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A PRENATAL BREASTFEEDING SCREENING TOOL FOR THE PRIMIGRAVIDA
By

Luanne Parks

A SCHOLARLY PROJECT

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

MASTER OF SCIENCE

College of Nursing

1 999

ABSTRACT
A PRENATAL BREASTFEEDING SCREENING TOOL FOR THE PRIMIGRAVIDA
By

Luanne Parks

Promoters of infant health agree that breastfeeding is the best way to nourish an
infant. Data suggest, however, that only slightly more than half of all pregnant women
choose to breastfeed their infants. Literature suggests that the primigravida can be
influenced by prenatal breastfeeding assessment and intervention. The purpose of this
project was to design a breastfeeding screening tool for use with the primigravida to
determine certain factors which may influence infant feeding after delivery. The
screening tool is designed for administration during the initial prenatal comprehensive
exam. Based on the Health Belief Model, the breastfeeding screening tool assesses for
modifying factors, perceived benefits, and perceived barriers to breastfeeding.
Assessment of the factors which influence breastfeeding could predict the likelihood of
successfiil breastfeeding and provide the Advance Practice Nurse (APN) with
information needed to develop an individual plan of care for the woman to promote and

enhance the breastfeeding experience.

This project is lovingly dedicated to my husband, Jerry, who has supported and

encouraged me to continue on.

iii

ACKNOWLEDGMENTS

This author gratefully acknowledges the guidance of Jackie Wright, RN, MSN
Her assistance and support during the formation and polishing of this project was
invaluable. Thanks are also due to Mildred A. Omar, RNC, PhD, and
Kathy Dontje, RN, MSN for their collaborative assistance. Their combined efforts to
make this project applicable and useable were greatly appreciated.

This author would also like to recognize the encouragement and support from
family, friends, and colleagues during the development of this project, without which it

would not have been possible.

iv

TABLE OF CONTENTS

LIST OF FIGURES ........................................................................................................ vi
INTRODUCTION ............................................................................................................... 1
Background of the Problem .................................................................................... 1
Problem Statement .................................................................................................. 3
PURPOSE ........................................................................................................................... 4
CONCEPTUAL FRAMEWORK ........................................................................................ 4
Conceptual definitions ............................................................................................ 7
Development of a Breastfeeding Screening Tool based on the HBM .................... 9
LITERATURE REVIEW AND CRITIQUE ..................................................................... 11
Modifying Factors ................................................................................................. 1 1
Perceived Benefits ................................................................................................ 18
Perceived Barriers ................................................................................................. 19

DEVELOPMENT OF A BREASTFEEDING SCREENING TOOL FOR THE

PRIMIGRAVIDA .............................................................................................................. 21
Design and Administration .................................................................................... 21
Prenatal Breastfeeding Screening Tool Development .......................................... 22

DISCUSSION ................................................................................................................... 26
Implications for the Advanced Practice Nurse ..................................................... 26

REFERENCES .................................................................................................................. 31

APPENDICES .................................................................................................................... 31
Appendix A. Provider Guide for the Primigravida Breastfeeding Screening Tool
................................................................................................................................ 36
Appendix B. Introduction to the Prenatal Breastfeeding Screening Tool ............ 40
Appendix C. Prenatal Breastfeeding Screening Tool for the Primigravida .......... 41

LIST OF FIGURES

Figure 1: The Health Belief Model ..................................................................................... 6

Figure 2: Adapted Health Belief Model ............................................................................ 10

vi

Introduction

The purpose of this scholarly project was to develop a screening tool that can be
used in the primary care setting to determine a primigravida woman’s modifying factors,
perceived benefits, and perceived barriers to breastfeeding. Assessing these factors is
necessary for health professionals in order to promote and support infant feeding
decisions (Marchland & Morrow, 1994). Identifying the factors which influence
breastfeeding is essential in the prediction of breastfeeding success and improvement of
the breastfeeding experience. The information ascertained from this screening tool can be
used to promote breastfeeding. The United States has a national goal of increasing the
incidence and duration of breastfeeding (US. Dept. of Health and Human Services,
1990). Development of a screening tool to assess for modifying factors, perceived
benefits, and perceived barriers to breastfeeding for primigravida women is needed for
further realization of this goal. A breastfeeding screening tool utilizing concepts of the
Health Belief Model (HBM) has been developed. The tool can be utilized during the first
trimester of pregnancy to identify factors which influence breastfeeding.
Baskgmundnmeblem

Promoters of infant health agree that breastfeeding is the best way to nourish an
infant (Stashwick, 1994). In response to the increasing evidence that breast is best,
Healthy People 2000 (1990), an initiative of the US. Department of Health and Human
Services, included among its objectives increasing to at least 75% the proportion of
mothers who breastfeed during the early postpartum period. The initiative also includes
objectives to increase to at least 50% the proportion who continue to breastfeed until
their babies are 5-6 months old. Since 1982, there has been a steady decline in initial and
prolonged breastfeeding (Ryan, Fritz, Krieger & Lewandowski, 1991). Data suggest that
only slightly more than half of all pregnant women choose to breastfeed their infants.

Many women initiate the breastfeeding experience, only to end it within 3 months
(Stashwick, 1994).

To better understand this decline and envision ways to reverse it, factors
influencing breastfeeding must be considered (Freed, 1993). Studies fiom several
disciplines have demonstrated that sociopsychological factors such as attitudes,
emotional states and culture have measurable effects on breastfeeding success (Keamey,
1987; Locklin & Naber, 1993 ). Other studies provide evidence that demographics such as
age, education, socioeconomic status, and ethnicity influence breastfeeding (MacGowan,
MacGowan, Sendula, Lane, Joesoef, & Cook, 1991) Successful efforts to promote
breastfeeding depend on understanding the myriad of influences that affects women’s
infant feeding methods (Kieffer, Novotny, Welch, Mor, & Thielc, 1997). To date, these
underlying reasons have been given only cursory attention (Rowley & Dixon, 1997).

The decision to breastfeed is often times made early in pregnancy or prior to
conception. Screening of the factors which influence breastfeeding during that time may
influence breastfeeding incidence and success (Lawrence, 1991; Newton, 1991). A
personal assessment of a woman’s perceptions of breastfeeding and those of people close
and significant to her is required in the prenatal period to promote successful
breastfeeding (Rowley & Dixon, 1997). The health professional in the primary care
setting is in the ideal position to assess factors which influence breastfeeding because the
care often precedes conception, extends through pregnancy and delivery, and continues
postpartum (Williams, 1995). The Advance Practice Nurse (APN) in primary care can
utilize his/her role as advocate, educator and practitioner to assess the influencing factors
of the clients’ infant feeding methods (Frantz, 1991).

Emblemfitatement

Primary care providers are one group of health care professionals responsible for
incorporating the promotion of breastfeeding into prenatal care. The Surgeon General’s
report, Healthy People 2000 (1990), calls for improved support from health care

2

providers in overcoming the barriers to breastfeeding. Traditionally, many primary care
providers have thought breastfeeding assessment and counseling not worthy of physician
time and need only be performed by nurses at the time of delivery (Freed, 1993).

