Breastfeeding as a Nursing Issue and Research

Overview of Selected Evidenced-Based Practice Project

Evidence-based practice is an approach to health care that ensures the best possible outcomes for the patients. In its currently accepted form, the approach is founded on three core principles: the values and expectations of the patients, clinical expertise of the provider, and evidence from available academic sources. The three principles are combined using critical thinking with the ultimate goal of achieving the best result. It is important to understand that due to the constant involvement of the critical approach and assessment of the process, the approach also necessitates adjustments as soon as the need for change is identified in one of the three domains. For instance, if the selected intervention is evidenced to provide insufficient improvement, it would be reasonable to consider other options.

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Research is thus one of the crucial elements of evidence-based practice. The main reason for this is the inherent limitations of individual judgment. Both the field expertise of the clinician and the preferences of the patient are subject to cognitive biases and cannot serve as the ultimate determinant of the decision-making in healthcare (Grove, Burns, & Gray, 2015). On the other hand, the research conducted according to the academic standards eliminates the overwhelming majority of the said limitation and can thus be used to determine the objective value of the selected approach to the client.

The nursing issue selected for the project is the challenges experienced by mothers during the breastfeeding process. According to the consensus, the rates of initiation and continuation of breastfeeding in many high-income countries are inadequately low (Renfrew, McCormick, Wade, Quinn, & Dowswell, 2012). The negative impact of the issue is twofold. On the one hand, the mothers who do not possess enough knowledge to breastfeed successfully experience a range of problems that include physical pain, psychological discomfort, and undesirable social and cultural issues.

On the other hand, and, perhaps, more importantly, the lack of breastfeeding has an adverse impact on public health, including the behavioral issues and challenges in education for the children that were not breastfed (Ericson et al., 2013). While support and counseling of breastfeeding mothers have been considered effective in resolving the issue, it is necessary to obtain reliable data in support of these claims.

Application to Selected MSN Program Specialty Track

My MSN Program specialty track is Family Nurse Practitioner. The responsibilities pertinent to the specialty include diagnosis and management of the common health problems, promotion of healthy living, and education of individual patients and families. The diversity of care provided in the primary setting includes breastfeeding issues and constitutes a high probability of encountering the problem in my future practice. By that point, it would be beneficial to identify the components of the intervention that could be applied to the issue and evaluate their relative efficiency in order to estimate the patient outcomes.

Resolving the issue of insufficient breastfeeding initiation and continuation is expected to impact the advancing practice in my specialty tracks in two major areas. First, the confirmation of the effectiveness of the suggested approach would likely impact the choice of strategies available to the nurses for supporting breastfeeding mothers.

The breastfeeding support phone line is a highly specialized area and requires allocation of resources and equipment for successful functioning. In order to obtain the necessary administrative support to introduce the practice, it is required to provide robust evidence of its efficiency in accordance with the principles of evidence-based practice. Second, the positive outcome of the project is expected to have numerous indirect effects. One of these is the overall improvement in the health of the patients, including the relief of issues such as breast pain and breast engorgement.

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By extension, the exhaustion and stress related to the problem will be decreased. Finally, a positive impact on child health can be expected, accompanied by respective improvements in behavior and academic performance. The combined effect of the said impacts will decrease the load on nursing practitioners, which is extremely important considering the constantly growing population and an increasing proportion of aging patients. Thus, the issue is directly related to my specialty track.

Nursing Issue and Supportive Evidence Regarding the Issue

Breastfeeding is an important part of the child’s development cycle, bearing multiple short- and long-term effects on their health as well as the health of the mothers. The areas of impact include child mortality, prevention of a number of gastrointestinal and respiratory diseases, childhood obesity and diabetes in children as well as the increased risk of breast cancer and cardiovascular disease in adults (Forster et al., 2014).

While the magnitude of the adverse impacts varies depending on several factors such as socioeconomic status, it is safe to conclude that the effects of not breastfeeding are universally negative across different population groups (Colen & Ramey, 2014).

