Impact of a Formal Lactation Curriculum for Residents on Breastfeeding Rates Among Low-Income Women

Abstract

Obstetrics-gynecology residents have inadequate training in lactation management and are typically unable to address basic breastfeeding needs. A retrospective study was performed to evaluate the impact of a formal lactation curriculum for obstetrics-gynecology residents on breastfeeding. Demographic information, medical history, and breastfeeding rates were derived from medical records and hospital lactation logs. Breastfeeding outcomes of women with term, singleton infants were analyzed before and after curriculum implementation. The study included 717 women, 337 prior to intervention and 380 after intervention. Women who delivered after curriculum implementation were more likely to breastfeed exclusively at 6 weeks postpartum (odds ratio [OR]: 2.01; 95% confidence interval [CI]: 1.28–3.15). A targeted breastfeeding curriculum was associated with increased exclusive breastfeeding rates at 6 weeks postpartum in a diverse, low-income population.

INTRODUCTION

Breastfeeding provides a perfect balance of nutrition for infants and bolsters their immune system. In the United States, thousands of infants are adversely affected by supplementation. Current evidence indicates that formula use is associated with an increased risk of obesity, gastrointestinal disorders, lower respiratory tract infections, childhood asthma, otitis media, atopic dermatitis, sudden infant death syndrome, childhood leukemia, and both type 1 and type 2 diabetes mellitus (Kellams et al., 2017; Baby Friendly US, 2011; Bartick et al., 2017; Bartick & Reinhold, 2010; Gartner et al., 2005; Ip et al., 2007; McNeil, Labbox, & Abrahams, 2010; UNICEF/WHO, 2009). In regard to maternal outcomes, a history of lactation has been associated with a reduced risk of type 2 diabetes, hypertension, metabolic syndrome, and cardiovascular diseases as well as breast and ovarian cancers (Feltner et al., 2018; Gartner et al., 2005; Ip et al., 2007; Ram et al., 2006). Suboptimal breastfeeding, when compared to optimal breastfeeding—90% of mothers exclusively breastfeeding each child for 6 months and continuing to breastfeed for at least 1 year—translates into billions of dollars in unnecessary costs annually in the United States and 3,340 premature maternal and child deaths (Bartick et al., 2017).

Due to the accumulation of data emphasizing the importance of breastfeeding for both maternal and infant health, many health organizations endorse exclusive breastmilk as the ideal form of nutrition for infants for the first 6 months of life and, with the addition of nutritious complementary foods, the continuation of breastfeeding for 1 year or more (Bartick, Stuebe, Shealy, Walker, & Grummer-Strawn, 2009; Gartner et al., 2005; UNICEF/WHO, 2009).

Research has demonstrated that supplemental (non-human milk) feedings in the hospital are a major contributing factor to the premature cessation of breastfeeding by mothers who had originally planned to breastfeed exclusively for 6 months (Kellams et al., 2017; Bartick et al., 2009; Blomquist, Jonsbo, Serenius, & Persson, 1994; Centers for Disease Control and Prevention, 2008; Declercq, Labbok, Sakala, & O'Hara, 2009; Digirolamo, Grummer-Strawn, & Fein, 2001). Unfortunately, in the United States, many healthy newborn infants are supplemented for questionable reasons. The maternity practices in infant nutrition and care (mPINC) surveys in the United States revealed that some maternity units have poor adherence with evidence-based practices and reported practices that interfere with breastfeeding (Centers for Disease Control and Prevention, 2017).

Cattaneo and Buzzetti previously showed that training hospital health professionals on breastfeeding promotion improves health professionals' breastfeeding knowledge, hospital compliance with the “Ten Steps to Healthy Breastfeeding” and patient exclusive breastfeeding rates at discharge (Cattaneo & Buzzetti, 2001). These data support the need for effective training involving both practical skills and counseling (Cattaneo & Buzzetti, 2001). Specifically, obstetricians can be key players in providing breastfeeding education and support throughout the prenatal and perinatal period but they need the appropriate training. Due to lack of breastfeeding training, many physicians are unable to address basic breastfeeding needs (Baby Friendly US, 2011). In a study of postpartum women in 2011, only 25% of women felt that their concern(s) about breastfeeding was addressed during the prenatal period (Archabald, Lundsberg, Triche, Norwitz, & Illuzi, 2011). Previous studies have demonstrated that obstetrics-gynecology residents and practicing physicians do not have adequate training in lactation management (Freed, Clark, Cephalo, & Sorenson, 1995). Another study revealed that a targeted breastfeeding curriculum can help to improve knowledge about breastfeeding as well as increase the rate of exclusive breastfeeding. Residents who underwent a formal lactation curriculum were more likely to perform bedside assessment of breastfeeding practices, counsel mothers regarding breastfeeding issues, and also assist with various feeding techniques (Feldman-Winter et al., 2010).

