Effect of Skill Orientation on Practice of Breast Feeding Technique among Mothers of Preterm Babies

Mrs. Jeenamol C J¹, Dr. Angela Gnanadurai², Mrs. Reena Vincent³, Dr. Rose Xavier⁴

¹Lecturer, Jubilee Mission College of Nursing, Thrissur - 5

²Principal, Jubilee Mission College of Nursing, Thrissur - 5

³Associate Professor, Jubilee Mission College of Nursing, Thrissur - 5

⁴Assistant Professor, Jubilee Mission Medical College and Research Institute, Thrissur

*Corresponding Author Email: jina88jose@gmail.com

ABSTRACT:

A woman’s confidence in her ability to breastfeed is crucial to her success in breast feeding preterm babies. Breastfeeding is instinctive on the part of the baby but is a learned skill for the mother. Breastfeeding is extra-important if the baby is born preterm.¹ Giving birth to a preterm baby can be a frightening and traumatic time for parent.² Breast milk has important health benefits for premature babies as it prevent damage to baby’s immature digestive system, provide immunological, nutritional and cognitive benefits and allow for optimum growth and development.³ Aims and objectives: The present study aimed at assessing the effect of skill orientation on practice of breast feeding technique among mothers of preterm babies. Methodology: Pre experimental one group pre test post test design was used. Thirty samples were selected using nonprobability purposive sampling technique from a tertiary hospital, Thrissur. Pre test was done using structured observation checklist on day 1, followed by demonstration of breast feeding technique to each mother of preterm babies for 2 days as 2 times per day. On 3rd day, post test was done using same observation checklist. The data obtained were analysed using descriptive and inferential statistics using Statistical Package for Social Services 17 (SPSS 17). Results: Results showed that majority of mothers (80%) of preterm babies were in the age group of 21 to 30 years. Most of the mothers of preterm babies (63.30%) had caesarean type of delivery. 50% of mothers of preterm babies belonged to joint family and 90% of them had family support from both husband’s side and mother’s side. 76.70% of mothers of preterm babies had excellent level of practice of breast feeding technique after the skill orientation. There was significant association between pre test level of practice of breast feeding technique with sociodemographic and clinical data variables like parity (p=0.03), family support (p=0.003) and baby’s body weight (p=0.006). This reveals that mothers who are multiparous and who have more family support have significantly higher level of practice of breast feeding. The level of breast feeding technique significantly improved with the increase in body weight of preterm babies. Study concluded that skill orientation on practice of breast feeding technique was effective among mothers of preterm babies in NICU.

KEYWORDS: Skill orientation; breast feeding technique; mothers of preterm babies.

INTRODUCTION:

Most expectant parents look forward to the arrival of a healthy, well-developed baby. A premature birth drastically alters this expectation. The parents will have immediate worries about their baby's survival. They are unfamiliar with the thin and frail appearance of a premature baby. They also have to deal with the noisy, busy, and technical environment of Neonatal Intensive Care Unit (NICU).¹Preterm birth, defined as childbirth occurring at less than 37 completed weeks or 259 days of gestation, is a major determinant of neonatal mortality and morbidity and has long-term adverse consequences for health.²

The ‘Global Action Report on Preterm Birth’ by WHO 2012 estimates that every year 15 million babies are born preterm and more than 1 million babies die annually shortly after birth.³ The report reveals that India has the highest number of deaths due to premature birth, and ranks 36^th among 199 countries in list of pre-term births globally. Of the 27 million babies born in India annually, 3.6 million are born premature and 3,03,600 babies don’t survive due to complications. Now preterm birth demands an urgent priority for reaching Millennium Development Goal 4, calling for the reduction of child deaths by two-third by 2015.⁴

When a baby is delivered prematurely, the situation causes a lot of stress and worries to the mother. It is an instinct that makes mothers anxious for the safety and survival of their premature baby. The first problem which comes to a mother’s mind is how her newborn can be provided with the right kind of nourishment outside her womb.⁵ Mothers of preterm or sick babies face specific difficulties related to early mother and baby separation in a time of crisis and disillusion; this leads to lack of appropriate bonding experiences.⁶Most difficulties with breastfeeding are due to restricted feeding time, lack of confidence or poor attachment of the baby at the breast. Most of these difficulties can be avoided if the mother understands how breastfeeding works. Most women need encouragement and skilled support to continue to breastfeed successfully.⁷

