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LIBRARY
Michigan State
University

 

 

 

This is to certify that the

thesis entitled

Social Support and Breastfeeding
Duration

presented by

Jeanette Jacobs

has been accepted towards fulfillment
of the requirements for

Masters degree inNursing

 

9/ '70
*Linda Beth Tiedje= P D, Rh

Major professor

Date—DacembeLzo,__1.996

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

 

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To AVOID FINES return on or More data due.

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MSU I. An Affirmative ActionlEquol Opportunity lnctltuton

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SUPPORT AND BREASTFEEDING DURATION

BY

Jeanette Jacobs

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree

MASTER OF SCIENCE IN NURSING

College of Nursing

1996

ABSTRACT
SOCIAL SUPPORT AND BREASTFEEDING DURATION
BY

Jeanette Jacobs

Support from professionals and members of one's social
network has been found to be associated with breastfeeding
duration in the literature. The purpose of this study is to
describe the relationship of perceived social support in
mothers who continue to breastfeed and mothers who have
terminated breastfeeding at eight weeks postpartum. Forty-
one women who committed to breastfeed for at least eight
weeks comprise the sample, 31 of these women continued to
breastfeed and 10 of them stopped by eight weeks postpartum.
The results indicate there is no significant difference in
social support and the duration of breastfeeding.
Implications for future research, including more precise
measures of social support are discussed, as well as

implications for Advanced Practice Nurses.

ACKNOWLEDGMENTS

I would like to thank my family for their support and
understanding during the completion of my academic goal. I
would like to thank my employers who made my work schedule
compliment my school schedule; this demonstrated their
commitment to nursing excellence.

I would like to thank my advisor and chairperson, Linda
Beth Tiedje, RN, PhD for the encouragement, help and support
through the completion of this thesis. I would also like to
thank my committee members, Jacqueline Wright, RN, MSN and
Claudia Holzman, PhD for their outgoing support, feedback
and time they devoted to reviewing my thesis.

I would also like to acknowledge Beth Klee, PhD who ran
the data analysis for me and to Sue Peter and Gayle Gross

who did more for me than they realize.

iii

TABLE OF CONTENTS

LIST OF FIGURES . . . . . . . .
LIST OF TABLES . . . . . . . .

INTRODUCTION . . . . . . . . .

Study Purpose and Research
Conceputal Definitions . .

THEORETICAL FRAMEWORK . . . . .

Review of Literature . . .
Summary . . . . . . . . .

METHODS . O I O I O O O O O O 0

Setting and Sample . . .
Protection of Human Rights
Operational Definitions of
Instrument . . . . . . . .
Data Collection Procedures

Question

Variables

Statistical Analysis of Data .

RESULTS 0 O O O O O O O O O O 0

DISCUSSION . . . . . . . . . .

Study Limitations . . . .
Study Assumptions . . . .

Practice Implications for the Advanced

nurse 0 I 0 O O O O O O 0
Future Research . . . . .

CONCLUSION . . . . . . . . . .
LIST OF REFERENCES . . . . . .

APPENDICES . . . . . . . . . .
Appendix A: UCRIHS Approval
Appendix B: Human Subjects Consent
Appendix C: Breastfeeding Attrition Prediction

(BAPT) . . . . . . . . . .

Appendix D: Scoring Guidelines for the BAPT

iv

Form

Practice

Page

UlUlH

. 11
. 20

. 20
. 21
. 21
. 22
. 23
. 24
. 26

. 30
. 31
. 31

. 31
. 33

I 40
. 4O
41

. 4S
. 50

LIST OF FIGURES

Figure
1 The Domain of Social Support . . . . . . .

2 Social Support and Breastfeeding Duration .

LIST OF TABLES

Table Page
1 Background Characteristics . . . . . . . . . . . . . . 28
2 Social Support in Breastfeeding and Bottle Feeding

Mothers at Eight Weeks Postpartum . . . . . . . . . . 29

vi

INTRODUCTION

Breastfeeding, once the most accepted method of infant
feeding, declined significantly in the United States in the
middle of this century. It is estimated that in 1946 the
number of U.S. women leaving the hospital breastfeeding was
38%. By 1956 this percentage decreased to 21% and to 18% by
1966 (Guthrie 8 Guthrie, 1966; Meyer, 1968). Although the
1980s brought an increase in breastfeeding from 1960 rates,
the incidence of breastfeeding of newborns declined from
59.7% in 1984 to 52.2% in 1989 (Freed, 1993). In the United
States in 1981 and 1988 61% and 54% of women were
breastfeeding upon discharge from the hospital respectively;
however only 27% and 21% continued to breastfeed for six
months (Martinez, 1984). The Healthy People Report of 1988
stated 54% of mothers were breastfeeding at the time of
discharge from the hospital. This rate varies considerably
with income, ethnicity and cultural factors with 32% of low
income mothers breastfeeding at the time of discharge from
the hospital; 25% of African-American mothers; 51% of Latino
mothers; and 47% of Native American mothers. Overall 21%
continued to breastfeed for 5-6 months.

In the Healthy People 2000 report (1990) the U.S.
Secretary of Health and Human Services set new goals for
breastfeeding in the United States to increase to at least
75% the proportion of mothers who breastfeed their infants

in the early postpartum period and to at least 50% the

1

2
proportion who continue breastfeeding until their infants
are five to six months old. The purpose of this study is to
describe the differences in perceived social support
measured after delivery and at eight weeks postpartum
between mothers who breastfeed and mothers who begin and
then terminate breastfeeding.

According to the World Health Organization, the
American Academy of Pediatrics, American Public Health
Association, and other health care authorities,
breastfeeding is the best way to nourish young babies (Hall,
1978). The benefits of this form of infant feeding for at
least six months for both the infant and the mother have
been widely recognized (Brown, Paige, & Chwalow, 1991).
Breastfeeding is one of the most natural and best forms of
preventive medicine (Yeung, Pennell, Leung, & Hall, 1981).
Breastfed infants have lower rates of hospital admissions,
ear and respiratory infections, diarrheal illnesses, and
atrophic skin disorders than their bottle fed counterparts
(Freed, 1993).

Attempts to identify the multiple, complex and changing
variables that are associated with continuation of
breastfeeding have resulted in extensive lists of modifiable
and nonmodifiable factors (Janke, 1994). Lawrence (1985)
states attrition most often occurs during the first six
weeks after birth with anywhere from 32 to 58% of
breastfeeding women prematurely switching to formula. It is

unclear why such a rapid decline in breastfeeding occurs

3
during the initial postpartum period (Buxton, Gielen, Faden,
Brown, Paige, Chwalow, 1991). The American Academy of
Pediatrics (1982) has researched the causes of early weaning
of infants to formula, such as; mother's perceived
inadequacy of milk supply, nipple soreness and
hyperbilirubinemia. They have recommended and emphasized
the benefits of breastfeeding as the preferred method of
infant feeding for the first six months of life.

Other researchers have attempted to identify factors
that may influence the continuance of breastfeeding and
reduce the attrition rates in the breastfeeding population
(Wright 8 Walker, 1983; Lawrence, 1985; Morgan, 1986;
Tulloch, 1995). Among the factors studied is the influence
of health care professionals. Page and Goertz (1989)
suggest that health care professionals should recognize the
importance of timely breastfeeding education and
anticipatory guidance in order to help delay a mother's
decision to discontinue breastfeeding. In order to increase
support of breastfeeding, key people must also provide
support. Social support for nurses, physicians, support
groups, family, and friends has also been related to
breastfeeding continuance (Saunders & Carrol, 1988;
Baranowski, Bee, Rassin, Richardson, Brown, Guenther, &
Nader, 1983). Social support can be provided by family,
friends, and health care professionals. Key people may vary
also by ethnic group (Baranowski et al., 1983). Lack of

knowledge and lack of support are often cited as the two

4
biggest hindrances leading to early termination of
breastfeeding (Ladas, 1970).

