Impact of Breastfeeding Education on Caesarean Delivery Mothers

This project outlines a quasi-experimental study investigating the impact of a breastfeeding education program on mothers who have undergone caesarean deliveries. The study aims to determine if prenatal breastfeeding education can encourage and motivate these mothers to breastfeed and increase the rates of exclusive breastfeeding within the hospital and at two months postpartum. The project includes a detailed literature review, rationale, study design, sampling methods, data collection and analysis methods, ethical considerations, and anticipated outcomes. The study compares a control group receiving standard hospital care with an experimental group receiving a breastfeeding education program. The education program involves a booklet, video program, and follow-up phone calls. The project also details the proposed timeline and budget justification. The study's significance lies in its potential to improve maternal and infant health outcomes by promoting breastfeeding practices.

1
Running head: HEALTH ADVANCEMENT AND PROMOTION
Health Advancement and Promotion
Name of student:
Name of university:
Author note:

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Table of Contents
Background................................................................................................................................3
Aims...........................................................................................................................................4
Research questions.....................................................................................................................4
Literature review and rationale..................................................................................................5
Study design...............................................................................................................................7
Sampling methods....................................................................................................................10
Sample size and power.............................................................................................................10
Data collection methods...........................................................................................................10
Data analysis method...............................................................................................................12
Ethical statement......................................................................................................................12
Anticipated outcome and significance.....................................................................................13
Proposed timeline.....................................................................................................................15
Justification of budget..............................................................................................................16
References................................................................................................................................18

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“The impact of breastfeeding education intervention on rate of breastfeeding for
mothers undergoing caesarean delivery- a quasi-exprimental study”
Background
Breastfeeding is a topic that has gained immense significance across age group,
cultures, geographical locations and economic statuses. The general agreement is that the
benefits of breastfeeding are multi-faceted. Research indicates that breastfeeding is directly
linked to the positive health outcomes of the newborn as well as the new mother. As per the
guidelines of WHO, exclusive breastfeeding helps in achieving optimal growth and other
health benefits. In addition, there is a protective effect against high incidence of morbidity
and mortality from gastrointestinal infections (Dieterich et al., 2013). Victora et al., (2016)
opined that breastfeeding is effective in promoting maternal-infant bond as well. This is
important since a high proportion of mothers, especially first-time mothers suffer postnatal
depression and chances of detachment from the child. Apart from the maternal and infant
health benefits, the economic, financial and social benefits of breastfeeding are also
important. Despite the prominent acknowledgement of the copious benefits of breastfeeding,
the prevalence of the same is not up-to-the-mark. Reports from communities across Australia
reflect the issues that surround reduced rate of breastfeeding and poor knowledge of new
mothers regarding the same. Lack of adequate knowledge combined with low-level
confidence has been indicated to be the prime reason why the prevalence of breastfeeding is
less across communities (Rollins et al., 2016). Breastfeeding education for mothers is
probably the best way in which the issue can be addressed.
Against this background, there is a crucial demand for large-scale interventions
considering breastfeeding education for increasing the prevalence of breastfeeding and

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appropriateness of it. Investigating the impact of breastfeeding education on mothers would
be a desirable approach to augment the prevalence.
Aims
The primary aim of the proposed study is to undertake a quasi-experimental study to
collect maximal level evidence of whether breastfeeding education program for women with
caesarean delivery is effective in motivating them for breastfeeding and increasing the rates
of the same practice.
Precisely, the aims of the study can be outlined as follows-
1. To study the efficiency of a prenatal breastfeeding education program for women
electing caesarean section as a delivery model in terms of providing encouragement
and fostering a positive attitude among the women
2. To analysse the efficacy of the prenatal breastfeeding education program in increasing
the rate of exclusive breastfeeding within hospital and at two month postpartum
Research questions
The proposed study would address the following research questions-
 Does prenatal breastfeeding education program help in encouraging and motivating
women opting for caesarean delivery towards breastfeeding?
 Does prenatal breastfeeding education program increase the rate of exclusive
breastfeeding within hospital and at two month postpartum?
Literature review and rationale
The profits of breastfeeding for infant and maternal health are well documented.
Breastfeeding is a non-substitutable and natural food for babies and WHO recommends

