mothers stop breastfeeding before they had pianned

(Hill, Humenick Argubright & Aldag, 1997: Loughlin, Clapp-Channing, Gehlbach,

Pollard, & McCutchen, 1985: Rogers, Morris & Taper, 1987). However, mothers in this study

generally breastfed as Iong as they intended. Without a control group, it is impossible to

determine whether or not study mothers would have breas~ed as long as they did without the

support they received at the Breastfeeding Drop-Ins.

"Retum to worK' was the most comrnon reason given for stopping breastfeeding before

six months. Five of nine mothers who stopped breastfeeding before six months did so because of

return to work Return to work is a common reason for weaning within the fmt four to six months

of infant age (Chornniak & Hubay, 1992; O'Campo, Faden, Gielen. & Wong, 1992). The current

study supports the findings of other studies.

Feelings of insufficient milk and illness-related fàctors were other reasons given for

stopping breastfeeding. These findings correspond with other research findings (Pastore &

Nelson, 1997; Sims-Jones & Bowes, 1997). Stopping breastfeeding because of feelings of

insuficient milk commonly occurs in mothers who are breastfeeding an infbnt three months of

age or younger (Health and Welfàre Canada, 1991). Two out of three mothers in the current study

who were supplementing breastfeeding with formula at the rime of theû fmt &op-in visit stopped

breastfeeding by i h n t age of three months.

Many researchers have proposed that feelings of insufficient milk are closely tied to

confidence (Allen & Pelto, 1985: Hill & Aldag, 199 1: O'Leary Quim, Koepsell, & Haller, 1997).


Mothers with Iower confidence may express greater uncertainty about their rnilk supply.

Unfortunately, this reiationship could not be examined in this study because of the smail sample

size and the few rnothers who stopped breastfeeding for this reason

Initial Breastfeedinp: Confidence and Intended Duration

It appeared that mothers who had higher breastfeeding confidence at their fmt &op-in

visit intended to breastfeed Ionger than mothers with lower initial breastfeeding confidence.

However, the age of idbts at first drop-in visit was a confounding factor of this relationship,

since mothers with older infànts intended to breastfeed longer by vime of aiready breastfeeding

older inhts. Therefore, this relationship was explored among mothers breastfeeding infants two

month of age or younger at first drop-in visit. When examined a m n g mothers with younger

infants, mothers who had higher initial breastfeeding confidence scores did not intend to

breastfeed significant ly longer than mothers wit h lower initial breastfeeding confidence.

Admittedly. the sample size of 20 mothers breastfeeding younger int'ants may have been

too small to detect a significant relationship between initial breastfeeding confidence and

intended duration, even if one existed Similarly, Morrow (1994) did not find a significant

relationship between intended duration and breastfeeding confidence in her sample of 72

breastfeeding mothers with newborns. Mothers with higher breastfeeding confidence did not

intend to breastfeed significantly longer than mothers with lower breastfeeding confidence

(Morrow, 1994).

Two possible reasons rnight explain why such a relationship was not detected between

initial breastfeeding confidence and intended duration in the current study. Fin& the distribution

of both variables was limited To identify a signifiant relationship between two variables in my

particular study, the sample must have an adequate distribution for each of the variabIes under


study. In the m e n t study, most mothers had high initial confidence scores and intended to

breastfeed for a long period of the . In Morrow's (1994) study, most mothers had only

moderately high confidence and intended to breasâeed for a shon period of tirne ( 1-3 montbs).

Little variability in breastfeeding confidence and intended duration may explain why a significant

correlation between breastfeeding confidence and intended duration was not detected

Second, breastfeeding confidence varied with the age of the idant. As illustrateci in the

current study, mothers breastfeeding older infants demonstrated higher breastfkeding confidence.

Mothers breastfeeding y ounger infints, as in Morrow 's study, demons tra ted lower bras tfeeding

confidence. The strong link between breastfeeding confidence and hfimt age, and the relatively

homogenous sample of mothers with older infàuts (in the current study) and younger infints (in

Morrow's study) decreased the likelihood of detecting a significant relationship between

breastfeeding confidence and intended duration,

Other studies have shown a positive and significant association between breastfeeding

confidence and intended duration (Lawson & Tulloch, 1995: Loughlin et a l 1989: O'Campo et

a l 1992). Findings show that the higher a mother's breastfeeding confidence, the longer she

intends to breastfeed There are methodo logical differences with these studies, however. Loughlin

et al. (1989) used only one question to assess mothers breastfeeding confidence. One question

may not provide a sufficient measure of breastfeeding confidence, as it may not capture tme

differences in breastfeeding confidence among mothers. According to Bandura (1997), a

comprehensive assessrnent of confidence (or self-efficacy) must assess three aspects of

confidence - level, generality, and strength. Differences in mothers confidence with respect to

higher Ieveis of task gradation or difficulty were not assessed in the study by Loughlin et al.

Therefore, even though two mothers may have stated that they felt 'very confident' in their ability

Breas$eeding Drop-In 85

to breastfeed, when prwented with &ou challenges associated with breastfeeding, their level of

confidence rnay have differed substantially.

O'Campo et al. (1992) and Lawson and Tuiloch ( 1995) measured mothers' confidence

with breastfeeding before their ïnfhts were b o n They found that mothers who had higher

breastfeeding confidence intended to breastfeed longer. According to Bandura ( 1997), measures

of confidence (or self-eficacy) in anticipation of an event. as opposed to an event that is

occurrhg at the present rime, represent inaccurate measurements of self-efficacy. Therefore, these

findiags are not comparable to the current study findings.

Theoretically, the relationship between confidence and intended duration is plausible.

Bandura's self-efficacy theory ( 1997) acknowledges that experience and confidence (or self-

eficacy) are closely linked Self-eficacy tends to increase with repeated experiencw in which

obstacles are encountered and overcome (Bandura, 1997). Mothers who attended their fmt drop-

in with infànts older than two months of age would have had more time to encounter and surpass

obstacles (thus demonstrating high initial breastfeeding confidence) than mothers with infants

two months of age or las who attended the drop-ins for their fust t he . Confidence and intended

duration are also closely linked Individuals with greater self-efficacy beliefs tend to set higher

goals for themselves (Bandura, 1997).

Morrow's findings and the m e n t study findings together suggest that breastfeeding

coddence and intended duration are moving targets that appear to Vary over tirne. Ail mothers in

the m e n t study had high breastfeeding confidence, and most intended to breastfeed longer than

six months. Most mothers in Morrow's snidy had only moderately high breastfeeding confidence,

and most intended to breastfeed for only a short period of time. As breasrfeeding confidence

increases, mothers rnay intend to breastfeed for longer periods of tirne. However, no baseline

measures of these variables were obtained for study mothers in the m e n t study. Baseline


measures r e k to breastfeeding confidence measured at the time of the infkt's birtk Therefore,

the cux~ent study alone cannot determine whether or not this is true. As weli, Morrow did not

examine breastfeeding confidence over time. Therefore. her finding alone are also unable to

support this.