Continuation of breastfeeding has been related to a
variety of variables; ranging from social, personal and
physiological. Demographic variables such as maternal age,
socioeconomic status, occupation, level of education,
parity, type of delivery, information and knowledge of
breastfeeding and previous breastfeeding experience have all
been related to continuation of breastfeeding (West, 1980;
Janke, 1988; Wright & Walker, 1983). Problems with
breastfeeding in the first few weeks postpartum have also
been associated with breastfeeding continuance. Problems
investigated have included incorrect latch-on/such,
sleepy/fussy baby, infant weight loss, maternal concerns
about insufficient milk and nutritional value of breast
milk, sore nipples, breast engorgement, fatigue and an
unsatisfied infant (Kearney, Cronenwett, & Barrett, 1990).

Although there are many factors associated with the
continuance of breastfeeding, this study will examine only
one of them, perceived social support and its influence on
breastfeeding duration. Many experts have stated that
support is essential for successful breastfeeding. However,
little agreement exists about what type of support or what
amount of support best facilitates successful breastfeeding.
Duration of breastfeeding related to social support will be

the focus of this study.

5
S! i E i E l i l'

The purpose of this study is to describe the
relationship between social support and the early
termination of breastfeeding during the first eight weeks
postpartum. The primary question addressed is:

Are there differences in perceived social support
measured at delivery and at eight weeks postpartum between
mothers who breastfeed and mothers who begin and then
terminate breastfeeding?

: l J E E' 'l'

The terms used in this study are conceptually defined
as follows:

Breastfeeding_duzatign. Breastfeeding an infant on
demand (which usually means intervals of 2-5 hours between
feeds, 8-12 times per day) with complementary bottled milk
or water being rarely used and no solid foods being
introduced for the first eight weeks of life (Freed,
Landers, Schanler, 1991).

Demand feedings encourage breast stimulation for milk
production and sufficient infant intake. Supplemental
feedings or solid food feedings should be avoided because
they can suppress milk production. Newborns demand feedings
every 1.5 to 3 hours throughout the day and night (Freed,
Landers, Schanler, 1991). Long intervals between feedings
should be discouraged in order for mother and baby to
practice the techniques of breastfeeding and build an

adequate milk supply for the infant's need. As the

6
breastfeeding experience progresses, longer intervals
between feedings will occur.

sggial_§nppgzt. The relative presence or absence of
psychosocial support resources from significant others
(Kaplan & Cassel, 1977).

Social support is the enduring interpersonal ties to
people who can be relied on to provide emotional,
instrumental, informational and appraisal support, help and
reassurance in times of need (Caplan, 1974). Social support
is likely to be useful to the individual only to the extent
it is perceived as supportive (Hughes, 1984). Health care
practitioners can be sensitive to the existence or
availability of people on whom the breastfeeding dyad can
rely; people who let them know that they are cared about,
valued and loved. Social support can be provided by many
sources: family, friends or health care providers.

THEORETICAL FRAMEWORK

The Social Support Theory (House & Kahn, 1985) serves
as the theoretical framework of this study. The Social
Support Theory is a multidimensional concept which defines
people as interpersonal resources who provide gratification
of basic human needs in relationships (Figure 1). Social
support is sometimes defined conceptually in terms of the
existence or quantity of social relationships. House (1981)
describes social support as an interpersonal transaction

involving one or more of the following: 1) emotional

 

a. Existence
b. Quantity

Social relationships

The Domain of Social Support

 

 

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Social support.
a. Type
D. Source

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Size

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. Multiplexity
. Reciprocity

. Durability
Intensity

. Frequency

. Dispersion
Homogeneity

 

 

 

Figure 1

Health

.____..__——————.—n——___——.—.————__.——_—.

8
support; 2) instrumental support; 3) informational support;
and 4) appraisal support.

Emotional support provides empathy, caring, love and
trust. This type of support sustains self-esteem by
reinforcing an individual's feelings of self-worth. The
supportive person acts as an advocate. Offering emotional
support includes providing comfort, sharing emotional
burdens through sympathy or empathy, providing
encouragement, and expressing concern. The desired outcome
of these behaviors is to foster feelings of comfort and lead
an individual to believe that s/he is admired, respected,
and loved, and that others are available to provide caring
and security (Jacobson, 1986).

Instrumental support directly helps the person in need
by taking over chores or duties. Within this context are
activities that provide needed goods and services (House,
1981).

Informational support helps people help themselves by
giving them information they can use in dealing with
personal and environmental problems. Informational support
includes giving advice and gaining access to new knowledge
(House, 1981).

Appraisal support is the transmission of information
relevant to self-evaluation. Appraisal support is similar
to informational support in that it gives information;
however, it is more like coaching.‘ By watching goal-related

activities, the supporter is able to provide guidance that

9
includes positive reinforcement and an honest appraisal of
shortcomings with appropriate correction or comfort. The
intent of all these types of support is to provide a buffer
or have a cushioning effect so that the recipient maintains
strength or endures (House, 1981).

Social Support Theory provides a general framework for
considering breastfeeding interventions which can be used by
health care practitioners in attempting to reduce the risk
of early weaning and therefore extend the duration of
breastfeeding. Recognizing that Social Support Theory is
helpful is not to suggest that it is prescriptive in nature.
The components of social support are overlapping and dynamic
and are therefore difficult to study in isolation from each
other.

Aware of this complex dynamic of social sUpport, the
health care practitioner can act as an advocate in
supporting the breastfeeding mother by reinforcing the
mother's feeling of confidence. Encouragement may be given
through functional support in the basics of breast functions
and expressing concern for success in breastfeeding. The
health care practitioner, as a counselor, can also enhance
the functioning of the social network by intervening to
assess and evaluate the effectiveness of actions that
increase breastfeeding duration. Social Support and its
relationship to breastfeeding duration is pictured in Figure
2. Antonucci (1986) theorizes supportive behaviors engaged

in by different support providers may be differentially

 

S

3 Significant
Others

Healthcare
Providers

Society in
General

xmoE-Imz 4:101:

 

 

 

 

 

adequate amount of support —)

inadequate amount of support — — —)

Figure 2 .