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sufficient and correct breastfeeding for all mothers. The necessity is prominent since infants
are protected from a wide range of health complications after birth if they are breastfed. It is a
practical nutrition as it is available on an immediate basis when required to feed the baby. For
making breast-feeding exclusive, sufficient and infant-centred, mothers are to be educated on
the different concepts pertaining to this topic. The aspects that are to be covered in such
educative interactions are to include benefits, suitable methods, contraindications, gadgets.
The best known modifiable factor for enhanced breastfeeding is self-efficacy, and the
importance of this in relation to breastfeeding outcomes has drawn the notice of many. Self-
efficacy is not to be confidence and includes an affirmation of the ability to carry out a
behaviour as well as the strength of the belief. Educational interventions address this aspect.
The relationship between the mother and the educator is important for understanding the
concerns faced by the mother and the gap in knowledge. It is desirable that the educator is
aware of the known informative and moralising principles while imparting the education.
Important features that have an impact on the quality of education imparted are spiritual,
socio-cultural and social characteristics of the participants (Stuart-Macadam, 2017). Ahmadi
et al., (2016) in a longitudinal study had found that mothers with low levels of self-efficacy
discontinued breastfeeding. Women with lack of confidence are twice likely to discontinue
breastfeeding before completion of two months owing to a number of challenges.
Cunningham et al., (2017) argued that new mothers often are in the need of assistance
and help from healthcare professionals rather than family members regarding breastfeeding.
Lack of assistance and adequate information might lead to failure in appropriate
breastfeeding. Education for a successful breastfeeding process needs to encompass two
different stages; education before newborn delivery and supportive assistance provided
afterwards. Early education is important for preparing a mother to take care of the newborn
and nurse the baby. Eduction is known to raise the level of confidence in the care taking

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abilities with sufficient concern and support. Undeniably, support in the form of relevant
education has been noted in a wide range of studies as a vital element influencing both the
occurrence and extent of breastfeeding. A number of reviews have studied the impact of
educational interventions on increase of breastfeeding. As the review by Pitts et al., (2015)
highlighted that nursing counsellors improve breastfeeding initiation, exclusivity and length.
A study carried out by the researchers Manahan et al., (2016) found out that duration of
breastfeeding can be increased through formal education on the topic at the time of pregnancy
and lactation consultation. The review of Lumbiganon et al., (2016) concluded that exclusive
breastfeeding increases when the interventions provided mainly focus on education.
Mesters et al., (2013) have to say that a number of breastfeeding education program
facilitate long duration breastfeeding. While some are successful some of them lead to
failure. The provision of breastfeeding skill‐based education antenatally leads to increased
breastfeeding rate. Wojcicki, et al., (2016) pointed out that strategies for promoting
breastfeeding education are to rest upon certain principles. These include the creation of a
breastfeeding friendly environment, empowering mothers to make informed decisions,
respecting mothers about decisions taken regarding breastfeeding, identifying barriers and
exploring situations, sustaining support and including partners and families in the education
process. The researchers further pointed out that peer breastfeeding support is also a
noteworthy tool. Apart from educating the mothers on breastfeeding, it is necessary to
motivate them and cultivate an enthusiastic and positive attitude towards the practice of
breastfeeding. Women are to be given the opportunity and time to understand that
breastfeeding is a pragmatic option. Discussing breastfeeding in a frequent manner is more
effective since message delivered more frequently is more effective. Concepts are to be clear,
and all doubts arising in the minds of the mother are to be addressed individually.

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Non-judgemental and hands-on activities would be beneficial for building skills and
knowledge. What holds prime value is that the risks and costs of not breastfeeding are to be
educated with equal importance as the benefits of it. While knowledge of the positive impact
of breastfeeding act as a motivating and encouraging factor, knowledge of the risks and costs
associated would compel mothers to practice breastfeeding. A realistic understanding of the
situation is more important in such cases (Mittal et al., 2016). Armstrong et al., (2014) in this
regard state that education on breastfeeding is to be sensitive to the issues faced by women,
such as culture, body image, economic condition and family support. Identification of
barriers and implementation of solutions is imperative.
Study design
The proposed study would have a quasi-experimental design. A quasi-experiment is
the experiential study undertaken for the estimation of the causal impact of any certain
intervention of the target population wherein random assignment is not done (Flick, 2015).
Such a design does not bear the characteristic of random assignment to control or treatment.
Instead, such a design allows the researchers to control the assignment to the intervention
through utilisation of some criteria apart from random allocation. The advantage of using
such as design for the proposed study would be that threats to ecological validity would be
minimised since the natural environment in which data would collect would not have the
issues of artificiality.
Consideration is to be given to the ethical concern that all women enrolled for
delivery by caesarean section in the hospital would have similar desire to be given emotional
support and educational information. They would have equal needs of gaining postpartum
breastfeeding help and related information. For this particular concern, the permuted-bock
random allocation process would not be carried out in the similar time sequence for the

