Best Start Northern Conference October 18, 2010

1. Best Start Northern Conference October 18, 2010 Research Study “Improving Breastfeeding Outcomes Among Aboriginal Women”

2. Research Team • Collaboration between Thunder Bay District Health Unit and Lakehead University • Collaborative community partner is Anishnawbe-Mushkiki • Funding from Registered Nursing Association of Ontario

4. Recommendations • Breastfeeding is recommended as the optimal source of nutrition for newborns for the first 6 months of life and beyond with the addition of complimentary foods (WHO, HC, CPA, AAP) • Benefits well documented for infants, mothers, families and society (Kramer et al., 2001; Stanley et al, 2007).

5. Clinical Problem • Despite the benefits of breastfeeding many women do not meet the breastfeeding recommendations • Stats Canada, 2003: 84.5% of women initiated breastfeeding, with only 18.7% exclusively breastfeeding at 6 months and 38.7% practicing any breastfeeding at 6 months. • Rates are lower in US

6. Breastfeeding duration tends to decrease quickly in the first four to six weeks (Barber et al., 1997; Sheehan et al., 2001; Sheenhan et al.,2006). • Rates are even lower in socially disadvantaged women (Dubois & Girard; Guise et al., 2003; Li et al., 2003). • Studies have also indicated that many mothers are not meeting their desired breastfeeding goals

7. 41%-53% of mothers reported meeting their intended duration of breastfeeding in 3 different studies (Chezem et al., 2003; Lavender et al., 2005; Kronberg & Vaeth, 2004). • Negative perceptions of the experience • Experience feelings of self-doubt, disappointment and/or guilt about not continuing • Many discontinue due to difficulties encountered rather than choice (Dennis, 2002; Gaffy & Taylor, 2005; Mozingo & Droppleman, 2000).

8. Variables • Reasons for discontinuation are multifactorial and complex • Socio-demographic variables • Attitudinal and intrapersonal characteristics (goals and intentions) • Hospital policies • Intrapartum experiences • Support • Breastfeeding difficulties • Psychosocial factors (anxiety, depression) • Confidence (self-efficacy)

9. Relevance to Aboriginal Mothers • Many studies have been conducted in larger urban centers with with different demographic characteristics than communities in Northwestern Ontario • Little research has been conducted with Aboriginal women • Health care providers should provide services that meet the unique needs of their community

10. Studies with Aboriginal Mothers • Ontario James Bay (Moose Factory), initiation rate of 51.9% (Black, Goodwin & Ponka, 2008) • Manitoba South First Nations reported initiation of breastfeeding between 43%-65% (Martens et al., 2008). • Labrador study had a 54% initiation rate among Aboriginal/Inuit mothers (McKim et al., 1998).

11. Proposed Research Purpose To evaluate two potentially modifiable variables affecting breastfeeding outcomes among Aboriginal women. • Breastfeeding self-efficacy also referred to as mothers’ confidence • Peer support

12. Breastfeeding Self-Efficacy • A mother’s confidence in her ability to breastfeed her infant (Dennis, 1999) • Has been identified as an important, potentially modifiable variable affecting breastfeeding initiation, duration and exclusivity in diverse settings with varying populations (Canada, UK, China, Australia, Poland, Primigravidas, WIC participants, adolescents)

13. Increased breastfeeding self-efficacy has been associated with increased initiation, duration and exclusivity (Blyth et al., 2002; Dennis & Faux, 1999; Kingston et al., 2007) • Many of the above studies also identified that a mother’s breastfeeding self-efficacy in the early postpartum period is predictive of breastfeeding outcomes • Therefore, we can identify mothers at risk for early discontinuation due to low-self efficacy

14. However… • The tool to measure breastfeeding self-efficacy has not been tested among Aboriginal women • The variable has not been identified as influencing breastfeeding outcomes among Aboriginal women • Very little is known about the goals and rates of breastfeeding initiation, duration and exclusivity among Aboriginal women

15. Research Questions • What is the reliability and validity of the BSES-SF in-hospital and 4 weeks postpartum among Aboriginal women?

16. Additional Questions • What are the breastfeeding rates and levels among Aboriginal mothers in-hospital, at 4 and 8 weeks postpartum? • What sociodemographic and early postpartum variables predict early discontinuation of breastfeeding among Aboriginal women?