We hypothesize that an increase in the lactation management knowledge of obstetrics-gynecology residents at a single institution would lead to an increase in the breastfeeding initiation rates and reduce non-medically indicated formula supplementation in the low-income women they serve. Therefore, the aim of our study is to investigate the impact of a formal lactation curriculum on breastfeeding initiation, exclusive breastfeeding rates at the time of discharge from the hospital and at the 6 week postpartum visit in a diverse, low-income population.

STUDY DESIGN

This is a retrospective cohort study evaluating the impact of a formal breastfeeding curriculum on breastfeeding initiation rates and exclusive breastfeeding rates at discharge from the hospital and the 6 week postpartum visit at a community-based clinic that provides care to mostly low-income women located in Lehigh County, Pennsylvania.

Study Population

Mothers who received their prenatal care at our clinic and subsequently delivered healthy, term (≥37 weeks estimated gestational age) infants were included in the study. Patients from two time periods were identified: patients prior to the intervention (January–2010) and patients after the intervention was established (January–2012). Patients were identified by insurance billing codes for vaginal or cesarean births at our hospital by faculty during these time periods. Infants who were admitted in the neonatal intensive care unit and mothers who received seven or fewer visits at our clinic were excluded from the study. Records of all infants who initiate breastfeeding are kept in a log by the lactation consultants at our tertiary care center. These records include a tally of patients who initiated breastfeeding, mode of feeding at discharge, supplementation rates, and the reasons the infants were supplemented. The records from January 2010 to May 2010 (prior to institution of formal lactation curriculum) and from January 2012 to May 2012 were reviewed after the institutional review board approved the study. Chart reviews occurred from July 2013 till November 2014. Data collected included maternal age, mode of birth, tubal sterilizations, maternal co-morbidities (such as preeclampsia, diabetes, mental health diagnosis, medications, HIV, hepatitis, etc.), and demographic characteristics (race, ethnicity, insurance coverage). For each recorded birth, initiation of breastfeeding, supplementation while in the hospital, indication for supplementation (if available), and breastfeeding at discharge was pulled from the lactation consultant records and added to the study database. Finally, the mother's medical record from the 6 week postpartum visit was reviewed to determine exclusive breastfeeding rates.

Intervention

A lactation curriculum was instituted in July of 2010 for obstetrics-gynecology residents at Lehigh Valley Health Network and continued through December of 2014. A previously studied model, Wellstart Lactation Management Self-Study Modules (Wellstart International and the University of California San Diego, 1999) was incorporated into the curriculum. There was an initial pre-test followed by three modules. The first module focused on the importance of breastfeeding as a basic health promotion strategy (Wellstart International and the University of California San Diego, 1999). Topics covered include breastmilk composition, recommendations for and the importance of breastfeeding, and breastfeeding contraindications (Wellstart International and the University of California San Diego, 1999). The second module focused on the functional aspects including anatomy and physiology, position and attachment, duration and frequency of feeding, as well as planning for transition to the home (Wellstart International and the University of California San Diego, 1999). The final module is a series of cases that addressed the common breastfeeding problems including inverted or sore nipples, engorgement, obstructed ducts, mastitis, low supply, contraception, and medical comorbidities (Wellstart International and the University of California San Diego, 1999). We then used a certificate of completion process for the Lactation Management Self-Study Modules (Wellstart International and the University of California San Diego, 1999). This is a free of charge, online examination that consists of 45 short answer questions (Wellstart International and the University of California San Diego, 1999). Examinees who achieve a score of 80% or greater, received a certificate (Wellstart International and the University of California San Diego, 1999). This certificate is then given to the faculty member who is in charge of maintaining the records.

