Challenging Dogma - Spring 2009

Thursday, May 7, 2009

Prenatal Breastfeeding Education: An Examination of Why Education Does Not Work In All Circumstances and a Proposed Intervention -Michelle O’Brien

As a maternal child health care provider and a public health practitioner, I am very interested in interventions aimed at increasing breastfeeding rates and longevity. At Boston Medical Center, a Baby Friendly hospital, we have many different interventions intended to impact breastfeeding rates. The Department of Pediatrics’ Adolescent Health Center Teen and Tot Program offers prenatal education classes for pregnant teenagers. The prenatal classes consist of a two hour session, once a week for ten weeks. The classes cover many important topics such as mind and body changes during pregnancy, common complications of pregnancy, family planning, child development, and newborn care. Breastfeeding is covered in one session, along with maternal nutrition, in the third week. The focus of the breastfeeding portion of the session is on the reasons to breastfeed, nutritional information about breastfeeding and resources to help with breastfeeding. There is no further mention of breastfeeding in the remaining seven weeks of classes. This is typical of most prenatal education classes as there is a lot to be covered in a short amount of time.
I will critique this intervention by focusing on the three most common mistakes made by healthcare professionals and health educators when creating and teaching prenatal breastfeeding education; over-reliance on the Health Belief Model, lack of focus on the needs of the intended audience and poor timing of the intervention.
Concept #1 - The Health Belief Model: “Breast is Best”
Many interventions in modern, Western medicine have a basis in the Health Belief Model. Doctors and other healthcare professionals use facts and data as the foundation of all that they do during their training years. They learn to trust knowledge and feel safe within the constructs of the Health Belief Model. Therefore, many of their interventions are linked to this model. However, there are many flaws with this theory, particularly when applied to the choice to breastfeed or formula feed.
Irrational behavior
The Health Belief Model is anchored in the belief that when presented with information about a desired behavior, the target audience will weigh the risks and benefits of adopting that behavior and make a rational choice. This has been proven to be untrue when applied to decision making regarding infant feeding (breast vs. formula). When questioned about the benefits of breast milk over formula, most women acknowledge the superiority of human milk over formula (1, 2). When asked specifically about the benefits of breast milk, the women are able to identify that breast milk has nutritional benefits over formula, that it can protect babies against disease, that breast milk is involved in both physical and psychological development of the child and that the act of breastfeeding creates a special bond between mother and child (1). In a study examining the reasons for infant feeding choices, this was true of both formula feeding and breastfeeding mothers. Women that had chosen to bottle feed acknowledged the advantages of breast milk over formula, although overall the difference between their ratings of breast milk over formula were smaller than for breastfeeding mothers (1). When looking at the decision making based on this information alone, it seems that prenatal education has been successful in educating the mothers on the benefits of breastfeeding but that this was not influential in the decision making in a large number of women. Another strategy used within the Health Belief Model when persuading women to breastfeed is an economic argument. Formula is very expensive when compared to breast milk. In the same study, women acknowledged the higher cost of formula but in women that chose to formula feed, the cost was not influential in their decision making (1). This is even more striking when you realize that the women sampled in this study were primarily low-income. One might even say it seems a bit irrational.
We are not all the same
Prenatal education as an intervention for breastfeeding assumes that all women will seek out information on breastfeeding. A sociodemographic difference in the women who attend childbirth preparation or prenatal education courses (3) has an impact on the overall effectiveness of this particular intervention, with poor minority women less likely to enroll in classes. For the women who do attend classes, use of the Health Belief Model assumes that they are all at the same level of education, have the same values and beliefs as each other and the health care providers and have the same support systems in place. Many prenatal education courses also assume that the baby is central to the decision regarding feeding methods. Research studies show that this is often not the case. There are other factors that supersede the needs of the baby; including perceived convenience of formula feeding over breastfeeding, feeling “tied down” with breastfeeding and pressures from family, significant others and friends to allow them to help feed the baby (1-2, 4). Women who are working or in school may not feel they have the time or a place to breastfeed or pump (1, 5). All these factors contribute to women rejecting the “facts” that they learn in the classes in making their infant feeding decisions.
Concept #2 - Know your audience: The teen mother
There are many studies that show that adolescents learn differently than adults and that their decision-making capacity is influenced by much different factors. In reference to breastfeeding, it is well known that teenagers are least likely to initiate breastfeeding and more likely to discontinue early (2, 4, 6-10). So breastfeeding interventions geared towards adolescents need to focus on the special needs and characteristics of their target audience.