The American Academy of Pediatrics (AAP) and the American College of
Obstetricians and Gynecologists (ACOG) have mutually developed W
W (1997). These guidelines suggest that for the successful management of
breastfeeding, it is important to begin preparation during pregnancy. The
recommendation is that prenatal care should include discussion of feeding plans, with the
decision to breastfeed reinforced. While ACOG supports breastfeeding, little attention is
given in regards to the assessment of feeding method during pregnancy. Only one area on
ACOG’s standard prenatal form addresses feeding intentions. The APN in primary care
has an obligation to further this assessment in order to promote the initiation and duration
of successful breastfeeding (Moskosky, 1995 ).

Literature suggests that the primigravida woman can be most influenced by
prenatal assessment and intervention (Sciacca, Phipps, Dube, & Ratliff, 1995).
Modifying factors, such as sociopsychological and demographic data, perceived benefits,
and perceived barriers of breastfeeding apply to all women of all gravida. The APN in
primary care may be able to increase the rates of breastfeeding incidence and duration by
assessing for these factors and providing specific interventions in the promotion of
breastfeeding for the primigravida woman (F reed, Clark, Harris, & Lowdermilk, 1996).

Research has identified that health professionals, and nurses in particular, can
increase rates of breastfeeding initiation and duration (Rajan, 1993). Yet despite the
almost universal recognition of the benefits of breastfeeding, many primary care
providers fall short in their assessment and support (Donnelly, 1994). Therefore, the
development of a screening tool to assess modifying factors, perceived benefits, and

perceived barriers of breastfeeding was conceptualized.

The purpose of this project was to develop a screening tool for the APN in the
primary care setting to screen for modifying factors, perceived benefits, and perceived
barriers to breastfeeding during the initial assessment of pregnancy to all primigravidas.

Conceptual Framework

Pregnancy is a period of significant life transition during which a woman must
adjust to changes in self, prepare for her role of motherhood, and prepare for childbirth
(Moskosky, 1995). Behaviors and beliefs are reflected upon during this time as well as
the preconception period. Impressions are created and decisions are made which extend
beyond the childbirth experience. Perceptions of breastfeeding are formed by the
primigravida at varying times during this life transition. Solidification of these
perceptions are complete for many women within the first trimester of pregnancy
(Lawrence, 1991).

It is important to understand the modifying factors and perceptions which affect
breastfeeding ideation during the early prenatal period to be able to predict breastfeeding
success and to improve the breastfeeding experience. The behavioral theory of the Health
Belief Model (HBM) has been demonstrated to be applicable in relation to studying
breastfeeding behavior (Richardson & Champion, 1992). In the next section, the HBM is
described and includes: (a) an overview of the Health Belief Model (HBM); (b)
conceptual definitions of the project variables based on the HBM; and (0) development
of a screening tool based on the HBM.

The Health Belief Model (HBM) was used in this scholarly project as the
conceptual fiamework for the screening tool (see Figure 1). The HBM was developed in
the early 1950’s by a group of social psychologists, and was derived from the Social
Cognitive Theory (Becker, 1974). The HBM was designed as a framework for exploring
why some people who are illness free take actions to avoid illness, while others fail to
take protective actions. The model was viewed as potentially useful to predict those
individuals who would or would not use preventive measures and to suggest interventions

4

that might increase predisposition of resistant individuals to engage in health-protecting
behaviors (Pender, 1996).

The HBM is most applicable with voluntary, health-related actions that involve an
element of uncertainty. Because it is a psychological model, it is applicable only to
behavior that can be explained by a person’s attitudes and beliefs. The HBM
encompasses a “value expectancy” approach which attributes behavior to the value an
individual places on the expected outcome of the action and also to the perception by the
individual that the specific behavior will result in the expected outcome (Janz & Becker,
1984).

The HBM hypothesizes that health related behavior occurs as a result of the
interactive and combined effects of two factors: (a) readiness to comply with
recommended action/s, and (b) modifying and enabling factors (Pender, 1996). The
factors that influence readiness to act include those dimensions known as health beliefs,
which include susceptibility, seriousness, benefits and barriers. The perception of a threat
to health is conceptualized as a combination of how susceptible the individual perceives
him/herself to be to a condition and how severe of an effect he/she believes the condition
would have on his/her life. The individual must also believe that the action to be taken
will result in the expected outcome and that there are not insurmountable barriers that

preclude goal attainment.

(ggghifm'gffib J Perceived benefits of

 

 

bemi’oetq . preventetrr ‘ actrc' a
(£350 ' , socizl class,

er and ererIce-group
pressure, etc.) -—)

.‘

minis
~ ' Perceived barriers to
btructural variables Dummy; gtion
& diseasfifrior
contact an the
disease, etc.)

Perceived susceptiulity i
to disease X
\L

 

 

 

 

 

 

 

 

 

Perceived I] I of Likelihoodoftakiu _
Perceived seriousness .% disease X ‘ recommended ”my”
(severity) ofdisean r) 1““ "t“

 

 

 

 

 

 

1‘

 

 

 

 

lines to action
Mass media
met-ism
Advice from others
Reminder postcard from
physical or dentist
Illness of family
reenter or friend
Newspaper or
magazine article

 

 

 

Figure 1. From "The Health Belief Model. Selected psychosocial models and

correlates of individual health-related behaviors.‘ by NIH. Becker and
SM Kasl etal. (1977). Medical Care 15 p. 27.

 

Perceived susceptibility refers to the subjective risks of a condition. It reflects the
individual’s feelings of personal vulnerability to a specific health condition. Individuals
vary widely in their feelings of personal vulnerability to a condition (Pender, 1996).
Perceived seriousness are convictions concerning the seriousness of a given health
condition. They also vary from person to person. The degree of seriousness may be
judged both by the degree of emotional arousal created by the thought of a health
condition as well as the kinds of difficulties the individual believes a given health
condition will create. These two dimensions of the HBM are beyond the scope of this
scholarly project.

Some factors may function as cues to action, also characterized as “triggering
mechanisms”. Cues to action indirectly affect the perceived health action. They include
mass media campaigns, advice fi'om others, reminder postcards from physician or dentist,
illness of a family member or friend, and newspaper or magazine articles. For the
primigravida woman, pregnancy itself is an example of a cue to action in regards to the
breastfeeding endeavor. For the purpose of this scholarly project, this factor will not be
assessed.

2 l l: E . .

Specifically, the HBM consists of the following dimensions known as health
beliefs: perceived susceptibility, perceived severity, modifying factors, perceived benefits
and perceived barriers. Modifying factors, perceived benefits, and perceived barriers
provided the basis for the development of the breastfeeding screening tool. The tool was
designed to determine the likelihood that a primigravida woman will breastfeed
successfully, and was based upon the concepts of the HBM, perceived benefits and
barriers. The modifying factors of demographic, sociopsychologic, and structural
variables were also included because of their reported influence on breastfeeding

success. These dimensions are further defined as follows.

W. While acceptance of personal susceptibility to a condition
believed to be serious was held to produce a force leading to behavior, it did not define
the particular course of action that was likely to be taken. This was hypothesized to
depend upon beliefs regarding the potential positive aspects of a particular health action.
The primigravida would not be expected to accept the recommended health action of
breastfeeding unless it was perceived as feasible and beneficial. For this scholarly project
perceived benefits were defined as the beliefs of the primigravida about the positive
aspects of breastfeeding.