Residents also spent 4 hours per week with the lactation consultants on the postpartum floor to incorporate direct patient interactions. This curriculum was completed during the designated outpatient rotations of the residency. There were a total of 20 residents in the department and 15 residents completed the curriculum at the time the study commenced. Five residents did not complete the curriculum because the initiative began after their year of residency in which outpatient rotation occurs.

We determined that we would need the following participants in order to see a 10% difference post intervention:

1. 301 participants in each arm of the study to find an increase in breastfeeding initiation rates from 69.2% to 79%.

2. 274 participants in each arm of the study to find a decrease from 27.6% to 17.6% in the rate of non-breastmilk supplementation at the time of hospital discharge post birth.

3. 349 participants in each group to find an increase in the rate of exclusive breastmilk feeding from 28.5% to 38.5% at the 6 weeks postpartum visit.

These sample size estimates, use a power of 80% and an alpha level (statistical significance) of 0.05. Based on the sample size calculations above, our goal was to review 350 charts in each arm in order to achieve statistical significance with all outcomes.

Statistical Analyses

Demographic characteristics and indications of maternal health was presented (means, counts and percentages) and compared between the pre- and post-curriculum study groups using chi-square or independent sample t-tests as appropriate. Factors differing significantly (defined as p < .05) between study groups were adjusted for in subsequent analyses.

The proportion of mothers who initiated breastfeeding, who were breastfeeding exclusively at discharge, and who were breastfeeding exclusively at 6 weeks postpartum was compared between pre- and post-curriculum groups using chi-square and odds ratios. Logistic regression was then performed to predict odds of breastfeeding in the post-curriculum period after adjusting for any between-group differences in demographics and/or maternal health. Separate models were generated for each outcome of interest (breastfeeding initiation, exclusivity at discharge, any at 6 weeks, and exclusivity at 6 weeks).

RESULTS

A total of 1037 charts were reviewed, 717 dyads were eligible, 337 were in the pre-intervention group, and 380 in the post intervention group. The mean age was 25 years. Most women were multiparous (64%), unemployed (61%), Hispanic (57%), married or in a stable relationship (76%). There were no significant differences in demographics when comparing the pre- and post-intervention group with the exception of marital status and insurance (Table 1). The pre-intervention group was more likely to be married (p = .001) and less likely to have insurance (p < .001).

TABLE 1. Demographic Representation of the Pre- and Post-Intervention Groups.

Characteristics	Pre-Intervention (n = 337)	Post-Intervention (n = 380)	p Value
Age (years) Mean (±SD)	24.8 (±5.6)	25.2 (±5.6)	.923
BMI (kg/m2) Mean (±SD)	26.3 (±5.9)	27.2 (±6.4)	.098
Gestational age (weeks) Mean (±SD)	39.5 (±1.1)	39.4 (±1.1)	.192
Mode of birth (%)	69.4	67.6	.205
Vaginal	2.4	5.0
Operative vaginal Cesarean	28.2	27.4
Primiparous (%)	37.7	34.6	.392
WIC participants (%)	85.7	84.4	.609
Unemployed (%)	59.1	63.4	.241
Insurance coverage (%)	88.7	99.2	<.001
African American/Black race (%)	11.3	13.5	.609
Hispanic ethnicity (%)	57.8	56.5	.722
Married	81.9	71.0	.001

Note. SD = standard deviation. WIC = The Special Supplemental Nutrition Program for Women, Infants, and Children

There was an increase in exclusive breastfeeding rates at 6 weeks postpartum in the post-intervention group (19.5%) when compared to the pre-intervention group (12.4%), see figure 1.

Figure 1.

Exclusive breastfeeding rates at 6 weeks postpartum were 12.4% in the pre-intervention group and 19.5% in the post-intervention group.

After adjustment for marital status and insurance, women who delivered after implementation of the curriculum had two times the relative odds of breastfeeding exclusively at 6 weeks postpartum compared to those who delivered before implementation of the curriculum (odds ratio [OR]: 2.01; 95% confidence interval [CI]: 1.28–3.15). Another factor that was positively associated with exclusive breastfeeding at 6 weeks postpartum was being in a stable relationship (p = .04). Formal curriculum did not positively impact the number of women who initiated breastfeeding or those exclusively breastfeeding at time of discharge from the hospital.