17. Relevance to RNAO Recommendation #3 • Nurses should perform a comprehensive breastfeeding assessment Recommendation #3.3 • Assessment tools should meet the needs of the practice settings

18. Community Support & Ethics • Study being conducted in collaboration with staff of Anishnawbe-Mushkiki • Involved right from the beginning with proposal development, questionnaires, use of their cite etc. • Ethics approval from TBRHSC and Lakehead University

19. Study in Progress • Participant recruited from the postpartum unit at TBRHSC • Eligibility: (a) Aboriginal heritage, (b) term infant, (c) intending to breastfeed, (d) speak and understand English, and (e) are 16 years of age or older • Ineligibility: (a) any condition that would interfere with breastfeeding such as premature, prolonged separation (NICU)

20. Methodology Cohort Study • Baseline data collected in hospital from eligible, consenting mothers • Telephoned by a research assistant at 4 and 8 weeks to evaluate method of infant feeding and variables affecting infant feeding

21. Outcomes • Infant feeding method • Level of breastfeeding • Breastfeeding self-efficacy

22. Results to date • To be described at the conference

23. Naadmaage Kwe (Women Helping Women)Breastfeeding Peer Support for Aboriginal Women

24. Research Questions • How does a community based peer support program affect breastfeeding outcomes with Aboriginal women? • How do the mothers evaluate their peer support experience? • How do the peers evaluate their experience providing peer support?

25. Breastfeeding Best Practice Guideline for Nurses RNAO 2003, Revision 2007 • Nurses support breastfeeding peer support programs and ensure that women are provided with peer support resources. • Organizations establish and support breastfeeding peer support programs. • Nurses provide informational support about breastfeeding.

26. Evidence supported practice • Pre and post natal peer support has been effective in increasing initiation and exclusive breastfeeding (Bonuck et al., 2005 and Chapman et al., 2004) • Telephone based peer support has been effective in increasing duration and exclusive breastfeeding (Dennis et al., 2002) • Antenatal education is effective in increasing breastfeeding initiation rates in low income women (Dyson et al., 2005) • Education is effective where initiation rates are low (Guise et al., 2003) • Lay support is associated with reduced cessation of exclusive breastfeeding ( Britton et al., 2007)

27. Prenatal Session Objective: to provide informational support in an small group setting • Facilitated by nurses • Face to face meeting with breastfeeding support peers • Content includes discussion of benefits of breastfeeding; myths, attitudes, and concerns; anatomy and physiology; and latching and positioning skills.

28. Breastfeeding Support Peers • Are Aboriginal women with a positive breastfeeding experience • Attend a training session • Receive a peer support manual • Document contacts on Peer Volunteer Activity Logs

29. Telephone support • Peers contact new mothers within 2-3 days following discharge from hospital. • Frequency of contact based on the new mother’s needs. • Suggested contacts are weekly for the first 4 weeks, every second week up to 3 months.

30. Research Tools • Prenatal demographic questionnaire and breastfeeding intention • Labour and postpartum questionnaire at 1 week • Infant feeding questionnaire 4, 8 and 12 weeks • Level of breastfeeding (Labbok and Krasovec) • Peer support logs • Maternal satisfaction questionnaire • Peer satisfaction questionnaire

31. Outcomes • Frequency, duration and types of support provided • Infant feeding practices at birth and monthly intervals up to three months • Maternal satisfaction with acceptability , benefits, barriers and recommendations. • Peers’ evaluation of benefits, barriers, and recommendations for the program

32. Community Partnerships • Consultation for program development and host site for peer training and prenatal sessions - Anishnawbe Mushkiki Community Health Centre. • Recruitment of peer volunteers and participants. Recruitment of prenatal aboriginal women with due date up to January 15, 2011.

33. Potential Contributions • Advance the body of knowledge regarding the reliability and validity of the BSES-SF • Identify important variables predictive of early breastfeeding discontinuation • Contribute to our understanding of the breastfeeding support needs of Aboriginal women • Present valuable information regarding breastfeeding outcomes among Aboriginal women in NWO to inform future research

34. Dissemination • Fall 2011 • Report • Conferences • Publications