Learning is boring
Most adolescent mothers are not interested in didactic education sessions. In order to keep their interest and attention, the educator needs to be creative. A program in Florida (11) utilized games to teach the adolescents about breastfeeding; a word search with common breastfeeding terms, “condom breasts” to demonstrate latch while also addressing safe sex issues, Breastfeeding Bingo and group activities such as “You Solve It” and Baby Boob Jeopardy. This adolescent-focused intervention showed a significant increase in breastfeeding initiation (65.1%) in comparison to girls who received “standard” breastfeeding education (14.6%). The typical prenatal education class is similar to a health class lecture. The teacher or educator imparts knowledge to the learner (adolescent mother) and allows time for questions at the end. More interactive learning is ideal in this age group particularly when addressing subjects that can be identified as embarrassing.
It’s Embarrassing
Adolescent mothers are more likely to cite embarrassment as the primary reason for not breastfeeding (2, 4). Prenatal education classes infrequently address the issues faced by adolescent mothers who are just becoming comfortable with the changes in their maturing bodies but do not yet have the mental maturity to assimilate breastfeeding and the purpose of breasts in infant feeding with their daily lives. When you add in the cultural context of sexuality and breasts found in this country (12), it is often too much for an immature mind to process without the proper support and guidance.
‘They” Don’t Want Me To
Not surprisingly, adolescent mothers are much more sensitive to the viewpoints of the people closest to them when making their infant feeding choices. The teens’ mothers are often the most influential in their decisions regarding infant feeding (2, 4) even if they don’t have a good relationship with their mother (2). Since most adolescent mothers still live with their parents, the maternal grandmother (of the infant) will shape her daughter’s decision based on her own experiences with breastfeeding and how involved she is with the care of the infant (ie Is she taking the “mother” role?) (2). If the mother’s mother will be assuming a large portion of the care duties (for instance, when the mother returns to school) she may be more likely to discourage the mother from breastfeeding so she can easily feed the infant with a bottle. The father of the baby also has significant influence on the decision of feeding method (2, 4). He may feel left out if the mother exclusively breastfeeds or may attach a sexual connotation to her breasts. A single two hour class on breastfeeding cannot even begin to address the influences of the mother (of the teen mother) and the father of the baby nor include them in any meaningful dialogue. As is common in individual based public health interventions, prenatal education classes do not always consider the greater context of the relationships and environment that the intended audience lives and works within.
Concept #3 - Timing is everything: Too little, too late
Finally, this intervention does not take into account the time needed to make a decision as complex as whether or not to breastfeed. A single two hour class does not do justice to the multitude of factors that play a part in each individual woman’s decision making process. As has been addressed in previous sections of this paper, pregnant teens are faced with many competing factors as well as dealing with pregnancy and impending motherhood. If an intervention truly intends to increase breastfeeding initiation, it needs to be more of a continuous ongoing intervention.
Most prenatal education classes take place in the seventh to eighth months of pregnancy. Studies have shown that in order to be effective breastfeeding interventions need to start much earlier (4, 11), perhaps even in schools before the teens are even pregnant (11). Breastfeeding presented in health class as a natural, normal way to feed your baby begins to lay the foundation for a different societal view of breastfeeding.
In summary, the Adolescent Center’s prenatal breastfeeding education intervention is less than ideal for many reasons. As demonstrated by the evidence cited, the decision whether to breastfeed or not is usually not a rational decision. Use of the Health Belief Model in breastfeeding promotion is misguided as it is in most public health intervention. Despite the fact the critiqued program is occurring within an Adolescent Center, they fail to consider the special needs of their population when approaching breastfeeding promotion. Innovative teaching methods are necessary to get the attention of the adolescent mind and the support people (mother, partner) need to be more integrated into the intervention beyond “inviting” them to attend classes. More thought should be put into the timing of breastfeeding interventions and collaborative efforts with the school systems should be explored.
A potential intervention that addresses the weaknesses of the Adolescent Center’s prenatal breastfeeding education class is one that I proposed in MC820 Planning and Program Development in Maternal and Child Health. This intervention combines several models of public health and healthcare interventions. The cornerstone of the intervention is an innovative model for prenatal care called CenteringPregnancy®. Developed by Sharon Schindler Rising, CNM, CenteringPregnancy® is group prenatal care which utilizes the power of self-empowerment and community to increase patient satisfaction, improve perinatal outcomes and increase breastfeeding rates (13, 14). A group of 10-12 women with similar due dates receive all their prenatal care in a group that is consistent throughout the nine months. Together the women teach and learn from each other, with guidance from a trained medical professional.