W. The potential negative aspects of a particular health action
may act as impediments to undertaking the recommended behavior. In this dimension of
the HBM the primigravida woman weighs the actions of breastfeeding’s effectiveness
against perceptions that it may be upsetting, unpleasant or painful, embarrassing,
inconvenient and time consuming. These negative aspects of health action serve as
barriers to action and arouse conflicting motives of avoidance. For this scholarly project
perceived barriers were what primigravida women perceive as the negative aspects of the
breastfeeding experience.

Waters. The modifying factors of the HBM include demographic,
sociopsychological and structural variables. These factors are considered to have an
indirect influence on health behavior by their effect on an individual’s health motivation
and perceptions. The three modifying factors are: a) demographic characteristics, such as
age, sex, race, educational level and socioeconomic status; b) socio-psychological

variables such as personality, culture, and reference-group pressure; and c) structural

variables which includes knowledge about breastfeeding and prior contact with
breastfeeding.

 

A primigravida woman has perceptions of her breastfeeding endeavor. These
thoughts or perceptions can occur before pregnancy or early in pregnancy and are

8

considered her own feelings of vulnerability and perceived seriousness of the
breastfeeding experience. Such feelings are accepted by the woman and produce a force
leading to breastfeeding. It does not define the particular course of action, however.

Modifying factors can influence the perceptions a primigravida woman holds in
regards to her own breastfeeding experience. These factors have an indirect influence on
her breastfeeding behavior by their effect on her motivation to breastfeed successfully
and her perceptions of successful breastfeeding. These modifying factors affect the
woman’s individual perceptions and the likelihood that she take action to breastfeed
successfully. Screening for the modifying factors involved in a primiparous woman’s
perceived ideas about the breastfeeding experience could provide predictive information
to the APN. Anticipating certain behaviors, the APN could provide anticipatory guidance
and interventions which may help to minimize the negative effects modifying factors
have on perceived breastfeeding success.

Although modifying factors and individual perceptions create a perception of
breastfeeding, perceived benefits and barriers to breastfeeding define the particular
course of action the primigravida will take to breastfeed successfully. A woman would
not be expected to accept recommended action unless it was perceived as feasible and
beneficial (Janz & Becker, 1984). The potential negative aspects and perceived barriers
of breastfeeding may act as impediments to the experience. To successfully breastfeed
the perceived benefits must outweigh the perceived barriers. Screening of a woman’s
perceived benefits and perceived barriers could predict the likelihood of successful
breastfeeding and provide the APN with information needed to assess fiirther and
develop an individual plan of care for the woman to promote and enhance the
breastfeeding experience. Figure 2 depicts the integration of the prenatal breastfeeding

screening tool within the HBM. Areas in bold were concepts addressed in the project.

lndividual Perceptions

 

Perceived susceptibiy
Perceived seriwsness

 

 

 

Modm 'ng Factors

numophk factors
(educdionel level, .
race, socioeconomic
«Us
a reference

accrue.
mg“ roles)

Structural factors
(Irriouledge d
breastfeetl'ng)

 

T'T‘

I—————I

 

 

Perceivedideasm

 

thebreastfwci'igexperience ‘

 

 

l

Cuestoaction

mass media
advice from dhers
reminder postcard
Mass of family
member or friend
newspapa or
magaz'ne article

 

 

 

 

Likelihood of Action

Perceiled hermit:

to bracketing

MINUS

Perceived buriere
to broadening

t___,__l

 

 

 

 

Lirelihood of successful
breastfeedhg experience

 

 

 

Figure 2. Adapted from "The Health Belief Model. Selected psychosocial models and

correlates of individual health-related behaviors”, by M. Becker. D. Hefner, and

DP, Kas! et al. (1977). Medical Qare,15,p. 27.

10

Literature Review and Critique

The literature is replete with scientific data on the incidence of breastfeeding and
how women can be persuaded that ‘breast is best’ (Price & Price, 1995). Factors
involving demographics, social systems, personal attitudes, perceived benefits, and
perceived barriers play a role in the initiation and success of the breastfeeding
experience. Examining beliefs fostering or inhibiting breastfeeding could increase
breastfeeding initiation and success (Lubbus, Bush, & Hockrnan, 1997). Literature attests
to complicated factors that must be taken into account to promote and support the
breastfeeding endeavor, yet does not reflect a formal screening tool for these factors
(Price & Price, 1995). The following sections address the literature and provide: (a) a
literature review of the modifying factors, perceived benefits, and perceived barriers of
breastfeeding as defined by the HBM; and (b) a critique of the literature.
I l ”I . E

Modifying factors of the HBM include demographic data, sociopsychological, and
structural factors. These factors indirectly affect the tendency toward breastfeeding by
the primigravida woman by affecting her motivation to breastfeed successfully and her
perceptions of successful breastfeeding. Demographic data reveal issues which play an
important role in the breastfeeding experience. Demographic data include educational
level, age, race, and socioeconomic status. These are further explained.

EducationalLeyel. The frequency of breastfeeding in the United States is
decreased among low-income and low-education women (Lawrence, 1991). A higher
education is positively correlated to breastfeeding (Ford & Labbok, 1990). Data from the
National Survey of Family Grth (CDC, 1995) describe women with no high school
diploma or GED breastfeed their infants only 43 percent of {he time. This is in sharp
contrast with those mothers with bachelors degrees or higher, who breastfeed their

infants 80 percent of the time. The National Survey data show incremental increases in

11

breastfeeding incidence as education of the mother increases. The need for assessment
and a better understanding of the role of educational level is needed in order to respond
to the lack of breastfeeding in lower educated women (Ryan, Rush, Fritz, Krieger, &
Lewandowski, 1991).

Ageandfiace, Age and race play an important role in breastfeeding initiation and
success. The National Survey of Family Growth (CDC, 1995) provides data about age
and race in regards to breastfeeding incidence. Only 45 percent of mothers under 20
years old breastfeed their infants, with 50.9 percent of mothers who are 20 to 24 years old
breastfeeding, 55.9 percent of mothers 25 to 29 years old breastfeeding, and 71.1 percent
of mothers 30 to 44 years old breastfeeding ( CDC, 1995). A Caucasian female is more
likely to breastfeed than an Afiican American female (Ford & Labbok, 1990). The
percent of breastfeeding women who are Caucasian is 61.2; Blacks, 27.5; and Hispanics,
67.4. Young, African American women often perceive that breastfeeding is old
fashioned, embarrassing, and would tie a woman down (Taylor, 1991). The young and
the minority are the most vulnerable segments of the population who would benefit by
intensive assessment, study, and intervention regarding breastfeeding (Ryan, Rush,
Krieger, & Lewandowski, 1991).

WSocioeconomic status is a strong determinant of
breastfeeding success. Hill (1991) conducted research which identified variables that
predicted breastfeeding duration for the first eight weeks postpartum. A total of 400
postpartum women completed the data collection survey. Content validity of the survey
was established by literature review, the investigator’s past experience, and use of some
questions from past studies. Interim reliability of the survey was not addressed. Income
was significantly correlated with breastfeeding initiation and duration (p = 0.018). The
study suggests that this variable, among others, can be used to identify those at risk for
unsuccessful breastfeeding. Locklin and Naber (1993) in a grounded theory study with
in-depth interviews, collected data from 10 low income, minority women. The study

12

reported that when support from family, friends, and peers was available, low income
and minority women breastfed successfully (Locklin & Naber, 1993).
2 . . IE I . E I . E .