It is possible that both the current study and Morrow's study missed critical periods for

studying the rehtionship between intended duration and breastfeeding confidence. The

relationship between confidence and duration rnight best be studied among mothers who have

infants who are neither very young nor very old An ideal time might be after the mother is

discharged &orn the hospitai, but before the infànt reaches two months of age, as the majority of

mothers who stop breastfeeding early do so before two months of age (Feinstein et ai., 1986:

Health and Welfàre Canada, 199 1). Understandably, the t h e before mothers are discharged from

the hospital tends to be chaotic. Two months later, conceivably, the mothers who have adapted

and persevered with challenges are stili breastfeeding, while those who did not overcorne

challenges or who intended to breastfeed for a very shon period of time have stopped

breastfeeding. However, within this tirne period, mothers may be uncertain about their abilities,

may vary in their intentions, and may be more amenable to professional intervention Further

research might clari@ if there is more variability in breastfeeding confidence and intended

duration of breastfeeding during this tirne, and whether a relationship between cog~dence and

duration may be detected. This has implications for the optimal timing of interventions to increase

breast$eeding duration for mothers at greatest risk of stopping early.

Admittedly, the m e n t study and Morrow's study differ with respect to one important

component: Morrow considered aIt fmt-thne mothers breastfeeding before hospita1 discharge

while the current study examined ail mothers stfi breastfeeding after hospital discharge, who

attended the Breastfeeding Drop-Ins. Needless to Say, the current study fmdings are bas& on a

select samp le of breastfeeding mothers. Mothers who stopped breastfeeding immediatety d e r

hospital discharge were not seen at the &op-ins. However, this does not change the interpretation

of these fmdings. Even among mothers* breastfeeding infants two months of age or les,

Morrow's fmding of no relationship between breastfeeding confidence and intended duration was

replicated Future research is needed to examine breastfeeding confidence and intended duration

longitudinatly fiom birth so that baseline scores of BFC are obtained for mothers who stop

breastfeeding eariy.

Initial and Four to Six Week Breastfeedin~; C o ~ d e n c e and Actual Duration

It seemed that mothers with higher initial breastfeeding confidence breastfed significantly

longer than mothers with Iowa initial breastfeeding confidence. However, infànt age e again a

confounder of this relationship, since mothers with older inf'ants had higher initial breastfeeding

confidence scores to begin with and were already more likely to be breastfeeding at six months.

Therefore, this relationship was examined among a subset of mothers with younger infants.

Among mothers with younger infants, those with higher initial breastfeeding confidence did not

breastfeed longer.

Similarly, in bivariate analyses mothers with higher breastfeeding confidence measured

four to six weeks after mothers' fmt drop-in visit were not more likely to be breastfeeding at six

months. However, as mothers with older infants were more likely to be breastfeeding at six

months, infant age was seen as a possible bias of the relationship. Therefore, to minimize the

impact of infànt age on this relationship, the relationship was examined among a subset of

mothers with infànts two months of age or younger. The results confmed that mothers with

higher breastfeeding confidence at four to six weeks after fmt drop-in visit were not more like1y

to be breastfeeding at inlànt age of six months.

Breastfeeding Drop-En 88

One reason that might explain why mothers with higher initial breastfeeding confidence

and higher breastfeeding confildence 4-6 weeks after the first drop-in visit were not more likely to

be breastfeeding at six months is that al1 mothers had high to very high confidence initiaily and

four to six weeb after their fkst drop-in visit Therefore, the distribution of breastfeeding

confidence was limited. Mothers with low breastfeeding confidence were not seen in this sample,

perhaps because mothers with low confidence were less Iikely to be breastfeeding when their

infknts were of the ages seen in this sample, or mothers were simply less likely to corne to a drop-

in.

Other researchers examined the relationship between breastfeeding confidence and

duration, and found that mothen with low confidence stopped breastfeeding early, and mothers

with high confidence tended to breastfeed longer (Loughlin et al, 1985: O'Campo et al. 1992).

However, the same problems that were criticisms of other studies regarding the relations hip

between breastfeeding confidence and intended duration apply to these studies examinhg the

relationship between breastfeeding confidence and actual duration instruments used provided

tirnited measures of breastfeeding confidence (Loughiin et a l 1985: O'Campo et ai, 1992) and

researchers measured breastfeeding confidence prenatally (O'Campo et al, 1992), thus possibly

providing inaccurate measures of confidence.

Theoretically, a relations hip between breastfeeding conf~dence and actual breastfeeding

duration is quite plausible. Recall that eficacy beliefs determine if one will even try a behaviour

and how long one persists with the behaviour in the face of obstacles (Bandura, 1997). Previous

performance accomplishments influence one's feelings of confiidence regarding a specific

behaviour. According to Bandura (1997)' individuais with low eficacy beliefi (or confidence)

tend not to continue with a behaviour in which they judge themselves to be inefficacious.

Obstacles that have been encountered and mastered early on likely heighten confidence.

It is not surprishg that mothers with older infànts. who were breastfeeding at their first

drop-in vis it, were still breastfeeding at six months. The majority of snidy mothers likely

encountered obstacles early on, mastered hem, attendeci a drop-in with an older infànt, had high

breastfeeding confidence at k t drop-in visit experienced increased confidence over tirne, and

continued to breastfeed at six months. A signifiant relationship was not detected between

confidence and duration likely because there was too little variability in breastfeeding confidence

to detect a signif~cant relationship.

Chanaes in Breastfeedina Confidence Over Time

Most mothers experienced an increase in confidence over time, whereas a smaller

proportion showed a decrease in confidence, and a few had no change in confidence. No one else,

to this researcher's knowledge, has examined changes in breastfeeding confidence over tirne.

These findings are consistent with Bandura's (1 997) self-efficacy theory. According to Banctura

judgement of one's abilities to perform an activity based on actual performance behaviour may

raise, leave unaffected, or lower confidence.

Those who encounter and surpass difficulties early on tend to have high confidence

(Bandura, 1997). Such accumulated experiences provide reassurance in one's abilities to

overcome n i m e obstacles. Mothers with younger i n h t s who had lower initial breastfeeding

CO nft dence experienced greater increas es in confidence and smaller decreases in confidence over

time than mothers with older inf'ants. These findings rweal two things:

1. Even though mothers with younger i a t s demonstrateci lower confidence at first,

the majority of change that o c m e d over h e happened with these mothers. In this sample of

breastfeeding mothers, confidence was more easily influenced for rnothers with younger infants

than for mothers with older infànts who had already estabIished breastfeeding,

Breastfeeding Drop-En 90

2. A critical period during which breastfeeding confidence changes rapidly may exist In

this study, the critical period for change in coafidence appeared to be between birth and two

months of age. Mothers with infànts in this age range at f b t drop-in visit experienced the greatest

increase in confidence over time.

Decreases in confidence over time were slight and were similar in amount for mothers

breastfeeding younger inftints as for mothers breastfeeding older infànts. Slight, periodic

decreases in confidence are not unusual for mothers who face dficult breastfeeding challenges.

Confidence miy fluctuate according to the mother's reaction to her own performance or to her

infant's behaviour.

Banmira (1997) maintains that when confidence (or selfsficacy) is hi& challenges

encountered do not present a great threat to the sustainability of a desired behaviour. The mothers

who experienced s light decreases in confidence in this study were not at increased risk to stop

breastfeeding by six months since all mothers demonstrated relatively high confidence to begin

with. Any decrease in conf5dence was not enough to significantly influence breastfeeding

outcornes. Future research could explore whether mothers who have low breastfeeding

confidence at birth and who expenence a substantial decline in confidence over tirne are at

increased risk of stopping breastfeeding.