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participants of the study. Thus, the study would compare two groups over dissimilar time
periods. The first part of data collection for the control group would be done for three months
and the second part of the data collection would be done for the experimental group would be
done for another three months leaving three months gap in between. The control group would
be receiving standard hospital care while the experimental group would be receiving
breastfeeding education program. It would also be desirable to conduct double-blinded
procedure and self-selection bias. The double-blinded method is a significant part of the
scientific research for preventing research outcomes from being impacted by the observer
bias, both conscious and unconscious. It ensures impartiality into the research process
(Panneerselvam, 2014).
The standard hospital care would be the set of interventions based on existing
literature. The first aspect of the care process would be regular activities for the promotion of
breastfeeding in the postnatal ward and prenatal checkup. Health teaching pamphlets would
be disseminated for breastfeeding. Three hours after the delivery the infant would be placed
to the postnatal ward, and the mother would receive education on different topic related to
breastfeeding with a special focus on advantages of breastfeeding. The mothers would be
discharged on the fifth day from the healthcare setting after the delivery.
The breastfeeding education interventional program would be marke by dissemination
of a twenty-page booklet along with at least 20-minute videotape program and three follow
up phone calls (Lumbiganon et al., 2016). The aim of this intervention would be
multifacteted. Firstly, it would be beneficial for providing information on the complete set of
benefits and advantages of commencing on breastfeeding after delivery. Secondly, resolving
the difficulties and issues with exclusive breastfeeding would be achieved. Thirdly, how
partners of the new mothers can help in breastbreasting would be demonstrated. The content

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of the education program would be suitably based on the analysis of existing relevant
literature (Crook & Brandon, 2017). Certain dominant themes would be identified by the
researchers that would be refined into the different topics. Apart from this standard phone call
would form an elementary protocol for the education program. Reinforcement for the
program would be upheld by the researchers through telephonic conversations. The first
would be undertaken within two days of participant recruitment and the second would be
undertaken a week afterwards. The calls would be made for reminding the participants to
read through the content of the booklet in a thorough manner and practice the material
contents on a regular basis. Practicing the materials would include answering a set of
questions related to the subject matter. The draft of the education program would be reviewed
by a set of experts for ensuring content validity. Minor modifications might be required
before the final content is made ready.
The patient demographic information would include the level of education, age,
professional background and the rationale for selecting caesarean delivery. Breastfeeding
attitude is to be determined with the help of Breastfeeding Attitude Scale proposed by
researchers Teng and group. The scale would consist of 28 items, and every item would be
answered on a five-point scale. In this scale, 1 would refer to strong disagreement, and 5
would refer to strong disagreement. A high score would indicate a positive attitude towards
breastfeeding. There would be three categories in the scale; the benefits and values of
breastfeeding, the interplay of breastfeeding and the chances of replacing the breast milk with
alternative options.
Sampling methods
The sampling criteria would be women aged between 36-39 weeks pregnancy
deciding on the ceaserean model of delivery. The participants need to communicate in

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English and must be agreeing on taking part in the study. The participants would be selected
from a reputed, large urban hospital in Australia. A study carried out by Haroon et al.,
(2013) indicates that the participants might feel the need of discussing or inquiring the
methods of the study pertaining to educational intervention. Thus it would be desirable in the
proposed study that the study for control group would be undertaken in the first three months
and the study for the experimental group would be undertaken three months later, for dealing
with the information bias mentioned above.
Sample size and power
Statistical power analysis would be used for calculating the required sample size. An
alpha of 0.05, a beta of 0.2 and a delta parameter of 0.30 would be assumed on the basis of
Cohen’s rule for effect size value. This would be beneficial for detecting the differences in
change in the breastfeeding attitude of the participants which is the primary outcome of the
study (Offredy & Vickers, 2013). After the formula for sample size estimation is applied, it is
found that the sample sie would be effective with 45 subjects in each of the two groups.
Initially, a larger sample size would be selected since there are chances of loss of participants
owing to different concerns. These would include the inability to contact the participants and
health complications of the mothers.
Data collection methods
The participants included in the experimental group would be provided with a free
booklet along with the video. On an average 15-20 minutes would be spent on the phone calls
and explaining the main directs of the booklet. The participants included in the control group
would not be given the breastfeeding booklet, phone call or video. Standard care would be
given to both the groups in respect to delivery and pregnancy. This would include access to
breastfeeding support in the respective ward of the hospital (Pitts et al., 2015).