Educational level, age, race, and socioeconomic information is included in this
review. The predominant data provided for educational level, age, and race was the
Centers for Disease Control (CDC). The CDC was found to have the most current
statistics. The CDC based the data on household interviews of samples of women in the
childbearing ages. The most recent data obtained was from the National Survey of
Family Growth, Cycle 5-1995. The methodology for data collection and sample selection
were not identified in the report. The CDC did note that their sample was mothers
interviewed in the first three months of 1995 with babies age three months and over.

Other literature cited (Ford & Labbok, 1990; Lawrence, 1991) studied data
obtained in the1980’s. The sample for the studies was, again, postpartum women.
Utilizing demographic data, Locklin and Naber (1993) interviewed postpartum women
also. The sample size, 10 low income, minority women, can be identified as too small a
sample for generalization to larger populations. The study did supply valuable
information about this population to guide further research. Hill (1991) provided a
concisely written report on variables affecting breastfeeding incidence and duration. The
sample size of 400 postpartum women was described and was considered a population
which would lend itself to generalization to other populations. The content validity of the
tool was described and verified by a team of experts. Results were documented and
discussed.

In general, the studies reviewed about demographic data which affects
breastfeeding were strong in the clarity of writing and result reporting. Weaknesses in the
literature include a lack of theory based research and studies of prenatal intentions with

postnatal practices.

l3

Sociopsxchologicalfictots

In the HBM, sociopsychologic factors are part of the modifying factors affecting
breastfeeding . Sociophychologic factors which influence breastfeeding include peer and
reference group pressure and maternal roles. The following literature review illustrates
these factors.

W. The support of the breastfeeding woman’s
significant other, her friends, and family was important to successfirl breastfeeding
studies suggest (Lithman, Medendorp, & Goldfarb, 1994; Matich & Sims, 1992). A
favorable attitude of partners towards breastfeeding is noted to be an important factor
associated with a woman’s initiation and success at breastfeeding (Guiglaini, et al., 1994;
Kessler, Gielen, Diener-West, & Page, 1995). Findings suggest that breastfeeding is the
outcome of a complex interaction of factors related not only to the mother but also to her
environment (Lothian, 1994). Lothian confirms that women choose to breastfeed because
they believe it is the best for the baby, and their network of family and friends also
believe in the importance of breastfeeding. Lothian calls for greater prenatal screening
and education to promote successful breastfeeding.

McClurg-Hitt and Olson (1994) piloted a questionnaire for their WIC clientele in
an effort to better support breastfeeding mothers involved in the Missouri WIC program.
The study was the pilot for the questionnaire. The number of questionnaires returned was
878. The population that completed the survey included 49 percent Caucasian women, 50
percent African American women, and one percent other ethnic groups combined. Rural
and urban populations were included. The questionnaire was developed to include
assessment of participants’ attitudes about breastfeeding, breastfeeding habits, problems
associated with the breastfeeding experience, sources of breastfeeding information, the
participants’ support structure, and hospital practices related to breastfeeding. Validity
and reliability of the questionnaire was not reported. Limitations to the study include
biases inherent in the survey process, lack of information about demographic data, and if

14

the client was enrolled in the WIC program. McClurg—Hitt and Olson suggest a revision
of the questionnaire to include demographic information. The results of the questionnaire
revealed that the main support for the breastfeeding endeavor were the women’s
husbands. While there are limitations of the assessment tool used, the study identifies the
need to include husbands in breastfeeding preparation whenever possible (McClurg-Hitt
& Olson, 1994).

Libbus and Kolostov (1994) found two factors that are positively associated with
breastfeeding: women whose mothers had breastfed, and support from the woman’s
significant other. This suggests that social support and role modeling may be part of the
determining components of breastfeeding inception and success (Libbus & Kolostov,
1994)

W. Maternal role ideas of protection, nurturance, and training of
children as part of the mother’s personality favors the breastfeeding experience. The
physical manifestation of providing nourishment to one’s infant reinforces this feeling
(Gigliotti, 1995). Locklin and Naber (1993) identified that mothers who breastfeed over
an extended duration of time are reported to have a positive attitude toward the practice,
to experience satisfaction and enjoyment fiom it, to feel encouraged, and to want to help
others do it. In other studies, women who did not breastfeed felt uncomfortable with the
idea of putting a baby to their breast (McClurg-Hitt & Olsen, 1994; Oxby, 1994). These
feelings may be deep rooted in the individual’s sense of self. A study by Barnes, Leggett,
and Durham (1993) suggests that breastfeeding mothers are clearer in their maternal and
sex role identification as well as in age, education, and economic status. Those more
likely to choose to bottle-feed their infants were those women who showed an unclear
sense of identity formation. The perception of how breastfeeding will fit into the
mother’s lifestyle also adds to this complex set of factors (Gigliotti, 1995). Gigliotti calls
for a holistic view in regards to breastfeeding to provide the basis for assessment, mutual
goal setting, and the development of sound interventions.

15

2 . . ES . l l . E I . E i
Maternal support in regards to breastfeeding has been widely studied (Gugliani et

al., 1994; Kessler, Guelen, Diener-West & Page, 1995; Littman, Mendendorp, &
Goldfarb, 1994; Lothian, 1994; Matich & Sims, 1992; McClurg-Hitt & Olson, 1994). All
studies confirm the conclusion that support from husband or significant other, family,
and friends play an important role in breastfeeding initiation and success. McClurg-Hitt
and Olson (1994) provided a clearly written research study. The study described the
methodology of the research performed. Information about the tool used was identified.
Validity and reliability of the tool was not reported. The sample used was large and
contained representation of races from both urban and rural populations. McClurg-Hitt
and Olson described the results succinctly and discussed the strengths an limitations of
the tool and the research.

Studies providing maternal role information were varied in their methodology and
procedures. This may be because of the very subjective and individual perceptions being
measured. Gigliotti (1995) utilized a qualitative method, providing an interview type of
format. Gigliotti’s sample size, three women, makes the information less reliable for
generalization. Gigliotti describes the research as a beginning in regards to evaluating
women’s and the nursing profession’s personal values in regards to breastfeeding. No
description of maternal tools for data gathering and analysis were discussed.

Barnes, Leggett, and Durham (1993) provide a clear, concisely written research
report. A review of literature was followed by a description of the methodology. The
sample was one of convenience and included 58 married primiparous women. No
documentation was provided in regards to the sample descriptions of race, age, rural, or
urban type of population. The instruments utilized were delineated a demographic
questionnaire and the Bern Sex Role Inventory (BSRI). The BSRI was found valid and
reliable by use in previous studies. No information was provided about the reliability or
validity of the demographic tool. Research findings were statistically presented with

16

correlation between clear sex role identification and breastfeeding exhibited. Limitations
to the study were discussed and included sample size and timing of the study in relation
to the activity giving birth having relevance to the woman’s perceptions.
SmicmraLEactch

Structural factors are included in the modifying factors of the HBM. Structural
factors influencing breastfeeding include knowledge about breastfeeding and prior
contact with breastfeeding. Rentschler (1991) did a study of factors related to
breastfeeding success. Breastfeeding success was defined as breastfeeding for at least 6
weeks. The sample was 150 married primigravidas planning to breastfeed. Of the 150
participants, 107 breastfed successfully. The pregnant woman’s level of information
about breastfeeding was found to be positively related to breastfeeding success
(Rentschler, 1991). Providing breastfeeding education prenatally yields an increase in
breastfeeding success, especially among low income women of color (Kistin, Benton,
Rao, & Sullivan, 1990).