Since mothers were seen later in the postpartum period, it was likely too late to detect any

real change in breastfeeding confidence. As well, the changes in breastfieeding confidence that

were seen, in this sample of mothers, may have been be due to random fluctuations of confidence

over tune as opposed to the infiuence of the drop-ins themselves. Without a control group, it Û

impossible to determine if the drop-ins were responsib le for boosting confidence in this sample of

breastfeeding mothers. As weli, it is unknown if more mothers would have experienced a


decrease in confidence, had they not come to the drop-in and received support and information on

how to overcome a probiem,

Further research is needed to look at how much change is due to random fluctuation, to

changes in breastfeeding confidence over time (using the same measure of breastfeeding

confidence), or to an intervention such as a Breastfeeding Drop-ln As alluded to previously, there

may be a critical period of time during which changes in breastfeeding confidence are best

observed Future research might explore breastfeeding confidence longitudinalIy fiom birth to

infânt age of six months to not only obtain baseline scores of breastfeeding confidence, but to

track changes in breastfeeding confidence over time. Perhaps then the critical period for change in

breas tfeeding confidence could be identified

Change in Breastfeeding Confidence in Relation to the Nurnber of D~oD-Ins

At the outset, the researcher anticipated that the more &op-ins a mother attended, the

more support a mother would receive for breastfeeding and the p a t e r the increase in confidence

a mother would experience. Mothers who attended more drop-ins did not breastfeed longer than

mothers who attended fewer drop-ins. It is acknowledged that mothers who attended the &op-ins

more often rnay have had more dificulty with breastfeeding and were at higher risk to expenence

a decrease in confidence than mothers who attended the &op-in only once or twice.

Furthemore, it is possible that mothers attended the &op-ins for reasons other than

needing help with a problem The &op-ins were promoted, along with being a place to get help

for problems, as a place for mothers to meet and chat with other breastfeeding mothers. In this

case, the number of &op-ins attended by mothers would have little effect on breastfeeding

confidence. By virtue of having older inf'ants at first drop-in visit and high breastfeeding

confidence, the number of drop-ins attended seemed to have Little influence on mothers'

breastfeeding confidence. This may be because the optimal period to influence confidence was

Breastfeeding Drop-in 92

missed Health care professiomls should consider intervening with breasdeeding mothers as early

in the postparturn period as possible to have a positive impact on breastfeeding confidence.

Predictinp Breastfeedina at Six Months

The most significant predictor of breastfeeding at six months in this sample was mother's

age. Mothers older than 30 years of age were more likely to be breastfeeding at six months than

mothers younger than 30 years of age. Since mothers who had infànts older than two months of

age were already identified as more likely to be breastfeeding at six months, inFdnt age was

treated as a confounder in the exploratory analyses. A logistic regression model was developed

that controlled for the bias of infant age. Older mothers were alrnost one and one half times more

likely to be breastfeeding at infànt age of six months in this data set.

The logistic regression rnodel although exploratory in nature, exhibits several

weaknesses. First the number of variables included in the logistic regression was large relative to

the number of subjects. One main probtem that arises with this approach is that the mode1 may be

over-fitted and may produce numerically unstable estimates (Hosmer & Lemes how, 1 989). This

is characterized by unrealistically large estimated coefficients and estimated standard errors.

Second, the more variables included in a model the more dependent the model becornes on the

observed data (Hosmer & Lemeshow, 1989). Thus the results of the logistic regression have

Limited generalizeability beyond the current study. Third, sample size estimation was calculated

for major study objectives. which included calculations of proportions and bivariate relationships.

but not for multivariate analyses.

One implication of having a srnall sample size relative to the test used is that results may

indicate no significant relationship between two variables, when in fact a significant relationship

does exist For example, smoking status was not found to be a potential predictor of breastfeeding

at six months in the logistic regression but this finding may not be a mie indication of the

Breasâeeding Drop-In 93

relationship between smoking statu and breastfeeding duratioa Only three mothers reported that

they were smokers. Smoking statu may not have been detected as a significant predictor of

breastfeeding duration when, in fàct, it might be (Type II errer)- Likewise, extent of breastfeeding

at f h t drop-in visit (full or partial) and breastfeeding confidence may not have been detected as

signifiant predictors when in Eict they may have beea The homogeneity of the sample and the

minimal variability in breastfeeding confidence arnong study mot hers may have obscured the

identification of these variables as significant predictors of breastfeeding at six rnonths. Although

a larger s q l e sue is desired for multivariable analyses, the purpose of this logistic regression

was pwely exploratory in nature. Nevertheless, chance of Type II error is hi& and these results

should be interpreted with caution.

The Iength of time mothers intended to breastfeed was not included in the logistic

regression mode1 because it was seen as a pathway variable. Confidence (or eficacy beliefk) is a

key factor of intention, and intention influences behaviour (Bandura, 1997). The more confident a

mother feeIs in her ability to breastfeed the longer she intends to breastfeed and the longer she

actually breastfeeds. Intended duration, on its own, was an excellent predictor of mothers

breastfeeding at six months in this sample, as those who intended to breastfeed longer than six

months tended to still be breastfeeding at six months, and those who did not intend to breastfeed

longer than six months usually stopped breastfeeding by six months.

Lawson and Tulloch (1995), using discriminant fùnction analysis, found that mothers

who mainrained full breastfeeding for at least a 12 week period had a higher education leveî, had

made their decis ion to breas tfeed prior to conception, intended to breastfeed for at least 4 to 6

months, and had an unfavourable attitude to formula-feeding. They found that confidence was not

predictive of breastfeeding status.

07Campo et al. (1992), using multivariable proportional hazard analyses, found that

intended duratioa materna1 confidence, normative beliefi (rnothers' perceptions of other peoples'

wishes with respect to b rmt or formula feeding), behavioural belieoi (rnothers' beliefs about the

consequences of breastfeeding), and social learning beiiefk (mothers ' exposure to breastfeeding

role models) were the rnost significant hctors influencing breastfeeding duration However, the

results of these and Lawson and Tufloch's (1 995) findings should be interpreted cautiously as

confidence was rneasured before the birth of the baby.

Loughlin et al. (1985) found that materna1 lack of confidence, short intended duration of

breastfeeding ( l es than six months), nursery staff ratings of uif'ants excessive crying, i f in t ' s

demanding personality, trouble with feeding, fiiture trouble with feeding, and supplementing with

formula together predicted 77% of mothers who stopped breastfeeding. As only one item was

used to measure confidence, the results of this variable are also questionable.

Clinical Imlications

Of those mothers who attended the &op-ins, most breastfed as long as they had intended.

Simply asking mothers how long they intend to breastfeed may be an excellent way of identiQing

mothers at risk for stopping breastfeeding before six months. Reasons for intending to breastfeed

for a short penod of tirne can be explored with mothers and benefits or solutions to prolonghg

breastfeeding can be discussed

In this sample, knowing the age of the mother was also an excellent way to identiq those

at risk for stopping breastfeeding. Future research might explore why younger mothers stop

breastfeeding early. ance thes e factors are identifie& health care profess ionals can then explore

these issues with younger breastfeeding mothers to influence breastfeeding duration.