 

Social

Support _

 

 

10

of

Social Support and Breastfeeding Duration

Brés?e§dihg

   

   
    

Discontinuingg;
Breastfeeding

 

11

perceived and differentially effective in the support
relationship. Support perceived to be available may be more
consistently related to positive outcome measures than
support actually received (Cohen 8 Wills, 1985; Kessler 8
McCloud, 1984; Wethington 8 Kessler, 1988). The most active
ingredient of social support may be individuals' beliefs
that they have people who value and care about them and who
are willing to try to help them if they need assistance or
other support (Sarason, Sarason 8 Pierce, 1990). A
supportive, accepting environment that encourages new
behaviors like breastfeeding is likely to be conducive to
the individual developing new skills, enjoying contacts with
others, and not catastrophizing when confronted with failure
or roadblocks (Sarason, Sarason 8 Pierce, 1990). The Social
Support Theory potentially assists the health care provider
in making a more systematic clinical assessment of the
breastfeeding mother's social network. Such a social
support assessment may lead to clinical judgements about
deficits, strengths and untapped resources to move her
toward behaviors potentially leading to increased duration
of breastfeeding through encouragement to do so from the
support network.
E . E 1.! l

While the recent increase in the incidence of
breastfeeding in the United States is encouraging, early
termination of breastfeeding remains a problem that is

poorly understood (Coreil 8 Murphy, 1988). Researchers have

12
found that little attention has been given to supporting
breastfeeding women after hospital discharge even though
organizations such as The La Leche League has been very
active in promoting breastfeeding. Although many authors
have recommended support after hospital discharge and a
significant number of breastfeeding women indicate a need
for breastfeeding assistance, only a few reported studies
have addressed the issue of systematically prolonging
breastfeeding (Saunders 8 Carroll, 1988). It is believed
that breastfeeding for six months or more is dependent on
multiple factors relating to the mother, the infant, and to
the supporting environment (Loughlin, Clapp-Channing,
Gehlbach, Pollard 8 McCutchen, 1985).

Increasing evidence suggests that social support
provided by one person or group of persons helps the mother
breastfeed for a longer time. Familiar and professional
support may also be important factors in both the rates of
initiation and eventual duration of breastfeeding (Freed,
Fraley 8 Schanler, 1992). Although studies linking
particular kinds of social support with breastfeeding are
few, Saunders (1988) states consistent support should be
provided to breastfeeding mothers so that both the incidence
and the duration of breastfeeding can be increased.

The application of Social Support Theory for empirical
research has provided insight into the potential impact of
specific variables on the breastfeeding experience. The

literature in many instances combines the types of support

13
(emotional, informational, instrumental and appraisal)
because one type of support often builds on another type of
support which enhances positive outcomes for the
breastfeeding dyad. It is difficult to separate these types
of support and measure them.

It is also diffiCult to separate professional from
family support. Some studies have attempted to assess the
impact of the health care provider's support on duration of
breastfeeding. Hall (1978) studied the influences of
professionals and education on the breastfeeding success of
40 women who gave birth in one community hospital. The
study participants were divided into one of three groups.
Group I (n=12) was mothers receiving routine hospital care;
Group II (n=13) was mothers receiving the routine care plus
a slide/tape presentation on breastfeeding andpa pamphlet to
take home; and Group III (n=15) was mothers receiving the
slide/tape and pamphlet teaching plus expert nursing
support. Nursing support was defined as giving guidance and
strength, providing relief from mental anguish and relating
an attitude of understanding and reassurance as well as
praise and encouragement. Minimum support was
operationalized as being with the mother at least once while
she was breastfeeding in the hospital, a visit or call each
day in the hospital, and calls home at one and two days and
one week postpartum. The results were that 80% of the Group
III mothers were breastfeeding at six weeks postpartum

compared with 50% of Groups I and II mothers. The

14
weaknesses of this study were that the study sample was
small and social support from other non-professional people
was not assessed or controlled.

Others have examined social support from only family
sources. Beske and Garvis (1982) identify factors that
influence a mother's decision to breastfeed, to wean, as
well as, when such decisions are made. Questions they
formulated for their study were “who or what are the sources
of encouragement and discouragement for breastfeeding?'.
The 94 participants were selected by convenience sampling
from a Minneapolis hospital. Data were collected using a
structured questionnaire developed from the study and
completed by the participants at three different times.
Results indicated the infant's father and the infant were
the predominant sources of encouragement for breastfeeding.
The infant influenced weaning the greatest in the long term
breastfeeders; the father in the short term breastfeeders.
Participants identified the greatest sources of verbal
discouragement to be the paternal grandmother, the maternal
grandmother and other family members and friends. Physical
discouragement was caused by reasons such as sleepy baby,
nipple tenderness, and difficulties in positioning for
comfort and modesty. Important to this study is the
identified value of consistent encouragement of both the
infant and the infant's father as influencing breastfeeding
duration. The key component of premature weaning was also

linked to the maternal and paternal grandmothers'

15
discouragement of breastfeeding. A failure to have
assessment of professional encouragement (social support)
for breastfeeding was the weakness of this study.

Coreil and Murphy (1988) studied the influence of
social support from family and friends on the introduction
of formula supplements. They conducted a longitudinal study
of 44 breastfeeding mothers. The sample of 44 mothers drawn
from childbirth education classes were Caucasian, middle to
upper class and married, with a median of 14 years of
education. Intended duration correlated strongly with
maternal confidence. Formula supplements were inversely
related to social support from family and friends. The
results of the study suggest that the lack of a supportive
environment for breastfeeding may influence mothers' use of
formula supplements. The emotional support of reinforcing
positive attitudes toward breastfeeding by the family
members and friends may be the most effective way to help
mothers breastfeed for a longer period of time. Again
professional support sources were not assessed in this
study.

Sloper, McKean and Baum (1975) studied patients on a
single maternity ward over nine 20 week periods to determine
the influence of professionals (e.g. nurses and M05) on
mothers' decisions to breastfeed and their breastfeeding
duration. The data for the study were collected using
questionnaires that were given to breastfeeding mothers at

hospital discharge, at three months, and again at eight and

16
one half months. The results indicated that the emotional
social support of the nursing staff and health professionals
(MD or midwife) caring for the mother did increase the
number of mothers initially breastfeeding their infants;
however, it did nothing to prevent the rapid decline in
lactation after hospital discharge. The researchers found
factors other than social support, e.g. how a mother had
been fed herself and her socioeconomic status, influenced
duration of breastfeeding most significantly. Social
support from family and friends was unmeasured in the study.
This is a limiting aspect of the research.

Kendall-Tackett and Sugarman (1995) studied 179 women
who breastfed one or more babies past the age of six months.
They used a closed-ended self administered 96 item
questionnaire and asked the women to rate the impact of
partners, friends, relatives, employers, strangers,
lactation consultants, and members of La Leche League (LLL)
on the women's feelings and behavior related to
breastfeeding. Nurses, physicians and other health care
providers were not included in the list of people to be
rated. Mother-to-mother support in breastfeeding had the
highest impact on breastfeeding with the LLL leaders and
members being very positive toward their breastfeeding
experience. A lower, but still large, percentage of women
indicated that their spouse or partner was ”very positive"
toward their breastfeeding experience. Negative responses

were from relatives and strangers. In this study there was

17
a strong positive association between perceived amount of
social support and positive breastfeeding outcome measured
by the positive responses and comments about the
breastfeeding experience from the women in the sample. The
study also combined personal and professional support
sources.

Bryant (1982) studied the impact of kin, friend and
neighbor networks to further assess social support on infant
feeding practices. Bryant interviewed a sample of 76
families in Florida, divided almost evenly among Puerto
Ricans (n=28), Cubans (n=28) and Anglo-Americans (n=20).
Anglo-Americans participants viewed their husbands and
friends as having the most significant impact on their
feeding decisions as well as the duration of breastfeeding
and rarely looked to their mothers for advice. For Puerto
Ricans and Cubans, however, mothers were the key members of
the extended family consulted on infant feeding and duration
of breastfeeding, although husbands were responsible for
most other family decisions. Professionals were not
included as offering social support for breastfeeding in
this study. The results did indicate culture does affect
the influence of social support on infant feeding.