DISCUSSION

It is widely known that breastfeeding is the preferred method of feeding infants worldwide, both for infant and maternal health. Knowledge about specific breastfeeding benefits, troubleshooting for the immediate and delayed postpartum period, and how to support patient-centered care while encouraging exclusive breastfeeding is not standardized among the providers who care for women and children. A targeted breastfeeding curriculum during obstetrics and gynecologic residency was associated with an increase in exclusive breastfeeding rates at 6 weeks postpartum in this diverse low-income patient population.

While this intervention had a positive impact on exclusive breastfeeding rates at 6 weeks postpartum, it did not positively impact breastfeeding initiation in the hospital or exclusivity rates at the time of discharge from the hospital. It is highly likely that the initiation and supplementation rates would also be affected by the education provided by the nurse caring for the patient during the labor process and at the time of birth/immediately postpartum, as well as the pediatricians or family practitioners caring for the infant. Even with no improvement in these two areas, the overall rate of breastfeeding exclusivity at 6 weeks postpartum was improved. The benefit of resident education may have a longer-term impact and require repeated interactions with patients during their postpartum stay. The patients were not followed long term to evaluate for exclusive breastfeeding at 6 months or continuation until 1 year. These would be important data to assess in future studies to determine whether there was a long-term impact of a formal lactation curriculum.

Our study was able to show a benefit in this specific population but it would be important to study a larger group of women, both private and clinic patients, before and after the implementation of such a curriculum. One limitation is that we did not include pediatric or family medicine residents in our study and these providers have a great deal of interaction with postpartum women and their infants. Another limitation of the study is the inherent issue of time constraints placed upon resident physicians during patient interactions, such as morning rounds and clinic encounters and how this can make counseling on breastfeeding difficult. This study employed a retrospective cohort design, prospective data regarding implementation of a breastfeeding curriculum may complement these results. Interestingly, the pre-intervention group had a significantly higher percentage of mothers who were married, which is known to increase exclusive breastfeeding rates and yet, the post-intervention group still had a higher rate of exclusive breastfeeding at 6 weeks postpartum.

Providing education directly for patients is also imperative for increasing rates of breastfeeding (Dyson, McCormick, & Renfrew, 2005). As many hospitals are becoming “Baby Friendly,” there is a push to educate providers caring for women and children surrounding breastfeeding. In the near future it may be a requirement for obstetrics and gynecology residents to be formally educated in these areas in order to better serve patients. This is also true of labor and birth and postpartum nursing staff. A strength of this study is that we utilized a free and readily available curriculum that can be implemented elsewhere. We believe that with combined efforts for formal education surrounding lactation, expanding beyond just resident training, there will be an increase in exclusive breastfeeding rates and downstream effects on overall infant and maternal health outcomes.

Implications for Practice

Formal education curriculums may help to improve the knowledge base as well as increase provider comfort with topics surrounding breastfeeding. This education should translate into practical skills that can be implemented into clinical practice. Residents, practicing physicians in pediatrics and family medicine, and perinatal health care providers should undergo formal training in an effort to improve breastfeeding rates. Efforts to increase perinatal healthcare providers' breastfeeding knowledge and practical skills may help improve maternal–child health outcomes and reduce health care costs.

Biographies

EMMA J. QURESHEY is a fourth year obstetrics and gynecology resident at the Lehigh Valley Health Network in Allentown, Pennsylvania. She is currently applying for a Maternal Fetal Medicine fellowship.

ADETOLA F. LOUIS-JACQUES is an Assistant Professor in the Maternal-Fetal Medicine Division at the University of South Florida, Morsani College of Medicine in Tampa, Florida. Her research has centered on disparities in lactation and the impact of lactation on maternal health across the life span.

YASIR ABUNAMOUS is a family medicine physician at the Lehigh Valley Health Network in Allentown, Pennsylvania. As a proponent of natural healing, he sees lifestyle measures as the first line of defense in promoting wellness and even tackling early-stage disease. His research interests include trauma-informed primary care and strategies for developing patient and provider resilience and joy in the patient-centered medical home context.

SANDRA CURET is an OBGYN who has been involved in the teaching and training of medical students, OBGYN residents and collaborated in the supervision of advanced practice clinicians.

JOANNE QUINONES is a maternal fetal medicine physician at the Lehigh Valley Health Network. Her interests include recurrent pregnancy loss and maternal complications in pregnancy with a focus on maternal cardiac disease.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.