Positioning of the baby’s body is important for good attachment and successful breastfeeding. Most difficulties can be avoided altogether if good attachment and positioning are achieved at the first and early feeds.⁵ Achieving correct attachment and positioning while assisting a mother to breastfeed a preterm baby can be a significant challenge, particularly if there is a considerable disparity between the size of an infant’s mouth and his mother’s breast. In order to achieve effective milk transfer an infant must obtain an adequate seal, sufficient negative pressure and an adequate suckling mechanism. Infants should be coaxed into a position of flexion with pillows.⁸ A common lament of nursing mothers in the NICU is that health care providers were really supportive of breast milk, but not very supportive of breastfeeding. Mothers may hear that breast milk is important, but get poor help in establishing breastfeeding with their preterm baby – a process which is often very challenging and often requires long term skilled assistance and support.² Nurses play a crucial role in assisting the attachment process by promoting and encouraging early mother‑infant interaction.⁷

A descriptive study was conducted to evaluate the feelings and expectations of mothers of preterm babies at discharge in Fortaliza General Hospital, Brazil. Data among 11 mothers of preterm babies from NICU were collected. The study revealed that although mothers experienced excitement and happiness at discharge, many reported being anxious and insecure on how to take care of their premature babies.⁹Birth of a premature baby is a distressing event in a woman's life. Therefore, it is important that the mother's need for support be recognized by the family and care providers, so that she can overcome the difficulties resulting from the child's health condition.¹⁰

The researcher confronted the situations of mothers of preterm babies and their practice of breast feeding with improper technique of positioning and attachment to the breast and hence found its importance to give a skill orientation on practice of breast feeding technique among mothers of preterm babies in NICU.

STATEMENT OF THE PROBLEM:

A study to assess the effect of skill orientation on practice of breast feeding technique among mothers of preterm babies in Neonatal Intensive Care Unit of Jubilee Mission Medical College and Research Institute, Thrissur.

OBJECTIVES:

1. Assess the level of practice of breast feeding technique among mothers of preterm babies in NICU before and after the intervention.

2. Evaluate the effect of skill orientation on practice of breast feeding technique among mothers of preterm babies in NICU.

3. Find out the association between practice of breast feeding technique with selected socio demographic and clinical data variables.

HYPOTHESES:

H_1: There is significant difference in the mean score on practice of breast feeding technique among mothers of preterm babies before and after the intervention.

H₂: There is significant association between the pre test scores and the selected socio demographic and clinical data variables on practice of breast feeding technique among mothers of preterm babies.

METHODOLOGY:

Research approach:

Quantitative evaluative research approach was adopted to assess the effect of skill orientation on practice of breast feeding among mothers of preterm babies in NICU.

Research design:

Pre – experimental one group pre test post test design was selected for this study.

Setting of the study:

Neonatal Intensive Care Unit of Jubilee Mission Medical College and Research Institute(JMMC&RI), Thrissur.

Sample and Sampling technique:

Thirty mothers of preterm babies in NICU of JMMC&RI, Thrissur were selected using non probability purposive sampling technique.

Criteria for selection of sample:

Inclusion criteria: Mothers whose baby is

· Admitted in NICU

· In the gestational age of 30 weeks to below 37 completed weeks

· Having weight from about 1 kg to below 2.5 kg at the time of study

· Attained sucking and swallowing reflex assessed by non-nutritive sucking and is able to be transitioned to at-the breast feeding

Exclusion criteria: Mothers

· Whose preterm baby is diagnosed with chronic medical problems (cardiac diseases, unresolved respiratory problems requiring oxygen, renal sepsis, surgery or medications with central effects, intraventricular hemorrhage) and congenital or neurological anomalies that affect breast feeding.

· Who had delivered a preterm baby previously

· Who has any sensory and neuromuscular impairment that affect breast feeding of the baby

Description of the tool:

Tool consists of 2 sections.

Section A:

It includes socio demographic and clinical data questionnaire of preterm babies and their mothers. It consists of 17 items.

Section B:

It consists of structured observation checklist on practice of breast feeding technique among mothers of preterm babies. It consists of 35 items under 6 components of breast feeding technique. The observations were marked under two headings ‘yes’ and ‘no’ for each item. The content of the intervention were prepared with the help of review of literature and guidance of experts in the subject area.

Data collection process:

Data was collected from the NICU of JMMC&RI, Thrissur. The researcher obtained permission from the concerned authorities. The data was collected for a period of four weeks from 21/1/2014 to 20/02/2014. After a brief self introduction, the investigator explained the purpose and nature of the study and informed consent was taken from the participants. The subjects were assured about confidentiality of their responses and maintained privacy for each mother. 30 mothers of preterm babies were selected using non probability purposive sampling technique from NICU of JMMC&RI, Thrissur. Pre test was done using the structured observation checklist on breast feeding technique on day 1, followed by demonstration of breast feeding technique to each mother of preterm babies for 2 days as 2 times per day. On 3^rd day, post test was done using same observation checklist. After the post test, pamphlets prepared by the researcher on breast feeding technique were provided to mothers of preterm babies as reinforcement.

RESULTS:

In order to interpret the data, both descriptive and inferential statistical analysis is done using Statistical Package for Social Services 17 (SPSS 17).