Neifert, Gray, Gary and Camp (1988) studied a subset of
60 primiparous breastfeeding adolescents regarding the
influences of several factors on their duration of
breastfeeding. The variables examined related to the

duration of breastfeeding were maternal age, ethnic group,

18
education level, involvement of the infant's father, timing
of the breastfeeding decision, intended duration of
breastfeeding, age at which formula supplements were
initiated, and availability of maternal support. None of
these variables were found to be predictive of breastfeeding
duration. Adolescent breastfeeding may have additional
factors which affect it and deserves further study.

The influence of social support on lactation duration
was studied in postpartum women by McNatt and Preston
(1992). The researcher mailed questionnaires to a
convenience sample of 45 primiparous lactating women from a
southeastern Connecticut community hospital at six weeks
postpartum to measure their perceived informational social
support and its influence on lactation duration. Also
evaluated by researchers were the size and structure of the
participants' personal support networks. Subjects were
asked to share their thoughts and feelings regarding
breastfeeding. The results of the study indicate that
increasing a woman's informational support network to
include qualified professionals may increase the duration of
the mother's breastfeeding experience.

Saunders and Carrol (1988) also studied the impact of
postpartum breastfeeding support on breastfeeding duration.
The results of the study were that the experimental group
offered informational support breastfed consistently longer
than the control group, with 80% of the experimental

participants breastfeeding at four weeks and 50% at 16

19
weeks. Of the subset of the experimental group members who
received all three activities offered (n=36), 95% of these
women were breastfeeding at four weeks and 67% at 16 weeks.
The results of the study suggest the importance of
professional informational support as a contribution to
breastfeeding duration but did not assess family or friend
support.

. West (1980) studied factors influencing the duration of
breastfeeding. Participants in her study were mothers
(n=239) who were breastfeeding upon hospital discharge who
had delivered mature, healthy babies. The mothers were
followed up by means of a mailed questionnaire when their
infants were six months old. Questions were asked about the
duration of breastfeeding, the timing and reasons for any
supplementary feedings in the first three months, and the
factors responsible for discontinuation of breastfeeding.
Women were also asked whether they enjoyed breastfeeding,
whether they had received enough support and whom they had
consulted about their problems. The results indicated
breastfeeding duration was significantly influenced by
assistance and emotional support to the breastfeeding woman
by relatives, professionals and breastfeeding support groups
which contributed to overcoming her problems. This is one
of the few studies which included social support from all

three groups (professionals, family and friends) in the

results.

20
Summary
The research literature does not categorize the
concepts of social support to breastfeeding mothers as
discrete entities of emotional, informational, instrumental
and appraisal support; it often describes social support as
a constellation of support activities. Social Support is
generally thought of as a good thing. Social Support from
relatives, friends and health care professionals often is
not clearly differentiated in the literature or when it is,
includes support from just one of these sources.
Conclusions drawn from these studies are often not
generalizable to a larger population because samples are
small for most studies done with white middle class women.
A woman's concerns about lack of social support have been
identified as barriers in duration of breastfeeding.
Studies also suggest many other things defined as
informational social support such as previous experience,
infant factors, and a strong commitment/confidence in
ability to breastfed interact to contribute to lengthening
breastfeeding duration.
METHODS
The purpose of this study is to describe the
differences in perceived social support measured after
delivery and at eight weeks postpartum between mothers who
breastfeed and mothers who begin and then terminate

breastfeeding.

21
W

This study is based on a secondary data set. A
convenience method of nonprobability sampling of 60 women
was used in the original study. The study was conducted in
1995 at a 650 bed tertiary care hospital in the Midwest on
the low risk postpartum unit. The hospital delivers 3,500
births a year.

Women who met criteria for inclusion in the study were
those who: 1) had given birth to a healthy term infant, 2)
spoke English, 3) planned to breastfeed for at least eight
weeks, 4) were primigravidas, and 5) were between the ages
of 18-40 years. Of the 340 women giving birth during the
one month study period, 100 met the criteria for inclusion
in the study, 60 consented to participate with a 60% overall
response rate. Eight weeks follow up data were obtained
from 41 women yielding a 32% lost to follow up rate.

E | l' E n E' I!

The research investigation was determined to pose no
risks to the physical, social, or emotional well-being of
its participants. The research proposal was approved by the
Wayne State University Committee for Protection of the
Rights of Human Subjects (#H 02-19-95(B03)-ER) and Michigan
State University committee for Protection of the Rights of
Human Subjects (96-396). Approval to conduct the study was
also granted through the internal Human Subjects Review
Board and Nursing Research Committee of the large, nonprofit

community medical center where the study was conducted (SJ

22
0295-01). To protect the rights of the participants, the
consent form (Appendix A) explaining the study as well as
the legal rights of the subjects was read, signed and a copy
presented to each of the study participants. The
confidentiality of the information and the voluntary nature
of the participation of all subjects were emphasized.

Operational definitions of breastfeeding duration and
social support are:

Breastfeeding was defined as: 1) any mother who
breastfed after delivery and planned to continue to
breastfeed; and 2) any mother who was still breastfeeding at
eight weeks postpartum. This was assessed by The
Breastfeeding Attrition Prediction Tool (BAPT) in question
#95 “What is the primary method of infant feeding you are
using with your new baby?”

Social Support was defined as the 13 subjective norm
items on the BAPT (questions 72-84) that focus on the
mother's perception of the desire by individuals or groups
(the baby's father, your mother, your doctor, etc.) for her
to breastfeed multiplied by how much she values the opinion
of those individuals or groups related to her feeding choice
(“care very much" to “do not care at all") . The BAPT was
completed at delivery and at eight weeks postpartum. Valued
opinion was considered a proxy for social support in this

study.

23
Instrument

The instrument used for the research study was the
Breastfeeding Attrition Prediction Tool (BAPT) developed by
Janke, (1994) (Appendix B). The tool was developed based on
the constructs of attitude, subjective norm and control of
the Theory of Planned Behavior (TPB) (Ajzen, 1985; Ajzen 8
Madden, 1986).

The BAPT consists of a two-part questionnaire. The
first part.measured the TPB constructs of attitude,
subjective norm and control using six-point summated rating
scales, and the second part consisted of a demographic
questionnaire (See Appendix C).

The Social and Professional Support Subjective Norm
Scale score was produced by multiplying each of the 13
belief statements (#72 to #84) by its corresponding
motivation to comply statement “do not care at all" (1) to
“care very much? (6). The six-point summated rating scale
format for the belief scores had anchors of “definitely
breastfeed” (1) to “definitely not breastfeed” (6) and “not
applicable” (0) in response to the statement, “For each of
the following individuals indicate how much they want you to
breastfeed," The anchors for the corresponding question
“How much do you care about the following people's opinions
on how you should feed your baby?” Were “do not care at all”
(1) to “care very much” (6) and “not applicable” (0) . Each
belief statement was multiplied by the corresponding

motivation to comply statement as follows: 30, 72; 31, 73;

24

32, 74; 33, 75; 34, 76; 35, 77; 36, 78; 37, 79; 38, so; 39,

81; 40, 82; 41, 83; and 42, 84. The sum of the multiplied

scores on the paired items produced the Social and

Professional Support Subjective Norm Scale score. The

higher the score, the greater the support of breastfeeding.

See Appendix C for the Scoring Guidelines for the BAPT.

The instrument's content validity was determined by a
panel of ten nurse lactation experts. The instrument's
overall reliability was .80 (Cronbach's alpha) when the
instrument was developed (Janke, 1994).
WWW

To implement the study, the following steps were taken:
1. Participants were breastfeeding primiparous women who

met the study criteria, who were hospitalized on a

postpartum unit of a large community medical center,

and who were at least eight hours post-delivery.