It is also important to understand that the issue of not breastfeeding bears significant considerations from the economic standpoint, primarily due to the high cost of care for the mothers and children who develop chronic conditions associated with the issue. Importantly, the lack of breastfeeding success cannot be attributed solely to the individual decision of the mother as it is strongly dependent on previous experience and available knowledge on the matter. As such, it is reasonable to expect that sufficient support provided to women will aid them in the initiation and continuation of the practice.

The issue is relatively common in the selected practice setting. According to the data provided by CDC, only twelve states have met the objectives set for breastfeeding as a part of the Healthy People 2020 initiative (CDC, 2016). The most significant discrepancy is observed in the infants of six months or younger, where the current rate is just below fifty-two percent as opposed to the sixty percent set as a target (CDC, 2016).

The difference is reduced with each subsequent age group, but several areas are still behind schedule in meeting the goals. It is also important to remember that the stated proportion is an aggregated result and that different states demonstrate varying results. It is also notable that the rates for breastfeeding after six months are universally lower, which suggests that mothers discontinue the practice despite the successful initiation. It is, therefore, possible to characterize the issue as relatively frequent in the practice area in question.

According to Renfrew et al. (2012), education is a crucial factor that determines breastfeeding success. Specifically, the greatest percentage of mothers that were breastfeeding received better health education and support compared to those that received no support at all (Renfrew et al., 2012). The accessibility to educational resources and counseling provided by the healthcare organizations was considered another important determinant of success with a positive correlation between the resources present within the community and the rates of breastfeeding continuation (Renfrew et al., 2012).

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Admittedly, support is a broad category that commonly includes delivery by a qualified nursing practitioner, the involvement of community organizations, one-on-one consultations, and dedicated educational events. Therefore, it would be reasonable to limit the scope of the project to proactive telephone support. One of the reasons behind this particular choice is the negative correlation between socioeconomic status and breastfeeding success where the disadvantaged women tend to terminate the practice earlier (Renfrew et al., 2012).

Telephone-based consultations do not pose challenges in terms of financial accessibility, and their delivery can be adjusted to the time restrictions that commonly prevent mothers from engaging in other activities (e.g. community meetings). Therefore, it is reasonable to expect higher population involvement in response to the selected intervention.

The two main stakeholders involved are the breastfeeding mothers and the nursing practitioners. The former are impacted directly by experiencing a range of physical, psychological, and social issues identified above and indirectly – by experiencing the health and behavioral disorders associated with discontinuation in the long run. The latter receive greater workload as a direct result of the issue and are required to provide extended care to mitigate the associated problems such as chronic conditions.

Other stakeholders include healthcare organizations that face administrative issues resulting mostly from the long-term outcomes of the problem as well as additional expenses and families of the impacted individuals who are strained both financially and emotionally by the negative health outcomes. Finally, educational organizations are impacted by the long-term outcomes of the issue, such as the declined academic performance and disrupted behavior (Ericson et al., 2013).

The successful implementation of the project is expected to clarify the effectiveness of the proposed support method and determine its applicability to nursing practice. As a result, it is reasonable to expect an increase in the number of breastfeeding mothers and, by extension, the decrease of the adverse public health effects associated with it. In addition, the decrease in expenses associated with additional care, overall improvement of patient outcomes, and the minimization of excessive workload among nurses can be expected.

Evidence-Based Practice Question

In accordance with the information presented in the previous section, the following components of the PICOT are proposed.

For the post-partum mother, would post-discharge breastfeeding support phone calls increase the likelihood of breastfeeding success versus mothers receiving no post-discharge support phone call at six-week post-partum?

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Where the population is post-partum mothers, the proposed intervention is breastfeeding support phone calls, a comparison is a group receiving no post-discharge support phone calls, the outcome is an increase of breastfeeding success, and the time for the project is six weeks.

Research Literature Support

The findings of the article by Borra, Iacovou, and Sevilla (2015) showed a very weak correlation between the distressed states of women suffering from postpartum depression and their breastfeeding patterns and activities. Regardless of the large size of the sample, the findings did not show any significant connections. Carlsen et al. (2013) studied breastfeeding behaviors in a sample of obese mothers and found that the length of breastfeeding did not affect the growth of infants but was in correlation with their initial size.