Section 1: Findings based on socio demographic and clinical data variables of mothers and preterm babies

· Majority of mothers of preterm babies, 24 (80%) were in the age group of 21 to 30 years and 15 (50%) of the mothers of preterm babies had pre degree level education. Most of the mothers 21 (70%) were housewives and 16(53.30%) mothers were having monthly income between Rs. 5000 – 10,000. Majority of mothers, 18 (60%) were Hindus and 15 (50%) mothers of preterm babies belonged to joint family. Most of the mothers of preterm babies, 19 (63.30%) were primigravidas and 19(63.30%) mothers of preterm babies had caesarean type of delivery. Data also reveals that 27 (90%) of the mothers of preterm babies had family support from both husband’s side and mother’s side and 25( 83.30%) mothers had no previous information on preterm baby care. 24 (80%) mothers had adequate breast milk to feed their preterm babies.

· Regarding the distribution of preterm babies, 13(43.30%) babies were in the gestational age of 33 - 35 weeks and were having body weight 2 to < 2.5 kg. More than half 19 (63.30%) babies were males as compared to 36.7% females. Majority of the babies, 23 (76.70%) were on phototherapy.

Section 2: Findings related to level of practice of breast feeding technique among mothers of preterm babies before and after the skill orientation.

Table 1 (a) Distribution of mothers of preterm babies according to pre test level of practice in different components of breast feeding technique. (n =30)

S. No	Components of practice	Pre test
		Excellent		Adequate		Moderately adequate		Inadequate
		f	%	f	%	f	%	f	%
I	Preparation for breast feeding	0	0	1	3.30	14	46.60	15	50
II	Positioning for breast feeding	5	16.60	8	26.70	10	33.40	7	23.30
III	Supporting the breast	1	3.30	12	40	0	0	17	56.60
IV	Attaching to the breast	8	26.60	7	23.30	7	23.30	8	26.70
V	Signs of good latch	9	30	5	16.70	9	30	7	23.30
VI	End of the feed	5	16.70	8	26.70	12	40	5	16.70
VII	Overall	0	0	11	36.60	6	20	13	43.20

Table 1(b). Distribution of mothers of preterm babies according to post test level of practice in different components of breast feeding technique. (n =30)

S. No	Components of practice	Post test
		Excellent		Adequate		Moderately adequate		Inadequate
		f	%	f	%	f	%	f	%
I	Preparation for breast feeding	22	73.30	5	16.70	3	10	0	0
II	Positioning for breast feeding	25	83.40	3	10	2	6.60	0	0
III	Supporting the breast	21	70	7	23.30	0	0	2	6.70
IV	Attaching to the breast	27	90	1	3.30	1	3.30	1	3.30
V	Signs of good latch	21	70	9	30	0	0	0	0
VI	At the end of the feed	20	66.70	7	23.30	3	10	0	0
VII	Overall	23	76.70	4	13.30	3	10	0	0

Figure 1 depicts that the overall mean post test practice score (28.87 + 4.27) was significantly higher (p=0.001) than the overall mean pre test practice score (16.43 + 5.38). The calculated paired t- test value on overall pre and post test practice score was 14.64 which was higher than the table value (2.04, df 29 at p = 0.001 level of significance). Hence, H_1: There is significant difference in the mean score on practice of breast feeding technique among mothers of preterm babies before and after the intervention, was accepted. It shows that skill orientation was effective in improving the practice of breast feeding technique among mothers of preterm babies.

Section 4: Findings based on association of pre test level of practice of breast feeding technique among mothers of preterm babies with selected socio demographic and clinical data variables.

There was significant association between pre test level of practice of breast feeding technique with selected socio demographic and clinical data variables such as parity (p = 0.03), family support (p = 0.003) and baby’s body weight (p = 0.006) at p <0.05. Mothers who are multiparous and who have more family support has significantly higher level of practice of breast feeding technique. The level of practice of breast feeding technique significantly improved with the increase in body weight of preterm babies. Hence, H₂: There is a significant association between the pre test scores and the selected socio demographic and clinical data variables on practice of breast feeding technique among mothers of preterm babies, was accepted.

DISCUSSION:

It is evident from the present study that the overall mean post test practice score of 28.87 is significantly higher than mean pre test score of 16.43 (t=14.64, t₂₉=2.04, p = 0.001 level). There is significant increase in the practice of breast feeding technique among mothers of preterm babies after the skill orientation (p=0.001). A significant association was found between the pre test level of practice of breast feeding technique among mothers of preterm babies with parity, family support and baby’s body weight at p<0.05 level.