The most common reason for stopping breastfeeding, among the few mothers who

stopped before infànt age of six months, was return to work Assuming that a mother wishes to

continue breastfeeding following her return to work, timely intervention by a health care

professional may encourage her to maintain breastfeeding. Important issues for health care

professioaals to discuss with those who wish to combine breastfeeding and work include

strategies for maintainhg rnothers' milk supply, expressing, and storing milk (Izatt, 1997).

Health care professionals can aiso act as advocates for breastfeeding in the workplace and

lobby for policy change. Some strategies that rnay be worthwhile Iobbying for include the

implementation of policies related to a rnandated period of paid Ieave for the recommended

period of breastfieeding to six months, the introduction of breastfeeding breaks in the workplace,

and incentives for employers to implement such measures (Galtry. 1997). Policy change is

instrumental for protecting and promothg breasrfeeding for mothers who wish to combine

breastfeeding and work

Mothers most commonIy stopped breastfeeding at around i&mt age of three months

because of feelings of insufficient m i k Early intervention by a health care professiona1 may

alleviate some of the anxiety associated with feelings of insufficient miik Provision of accurate

information is essential in addressing these feelings, as most mothers are physio logically capable

of producing sufficient milk (Lawrence, 1994). Accurate information pertaining to possible

conaibuting fàctors of decreased milk supply, such as smoking (Hill and Aldag, 1996), cm be

discussed so mothers are informed of factors that are known to be linked to reduced milk supply.

If a mother is concemed, suggestions for enhancing milk supply rather than encouraging formula

supplementation are appropriate. Formula supplemenm tion is h o w n to interfere with

breasaeeding, and is a major conaibuting factor of early breastfeeding cessation (Canadian

Institute of Child Health, 1996; CPSiDietitians of Canada, Health Canada, 1998).


Confidence was not a predictor of breastfeeding duration in this sample. However, this

does not mean that confidence may not be a reliabie predictor of breasseeding cturation in other

sampies. The m e n t sample consisted of a fairly hornogenous group of mothers whose

confidence was most O ften rneasured later on in the postpartum period T herefore, the s trength of

the relationship between confidence and duration may have been minimized, as breastfeeding

confidence scores were not obtained at the time of birth, and the least amount of change in

breastfeeding confidence over time occurred in mothers whose infants were older at the rime of

their first drop-in visit Most mothers had infaats who were older than one month of age at their

first drop-in visit.

That breastfeeding confidence changes over t h e is promising because it suggests that

breastfeeding confidence might be amenable to prof~sional intervention. Health care

professionais may be able to positively influence breastfeeding confidence through intervention

strategies, such as support and teaching. Since breastfeeding confidence increased the most

among mothers who had Iower initial breastfeeding confidence and younger intants, these

mothers rnay be more amenable to professional intervention As the m e n t study indicated,

mothers with younger &ts had lower confidence. Therefore, the earlier the intervention by

health care professionals the greater the possible impact on breastfeeding confidence.

Bandwa's self-eficacy theory extends the current knowledge of the interrelationships

between breastfeeding support, confidence, and breastfeeding duration. The confidence a mother

feeis in her ability to breastfeed may not only influence whether or not she will start

breasdeeding, but may also influence how long she wiii persevere with breastfeeding in the face

of obstacles. This provides m e r evidence of the importance of health care professionals to

intervene early, and to pay particular attention to the issue of breastfeeding confidence both

prenatally and postnatally. It is acknowledged that, in this study, breastfeeding confidence was


not significaatly related to breastfeeding at six montbs, for various reasoos poss ibly attn'butd to

saxnple limitations. Clearly, hinher research is needed on this topic before health care

professionals can assess breastfeeding confidence in a clinical setting to identify mothers at risk

for stopping breasûeeding before six months.

Breastfeeding Drop-los are an excellent means of providing breastfeeding support for

mothers. Support groups offer munial support. ernpowerment of the individual affirmation and

developrnent of coping abilities, a social outlet, and a chance to leam alternate behaviours (Ryan,

1997). Some mothers who breastfed longer than four months and who were part of a study by

Health Canada (1995) mentioned attending a breastfeeding clinic was a practicai solution to

overcorning breasûeeding problems. As one mother exclaimed:

At the clinic, they explain to you that breastfeeding is really important and how

to actually do it. They obsenre you while you are breastfeeding, and give you advice on

holding the baby, the right or wrong positions, etc. They afso m a t you as an individual,

not just part of the herd (Health Canada, 1995, p. 62).

However, Breastfeeding Drop-ins are just one of the pieces of the 'support puzzle'. As

such, they are not expected to reach al1 rnothers, or satisQ ail mothers' needs and breastfeeding

problems. Several approaches may be needed to reach a large proportion of breastfeeding

mo thers. Nevertheless, as financial resources are increas ingly Iimited, considerable thought

should be given to targeting groups of breastfeeding mothers who are known to be at risk for

stopping breastfeeding early, such as single rnothers, teenaged mothers, and mothers living in

lower socio-economic circurostances. Older, well-educated, married and high-income rnothers are

likely to breastfeed for longer penods of rime in any circumstance (Maclean, 1998).


Lastly, health care professionals can be infïuential in increasing the social acceptability of

breastfeeding by educating the public about the health promotion benefits and cost-saving

benefits afTorded by breastfeeding. Breastfeeding offers short and long term benefits associated

with materna1 outcomes, as well as short and long-term infant outcomes in the area of physical

growth, cognitive development, and infant intelligence (Rogan & Gladden 1993). As Fredrickson

(1993) exclaims "Breastfeediig promotion lags 30 years behind smoking cessation.. ... [and we

do not have] the time or money to wait 30 more years to mimic the s low trajectory of smoking-

related research and policy changes for breastfeeding" @. 149).

Future Research Sumestions

The small sample size and the homogeneity of the sample limited the extent to which

conclusions could be drawn regarding the relationship between breastfeeding confidence and

duration Future research should examine whether or not different breastfeeding support services

appeal to breastfeeding mothers of different socio-dernographic characteristics, and to mothers in

different stages of the postpartum period

A more in-depth look is needed at intended duration, as this factor appears to be strongly

related to breastfeeding duration A longitudinal assessrnent of intended duration throughout the

prenatal and postnatal penod might shed some more light on this factor. Whether or not intended

duration changes over time and is amenable to professional intervention are questions that need to

be asked

Future research is also needed to examine breastfeeding confidence and intended duration

longihidinally from birth so that baseline scores of breastfeeding confidence are obtained. By

detennining baseiine scores one can then develop a more complete picture of the changes that

occur in breastfeeding confidence over time during the postpartum period Identwing the critical


penod where the greatest changes in breastfeeding confidence are seen may have important

implications for practice, as health care professionals could target this time for intensive health

teaching and support. By identifying the critical period of change, future research could also

examine the amount of change in breastfeeding confidence in relation to breastfeeding duration

As mothers in the current study had high breastfeeding confidence to begin with, littie change

was seen over time, and most mothers continued to breastfeed to inFant age of six months.