Rentschler (1991) provided literature about the level of information about
breastfeeding and how that information correlated to successful breastfeeding. The report
was clearly written with a review of pertinent literature, concise methodology, results
reporting, and a discussion of the research. The instruments utilized for data gathering
were identified, with reliability and validity established. The sample size consisted of 150
primiparous women who planned to breastfeed. The sample was identified as average
age of 28, married, 94 percent Caucasian, average income of $31,000-40,000, all with
high school degrees, and 77 percent had attended college. The author acknowledges
limitations to the study. These limitations include a relation between the demographic
characteristics of the sample and the results, and that the analysis could not extrapolate

the reasons for the relationship between breastfeeding and educational level.

17

W

According to the HBM, perceived benefits are beliefs about the effectiveness of
breastfeeding. Perceived benefits and barriers help to define the particular course of
action the primigravida will take to breastfeed successfully. A woman would not be
expected to accept a course of action unless it was perceived as beneficial and feasible.
To breastfeed successfully, perceived benefits must outweigh perceived barriers.

It is generally accepted by women that breast milk is nutritionally superior and
more natural than any other form of infant supplementation. Enhanced mother-infant
bonding during the breastfeeding experience is also perceived as a benefit (Alexy &
Carter, 1994; Gigliotti, 1995; Marchland & Morrow, 1994). Prevention of infant ear
infection (William & Pan, 1994), convenience and decreased expense are also perceived
benefits of breastfeeding (Dungy, Losch, & Russell, 1994; McClugg-Hitt & Olsen, 1994).
A family history of milk allergies also influence women’s reasons for breastfeeding
(McClurg-Hitt & Olsen, 1994). Health benefits of the breastfeeding mother, such as
decreased risk of breast and endometrial cancer also are considered benefits (Gwinn, Lee,
Rhodes, Layde, & Rubin, 1990). Screening of perceived benefits to breastfeeding may
reinforce the breastfeeding decision (McClurgg-Hitt & Olsen, 1994). In a study by Alexy
and Carter-Martin (1994), perceived benefits and barriers between women who planned
to breastfeed, those who were uncertain, and those who did not plan to breastfeed were
investigated. One hundred and forty two women participated in the study. Volunteers
were obtained from rural and urban prenatal clinics. Half the women were married, the
average age was 23, 38 percent were African American, 25 percent had not graduated
from high school, and 46 percent were planning to return to work. The tool consisted of
13 items to measure benefits, 15 to measure barriers, and open-ended questions. The
authors reported that women who were interested in breastfeeding perceived more
positive factors and fewer perceived barriers. Women who were not interested in
breastfeeding indicated fewer perceived positive factors and greater perceived barriers.

18

Alexy & Carter-Martin (1994) conclude that perceived benefits are important to assess
when working with expectant women.
E . l E .

The HBM describes perceived barriers as the most important aspect involved in
the application of the health promoting behavior of the individual. Perceived barriers to
the breastfeeding experience are the negative aspects of the experience. The potential
negative aspects of breastfeeding may act as impediments to the experience. Perceived
barriers must factor less than perceived benefits for a successful breastfeeding experience
to occur.

Intent to return to work after the baby’s birth is considered a significant reason for
not breastfeeding, and shortening the breastfeeding experience (Alexy & Martin, 1994;
Wilson-Clay, 1996). Not feeling comfortable with putting the baby to breast is also a
highly recognized barrier to the infant feeding experience (McClurg-Hitt & Olsen, 1994;
Oxby, 1994). Frequently cited in the literature is the perception of the mother of the
inability of others to feed the infant (Libbus, Bush & Hockman, 1997). Other barriers
include those of perceived physical inability to breastfeed and include insecurities of
insufficient milk from breasts, inverted nipples, physical discomfort, and breasts too
small (Marchland & Morrow, 1994; McClurg-Hitt & Olsen, 1994). Perceived barriers
and benefits are important to screen when working with expectant women (Alexy &
Carter-Martin, 1994).

Ha .‘ o l‘ ' ' 13": no ' ' -. Lu”; "er ‘ i: 4' .

A variety of research regarding the benefits to breastfeeding were identified in the
literature. Most research validated findings of other studies (Alexey & Carter-Martin,
1994; Gigliotti, 1995; Marchland & Morrow, 1994). Alexy and Carter-Martin (1994)
provided a concise study involving the benefits and barriers to breastfeeding by women
in rural and urban settings. The methodology of the study was outlined with identification
of the sample, instrument, procedures, and data analysis performed. The instrument was

19

determined to have validity and reliability for use. Data analysis was documented and
utilized chi-square, analysis of variance, and discriminant function analysis. The results
were reported with the use of percentages and associated “p” values. The discussion
portion address strengths of the study, findings, and need for further study. Limitations to
the study were not addressed.

The literature review, in general, provided information regarding various aspects
involved in breastfeeding incidence and success. The data provided did not address any
type of prenatal screening tool for the primigravida to assess for the factors identified as
affecting breastfeeding incidence and duration. A lack of theory application to the
literature was also very evident during this review. Despite these weaknesses, the studies
reviewed did demonstrate sound research.

Fifty three percent of women decide upon an infant feeding method prior to their
second trimester of pregnancy (Newton, 1991). It is hypothesized that a formal screening
tool would be beneficial to the encouragement of breastfeeding during that time. To
screen modifying factors, perceived benefits, and perceived barriers to breastfeeding
using the Health Belief Model concepts may provide information that could be used to
improve the breastfeeding experience and predict breastfeeding success. Although it is
not currently proven that screening of these factors will influence the decision to
breastfeed, future study of this may provide useful information.

Can prenatal identification of modifying factors, perceived benefits and perceived
barriers to breastfeeding within the primary care setting affect primigravida women’s
breastfeeding experience postpartum? Research has done much to identify perceptions
and factors involved in successful breastfeeding. Implications of these studies suggest
further screening and assessment of the modifying factors, perceived benefits and
perceived barriers to breastfeeding within the primary care setting may be beneficial to
promoting successful breastfeeding. Little research has been done, however, on the
implementation of a prenatal screening tool, as well as how it affects the primigravida

20

woman’s breastfeeding experience. This opens an opportunity for the APN in primary
care to not only potentially increase breastfeeding rates, but contribute to the furthering
of knowledge in regards to infant feeding decision making.

Development of a Breastfeeding Screening Tool for the Primigravida
E . l 5 l . . .

There are no specific tools available for the screening of modifying factors,
perceived benefits, and perceived barriers to breastfeeding. The development of such a
screening tool may benefit the breastfeeding experience. In developing a breastfeeding
screening tool for the primigravida, the current project built upon previous work on
modifying factors, perceived benefits, and perceive barriers to breastfeeding. This
process generated an item pool from which the questions were formed. This tool is
designed to be self-administered and is formatted using a Likert scale representing a
spectrum of emotion about a particular question. Some demographic questions are short
answer. The tool is to be introduced during the initial prenatal assessment of the
primigravida. The reading level of the tool was at a third grade level as determined by the
Flesch-Kincaid Reading Grade Scale.