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The second phase of data would be collected five days after delivery when the
breastfeeding attitude would be studied post-test. The breastfeeding and rooming-in rates
would be calculated. The duration of time the baby and the mother shared the same room
would be recorded, excluding the time when the baby would be receiving any form of
medical treatment. It would be kept in mind not to separate the mother and the infant for
more than two and a half hours. In case they did not share the same room for the day the case
would be dismissed. Breastfeeding would be divided into two categories; exclusive and non-
exclusive breastfeeding. Exclusive breastfeeding would not include any baby food
formulation or water. The non-exclusive breastfeeding would comprise of a combination of
breast milk and water or baby formulation. Personal interviews and observations about
breastfeeding and rooming-in together with the medical record would enable the researchers
to estimate the rates of the same at the time of postpartum hospital stay in an accurate
manner. As opined by Flick (2015) personal interviews are important for extracting optimal
data from participants as the views and opinions of the participants can be known in details.
The advantages of face-to-face personal interviews are many. Accurate screening is the most
important benefit of interviews. Non-verbal and verbal cues can be understood in this
process. Focus can be kept on the control over the interview. The participants can be guided
in answering all the questions properly. Observations help in collecting data in the natural
settings. Chances of bias is less in such cases. The third lag of data would be collected one
month after the delivery.
Data analysis method
Statistical data analysis would be carried out with the help of SPSS statistical software
package. Clinical characteristics and demographic data would be organised as the mean and
standard deviation for continous variables and as proportions for categorical variables. For

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comparing the difference between the groups after and before the test, it would be desirable
to use the paired t-test for analysing the continuous endpoint, that is breastfeeding attitude.
The paired t-test is used for comparing the two population means between two samples. The
observation of one sample can be compared to that of another sample. In such a test, the
subject is measure twice and thus results in pairs of observations. Statistical value is
determined by the p-value (Panneerselvam, 2014). It would be desirable to use the McNemar
test for analysis of categorical endpoint, which are exclusive breastfeeding rates and
rooming-in. This particular test is a significant statistical test used on paired nomial data.
McNemar's test is widely used for comparing dependent proportions. The tests would be
performed at 5% significance level.
Ethical statement
Ethics is a key consideration for primary research with human participants. The
reason behind this is that involvement of human participants in a research might take
different forms. Approval is indispensable to be taken from the local committee (Pelletier et
al., 2015). The proposed study is to receive approval from the ethics committee. It would be
imperative to get written informed consent from each of the participants before commencing
on the enrollment for the study. Informed consent is the knowledge of the impending risks
intrinsic in participating in research and personal or general benefits from the study. The
participants are to be explained thoroughly the aims and scope of the research. The purpose
of the same is also to be explained to the participants. Any doubts or clarification from the
participant’s side would be resolved immediately. Subjects who would not meet the criteria
about the basic attributes would need to complete the pretest about breastfeeding attitude.
The three basic ethical principles that would be abided by are respect for participants,
beneficence and justice. Participants are to be treated as autonomous agents, and they would

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not be pressurised to take part in the study. Further, the participants would have the option of
quitting the study under any unavoidable circumstances. There would be no penalty or
prejudice for the same. Special considerations would be taken for those who would not be
able to understand the information adequately while communicating. In addition, for securing
the wellbeing of the participants, the actions taken are to protect them from any possible harm
or injury. The concept is much more than mere physical injury. Incidents of embarrassment
and stress are to be avoided. In addition, equal opportunity would be given to every possible
participant, irrespective of eduction level, status and race. This would ensure justice. The
patient information would be maintained with privacy and confidentiality as ethical principles
(Faden et al., 2014).
Anticipated outcome and significance
The aim of the proposed study would be to augment the success rate of breastfeeding
among women choosing to deliver their baby through the caesarean model. The intervention
would be the education program that would potentially help in promoting the beliefs and
attitude of breastfeeding and rate of infants and mothers sharing a room apart from exclusive
breastfeeding. The study would be providing an answer to the question of whether learning
levels of mothers before the delivery process is increased after going through the intervention
process. The positive affect of the breastfeeding educational initiative is likely to be achieved
at the end of the program. It is further expected that the women from the intervention group
would have increased the urge to breastfeed their infants as compared to the control group. It
is known that knowledge on a particular health topic influences the attitude towards the
practice of the same. There is a change in the behaviour due to the change in the level of
knowldge (Haider et al., 2014). Images and videos have been proved to allow mothers boost
heir level of confidence and reduce anxiety as they move towards a more difficult phase of