It is also recommended that hture research explore this relationship with a diverse

sample of breastfeeding mothers, as that was one of the Limitations of the current study. Such a

sample might best be obtained before mothers are discharged fiom the hospital to ensure more

vanability in socio-demographic characteristics. This study did not address ethnicity. Other

studies might consider this hctor as it pertains to breastfeeding confidence and chration

Conclusion

Seventy-six percent of mothers continued to breastfeed to infànt age of six months.

Breastfeeding confidence was not related to breastfeeding duration in this sample of mothers who

attended Breastfeeding Drop-Ins in Kingston, Ontario. Mothers who carne to the drop-ins

exhibited high breastfeeding confidence and tended to have older infànts at the tirne of their fust

visit. Mothers with older inEants were more Wely to be breastfeeding at six months than mothers

with infànts younger than two months. Controlling for infànt age, older mothers and rnothers who

intended to breastfeed longer were most tikely to be breastfeeding at six months. Breastfeeding

confidence increased over time for the majority of mothers. Mothers with younger i n h t s

experienced the largest increase in confidence. Viewing the concepts of breas tfeeding confidence,

behaviour, and duration of breastfeeding within the framework of Bandura's self-efficacy theory

extends our current understanding of these relationships.


Refer enc es

Allen, L., & Pelto, G. (1985). Research on determinans of breastfeeding duration:

Suggestions for bioculniral studies. Medical Amhropolow, 99- 105.

Band- A (1977). Social Learninn Theorv. Englewood Cliflk, NJ: Prentice-HalL Inc.

Banbura, A. (1997). Seif-efftcaw: The exercise of control. New York: W. H. Freeman

and Company,

Beaudry, M., & Aucoin-Larade, L. (1989). Who breastfeeds in New Brunswick: When

and why? Canadian Journal of hbiic Health 80, 166- 1 72.

Beaudry, M., Dufour, R, & Marcoux, S. (1995). Relation between infant feeding and

infections during the fmt six months of life. The Journal of Pediatrics. l26(2), 19 1 - 1 97.

Brent, N., Red& B., D w o r e ~ A., D'Arnica, F., & Greenberg, J. (1995). Breast-feeding in

a low-income population: Program to increase incidence and duration. Archivals of Pediatric and

Adolescent Medicine, 149, 798-803.

Bryant, C. (1982). The impact of k i q fkiend and neighbor nehlrorks on infant feeding

practices. Social Science and Medicine. 16, 1 757- 1765.

Buclmer, E., & Matsubara, M. (1993). Support network utilization by breastfeeding

mothers. Journal of Human Lactation. 9(4), 23 1-23 5.

Canadian Institute of Child Health ( 1996). National Breastfeeding Guidelines for Health

Care Providers. Ottawa: Canadian Institute of Child Health.

Canadian Paediatric SocietyDietitians of Canada/Health Canada. (1998). Nutrition for

Healthy Term Infants. Ottawa: Minister of Public Works and Government Services Canada.

Caplan, R. Robinson, E., French Jr. J., Caldwell, I., & Shinn, M. (1976). Adhering to

Medical Renimens: Pilot Emeriments in Patient Education and Social S u ~ ~ o r t . Ann Arbor, MI:

Institute for Social Research


Chomniak K.. & Hubay, S (1992). Peterborough CountyCity Health Unit - 1990

breastfeeding survey. Phero, 3(3), 34-3 6.

Cohen, J. (1 988). Statistical power analvsis for the behavioral sciences. Hillsdale. NJ:

Lawrence ErIbaum Associates.

Coreil J., Bryant, C., Westover. B., & Bailey, D, (1995). Health professionals and

breastfeedig counseling: Client and provider views. Journal of Human Lactation 1 I(42 265-

27 1.

Coreil, J., & Murphy, J. E. (1988). Matemal cornmitment, lactation practices. and

breastfeeding duration Journal of Obstetric. Gvnecological. and Neonatal Nursinn. 1 7, 273-278.

Cronenwec L., & Reinhardt, R (1987). Support and breastfeeding: A review. Birth. 14

(4), 199-202.

CrundaV 1.. & Foddy, M. (1981). Vicarious exposure to a task as a basis of evaluative

competence. Social Pmcholow Quarteriy. 44, 33 1-33 8.

Dignam, D. ( 1 995). Understanding intimacy as experienced by breastfeeding wornen

Health Care for Women International. 16,477-485.

Feinstein, J., Berkelhamer, J., Gniszka, M., Wong, C., & Carey, A. (1986). Factors

related to early termination of breast-feeding in an u r k n population, Pediaaics, 78(2), 2 10-2 15.

Ferris, A., McCabe, L., Allen, L., Pelto, G. (1987). Biological and sociocultural

determinants of successful lactation among women in eastem Connecticut. Journal of the

American Dietetic Association, 87(3), 3 16-32 1.

Ford, R, Taylor, B., Mitchell, E., Enright, S., Stewart, A., Becroft, D., Scragg, R.

Hassali, 1.. Barry, D., Allen, E., & Roberts, A. (1993). Breastfeeding and the risk of sudden infânt

death syndrome. Intemational Jouml of Epidemiolow. 22(5), 885-890.

Bras tfeeding Drop-In 1 02

Frank, D., Wirtz, S., Sorenson, J., & Heerm A. (1987). Commercial discharge packs and

breastfeeding counselling: E ffects on infant feeding practices in a randomised trial. Pediatrics. 80,

845-8 54.

Fredrickson, D. (1 993). Breastfeeding research prionties, opportunities, and study

criteria: What we leam from the smoking mil. Journal of Human Lactation 9(3), 147-150.

Galtry, J. (1997). Lactation and the iabor market: Breasneeding, labor market changes,

and public policy in the United States. Health Care for Women International, 18,467-480.

Goodine, L., & Fned, P. (1984). uifant feeding practices: Pre- and postnatal factors

af5ecting choice of method and the duration of breastfeeding. Canadian Journal of Public Health,

75,439-444.

Guiliver, S., Hughes, J., Solomon, L., & Dey, A. (1995). An investigation of self-

efficacy, pamer support and daily stresses as predictors of relapse to smoking in self-quitters.

Addiction. 90, 767-772.

Hanly, P., Laundry, B., & Madill, C., (1993). S w e y of breastfeeding practices of Perth

country mothers. Breastfeeding Survey Steering; Cornmittee, 1-22.

Health and Welfkre Canada. ( 199 1 ). Present patterns and trends in infànt feedina in

Canada. Ottawa, ON: Minister of Supply and Services Canada.

Health Canada. ( 1994). Survev of breastfeeding suDDort services in North America.

Ottawa, ON: Minister of Supply and Services Canada.

Health Canada. (1995). SN& of attitudes on breasdeeding. Ottawa, ON: Minister of

Supply and Services Canada.

Hellings, P. (1985). A discriminant mode1 to predict breast-feeding success. Western

Journal of Nursing Research 7(4), 47 1-478.

Breastfeeding Drop-In 1 O3

Hill P., & Aidag, J. (199 1). Potential indicators of insufficient milk supply syndrome.

Research in Nursing & Health, 14, 1 1 - 19.

Hill, P., & Aldag, J. (1996). Smoking and breasdeeding status. Research in Nursing &

Health. 19, 125-132.

Hill, P.. Humenick, S., Argubright, T., & Aldag, J. (1997). EfTects of par@ and weaning

practices on breastfeeding duration, Public Heaith Nursina 14(4), 227-234.