Additionally, the researchers noted that the group that received support using telephone calls continued to breastfeed for longer periods than the control group that was given no such support. Figueiredo, Canário, and Field (2014) studied the impact of breastfeeding on the prevalence of postpartum depression. The findings of this research indicated a correlation between the length of the breastfeeding period and the rates of depression in mothers. In particular, it was detected that the women who continued breastfeeding for longer than three months postpartum also experienced a significant decrease in the magnitude of depression.

In another related research, Hatamleh (2012) focused on the increase of breastfeeding period among low-income mothers. A prenatal breastfeeding intervention was found to be effective for the increase in the length of the breastfeeding period. Papathanasiou, Sklavou, and Kourkouta (2013) relied on the adaptation approach to develop a deeper understanding of women’s reaction to postpartum changes. This framework is suitable for the research because it allows studying and understanding the behaviors of participants from a psychological perspective. Mitchell (2013) described a change theory developed by Lewin that is suitable for the practical aspects of the research implementation as it breaks down the process into three major steps – unfreezing, moving, and refreezing.

Pope and Mazmanian (2016) explored the relationship between postpartum depression and the duration, dose, intention, and initiation of breastfeeding. The researchers overviewed multiple articles using diverse methodologies and recommended that a set of standardized measuring protocols is created for the collection of transferrable and reusable data and that the variables used to measure and define breastfeeding are operationalized. Jain, Tyagi, Kaur, Puliyel, and Sreenivas (2014) attempted to detect connections between the birther of girls, postnatal depression, and exclusive breastfeeding.

The prevalence and levels of depression in women were measured using the Edinburgh Postnatal Depression Scale (EDPS). The authors found that the women with higher scores of depression were less likely to breastfeed within the first 48 hours postpartum. Additionally, male infants were exclusively breastfed within the first 48 hours of life in a significantly greater number of cases than female ones. Abuchaim, Caldeira, Lucca, Varela, and Silva (2016) attempted to find relevance between maternal self-efficacy for breastfeeding and postpartum depression. The researchers found that a high score on depression among the participating mothers was strongly associated with a reduced breastfeeding self-efficacy score.

At the same time, the findings also showed that medium and high self-efficacy scores in breastfeeding women led to the reduction of depression scores by over 27 and over 38 percent respectively. Brown, Rance, and Bennett (2016) researched the role of pain and psychical discomfort in the correlation between postnatal depression and breastfeeding. The researchers attempted to find whether physical difficulties in breastfeeding that arere-linked to the prevalence of postnatal depression come before or after the diagnosis. The authors found a significant correlation between the increase in depression scores and the discontinuation of breastfeeding due to pain that is followed.

It is important to note that many of the overviewed works used EDPS for the purpose of measuring the scores of postnatal depression in women, and thus managed to collect standardized sets of data that can be used for further research in the field. Ahn and Corwin (2015) researched the issue of correlation between breastfeeding patterns and postnatal depression and found to visible correlation based on a self-report; however, it was noticed that the group of women who primarily breastfed had a lower level of salivary cortisol in the morning than the group of women who primarily bottle-fed their infants. Sharma and Sharma (2012) provided a theoretical exploration of postpartum depression, its causes, and outcomes.

The authors noted that postpartum depression is difficult to diagnose and treat. It is critical to focus on its signs and attempt to prevent its aggravation and development because it is associated with some comorbid risk factors. Gulamani, Premji, Kanji, and Azam (2013) explored the phenomenon of postpartum depression and the factors that can contribute to its prevalence in order to understand the condition better and identify the influences that need to be voided or minimized. The authors are in agreement with Sharma and Sharma (2012) and stated that regardless of the devastating effects of the condition, it is difficult to detect.

Kao, Johnson, Todorova, and Zlotnick (2015) researched the influence of a group intervention as a method of helping to prevent postpartum depression. The researchers found that the women who undertook the intervention demonstrated a long commitment to breastfeeding even though the breastfeeding initiation rates were similar in both intervention and control groups. Montgomery-Downs, Stremler, and Insana (2013) linked new mothers’ decision to breastfeed as a significant factor that impacts their sleeping patterns and can contribute to sleep deprivation which, in turn, may lead to aggravation or development of postnatal depression.