2. Prospective participants were informed of the format of
the study. The voluntary nature of the participation
was stressed as was the fact that the woman's decision
to participate or decline participation would in no way
affect her care while in the hospital or her
breastfeeding follow-up care.

3. Participants were informed that all data collected
would remain confidential and that they would be
identified on their questionnaires only by code
numbers. No adverse consequences were anticipated.

Informed consent was obtained. Participants returned a

25
copy of their signed consent describing the study and
were given their own copy of their signed consent
describing the study.
The Breastfeeding Attrition Predication Tool (Janke,
1994) was completed in privacy by each participant
after the investigator fully explained the directions
and answered any questions. The completed tool was
then sealed in a blank envelope by the participant and
was collected by the investigator the same day.
At the time the initial BAPT was completed in the
hospital, the participant was asked to place a copy of
the BAPT with her code number inscribed on it along
with a stamped envelope addressed to the investigator
into a second stamped envelope on which the participant
was asked to write a valid address where the envelope
would be mailed to her in eight weeks. Lastly, the
participant was asked to complete a third envelop with
a valid addressed to be used to mail a second BAPT at
ten weeks postpartum only in the event that the first
mailed BAPT was not received by the investigator. The
second and third envelopes discussed were collected by
the investigator when she picked up the initial
completed BAPT.
Seven weeks after the delivery of the participant's
infant, the investigator mailed the self-addressed

envelope containing the BAPT, and the stamped envelope

26

addressed to the investigator to return the completed

BAPT.

7. The participant was asked to respond to the BAPT with
the private code number inscribed on it; place it into
the stamped envelope addressed to the investigator, and
mail it to the inVestigator. The investigator's
private work telephone number was included in the BAPT
so that questions could be answered. The participants
were asked to refer to themselves only by code number
in the event that they called with questions.

Forty-one of the returned questionnaires were complete
enough to be utilized in this study. The final sample of 41
mothers contained 31 still breastfeeding at eight weeks
postpartum and 10 who were bottle feeding.
SIaLiatinal_ADAl¥fiifi_Q£_Data

This was a descriptive study. Basic descriptive
statistics, frequency counts were computed for the study
variables. Descriptive statistics were utilized to analyze
characteristics of the sample. Sociodemographic data were
used and included age, ethnicity, income, and education.

Social Support scores were computed at birth and eight
weeks postpartum for women who continued to breastfeed at
eight weeks and those who began but terminated
breastfeeding. The mean scores of the two groups were
analyzed for statistical significance using the t-test. The
t-tests were used because, despite differences in the group

size, the variances were approximately equal. The t-test

27
analysis is a statistical test used for analyzing the
difference between two means (Hungler 8 Polit, 1991). Data
were analyzed using the SPSS-PC statistical program.
RESULTS

Forty-one completed and returned the questionnaires and
were the subjects of this report. Of the 41 mothers
participating 31 (75.6%) continued to breastfeed and 10 who
began breastfeeding were bottle feeding at eight weeks
postpartum.

See Table 1 for the sample background characteristics.
Table 1 states the maternal variables of age in years,
education in years and income for the breastfeeding mothers
and the bottle feeding mothers at eight weeks postpartum.
It also states the baby variables of birth weight in pounds
and how soon after birth in hours the babies were breastfed
for the breastfeeding mothers and the bottle feeding
mothers. The demographics of the sample revealed no
statistically significant differences on these variables
between the group of breastfeeding and bottle feeding
mothers.

The question asked in this study centers on the
differences in perceived social support measured after
delivery and at eight weeks postpartum between mothers who
breastfeed and mothers who began but terminated
breastfeeding. The BAPT score of the two respondent groups
is reported in Table 2. There were no significant

differences in the two groups at birth (t=.20, df=38, p=.84)

28

 

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30
and at eight weeks (t=.31, df=38, p=.76) in social support
levels.
DISCUSSION

This study revealed no difference in perceived social
support measured after delivery and at eight weeks
postpartum between the women who breastfed and the women who
began but terminated breastfeeding. This may be in part due
to the test instrument. The BAPT may not be a valid measure
of social support provided to the breastfeeding mother.
Certain activities which might relate to emotional,
instrumental, informational, and appraisal support from the
social support network were not addressed on the BAPT tool.
Perhaps separate perceived support scales for each group of
support providers listing specific activities would be more
appropriate to measure specifically the type of-social
support affecting breastfeeding duration. The BAPT measured
valued opinion rather than social support.

Both groups started out breastfeeding so initial
differences in social support might be hard to show since
both groups were initially similarly breastfeeding and
similar in social support. Since social support changes
slowly, differences at eight weeks would be impossible to
capture. Social support may influence initiation of
breastfeeding. Using groups would begin to breastfeed and
stop makes it difficult to sort out how support influences

how long a mother breastfeeds.

31

E! i I' 'l ll

Results of this small sample of mothers are not
generalizable to represent breastfeeding mothers as a whole.
The population at a 650 bed tertiary care hospital on a low
risk postpartum unit are different from the population as a
whole. Data were limited mainly to Caucasian, middle class,
primigravida females. The reasons mothers gave for not
continuing to breastfeed were not available. Therefore,
conclusions regarding these reasons are beyond the scope of
this study. Breastfeeding support was measured more as a
valued opinion, so a real measure of all aspects of social
support is needed.
We

The following assumptions were identified for the
purpose of this investigation:
1. Breastfeeding attrition occurs most often in the first

eight weeks postpartum.
2. Social support is not a single phenomenon but is a

cluster of factors that act together.
3. The perceived self reported data were'accurate.

Ii I 1i |° E II E1 1 E l' H

The results of this study have many implications for
nursing. Although the study showed no statistically
significant differences between social support and duration
of breastfeeding, the Advanced Practice Nurse can still
benefit from the study in better understanding the

complexity of social support and the continuance of

32
breastfeeding. The Advanced Practice Nurse can assist by
educating women about normal adjustments necessary to
becoming a successful breastfeeding dyad. Advanced Practice
Nurses can further assist the breastfeeding dyad by
promoting breastfeeding and have an understanding of the
importance and intricacies of social support. Advanced
Practice Nurses study of social support (informational,
emotional, instrumental and appraisal) has a high
probability of improving health care to the breastfeeding
mothers and families. Advanced Practice Nurses can also
study other factors that influence breastfeeding
continuance.

Additionally, tools used for assessing social support
can improve upon the BAPT. The BAPT clearly measures how
much opinions are valued. A better measure of true social
support related to breastfeeding is needed for research and
clinical practice. A tool designed as a checklist using the
theoretical definitions of social support as described by
House (1984) could serve as the framework for asking the
women to identify her interpersonal support system. This
would include: 1) the nature, strength, kind and the
availability of this support; 2) a definition of her role
obligations; 3) an indication of the amount of support
available to meet these role obligations during
breastfeeding; 4) the woman's patterns of social
affiliation; and 5) a woman's need for social affiliation

during her breastfeeding experience.

33
£utnrs.Researsh

This investigation opens several possibilities for
future research. These include the following: 1) accessing
a larger, more heterogeneous, randomly selected sample to
reveal differences between perceived support and
breastfeeding duration at eight weeks; 2) use of another
tool to measure social support; the BAPT is not a valid
measure of all kinds of social support (emotional,
instrumental, informational, and appraisal); 3) development
of a tool for nurses and lactation consultants to assess a
breastfeeding social support after delivery.