Hosmer, D., & Lemeshow, S. (1989). Amlied Logistic Regressioa New York: John

Wiley & Sons.

House, J. (198 1). Work Stress and Social Sumort. Medo Park CA: Addison-Wesley

Pubtishing, 24-26.

Houston, M., Howie, P., Cook, A,, & McNeilly. A, (1981). Do breastfeeding mothers get

the home support they need? Health Bulletin. 39, 166- 172.

Isaacs, S., & Litw& N. (1996). Wellington-Dufferin Guelph health unit breastfeeding

survey- November 1995. PHERO, 1 15- 1 17.

Isabella, P., & Isabella, R (1994). Correlates of successfut breastfeeding: A study of

social and personal factors. Journal of Human Lactation, 10(4), 257-264.

Izatt, S. (1997). Breastfeeding counseling by health care providers. Journal of Human

Lactation, l3(2), 109-1 13.

Jenner, S. (1988). The influence of additional information, advice and support on the

success of breast feeding in working class primiparas. Child: Care, Health and Develo~rnent. 14,

3 19-328.

Kaufman, K., & Hall, L. (1989). Influences of the social network on choice and duration

of breast-feeding in rnothers of preterm iufb.16. Research in Nursing and Heaith 12, 149- 159.

Breastfeeding Drop-ln IO4

Kearney, M. (1988). Identming psychological obstacles to breasfeeding success. Journal

of ObstetricaL GvnacologicaL and Neonatal Nursing March/A~riL 98-105.

Kingston, Frontenac, Lennox and Addington Health Unit. (1997). Infànt feedin~ survey.

Klonoff-Cohen, H., Edelstein, S., Schneider, E.. Srinivasan, 1.. Kaegi, D., Chang, J., &

WiIey, K. (1995). The effect of passive smoking and tobacco exposure through breast rnilk on

sudden infant death syndrome. Journal of the American Medical Association 273 ( 1 O), 795-798.

Lawrence, R (1994). A Guide For the Medical Profession. C. V. Mosby: St. Louis, 633-

645.

Lawson, KI, & Tulloch, M. 1. (1995). Breastfeeding duration: prenatal intentions and

postnatal practices. Journal of Advanced Nurs in~ 22,84 1-849.

Lee K., Perlman, M., Ballantyne, M., Elliott I., To, T. (1995). Association between

duration of neonatal hospital stay and readmission rate. Jounial of Pediatrics, 127, 758-766.

Locklin, M. P., & Naber, S. J. (1993). Does breastfeeding empower women? Insights

from a select group of educated low-income minority womea Birth. 20,30-35.

Loughlin, H., Clapp-Channing, N., Gehlbach S., Pollard, J.. & McCutchen, T. (1985).

Early termination of breast-feeding: IdentiQing those at risk Pediatrics. 75(3), 508-5 13.

Lucas, A., Fewîrell, M., Davies, P., Bishop, N., Clough, H., & Cole, T. (1997).

Breastfeeding and catch-up growth in infânts born small for gestational age. Acta Paediatrica 86,

564-569.

Lynch, S., Koch, A., Hislop. T., & Coldman, A. (1986). Evaluating the effect of a

breastfeeding consultant on the duration of breastfeeding. Canadian Journal of hiblic Health 77,

190-195.

Maclean, H. ( 1998). Breastfeeding in Canada: A demographic and experiential

perspective. Journal of the Canadian Dietetic Association, 59( 1 ), 1 5-23.

Martorell, R, and O'Gara, C. (1985). Breastfeeding, &nt health, and socioeconornic

status. Medical Anthro~ologv, Spring Issue, 173- 18 1.

Matthews. K., Webber. K., McKim, E., Banoub-Baddour, S., & Laryea, M. (1995). Intànt

feeding practices in Newfoundland and Labrador. Canadian Journal of Public Health 86(5), 296-

300.

McNan M., & Freston, C. (1992). Social support and lactation outcomes in postpartum

women. Journal of Human Lactation 8(2), 73-77.

Minde, K., Shosenberg, N., & Thompson, J. (1983). Self-help groups in a premature

nursery, inFant behavior and parental cornpetence one year later. In E. Galenson & J. Cal1 (Eds.),

Frontiers of Infant Psvchiatry, 264-271. New York: Basic Books.

Ministry of Indusûy. ( 1996). Growing up in Canada: National Lonp;itudinal S w e v of

Children and Youth. Ottawa: Ministry of Industry.

Morrow, L. (1 994). Breastfeedine: confidence and breastfeeding: duration Unpublished

Master's Thesis, University of Long Beach: California.

Morse, J. M. (1990). Initiating breastfeeding: A world survey of the timing of postpartum

feeding, InternationaI Journal of Nursing Studies, 27(3), 303-3 13.

O'Campo, P., Faden, R, Gielen, A., & Wang, M. (1992). Prenatal factors associated with

breastfeeding duration: Recommendations for prenatal interventions. BiRTH. 19(4), 195-20 1.

O'Leary Quinn, A., Koepseil, D., Haiier, S. (1997). Breastfeeding incidence after early

discharge and factors infïuencing breastfeeding cessation. Journal of ObstetricaL G~naecological,

and Neonatal Nursin~ 26(3), 289-297.


Ontario Ministry of Health. (1997). Mandatorv Health Promams and Services Guidelines.

Ottawa: Ministry of Health, Public Health Branch

Pastore, M., & Nelson, A. (1 997). A breastfeeding drop-in center survey evaluation

Journal of Huxnan Lactation 13(4). 29 1-298.

Polit, D. (1996). Data Analysis & Statistics for Nur s in~ Researck Appleton & Lange:

Connecticut.

Registered Nurses Association of Ontario. (1998, Winter). Policy statement: Shortened

length of obstetrical stay, Pednig; News, 14- 16.

Roberts, C., & Burke, S. (1989). Nursing; Research: A Ouantitative and Qualitative

A~uroach. Boston, MA: Jones and Bartlett PubIishers.

Rogan, W., & Gladen, B. ( 1993). Breast-feeding and cognitive development. Earlv

Human Development, 3 1, 18 1 - 193.

Rogers, C., Morris, S. & Taper, L. (1987). Weaning fiom the breast: Influences on

materna1 decisions. Pediamc Nursina 13(5), 341-345.

Ryan, K. (1997). The power of support groups: Influence on i n h t feeding trends in New

Zealand, Joumal of Human Lactation, 13(3), 183- 190.

Saunders S. & Carroll, J. ( 1988). Post-partum breastfeeding support: Impact on chration.

Journal of the American Dietetic Association. 88, 2 13-2 15.

Schlessleman, J. (1 982). Case-Control Studies: Desi= Conduct, Analvsis. New York

Oxford University Press.

Sigel S. (1956). Non~arametric Statistics for the Behaviorai Sciences. New York:

McGraw-Hill Book Company.

Sims-Jones, N., & Bowes, J. (1997). Evaluation of breastfeedinp; sup~ort droo-in clinics.

Ottawa Carlton Health Unit.


Simopoulos, A., & Grave, G. (1984). Factors associated with the choice and duration of

&t-feeding practice. Pediatrics (Supplement), 603-6 14.