In that way, it can be concluded that the relationship between breastfeeding (including its dose, length, initiation, and intention) and postnatal depression is very complex and can be interconnected with a variety of additional factors. Researching the association between exclusive breastfeeding and postpartum depression, Silva et al. (2017) found that postpartum depression resulted in the decreased practice of exclusive breastfeeding and concluded that due to this condition and its dangers, early postnatal support needs to be included in care programs. Interestingly, the authors of the overviewed articles found a mutual connection between the rates of breastfeeding and the prevalence of postnatal depression.

Practically, the lack of breastfeeding may lead to the aggravation of postnatal depression and, at the same time, postnatal depression may cause a decrease in the intention to breastfeed. As a result, the decision to continue to breastfeed is likely to produce a significant positive impact on new mothers, and thus it should be supported by the providers of early postnatal care.

Research Approach

The proposed research will be focused on the initiation and stimulation of breastfeeding in new mothers who have been discharged from hospitals. The intervention intended to stimulate breastfeeding intention in women will be delivered in the form of telephone communication between the providers of postnatal care and the new mothers for the purpose of the provision of support to the latter so they could continue breastfeeding. The intervention is expected to last for six weeks.

The proposed research approach will be of qualitative nature. It will aim to collect qualitative data from the participating new mothers regarding their attitudes to breastfeeding, as well as the levels of self-efficacy of their breastfeeding practices. The phenomenological design will be selected for this study. This type of research design is focused on the collection of subjective data from the participants for the purpose of analyzing the nature and development of the researched phenomenon or connection. In the case of the present research, the issue in focus covers breastfeeding success among new mothers who are receiving support from the providers of postnatal care using telephone communication.

The subjective experiences recorded with the help of phenomenological design will allow understanding the participants’ perceptions of the intervention and understand its effects. The rationale for the selected design is based on the need to study the effects of the selected form of intervention on the participants’ behaviors regarding breastfeeding. It is hypothesized that the intervention will stimulate the breastfeeding intention in the participating women and lead to a more successful rate of breastfeeding in the intervention group compared to the control group.

The main advantage of the selected design is its focus on the collection of subjective data providing precise a description of the participants’ attitudes towards the intervention and the effects it has on them. At the same time, the subjective data will also serve as one of the main disadvantages of the selected design because there exists the potential for the participants to provide biased, incomplete, or altered information which would not reflect the trust, and thus would undermine the reliability and validity of the research findings.

Sampling

The target population of the proposed study includes new mothers who have been discharged from hospitals. Probability sampling giving all members of the target population an equal opportunity to be selected as participants will be used for the study. The sample will be selected from the population of the recently discharged new mothers from one or two hospitals in a specific geographic area.

The women will be approached by their care providers and informed about the research and the intervention. Informed consent will be received from each of the participants prior to their inclusion in the sample; also, all of them will be assured that they are guaranteed to have full confidentiality and anonymity for their protection and safety. Further, the sample will be randomly divided into two equal groups – control and intervention.

The first disadvantage of the selected sampling procedure will be likely to limit the sample to a small size making it under-representative. The second disadvantage is that some women may express the desire to be included in the intervention group thus disrupting the random division into control and intervention groups. The advantages include, first, the small sample which will make the collection of data faster and reduce costs of the study; and, second, the opportunity for researchers to focus on each participant’s subjective experience more thoroughly and collect more accurate data.

Conclusion

Breastfeeding behaviors of new mothers are affected by a variety of factors and can be disrupted causing the development of aggravation of postnatal depression. Because of the potential dangers and diverse effects that can be inflicted by the disruption of breastfeeding, mothers and infants are potentially at risk. As a result, supportive measures should be taken in order to help the women cope with the problem. A supportive post-discharge intervention for breastfeeding based on telephone communication is proposed. Its effectiveness and impact will be researched with the help of a phenomenological qualitative study targeting the perceptions and experiences of the participating women.

References

Abuchaim, E., Caldeira, N., Lucca, M., Varela, M., & Silva, I. (2016). Postpartum depression and maternal self-efficacy for breastfeeding: Prevalence and association. Acta Paulista de Enfermagem, 29(6), 664-70.