This sample was homogeneous with regard to
breastfeeding intention, healthy baby and first birth.
Using a larger, random sample of breastfeeding mothers in a
primary care setting would improve the variability, and the
generalizability of this study. This, along with a more
valid measure of social support may help to determine if
there are differences between perceived support and
lactation outcome.

Using another more valid scale to determine what kinds
of support are needed and helpful to the breastfeeding is
recommended. The Hughes Breastfeeding Support Scale
(Hughes, 1984) could be used to better measure a lactating
woman's social support (emotional, instrumental, and
information support). Personal and professional aspects of

support should always be included in a comprehensive social

3 4

support assessment. The use of a more valid tool may help
in explaining differences in breastfeeding duration.

Breastfeeding is a complex process affected by many
variables. A more multivariate model might help to identify
and clarify the relationship between breastfeeding outcome
and all variables. Social Support in and of itself although
important must be considered as a part of a constellation of
variables affecting breastfeeding duration. Other factors
such as awareness of the physical and psychological benefits
for the infant (Lawrence, 1985; Hall, 1978), milk supply,
and infant factors (hyperbilirubinemia) need to be
considered. Studying heterogeneous samples of women of
different cultures and ethnic backgrounds (Wright, Holberg,
8 Taussig, 1988) would also be helpful.

CONCLUSION

The results of this study have implications for the
Advanced Practice Nurse whose practice includes
breastfeeding mothers. By utilizing these findings and
developing more valid tools to explore a breastfeeding
woman's support network, lactation specialists and other
health care providers may potentially find what is most

helpful in increasing breastfeeding duration.

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APPENDICES

APPENDIX A

UCRIHS Approval

40

MICHIGAN STATE

fl

UNIVERSITY

 

November 6, 1996

TO: Jeanette Jacobs
60353 Shawnee Ln.
Washington, MI 48094

RE: 1R8“: 96-396
TITLE: SOCIAL SUPPORT AND BREASTFEEDING DURATION
REVISION REQUESTED: 10/21/96
CATEGO Y: l—E
APPROVAL DATE: 08/02/96

The University Committee on Research Involving Human Subjects'(UCRIHs)
review of this preject is complete. I am pleased to adVise that the
rights and welfare of the human subjects appear to be adequately

rotected and methods to obtain informed consent are appropriate.
Therefore, the UCRIHS approved this project and any reVisions listed
above.

RxWxWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project bexond one year must use the green renewal
form (enclosed with t e original agproval letter or when a
project is renewed) to seek ggdate certification. There is a
maximum of four such expedit renewals ssible. Investigators
wishing to continue a project beyond the time need to submit it
again or complete rev1ew.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the reen renewal form. To
revise an approved protocol at an 0 her time during the year,
send your written request to the CRIHS Chair, requesting revised
approval and referencing the project's IRB u and title. Include
in your request a description of the'change and any revised
instruments. consent forms or advertisements that are applicable.

 

PROBLEMS]
cannons: Should either of the following arise during the course of the
work, investigators must noti UCRIHS romptly: (1) roblems
my (unexpected side effects comp aints, e c.) involving uman
RESEARCH . subjects or (2) changes n the research environment or new
information indicating greater risk to the human sub ects than
Aflg existed when the protocol was previously reviewed an approved.
GRADUA
STUDIES If we can be of any future hel , lease do not hesitate to contact us
_ at (517)355-2180 or FAX (Sl7)4 2- 171.
thmflNCuMMMnee
quunauummn
Human 30M Sincerel

   
     
     

A . David B. Wri ht. Ph.D.
East M “W CRIHS Chai rg

DEW:bed

/

517055-21”

FAX: 517/432-1171
ccvéda Beth Tiedje

tr. Mach-pa Sit: (Am-am
OHuMmMauamnm
(new a lam

M50 05 a! mum-m
m 0:qu mum-m

APPENDIX B

Human Subjects Consent Form

41

Humon om: Amman Inveanohon COlnmfllees
Goon. 4335(131con H SCOH HOII

540 f Cum-ma Avenue

Denon N1:(‘hu)0l\ 118201

(313)577 10:8
Wayne Slate Unwemry -
Multiple Assurance“ M1261
IRE“ 01
MEMORANDUM
TO: Therese Mitchell Reddan, Nursing

2043? Kenosha
Harper Wodds, MI 48225

FROM: Peter A. Lichtenberg, 1:11.13.ng W9? flip

Chairman, Behavioral Investigation Committee

SUBJECT: Expedited Approval of Protocol #H 02-19-95(BO3)-ER;
Breastfeeding Atttrition: Factors Influencing Outcome in
the Early Postpartum Period

DATE: March 9, 1995

 

As required under provisions of the Department of Health and Human
Service Regulation 45 CFR 46 (as amended) and or other pertinent
federal regulations to assure that the rights of human subjects
have been protected, the above protocol and informed consent
submitted to/supported by W was approved
following expedited review by the Wayne State University Behavioral
Investigation Committee (803) at its meeting of March 9, 1995.

Since the BIC has not evaluated this proposal for scientific merit
except to weigh the risk to the human subjects in relation to
potential benefits, this approval does not replace or serve in
place of any departmental or other approvals which.may be required.

This protocol will be subject to annual review by the BIC.

'42

St. [v]

John

 

llus‘pil; II and Mulic: II LI III”

3: N'; luflofi\ Reg-I
Inna. .‘lI'UIL‘Jfl Mleznz
HUI Hills:

PROM: St. John Hospital 5 Medical Center
Nursing Research Committee

RE: Research Adviser
Institution of Higher Learning

Dear Advisor:

St. John Hospital Nursing Research Committee will review research
proposals for potential implementation at St. John Hospital and
Medical Center.

The proposal should be in final form with all revisions completed,
approved by the academic advisor, and approved by the Human
Subjects Committee if required by your institution. The advisor's
recommendation is based on the proposal's merit and adherence to
approved research methodology.

The Nursing Research committee will not accept proposals in draft
form or not signed off as completed by their advisor.

PLEASE COMPLETE:

I recommend this research project for implementation at St. John
Hospital and Medical Center.

Breastfeeding Attrition: Factors Influencing Outcome in the Early Postpartum Period
Title

RN BSN
Investigator/Student
This proposal has been reviewed and approved in final form.

ggs¥t330r of Nursing
Advisor Title Wayne State University

Wayne State University
Institution

 

\ “13...! ”I III.- \I\III\ u: ‘l 'a-~O ;-I. II: .Illl- \\ ~I- III

St. ['1
Job

43

”I)\|)li.'ll .‘tiitl \it'tlit'gil i (‘lllt‘l

f.’l“1\IO'lll\‘ RI‘.|I|
l).~II..ir \lk my“, piggy. _-]j_
1”“ Lilillll

BREASTFEEDING STUDY

Human Subjects lnforrned Consent Form

I am being asked to partitipate In a research study. I understand the purpose ol‘the
research is for nurses and others who care for newborns and new mothers to understand
and identify what factors and characteristics place women at risk for stopping
breastfeeding during the first eight weeks postpartum. l undersrand that if l agree to to
partICIpate. l WI” be asked to complete a quesrionnaire while In the hospItal and again
when it is mailed to me at eight weeks postpartum. The questionnaire is desrgned to
Identify how I feel about breastfeeding and formula feeding, how much my family and
my health care team want me to breastfeed, how much I value the Opinions of these
indivuduals related to breastfeeding, and how confident I feel about my abilities to
breastfeed. The next part of the questionnaire asks for personal information about my
choice of infant feeding, my delivery, my level of education as well as other social and
financial information. Each time i fill out the questionnaire (once in the hospital and
again eight weeks later) it will take approximately 20 minutes. I realize that
approximately 60 women are being asked to participate in this study and that my
participation will not directly benefit me or influence my care while in the hospital or my
follow-up care at home. but my participation may help nurses and other health care
professmnals in the support and care of breastfeeding women. 1 understand that there is a
minimal risk of being in the study, and that risk is related to possibly experiencing
psychological stress related to being asked to fill out the questionnaire at eight weeks in
the event that l have decided to stop breastfeeding. i do realize that my input is valued
and needed regardless of my feeding method at eight weeks (breastfeeding, formula
feeding; or a combination of both. ). i understand that if I do experience any stress related
to this study, 1 am free to withdraw my consent and to discontinue my participation in the
study at any time. Also, 1 am free to have my questions answered or my concerns
addressed by the researcher at any time during the study.