My intervention adds a hands-on breastfeeding education component to CenteringPregnancy® that starts at the very beginning of prenatal care, occurs at each visit and happens in the group setting. This breastfeeding education allows women to practice breastfeeding techniques with life size dolls and cloth breast models, visualize the size of a newborn’s stomach and discuss what to expect in the first couple days to weeks of breastfeeding. While there would be some teaching about the benefits of breast milk and why it is the ideal nutrition for newborns, this would not be the core of the breastfeeding education curriculum. A certified lactation consultant would participate in the design of the curriculum and would help the health care providers in demonstrating and problem solving with the women.
Previously, I discussed some of the limitations of other breastfeeding promotion interventions. This intervention directly addresses the weaknesses of the previous model; over-reliance on the Health Belief Model, lack of focus on the needs of the intended audience and poor timing of the intervention.
Concept #1 Redo - The Health Belief Model: “Breast is Best”
A skill based, hands on intervention does not rely on the concepts of the Health Belief Model. The Health Belief Model relies on presenting the target subject(s) with information and facts and trusting that these subjects will make rational decisions based on this information. The proposed intervention allows for the practice of techniques with props, while in a group setting where they can watch other women doing the same and learning from each other about what does and does not work. It gives women practical skills, not just facts. There is not so much a process of weighing the risks and benefits of the information gained as the achievement of skills that may or may not be utilized depending on the woman’s intentions regarding breastfeeding. By allowing the women to practice and consider the implications of breastfeeding beyond nutrition for the baby, it makes it more concrete and allows them to make a decision that works best for them. This type of learning has been found to be effective in several studies (15-18). And while this does have some foundation in Bandura’s Social Cognitive Theory (19), the limitations of this model are mitigated by the second portion of the intervention, the Centering® model.
The CenteringPregnancy® portion of the intervention uses social network theory. Social network theory describes the power that a group that is tied to each other in a social manner can influence and affect behavior of individuals in the group. By sharing an important time in their life with other women going through the same experience, the women involved in Centering® form strong relationships within the social network of the group. The healthcare provider participates as a member of the group, facilitating but not leading discussion or lecturing. So often the “answers” or proposed behavior changes are suggested by other members of the group and not necessarily by the authority figure of the healthcare provider. The type of group care in a Centering model is also contrary to the Health Belief Model because it is not a one size fits all approach. The conduct within the group is centered on every participant having an equal say, and while the care is done in a group, it is individualized for each woman. My proposed intervention would build on that. While the activities presented would be similar, each woman could choose to focus on what is most important to her and her needs.
Concept #2 Redo - Know your audience: The teen mother
Teenagers would be the ideal group of women for this intervention. First of all the hands-on, practical aspects of the intervention would appeal to many adolescents. It is often embarrassing for young women to talk about breasts, due to the sexualization of the breasts by our society. By getting comfortable with the cloth breasts and the baby models, teenage mothers are more likely to feel a little less embarrassed and self-conscious about trying breastfeeding when the time comes. As mentioned previously, it has been found that adolescents learn better when the information is presented in a creative or interactive way (11).
CenteringPregnancy® has been found to be very effective with adolescents (14). The model is aimed at empowering the women to take control of their health care and their bodies by allowing them to be actively involved in self care and other healthcare activities. This empowerment helps adolescent mothers have confidence in their decisions for themselves and their babies. The influence of the adolescent’s mother or the father of the baby on the young mother’s feeding decision lessens when she feels that she has control over her body and health. Many CenteringPregnancy® groups include support people in each session so they have the opportunity to hear the same information, hear what other fathers or grandmothers are saying about breastfeeding and bottle feeding.
The Centering® model has some elements of diffusion of innovation theory. Teens are very much influenced by leaders or innovators. Often they follow or imitate unhealthy or destructive behaviors. With CenteringPregnancy®, these young women see that it can be “cool” to take care of your body, to have respect for yourself and the decisions you make.
Concept #3 Redo - Timing is everything: Too little, too late
The proposed intervention would begin early in pregnancy. It would be a component of each group prenatal visit. Early introduction of breastfeeding interventions and support has been shown to be effective (4,11). By using the ideas presented in framing theory, breastfeeding preparation is reframed to become a part of normal prenatal care. By addressing breastfeeding and breastfeeding preparation at each prenatal visit, the concept becomes as normal and routine as a weight or blood pressure check. Because of the marketing of formula and even promotion of formula feeding by health care providers in this country, breastfeeding is often viewed as “extra” or something special that only some mothers do. Incorporating it into the usual prenatal routine helps send the message that breastfeeding is normal and natural.
While breastfeeding is not for everyone, more efforts need to be made in the clinical and public health arenas to better prepare women for breastfeeding, allow them the opportunity to experience the “process” of breastfeeding before the baby is born and normalize breastfeeding a natural and healthy choice for women and their babies. I propose that my intervention is just one way that this could be accomplished but does have the potential to work particularly well in a pregnant adolescent population.

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