Ahn, S., & Corwin, E. (2015). The association between breastfeeding, the stress response, inflammation, and postpartum depression during the postpartum period: Prospective cohort study. International Journal of Nursing Studies, 52(10), 1582-1590.

Borra, C., Iacovou, M., & Sevilla, A. (2015). New evidence on breastfeeding and postpartum depression: The importance of understanding women’s intentions. Maternal and Child Health Journal, 19(4), 897-907.

Brown, A., Rance, J., & Bennett, P. (2016). Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing, 72(2), 273-282.

Carlsen, E. M., Kyhnaeb, A., Renault, K. M., Cortes, D., Michaelsen, K. F., & Pryds, O. (2013). Telephone-based support prolongs breastfeeding duration in obese women: A randomized trial. The American Journal of Clinical Nutrition, 98(5), 1226-1232.

CDC. (2016). Breastfeeding report card. Web.

Colen, C. G., & Ramey, D. M. (2014). Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States using sibling comparisons. Social Science & Medicine, 109, 55-65.

Ericson, J., Eriksson, M., Hellström-Westas, L., Hagberg, L., Hoddinott, P., & Flacking, R. (2013). The effectiveness of proactive telephone support provided to breastfeeding mothers of preterm infants: Study protocol for a randomized controlled trial. BMC Pediatrics, 13(1), 73-82.

Figueiredo, B., Canário, C., & Field, T. (2014). Breastfeeding is negatively affected by prenatal depression and reduces postpartum depression. Psychological Medicine, 44(5), 927-936.

Forster, D. A., McLachlan, H. L., Davey, M. A., Amir, L. H., Gold, L., Small, R…. McLardie-Hore, F. E. (2014). Ringing up about breastfeeding: A randomized controlled trial exploring early telephone peer support for breastfeeding (RUBY)–trial protocol. BMC pregnancy and childbirth, 14(1), 177-186.

Grove, S. K., Burns, N., & Gray, J. (2015). Understanding nursing research: Building an evidence-based practice (6th ed.). St Louis, MO: Elsevier Health Sciences.

Gulamani, S., Premji, S., Kanji, Z., & Azam, S. (2013). A review of postpartum depression, preterm birth, and culture. The Journal of Perinatal & Neonatal Nursing, 27(1), 52-59.

Hatamleh, W. (2012). Prenatal breastfeeding intervention program to increase breastfeeding duration among low income women. Health, 4(3), 143-149.

Jain, A., Tyagi, P., Kaur, P., Puliyel, J., & Sreenivas, V. (2014). Association of birth of girls with postnatal depression and exclusive breastfeeding: An observational study. BMJ Open, 4, 1-6.

Kao, J., Johnson, J., Todorova, R., & Zlotnick, C. (2015). The positive effect of a group intervention to reduce postpartum depression on breastfeeding outcomes in low-income women. International Journal of Group Psychotherapy, 65(3), 445-458.

Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20(1), 32-37.

Montgomery-Downs, H., Stremler, R., & P. Insana, S. (2013). Postpartum sleep in new mothers and fathers. The Open Sleep Journal, 6(1), 87-97.

Papathanasiou, I., Sklavou, M., & Kourkouta, L. (2013). Holistic nursing care: Theories and perspectives. American Journal of Nursing Science, 2(1), 1-5.

Pope, C. J., & Mazmanian, D. (2016). Breastfeeding and postpartum depression: An overview and methodological recommendations for future research. Depression Research and Treatment, 2016, 1-11.

Renfrew, M. J., McCormick, F. M., Wade, A., Quinn, B., & Dowswell, T. (2012). Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Systematic Review, 5(5), 1-142.

Sharma, V., & Sharma, P. (2012). Postpartum depression: Diagnostic and treatment issues. Journal of Obstetrics and Gynaecology Canada, 34(5), 436-442.

Silva, C., Lima, M., Sequeira-de-Andrade, L., Oliveira, J., Monteiro, J., & Lima, N., … Lira, P. I. (2017). Association between postpartum depression and the practice of exclusive breastfeeding in the first three months of life. Jornal De Pediatria, 93(4), 356-364.

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