The target population for which this screening tool was developed for was those
primigravida women of childbearing status, ages 19-40, who have sought prenatal care
through the health care system. The tool was designed for use with all educational levels,
socioeconomic status, marital status, ethnicity, and women who can read at a third grade
leveL

The tool is to be used in any setting that delivers prenatal care via primary care
physician, obstetritian, or nurse practitioner. The tool is intended to be given to the
primigravida in the waiting room for completion. Office staff will need to be introduced
to the tool and how the primigravida should complete it, so they can give proper
instruction to the woman. The tool should take approximately five to ten minutes to
complete by the primigravida, depending on how long she contemplates the questions.

21

The completed tool should then be added to the chart so the provider can review the
information prior to assessing the primigravida.
E l E E I. S . I l E l

The Prenatal Breastfeeding Screening Tool for the Primigravida consists of 17
questions pertaining to modifying factors, perceived benefits, and perceived
barriers to breastfeeding in the following content areas: (a) demographic data (5 items);
(b) sociopsychologic perceptions (8 items); (c) knowledge about breastfeeding (1 item); I
(d) perceived benefits of breastfeeding (1 item); and (e) perceived barriers to
breastfeeding (1 item). The tool is preceded by a provider guide (Appendix A) to
familiarize the provider with the design and administration of the tool. An introduction
page is also included (Appendix B) for the woman.

The screening tool (Appendix C) was designed with key questions in each of the
designated areas. It was believed that a written, in-depth tool would be too time
consuming, not practical, and not useable in the primary care setting. Additional
information may be gleaned with the tool as the provider’s source of screening
information for further assessment of the factors influencing breastfeeding. It was this
author’s intent that the administration of the tool would facilitate further discussion by
the APN and the primigravida woman regarding breastfeeding. The APN needs to
carefully review the information from the self-administered tool with the woman to
clarify answers and discuss pertinent issues during the initial exam of the primigravida. If
time does not allow for a full discussion of the issues identified in the breastfeeding
screening tool during the initial visit, further discussion can be incorporated during other
prenatal visits with the woman.

Qemogmphjcflata. Questions one through six of the screening tool address
demographic data. Age, race, income, and education information comprise this section.
Marital status and feeding intentions are also included in this group of questions. It is
believed by the author that feeding intentions, although not identified in the demographic

22

data during the literature review, is vital information to know when planning
interventions which facilitate the breastfeeding experience.

SjmcnrraLData. Structural information is obtained by question 8 of the screening
tool, where the woman provides her perception of her own knowledge about
breastfeeding. This can be further explored by the APN during the interview process.
Research indicates that the level of knowledge concerning infant feeding is closely linked
to breastfeeding (Labbok & Simon, 1988). This would suggest the probable advantage of
breastfeeding education and promotion during antepartum visits. Exploring this question
with the woman gives the APN direct information about knowledge deficits so that
proper intervention could be implemented. Demographic information can be utilized to
present educational material appropriate for the age and educational level of the woman.

Matemalfioles, Maternal roles are addressed in questions 7, 9, 15, and 16. These
questions are not all encompassing, but were chosen as screening questions in this area.
Knowledge about how a woman feels about motherhood, how it could fit into her
lifestyle, if she is comfortable with the idea of putting her baby to her breast, and what
she thinks breastfeeding will be like can give the provider clues to the woman’s maternal
role idealizations. The answers obtained on the screening tool can be explored between
the woman and provider. Clear maternal role ideas are associated with successful
breastfeeding (Gigliotti, 1995). Strong maternal role idealization can be a predictor of the
breastfeeding decision and success. Maternal role views provide the basis for assessment,
mutual goal setting, and development of sound intervention. Identification of maternal
attitudes concerning breastfeeding provides an opportunity to implement strategies that
support breastfeeding (Dungy, Losch, & Russell, 1994).

SociaLSupmfl. Social support is one of the key influences in a woman’s decision
and success with breastfeeding (Littman, Mendendorp, & Goldfarb, 1994). Questions
11,12,13, and 14 obtain information about the support of family, friends, and significant
other in regards to breastfeeding for the woman. Strong approval of breastfeeding by

23

support systems is associated with a high incidence of breastfeeding (Littman,
VanderBrug—Mendendorp, & Goldfarb, 1994). Important support people could be
included when discussing breastfeeding. Cultivation by the woman of a supportive social
system for breastfeeding may assist her in her breastfeeding endeavor. Strategies that
involve the support system or partner during prenatal counseling might increase
understanding and support (Alexy & Carter-Martin, 1994). If an area is found to be
scored low on the Likert scale, the APN can further analyze, facilitate education, and
incorporate involvement of other support systems.

W. Alexy and Carter-Martin (1994) describe perceived benefits
as the most important predictor of the breastfeeding decision. Question 10 asks the
woman if she feels there are benefits to breastfeeding. This is intended as a screening
question to be followed-up with further discussion with the provider.

W. Perceived barriers are addressed in question 17. Asking the
woman if there are things that could keep her from breastfeeding provides the APN with
an idea of the woman’s perception of barriers to the breastfeeding experience. As with
many of the other questions, this is designed as a screening for further discussion. To
attempt to incorporate all aspects of assessment into one tool would be a monumentous
task. Description of a woman’s perceived barriers can occur verbally with the APN.
Women’s negative feelings and thoughts about breastfeeding should be discussed and
clarified (Dix, 1991). Interventions to increase breastfeeding incidence and success
should provide women with the abilities to overcome possible breastfeeding problems
prior to the birth of the child (Sciacca, Dube, Phipps, & Rattliff, 1995). If the barriers are
rated higher than benefits, the APN must focus on ways to decrease those barriers.
Guided exploration of the woman’s benefits and barriers may provide useful information
to promoting a successful breastfeeding experience.

Using this screening tool the APN can address individual areas which influence
breastfeeding for that individual and formulate with that woman a plan to promote

24

successful breastfeeding. Identifying areas of intervention allows for individualized
planning. Current literature contains little information about successful use of
intervention during the prenatal period. It is hoped that this screening tool may spur such

information.

 

A formal pilot testing
of the tool was not conducted for this scholarly project; instead the tool was presented at
the Lakeshore Nurse Practitioner Network’s January 1999 meeting for comments. Four
family nurse practitioners, which provide prenatal care in their practices, evaluated the
provider guide and the screening tool. Comments about the screening tool included
positive remarks about the length and easily understandable questions. Other positive
comments included the support, maternal role, and benefit/barrier areas of questioning,
since these areas are not well represented in current prenatal forms. All four nurse
practitioners requested information on interventions which could be applied to promote
breastfeeding in their clientele. One nurse practitioner asked if she could start to use the
form immediately with her patients. Very little attention was given to the provider’s
guide. It is this author’s observation that the guide appeared too wordy for the nurse
practitioners to pay full attention to it. A shorter, more succinct guide may be more
useful. The tool was also presented to a committee of professors with experience in
women’s health and prenatal care. Upon their recommendation, some of the questions
were revised for easier understanding. There was also concern about the inclusion of
demographic data on the tool, since that information could be gleaned from the chart
without asking the woman. It was noted that some patient charts may not have all the
information presented on the breastfeeding screening tool, and since it is important
information to screen for, it should remain on the form until a pilot is performed.