Solway, K. (1992). W t feeding practices survey report. Red Deer Regional HeaIth

Unit: Alberta. -

S tefiuk, W. ( 1 997). The Saskatoon breastfeeding centre. Canadian Lactation Consultant

Association News. 1 1(3), 1-3.

Stewart, P., & Potter, J. (1 990). Parent child health survey. Parent Child Planning

Cornmittee: Ottawa-Carlton Health Department

Valaitis, R, Ciliska, D., Sheeshka, J., and Sword W. (1996). Surveying inFant feeding

practices. Canadian Nurse. 92(4), 2 1.

Watters, N., & Kristiansen, C. (1995). Two evaluations of cornbined mother-infant versus

separate postnatal nursing care. Research in Nursin~ & Health. 1 8, 1 7-26,

Wood, C., Isaacs, P., Jensen, M., & Hilton, H. (1988). Exclusively breastfed infants:

Growth and caloric intake. Pediatric Nursina 14(2), 1 17- 124.

World Health Organization (WHONnited Nations International C hildren's Emergency

Fund (LJNICEF). (1990). Innocenti declaration on the protectios promotion. and support of

breastfeeding. ln: Breastfeeding in the 1990's: A global Initiative meeting in Florence. Italv and

New York: UNICEF.


Appendix A

Program Evaluation of Breastfeeding DropIns: Information Sheet and Consent Form


Program Evaluation of Breastfeeding Droplns: Information Sheet and Consent Form

(Page 1 of 2)

Dear Participant

1 am a nurse working on a Master's degree at Queen's University. My research is with the Kingston, Frontenac, Lennox and Addington Health Unit. My project will find out if Breastfeeding Drop-Ins help the women who corne.

If you decide to take part in this research project, 1 witl ask you to fil1 out two surveys. This will take you about 15 mimites. The fint survey will ask questions about yourself and your breas tfeeding experience. The second survey wiil as k you about your breas tfeeding confidence.

I will telephone you 4-6 weeks fiom today to ask if you are still breastfeeding, how long you plan to breastfeed. about the support services you may have used and about your breastfeeding confidence. This should take about 10 minutes. When your baby is six months of age 1 will telephone you again to find out if you are still breastfeeding.

Participation in this raearch will benefit other breastfeeding women by allowing health care professionais to learn more about their needs. You do not have to take part in this study. Whether or not you take part, you are welcome at the Breastfeeding Drop-Ins. The care you receive will not be affected now or in the future. You may withdraw from this research at any t h e . even after signing the attached consent form

The answers you provide are private. No one but the research staff and 1 wilf have access to this information. Your name will not appear on any of the interview forms. OnIy a code number will be used Information will be stored in a locked cupboard at the Health Unit. Any reports about this study will discuss the experience of the women as a group, and no one will be able to identiw information collected from you.

The final results of this evaluation will appear in a sumrnary paper. You may contact me if you are interested in seeing a copy of this paper. If you have any questions or need more information please cal1 me. 1 rnay be reached Tuesday through Thursday at ( 1 -

ext. .

Lori Van Manen, M.Sc. Student 22 1 Portsmouth Avenue Kingston, Ontario K7M IV5

Further information about the study is availabt e korn:

Pam Carr, RN, MSc. Sharon Burke, RN, Ph.D. Manager, Health Promotion Division Professor, School of Nursing Kingston, Frontenac, Lainox and Addingtm Health Unit Queen's University 549- 1232 1-800-267-7875 545-6000 ext. 4744


Code #

Program Evaluation of Breastfeeding DropIns: Information Sheet and Consent Form

(Page 2 of 2)

1 have received a copy of the Program Evaluation of Breastfeeding Drop-Ins: Information

Sheet and understand it. I understand 1 wiIl be asked at my first &op-in visit to fil1 out two

surveys about rny breastfeeding experience and confidence. 1 am aware that Lori Van Manen will

telephone me 4-6 weeb from today and again when my baby is six month old to ask me about

my breastfeeding experience.

1 understand that my answers are private and 1 will not be identified personally in any

reports of this project. I also understand that I may refuse to be in this study without penalty. 1

may choose not to answer any part of the surveys, and 1 rnay withdraw from the study at any tirne.

1 am aware there are no known risks to participating in this study. 1 have been told that 1

can get a copy of the summary paper to review, at my request.

PARTICIPANT 1 agree to take part in the research:

(P Ieas e print y O w name) (Signature) (Date)

(Telephone Number)

In case you move or your number changes, is there a person I could talk to who could tell me how to reach you? Name of Contact Telep hone

1 have discussed the Program Evaluation of Breastfeeding Drop-Ins: Information Sheet and Consent Form with the participant, and beIieve that she understands the purpose of these documents and the information contained within them.

RESEARCHER

(Please print your name) (S igname) (Date)

This copy to mothas, yelIow copy to investigatar for files.

Breastfeeding Drop-In 1 I 1

Appendix B




Please circle the number that best fits p u r answer to the question. nere are no right or wrang answers.

Strongiy Neither Agree strongiy Question: Disigree Disagree Nor Disagree Agree Agree

1) 1 know how often 1 I 2 3 should breastfeed my baby.

2) I know how long I 1 2 3 should breastfeed my baby at each feeding.

3) 1 know how to attach 1 my baby to the breast.

4) I feel that my baby 1 is sucking correctly while breastfeeding.

5) At the end of a feeding, 1 know my baby is satisfied

6 ) I know how to hold my baby while bras tfeeding.

7) I feeI that I have enough instruction to breastfeed well at home.

8) I know where to get 1 help with bras tfeeàiig if I need it.

9) 1 think 1 c m breastfeed 1 my baby for as few or as many months as 1 want.

Strongiy Neither Agree Strongly Question: Disagree Disagree Nor Disagree Agree Agree

10) 1 believe my baby will 1 2 3 grow and gain enough weight while taking oniy breastmiik

1 1) 1 h o w that 1 am capable 1 of making enough milk for my baby to grow welL

12) If 1 experience any 1 nipple problerns, i will consider discontinuhg breas tfeeding.

1 feel embarrassed 1 about exposing my breasts during feedings.

My fnends support 1 my decision to breastfked

1 have known mothers 1 who have been success- hl wi th breastfeeding.

Strongiy Neither Agree Strongly Not Question: Disagr ee Disagree Nor Disagree Agree Agree Applicable

My partner feels 1 2 3 4 5 6 embanassed about me exposing my breasts during feedings.

My partner supports 1 2 3 4 5 6 my decision to breas tfeed

My mother supports 1 2 3 4 5 6 my decision to b r a s tfeed

(Adapted fiom Breastfeeding Confidence Scale by Lin& G. Morrow. 1994)

Appendix C

Breastfeeding DropIn Survey

Breastfeeding Drop-In Survey

1. When was your baby born? Day Month y=-

2. Have you breastfed any of your other children? Yes

- No (skip to question 5) Have never had any other children (skip to question 5)

3. What was the longwt penod of time you have breastfed any of your other chiidren? Less than one month 7-9 months 1-3 months 10- 12 months 4-6 months More than 12 months Other (Specify)

4. Overaü, on a scale from 1 to 5, with 1 being an unsatisfying experience and 5 being a satisfying experience, how would you describe your breastfeeding expenence with your previous child(ren)? (Please check)

5. How are you feeding your baby now?

full breastfeeding Bremt milk IS the main source of rnilk. Formula may be used but less than once a day.

partial breastfeeding Both breast milk & fonnula milk are used al least once a dw-

bottle feeding Infant fonnula i(s the main source of milk foryour baby. Breastmilk may be used but less fhan once a day.