\t|lq " ‘-l Ni ii" "~it ' " lot~o Hi II”: P. It .' I

44

Stir] , .
JO] Hospital and MethuIl Lcnlt-r
III

22“” “Milan K-utl
“cum! “I: imam ML!» (If:
(31;!) Suit-Juli

I further understand that:

i. All information is confidential and will not be disclosed outside the hospital
except as information reported collectively in a research paper for the purposes
of advancrng health care knowledge related to breastfeeding; with my written
permission; or as required by law.

2. My participation is voluntary.

My decision to participate will not affect the care or service I receive from

St. John Hospital and Medical Center.

4. I may choose not to answer any questions I do not wish to answer.

. I will receive a signed copy of this consent form.

6. If l have any questions about this research study now or in the future, I can ask
the research nurse, Therese Reddan, RN, MSNc at (3l3) 343-6323.

b)

M

I understand that in the unlikely event of any injury resulting from this research, no
reimbursement, compensation, ar free medical treatment is offered by Wayne State
University or St. John Hospital and Medical Center.

l have read or had read to me all the information about this research study included in
this informed consent. 1 have discussed this study with g

and hdshe has offered to answer any questions i have concerning the procedures,
potential risks, and likelihood of any benefit to me related to this research. The content
and meaning of this information has been explained and is understood. 1 am aware to
contact Dr. Paul Bush at (3 l3) 343—3763, if I have any questions regarding research
subject's rights, or my participation in the study. 1 hereby consent and voluntarily offer to
follow the study requirements and take part in this research study.

 

 

 

 

Participant's Signature: Date:
Printed Name of Participant: Date:
Witness's Signature: Date:

 

 

lRB Approval Date:

page 2 of 2

- \llh'llllh'l ul lili' \Isirn ..i \l I.... (,h ll. ,il'li v «(In

APPENDIX C

Breastfeeding Attrition Prediction Tool (BAPT)

45

 

 

BREASTFEEDING ATTRITION
PREDICTION TooL

(BAPT)

O Jill Janke RNC. DNSe
University of Alaska Anchorage
School of Nursing and Health Sciences
32” Providence Drive
Anchorage, Alaska 99508

 

 

PLEASE CIRCLE THE NUMBER THAT MOST CLOSELY DESCRIBES HOW YOU FEEL ABOUT EACH

46

STATEMENT.

21.
. Formula feeding lets the father become close to the baby.
23.
24.
25.

26.
27.
28.
29.

FOR EACH OF THE FOLLOWING INDIVIDUALS INDICATE HOW MUCH THEY WANT YOU TO BREAQTFEED.

30.
31 .
32.
33.

35.
37.
39.
40.

41.
42.

_ Breastfeeding is more convenient than formula leading.
. Breastfeeding is painfu.

Formula feeding allows the mother more freedom.
Infant formula can cause allerg‘es.
Breastrnillr is healthy for the baby.

No one else can help feed the baby when you breastfeed.
ft is (infant to breastfeed in public

Formula fed babies tend to get sick

Breastmillt is more nutritious lien infant formula.

. Breastfeeding makes your breasts sag.

. Formula feedng is easier than breastfeedng.

. Formula fed babies are more fussy than breastfed babies.

. Breastfeeding makes you closer to your baby.

. Breastfeeding makes returning to worlt dfleult

. Formula fed babies are easier to satisfy man breastfed babies.

. Formula fed babies tend to be overweight.

. Breastfeedng is more economical than formula feedng.

. When you breastfeed you never know if the baby is getting enough millc
. Mothers who formula feed get more rest than breastfeedng mothers.

. Breestfeedng ls naturd.

Breastfeedng is more tlrne consulting than formula fearing.

Infant formula can cause constipation
Breastfeedng is best for the baby.
Breestfeedng is personally ealsfying.

Breastfeedng is messy.

Breestfeedng lies you down.

Breastfeedng helps you bond with your baby.
Mothers who formula feed get back into shape sooner.

Delnlhly
breastfeed
The baby‘s father thinks I shoud: 1 2 3 4
My mother thinks I ehoud: 1 2 3 4
My mother-in-law thinks I should: 1 2 3 4
My sister drinks 1 shoud: 1 2 3 4
.Mycloeestfemalefriendthinkslshoud: 1 2 3 4
My doctor thinks I shodd: 1 2 3 4
. My midwife thinks I shoud: 1 2 3 4
La Leche League thinks I should: 1 2 3 4
.Thehospitalnursesthinltlshould: 1 2 3 4
My baby's doctor thinks I should: 1 2 3 4
My childbirth educator thinks 1 should 1 2 3 4
Other relatives think I shoulct 1 2 3 4
People who are important to me think I should: 1 2 3 4

Show
agree
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2

UIUIMUIM (”010‘"fo

UlUIU‘

Delnhty NOT
breastfeed

OGODOOD $01050!»

OlOfOl

UUUUU

UUUUU UUUUU

UUUUU UUUUU

UUU

‘b‘bb b.5‘b ‘5‘.) bhbbb Lbbbb

‘5‘

00101010!

010301 “C3000!“ 001050!“ 010100!“ 0301000101

@0000 001030101

OOOOO

Not

OOOOO

000 00900

Appkabla

Stongfy
disagree

58.
59.

61 .
62.

47

PLEASE INDICATE BELOW HOW IMPORTANT EACH OF THE FOLLOWING STATEMENTS ARE TO YOU.

Using a feerang method that is convenient is:

Using a feeding method that doesn‘t cause me pain is:
Using a feeding method that lets me have some freedom is:
Using a feeding method that won‘t cause atlerg‘es is:

. Using a feeding method that is healthy for my baby is:

Using a feedng method that lets someone else feed my baby is:
Usingafeedng memodthatiseasyto doin publicis:
Usingafeedng methodthatprotectsmybabyfromgetlngsickis:

. Usingafeedngmethodthatisnutritiousis:

Using a fearing method that wont make my breasts sag is:

Using a feedng method that is easy is:

Using a feedng method that keeps my baby from being fussy is:
Using a feeding method that lets me be close to my baby is:
Using a feeding method that makes 'a easy h retum it work is:

. Using a fearing method that satisfies my baby it

Using a feeding method that keeps my baby from being overweight is:
Usingafeedngmelhodthatiseoonomicalis:

Using a feeding method that lets me know the baby b getting enough is:

Usingafeedng methodthatletemegetlolsofrest:
Using a feeding method that is natural is:

Using a fearing method that saves time is:

Using a feeding method that lets the famer be close to the baby is:
Using a feeding method that doesn't cause corietipaeon is:

Using a feedng method that is best for my baby is:
Usingafeedng methodthatis personaIyse’ufyingis:

Using a testing method that is not messy is:

. Using a feeding method that doesn't be me down is:

Using a feeding method that helps me bond with my baby is:

. Using a feeding method that lets me get back into shape is:

Important
b M.
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2

UUUUU UUUUU UUUMU UUWWU

UUQUU

UUUU

##### ##### ##### ##### #####

####

00000 00000 00000 000010

00000

010100

Not bnportant
b the

00000

0000 00000 00000 00000

HOW MUCH DO YOU CARE ABOUT THE FOLLOWING PEOPLES OPINION ON HOW YOU SHOULD FEED YOUR
BABY?