This was supported by a study to assess the effectiveness of video teaching programme on breast feeding among primi gravida mothers admitted in urban health maternity centres, Coimbatore. The finding of the study revealed that 15 mothers of experimental group had pre test knowledge mean score of 2.533 + 1.699 and practice score of 12+2.044 which was improved to post test knowledge score of 13.33 + 0.949 and practice score of 26+ 1.034. The study concluded that the education on breast feeding will improve the mother’s knowledge and practice and can reduce the neonatal morbidity and mortality rate.¹¹

A cross sectional observational study was conducted among mothers attending hospitals at Benghazi where 192 mother-neonate units were observed for mothers and baby's position, attachment and effective suckling. There was poorer positioning among primipara (24.0%) than multipara (8.9-12.5%) mothers. Poor attachment was also more evident among primi para (30%) compared to multi para (20.9%) mothers. Thus, findings showed that parity was significantly associated with poor position and attachment. Young and primi para mothers were more in need of support and guidance for appropriate breast feeding techniques.¹²

CONCLUSION:

The findings of the study showed that 13 (43.2%) mothers of preterm babies had inadequate level of practice and 6 (20%) mothers had moderate level of practice of breast feeding their preterm babies in the pretest. There was significant increase in the practice of breast feeding technique after the skill orientation with a mean difference of 12.44. Majority of mothers of preterm babies, 23 (76.7%) had excellent level of practice of breast feeding in the post test. There was a significant association of pre test level of practice of breast feeding technique among mothers of preterm babies with selected socio demographic and clinical data variables like parity, family support and baby’s body weight (p<0.05). The study concluded that skill orientation on breast feeding technique is effective method in improving the practice among mothers of preterm babies as a supportive measure in the NICUs.

RECOMMENDATIONS:

1. A similar study may be replicated with larger sample size in other setting for a valid generalization.

2. A true experimental study with control group can be done to assess the effectiveness of skill orientation on practice of breast feeding technique.

REFERENCES:

1. Melnyk BM. Because of nursing research: helping families cope with premature births [Internet]. 2012 [cited 2014 Jun 4]. Available from: http://www.ninr.nih.gov/newsandinformation/because-of-nursing-research-cope#.U47o7ija_C4

2. Beck S, Wojdyla D, Say L, Bertran AP, Meraldi M, Requejo JH et al. The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity. Bull World Health Org Suppl. 2010 Jan 1; 88(1): 31–8. doi: 10.2471/BLT.08.062554.

3. Blencowe H, Cousens S, Chou D, Oestergaard M, Say L, Moller AB et al. Born too soon: the global epidemiology of 15 million preterm births. Reprod Health. 2013 Nov 15; 10(1): 2. doi: 10.1186/1742-4755-10-S1-S2.

4. Born too soon: the global action report on preterm birth [Internet]. WHO. 2012 May 2 [cited 2014 Mar 17]. Available from: http://www.who.int/pmnch/media/news/2012/preterm_birth_report/en/

5. Special breastfeeding technique for premature newborn babies. Breast Feeding Well [Internet]. [cited 2014 Jun 4]. Available from: http://breastfeedingwell.com/special-breastfeeding-technique-for-premature-newborn-babies

6. Weimers L, Svensson K, Dumas L, Naver L, Wahlberg V. Hands-on approach during breastfeeding support in a neonatal intensive care unit: a qualitative study of Swedish mothers’ experiences. Int Breastfeed J. 2006 Oct 26; 1(1):20. doi:10.1186/1746-4358-1-20

7. Vinther T, Helsing E. Breast feeding: how to support success - A practical guide for health workers. Copenhagen: WHO; 1997. 10-2.

8. Jones E, King C. Feeding and nutrition in the preterm infant. Churchill: Elsevier Health Sciences; 2005.

9. Rabelo MZ, Chaves EM, Cardoso MV, Sherlock M. Feelings and expectations of mothers of preterm babies at discharge. Acta Paulista de Enfermagem. 2007 Sep; 20(3): 333–7.

10. Davim RM, Enders BC, Rosendo da Silva RA. Mothers' feelings about breastfeeding their premature babies in a rooming-in facility. Rev esc enferm. 2010 Sep; 44(3). doi.org/10.1590/S0080-62342010000300023

11. Santhi MD, Kokilavani. Effectiveness of video teaching programme on breast feeding among primi gravida mothers. Int Jrn of Nurs Care. 2013; Apr 3; 1(1); 77-82. Available from: http://www. Indianjournals.com

12. Goyal RC, Banginwar AS, Ziyo F, Toweir AA. Breastfeeding practices: Positioning, attachment (latch-on) and effective suckling - A hospital-based study in Libya. J Family Community Med. 2011 May; 18(2): 74–9. doi: 10.4103/2230-8229.83372

Received on 09.12.2015 Modified on 06.02.2016

Asian J. Nur. Edu. and Research.2016; 6(4): 517-522.

DOI: 10.5958/2349-2996.2016.00097.5