6. Of this List of people, please check wbo bas helped you with breastfeeding this baby.

public health nurse - reading books, pamphIets - La Leche League - family - hospital staff - partner - (Not Applicable ) doctor - fiiends - other

7. Have you ever atteoded a prenatal class? y =

No


8. Are you presently working outside the home? Yes If <Y-, skip to question number 10 No

9. Are you planning to work outside of the home? Yes No

IO. How long are you planning to breastfeed your baby? Less than one month 7-9 rnonths 1-3 months 10- 12 months 4-6 months More than 12 months Other (Specis.)

1 1. At the present tirne, do you srnoke? daily occasionaIly not at al1

The next questions will provide information about women in different categories of age, education, living arrangements and incorne. This information will be used to mate an overall picture of the wornen who use the Breastfeeding Drop-in.

12. How old are you? Under 15 25-29 - 40-44 15-19 3 0-34 45 and over 20-24 35-39

13. What was the highest grade level you completed in school? less than grade 9 some high schoo 1 cornpleted high school some college/university completed college/university

14. Are you presently married or living in a common-taw relationship? Yes No

15. What are the sources of income in your household? (Check aiï that apply) fiill-time employ ment fimily welfare assistance part-time ernp loyment emp Ioyment insurance self-emp loyment Canada pension plan seasonal empioyment workers compensation general welfare assistance O ther (speciQ)

7'hank-you for taking the tirne tom out thk surwy.


Appendix D

Breastfeeding DropIn Sumey - Telephone Foilow-up

4-6 Weeks After Initial DropIn Visit


Date Site Code # yymmdd

Breastfeeding DropIn Survey - Telephone Foilow-up

4 4 Weeks After Initiai DropIn Visit

1. How are you feeding your baby now? ( h m #5 in BFDI Suv~y) *Re& List of Descrbtions

full breastfeeding B ~ I mük i s the main soume o/rnilk Formula may be used but less [han once a day.

partial breastfeeding Buth brerzst milk & fonnuIa m used at f m r once a day.

bottle feeding Infnt/onnufa is rhe main sourre of mifk for y u r baby Brecrrnnilk m-, be usad but less thun once a day.

a. If bottlefeeding:

How old was your baby when you stopped britastfeeding?

Why did p u stop brcastfccding?

2. Of this List of people, please t e 1 me who has helped you with breastfeeding this baby. (fiom # 6 in BFDI survey) *Read List

Public health nurse La Leche League Hospital staff Doctor

reading books, pamphlets W ~ Y - partner m o t App1icable-J fiiends other

{If not Breastfeeding skip to #4, and check NIA for #3) 3. How long are you planning to breastfeed your baby? (fiorn # 10 in BFDI survey)

Less than one month - 7-9 rnonths 1-3 months - 1 O- 12 months 4-6 months - More thân 12 months Other (SpeciQ) N/A (no longer breastfeeding)

4. How many Breastfeeding DropIns have you attended in this region so far? (Include f m t DI)

FIU OUT BREASTFEEDING CONFUIENCE SCALE - GREEN SHEET C ommen ts :

Appendix E

Breastfeeding DropIn Survey - Telephone Foliow-up Baby at Six Months of Age

Breastfeeding Drop-ln 1 20

Date- - - Site Code # yy mm dd

Breastfeeding DropIn Survey - Telephone Follow-up

Baby at Six Months of Age

1. How are you feeding your baby now? ( h m #5 in BFDI S w e y ) * R e d List of Dcscri~tions

full breastfeeding Breast milk is rite main soume ofmilR Fonnuia may be used bur less thon once a dq.

Borh breasr milR &jionnuia are used ar laarr once n d l .

Infinr fonnula is rhe main sourre of m i k for.rvur babv. Breasnniik may be used bur less than once a d q .

partial breastfeeding

bottle feeding

If bottlefeeding:

How oId was your baby whcn you stoppeci ixcascfctding?

Why did p u stop brcastfceding?

Of this List of people, please tell me who has helped you with breastfeeding this baby. (from # 6 in BFDI survey) * R a d List

Public health nurse La Leche League Hospital staff Doctor

reading books, pamphlets M ~ Y - partner (Not Applicable__) fiends other

3. How many Breastfeeding DropIns have you attended in this region so far? (Include fmt DI)

ïhank - p u for partic@aring in this study. nere will be no furrher relephone follo w-up calis.

Comments:


Appendix F

Logistic Regressioo Model Number 2: Excluding Infant Age from the Model


Mode1 2

A second model was developed which included only mothers with infànts two months of

age or younger (n = 20) to control for the possible bias introduced to the model by the fàctor of

h f b t age.

Four variables were entered in the initial model: extent of breastfeeding, smoking status,

initial BFC scores, and maternal age (Table 1 1). In the initial modei, none of the variables were

significantly correlated with breastfeeding at six months. Shce smoking status was the least

signiftcant predictor @ = .88), it was removed from the equation and maternal age was found to

be simcantIy related to breastfeeding at six months @ = .OS). in step 3 of the model (TabIe 1 l),

the independent variable (initiai BFC score) was removed fiom the equation. Matemal age

remained simant @ = .05). in step 4 of the modei, the next least significant predictor of

breastfeeding at six months, extent of breastfeeding, was eliminated fkom the equation

Matemal age comprised the b a t and final modei, accurately predicting 75% of mothers

who breastfed to six rnonths (Table 11). Thus, maternal age was the best predictor of

breastfeeding at six months for this sub-sample of breastfeeding mothers (n = 20) with infmts

two months of age or younger (odds ratio = 1.3; p = -04). As shown in Table 1 1. the overall

model was statistically signifcant; model A? ( 1. n = 20) = 5.63, p = .O 18. Results of this model

should be interpreted with caution, as power is likely to be sacxificed due to the small sample size.

The chance of committing a type II error is extremely high, and these results are not

generalizeable beyond this sample of breastfeeding mothers.


Model2: Logistic Regression Mode1 to Predict Breasneedinp: to Six Montbs Arnong Motfiers

With Younger Infànts (Exciuding I&t Age From the Lonistic Remession) (n = 20)

- -- - -- - - - -

Initiai Modei Stm 2 Stev 3 Finai Mode1

b SE P b SE p b SE p b SE p

Mat anal 31 .17 .O6 -32 -16 .O5 .32 .16 .O5 26 .13 -04 Age

Initial BFC 1.39 2.14 -5 1 1.46 2.07 .48 - - - - - - Score

C~mtant -25.69 11.22 .O2 -17.83 11.16 .11 -17.83 11.16 .20 -7.87 4.10 .O5

Mode1 Chi 8.06 Square

IMAGE WALUATION

APPLIED IMAGE. lnc - = 1653 East Main Street - -. - - Rochester. NY 14609 USA -- -- , -- Phone: 71 W482-0300 -- -- - - Fax: 716iZüû-5989

O 1993. Image. Inc.. NI Righis Resenied

van · dierdre waywell at the famiiy medicine centre, donna wood at the community midwives centre,...

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