The screening tool was also given to a pregnant, Caucasian, 25 year old woman
for her completion and to evaluate for ease of use and understanding. The woman felt
they all were good questions, spurring her to reflect on her own ideas of motherhood and

25

breastfeeding. She had no difficulty understanding what was being asked of her, stating
“it was a good basic survey”.
Discussion

Various attempts have been made to direct women down the path of successful
breastfeeding. From education to incentives, women have been lured in the direction that
practitioners and educators believe is the correct path to promote the breastfeeding
endeavor. These well-intentioned efforts have had varying results. Research, as yet, is
unable to reproduce interventions which provide effective results to improve
breastfeeding incidence and duration. Prenatal screening of the factors which affect
breastfeeding should be considered the first step toward support of a successful
breastfeeding endeavor. It is hoped by this author that the information obtained by the
prenatal breastfeeding screening tool will lead to unique and appropriate interventions
which promote successful breastfeeding.

ImplicationsfoLEmcfice. The APN in primary care is in an excellent position to
utilize the prenatal breastfeeding screening tool. Since the APN has the specific task of
health promotion, the screening and promotion of breastfeeding falls easily into the
APN’s domain. Applying nursing knowledge, the APN can screen the modifying factors,
perceived benefits, and perceived barriers to breastfeeding by the primigravida. The APN
can then formulate an individual plan of care for the woman to support and enhance her
breastfeeding endeavors.

Not only can the APN educate women about breastfeeding, the APN can utilize
his/her knowledge base in the formation of a breastfeeding plan of care incorporating
information obtained from the prenatal breastfeeding screening tool. The APN in primary
care can also educate collaborators and peers in the use of the prenatal breastfeeding
screening tool, so it’s usage is more widespread. Interventions which work can be shared
with peers to increase the incidence and duration of the breastfeeding experience.

26

One must consider the definition itself of successful breastfeeding when applying
this screening tool. The APN must be cognizant that his/her ideas of successful
breastfeeding may not be the same as that of the breastfeeding woman. Implementing
interventions during the prenatal period must reflect the woman’s own definition of
successful breastfeeding.

In the zeal to make the Healthy People 2000’s (1990) goal of increasing the
incidence and duration of breastfeeding a reality, care must be taken to ensure that
feelings of guilt are not instilled in those who choose to bottle feed their infants.
Breastfeeding is not for everyone. Some barriers to breastfeeding may be insurmountable.
The final outcome of all should be the happiness and fulfillment of both infant and
parent.

Implicafionsforfleseamh. Further research is needed to refine the Prenatal
Breastfeeding Screening Tool. A pilot should be performed to refine and promote initial
support of the tool for use. The necessity of the demographic data on the tool should be
explored Demographic information is important in the screening of the woman,
however, the information could be gleaned from other areas in the patient’s chart. An
evaluation of the quality of the tool, based primarily on evidence of the tool’s reliability
and validity should be performed.

Other populations, such as adolescents, could benefit from the screening tool. The
tool could be adapted for use with these populations. The applicability of the tool in the
second or third trimester of pregnancy should also be explored, since it is unknown if
assessment of the factors which influence successfirl breastfeeding would be beneficial at
that time. The breastfeeding screening tool implementation also needs postpartum
follow—up to determine the effectiveness of the tool’s use. This could be performed at the
six week check up and again at six months during postpartum exams.

Not all primary care providers understand breastfeeding enough to perform
further breastfeeding assessment. This could decrease the screening tool’s effectiveness

27

and usability. The development of a protocol to guide the provider through the screening
tool and to further assess for breastfeeding success would be beneficial.

The APN has an unique opportunity to utilize the prenatal breastfeeding screening
tool for further research in breastfeeding intervention. The use of a Likert scale for
individual responses in the self-administered portion of the screening tool lends itself
more easily to the application toward research. Screening of modifying factors, perceived
benefits, and perceived baniers to breastfeeding is the first step to identifying factors and
applying interventions which could increase the incidence and success of breastfeeding.

Further research is also needed to examine whether prenatal breastfeeding
screening actually does increase the incidence and successfulness of the breastfeeding
experience. What types of prenatal screening and use of the information once retrieved is
of importance if one is to expand breastfeeding knowledge. The APN in primary care is
in an advantageous position to perform this research.

Healthy People 2000 (1990), in the quest to increase breastfeeding incidence and
duration, calls for professional education and improved support from health care
providers. Studies have shown that health professionals, and nurses in particular, can
improve breastfeeding initiation and success. However, nursing education may not
prepare students for effective breastfeeding promotion. It has been reported that almost
three quarters of nursing students were confident in their own breastfeeding assistance
abilities, yet one forth to one half showed deficiency in fundamental breastfeeding
knowledge when examined (Freed, Clark, Harris, & Lowdermilk, 1996). These findings
suggest that nursing programs do not adequately prepare student nurses for their role in
breastfeeding promotion. Incorporating the prenatal breastfeeding screening tool and the
theory behind it, along with other aspects of breastfeeding education may improve

nursing student competence in the promotion of successful breastfeeding.

28

Primary care providers are a frequent source of both prenatal and postnatal health
care for women. Pediatricians, obstetricians, and family practice providers have the ‘most
frequent opportunities to provide breastfeeding promotion and assistance. Considerable
evidence suggests that physicians are ill-prepared to offer prenatal breastfeeding advice
(Freed, 1993). A more thorough incorporation of breastfeeding into medical school
curriculurns would better prepare physicians to provide breastfeeding promotion and
support in their practices.

The Prenatal Breastfeeding Screening Tool for the Primigravida was developed to
provide the primary care provider with a tool to screen prenatally for factors which would
influence the breastfeeding experience of women. The quality of the tool’s application is
dependent on the provider’s interest in furthering successful breastfeeding. It is hoped
that the tool is embraced and utilized by those with that goal in mind. It is also hoped that
this tool will spur the creation of effective interventions to encourage and support the

breastfeeding endeavor.

29

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declines in breast-feeding in the United States, 1984 through 1989. W4),
719-727.

Sciacca, J. ,Dube, D. ,,Phipps B. ,& Rattliff, M (1995). A breastfeeding education
and promotion program. effects on knowledge, attitudes, and support for breastfeeding.

lQumaLcLCQmmunirst-calthlmm 473-490

Stashwich, C. (1994). Overcoming obstacles to breastfeeding. Karim Feb.
15, 88-112.

U. S. Dept. of Health and Human Services. (1990). WWW
WWWaSMngmn DC: 379-380

Williams, E. (1995). New physician organization for promotion of breast feeding.

AmencaniamrlxflhxsrcranAugust, 387

Williams, E., & Pan, E. (1994). Breastfeeding initiation among a low income
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Lactation._10(4), 245-250.

Wilson-Clay, B. (1996). Informed choice, infant feeding, and guilt. Intematinnal
lQumamLChildbinhEdnszammallfi) 26 27

33

APPENDICES

APPENDIX A

Appendix A
Provider Guide for the Primigravida Breastfeeding Screening Tool

The prenatal breastfeeding screening tool is designed for use prenatally with the
primigravida to screen for certain factors which may influence infant feeding after
delivery. It was developed to increase the incidence and success of the breastfeeding
experience. The tool is composed of a self-administered portion utilizing a Likert scale
format for the screening of factors which influence breastfeeding. Demographic data is
asked directly in the tool. The screening tool is developed for administration during the
initial prenatal comprehensive exam. The receptionist may provide the self-administered
tool to the client to be completed while in the waiting room. The receptionist should be
instructed to give the screening tool to all primigravidas between the ages 1940 when
scheduled for their initial prenatal comprehensive exam, not an exam which confirms
pregnancy.