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their lives. The expected outcome is that education of breastfeeding would raise the
knowledge and subsequent attitude, thereby increasing the rate of breastfeeding by mothers
who would consider exclusive breastfeeding.
As per the previous studies conducted in this regard, repeated sessions carried out for
viewing, reading and practising of educational materials is essential for obtaining successful
breastfeeding results. Stress is given on the fact that after undergoing a successful caesarean
section, mothers are to be educated properly on the appropriate breastfeeding postures and
techniques (Crook & Brandon, 2017). The study would, therefore, suggest whether mothers
undergoing caesarean delivery would need to be educated for a longer duration as compared
to those undergoing normal delivery.
Global health organisations are promoting the valuable concept that mothers and
newborns are to be in the vicinity for the effective nursing process. The findings of the study
would be important for gaining information on whether professional education is helpful in
directing the willingness of mothers to breastfeed their babies. In future, breastfeeding
education programs can be set up based on the results of this study. The number of women
delivering child through caesarean delivery model is high. Thus this study would be a guiding
source for helping construct beneficial educational programs. Chances are high that the
proposed educational materials would be passed on to different areas of the country for
increasing the rate of breastfeeding across communities (Haroon et al., 2013).
The proposed study would be helpful for healthcare professionals across the
community, especially the nurses, when addressing the needs of new mothers and promoting
their health and wellbeing. The rate of infant mortality due to long term and short term
complications would also be reduced considerably. As the study overview would present
clear and affirmative results, persuasive evidence would be available to support

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recommendations for healthcare authorities on breastfeeding. National goals for breastfeeding
can be modified based on this. The goals and recommendations for breastfeeding would be an
optimal way for reducing the burden of complications arising from non-adherence to
breastfeeding.
Proposed timeline
The following is the timeline of the proposed study that would be strictly adhered to.
Work to be
done
Month 1 Month 2 Month 3 Month 4-9 Month 10 Month 11-12
Ethics
clearance

Project set-up 
Development
of intervention

Enrolment of
participants

Intervention
implementatio
n

First round of
data collection

Second round
of data
collection

Third round of
data collection


16HEALTH ADVANCEMENT AND PROMOTION
Data entry and
analysis

Preparation of
scientific paper

Justification of budget
It is suitable to outline a budget for the complete project so that resource allocation is
done adequately. The following is the finanicial information for the project that has been
estimated at 3116500 dollars. It is expected that the study would be controlled within this
budget.
Resource Budget (in $)
Consumables and materials 20,00000
Equipment 250000
Staff salary 150000
Travel and communication 200000
Miscellaneous costs 110000
Total direct costs 2710000
Total indirect costs 406500
Grand total 3116500

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Ahmadi, S., Kazemi, F., Masoumi, S. Z., Parsa, P., & Roshanaei, G. (2016). Intervention
based on BASNEF model increases exclusive breastfeeding in preterm infants in Iran:
a randomized controlled trial. International breastfeeding journal, 11(1), 30.
Armstrong, J., Abraham, E. C., Squair, M., Brogan, Y., & Merewood, A. (2014). Exclusive
breastfeeding, complementary feeding, and food choices in UK infants. Journal of
Human Lactation, 30(2), 201-208.
Crook, K., & Brandon, D. (2017). Prenatal Breastfeeding Education: Impact on Infants With
Neonatal Abstinence Syndrome. Advances in Neonatal Care, 17(4), 299-305.
Cunningham, A. S. (2017). Breastfeeding: adaptive behavior for child health and
longevity. Breastfeeding: Bicultural Perspectives.
Dieterich, C. M., Felice, J. P., O’Sullivan, E., & Rasmussen, K. M. (2013). Breastfeeding and
health outcomes for the mother-infant dyad. Pediatric Clinics of North
America, 60(1), 31.
Faden, R. R., Beauchamp, T. L., & Kass, N. E. (2014). Informed consent, comparative
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Haider, S. J., Chang, L. V., Bolton, T. A., Gold, J. G., & Olson, B. H. (2014). An evaluation
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18HEALTH ADVANCEMENT AND PROMOTION
Haroon, S., Das, J. K., Salam, R. A., Imdad, A., & Bhutta, Z. A. (2013). Breastfeeding
promotion interventions and breastfeeding practices: a systematic review. BMC public
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Lumbiganon, P., Martis, R., Laopaiboon, M., Festin, M. R., Ho, J. J., & Hakimi, M. (2016).
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Pitts, A., Faucher, M. A., & Spencer, R. (2015). Incorporating breastfeeding education into
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