72.
73.
74.
. Your sister
76.

. Your doctor

. Your baby's doctor

Donoteare
at al

The baby‘s father
Your mother
Your mother-in-law

.a-a-aad
UUUUU
#####

Your closest female friend

Your midwite
Le Leche League
Your hospital nurse

add-ed
UUUUU
#####

Your childbirth educator 1
Other relatives 1
People who are important to you 1

NNN NNNNN NNNNN

DUO)
###

00000

UIUIUIUIU'I

church

Care very

00000 00000

000

Not
Am“

00000 00000

000

48

PLEASE INDICATE THE DEGREE TO WHICH YOU AGREE OR DISAGREE WITH THE FOLLOWING

STATEMENTS.
Agree Disagree

85. I have the necessary skills to breastfeed I 2 3 4 S 6
86. I am physically able to breastfeed I 2 3 4 S 6
87. I know how to breastfeed l 2 3 4 S 6
88. Iarnernotionallyrcady to breastfeed I 2 3 4 S 6
89. I am detar'rninad to breastfeed l 2 3 4 S 6
90. I won't need heb to brasdeed I 2 3 4 S 6
9|. I have total control over my breastfeeding I 2 3 4 S 6
92. W; is easy I 2 3 4 S 6
93. I am confident I can breastfeed l 2 3 4 S 6
94.lImovavihaveanoughmilriorthebaby I 2'3 4 S 6

PLEASE CIRCLE THE CORRECT ANSWER OR FILL IN THE ILANKS FOR THE FOLLOWING QUESTIONS:

95.

96.

97.

98.

99.

IOI.

I02.

I03.

I 04.

WhaslsthePRlHARY meshodofinfanefeedingareyouushgwithyounewbaby!
a. Brusdeeding (if circled. proceed to question #96)
b. Formula feeding (ll circled. skip to question IMO)

How long do you intend to brusdeedl

Muddyoudeddeyouweregohgtobrasdeedl

a. Bdoreyoubecarnepregnans

b. Mgdiefirsedireemonehsofyowpregnancyflstm
c. Mgtheniddedimmnrhsofmmandm

d. thgthelastthreemonchsofyourpregnancyardm
e. Ahershebabywesborn

HoweooeeherthebhhdidyouhstbmsdeedyowlnIand—(hoin)

Whaewesthemainreesodsnouchosetobrassdeedf (lssesmnyreasonsthatepply)

 

 

 

 

Macbdiebhhdateolyournevbom
Whasrypeofblrthdidyouhavel

LVaganblnh
b. Cesarnnblnh

Howaurchdidyourbabyweighubkflrimnds ounces
Whaewesyourlnfans'ssexi_meie_fermle
Haveyoueverbreasdedbeforei

a. Yes (ifyes. proceed to question ”05)
b. No (‘1 no. skip to question ”01)

I05.

I06.

I 07.

I 08.

HO.

II2.

II3.

II4.

119

How long did you breastfeed your last child!

Was the experience

a. Extrunefy successbl

b. Very successful

c. Moderately successhl
d. Slightly successful

0. Not at all successful

Hownlanychidrenhaveyougivenbinhtof

 

Your age:

Youreshnicorlgin:
said:
b.Ashn
cMhe
dthanlc

e. Nativeamerian

I. Other(plnsespecify):

 

Ordethehmmm
Gndoschoot 5 6 7 8
Humor 9101112

CoIege 13l4l516
GredueeSdiook 17 I8 I9 20

Anni-I funlylncome:
a. “0.000 or less

b. ”0.001 to 325.000
c. $25.01" to 840.000
d. $40.00I to 355.000
a. $35.01" to 370.000
I. $70.00! to 885.000
x. 883.0!" to ”00.000
l1. over “00.000

Her-Ital stems:

Who is YOUR prbmry health are provider!
a. Musemldwl‘e

b. m

c. Faniyprealcephyslehn

d. Other(pl.se "‘

.r v“,

WholedreSABY‘Sprhtar-yheelthareprovider!
LMnepracskloner

em

cFamlypracslcephysidsn

d. Othcbhsespecdy)

 

Mite-idle“ lyubnwmhemuaufiebddiam
Myoeferyoulaea

APPENDIX 13

Scoring Guidelines for the BAPT

50

 

 

SCORING GUIDELINES

for the

BREASTFEEDING ATTRITION

PREDICTION TOOL

(BAPT)

O JIII Janka RNC, DNSc

University of Alaska Anchorage
School of Nursing and Health Sciences
321! Providence Drive
Anchorage. Alaska 99588

 

 

1.

51

ATTITUDINAL FACTORS

a. Negative Breastfeeding Sentiment (NBS) Attitudinal Scale.

Multiply each belief score by Its corresponding outcome evaluation.
The Items to be multiplied are as follows: 2.44; 3,45; 6.48; 7,49; 10.52;
11.53; 14.56: 15.57; 18.60; 19.61; 21.63; 22.64; 26,68; 27,69; 29,71.

(1) Example: a person scores a 6 for item 2 "breastfeeding ls°
painful” and a 4 for item 44 ”using a feeding method that
doesn‘t cause me pain Is ...". These scores are multiplied for
an item attitudinal score of 24.

Sum all multiplied scores for the "Negative Breastfeeding Sentiment“
attitudinal score.

The higher the score. the greater the negative breastfeeding
sentiment.

b. Positive Breastfeeding Sentimegt (PBS) Attitudlnal Scale.

Multiply each belief score by Its corresponding outcome evaluation.
The Items to be multiplied are as follows: 1,43; 4.46: 5.47; 8.50: 9.81:
12.54; 13.55; 16.58: 17.59; 20.62; 23,65; 24.66; 25.67: 28.70.

(1) Example: a person scores a 2 for Item 5 ”Breastmilk Iszhealthy
for the baby” and a 8 for Item 47 “Using a feeding methodthat
Is healthy for my baby ls...”. These scores are multiplied-for an
Item attitudinal score of 12.

Sum all multiplied scores for the “Positive Breastfeeding Sentiment“
attitudinal score.

The lower the score. the greater the positive breastfeeding sentiment.

SOCIAL AND PROFESSIONAL SUPEOBT SCALE ISPSI

a. Multiply each belief statement by Its correspondlng motivation to comply-
statement. The Items to be multiplied are as follows: 30.72: 31.73: 32.744
33.75: 34.76; 35.71: 38.78: 37.79; 38.80; 39.81; 40.82; 41.83; 42.84.

b. Sum all multiplied scores for the ”Social Support” scale.

e. The higher the score. the greater the support for breastfeeding.
BREASTFEEDING CONTROL §CALE IBFC)

a. Sum scores for Items 85-94.

b. The lower the score. the greater sense of control the woman has over her-

ability to breastfeed.

"IIIIIIIIIIIIIIIIIIII