The prenatal breastfeeding screening tool is based upon the Health Belief Model
(HBM) and incorporates modifying factors, perceived benefits, and perceived barriers to
the breastfeeding experience. The completed tool is to be reviewed by the primary care
provider in order to develop a plan of care that promotes a successful breastfeeding
experience. This can be accomplished throughout the prenatal visits. Identifying areas of
intervention allows for individualized planning. There is space provided for notes. Using
this screening tool, the provider can formulate with the woman a plan to promote
successful breastfeeding. The information is categorized as follows: modifying factors,
including demographic data, sociopsychological, and structural factors; perceived
benefits; and perceived barriers.

34

Modifyingfaflm:

Demographicfiata. Age (question 1): The younger the primigravida, the lower
the incidence of breastfeeding incidence and success. Of primigravidas under 20 years
old, 45% will breastfeed successfully. For 20 to 24 year olds, 50.9% will breastfeed
successfully. F ifiy six percent of pregnancy women ages 25 to 29 years old will
breastfeed successfully. The highest incidence of successful breastfeeding occurs with a
maternal age of 30 to 44, who breastfeed successfully 71 percent of the time.

Race (question 2). Caucasian women breastfeed successfully 61 percent of the
time, African Americans 27.5 percent, and Hispanics 67 percent.

Socioeconomic status (question 3). Low income correlates with decreased
incidence and success of the breastfeeding endeavor.

Education (question 4). Those with no high school diploma or GED. have the
lowest breastfeeding incidence and success (43 percent). There are incremental increases
in the incidence and success of breastfeeding as education increases, with those pregnant
women with Bachelors degrees or higher having the highest incidence and success
breastfeeding (80 percent).

Sminnsychnlogical, Maternal role perceptions (questions 7, 9, 15, and 16) are
identified in the literature as areas which influence breastfeeding incidence and success.
Women with a strong sense of identity about themselves and their maternal role
breastfeed over an extended duration of time and are satisfied with the successfulness of
their breastfeeding experience.

Social support. A primigravida’s significant other, family, and friends (questions
11, 12, 13, and 14) are identified in the literature as factors which influence breastfeeding
incidence and success. Husbands are the most influential. The woman’s mother and

friends also influence the primigravida’s breastfeeding initiation and success. A

35

primigravida is more likely to breastfeed successfully if she has a mother who breastfed
her children and friends who have breastfed. When support and encouragement is
provided by the significant other, family, and friends, breastfeeding incidence and
success is increased.

SlmcflrmLfacmrs. Perception of knowledge about breastfeeding (question 8)
identifies how much the woman thinks she knows about breastfeeding. This can provide
useful information to the provider regarding whether the woman has any misconceptions
about breastfeeding and can lead to an assessment of her actual knowledge about the
breastfeeding endeavor. Research has identified that the more knowledge the pregnant
woman has about breastfeeding, the greater the breastfeeding incidence and success.
W The perception of benefits to breastfeeding
by the woman (question 10) and the perception of things that could keep the woman from
breastfeeding (question 17) strongly influence breastfeeding initiation and success. To
breastfeed successfully, the woman must perceive that the benefits to breastfeeding
outweigh the barriers. Every woman has individual perceptions, weighing each
perception differently. It is the provider who must help the woman to identify these
perceptions and increase the perceived benefits to breastfeeding by the primigravida.

The Health Belief model guides the practitioner in the incorporation of the
information obtained from the prenatal screening tool. Modifying factors have an indirect
influence on breastfeeding behavior by their effect on motivation to breastfeed
successfully and perceptions of successfirl breastfeeding. These factors affect the
likelihood that the woman will take action to breastfeed successfully. The screening of
modifying factors involved in a primigravida woman’s perceived ideas about the
breastfeeding experience could provide predictive information to the APN. Anticipating

certain behaviors, the APN could provide anticipatory guidance and interventions which

36

would help to minimize negative effects the modifying factors may have on perceived
breastfeeding success.

Perceived benefits and barriers to breastfeeding define the particular course of
action the primigravida will take to breastfeed successfully. A woman would not be
expected to accept recommended action unless it was perceived as feasible and
beneficial. The potential negative aspects and perceived barriers of breastfeeding may act
as impediments to the experience. To successfully breastfeed the perceived benefits must
outweigh the perceived barriers. Screening of a woman’s perceived benefits and
perceived barriers could predict the likelihood of successful breastfeeding and provide
the APN with information needed to create an individual plan of care for the woman to

promote and enhance the breastfeeding experience.

37

APPENDIX B

Appendix B
Introduction to the Prenatal Breastfeeding Screening Tool

Congratulations on your pregnancy. Your health care provider is here to care for
you during this time of change. Among the many things to think about is how you plan to
feed your baby. Please complete the following short survey about your infant feeding
ideas. Your answers are intended to give your health care provider information that can
help support your infant feeding decisions. All responses are confidential. There are no
right or wrong answers, so feel free to tell us just how you feel. Your responses are

greatly appreciated.

38

APPENDIX C

Appendix C

11! IlIli IE I' Ill]: III E '1

Welcome. Please take a few moments to answer the following questions. Place an X in the space
which best describes you and your situation. Your honest answers will help your provider to support
your infant feeding decision.

1. How old are you? years
2. What is your race?
Caucasian Hispanic

African American Native American Other

3. What is your yearly household income?

Under 15,000 $15,001 to $25,000

$25,001 to $35,000 $35,001 +
4. How many years of education have you completed?

Grade school G.E.D.

No high school diploma College, less than Bachelors Degree

High school diploma College, Bachelors degree or more
5. Are you: Single Single, living with significant other

Married Divorced Widowed Separated
6. Have you given any thought to how you might feed your baby? yes no
If yes, are you planning to:
Bresstfeed Bottle feed Undecided

Please circle the number on the scale or place an X in the blank which describes how strongly you feel
about the question. One response is no better than any other. Your answers help your provider to

support you.

7. How excited do you feel about becoming a mother?
(afraid) I 2 3 4 5 (excited)

8. Do you feel you are knowledgeable about breastfeeding?
yes no

 

9. How do you believe breastfeeding would fit into your life?
(not at all) 1 2 3 4 5 (very well)

10. Do you feel there are benefits to breastfeeding?
yes no don’t know

 

11. Do you have friends that have ever breastfed?
yes no don’t know
If yes, was it a good experience for them? yes no unknown

 

 

39

12.

l3.

14.

15.

16.

17.

How supportive is your family of breastfeeding?

 

(not at all) 1 2 3 4 5 (very supportive)
Did your own mother breastfeed her children? yes no
Was it a good experience for her? yes no don’t know

How supportive is your significant other of breastfeeding?
(not at all) 1 2 3 4 5 (very supportive) not applicable

How comfortable/uncomfortable do you feel about putting your baby to your breast?
(uncomfortable with the idea) I 2 3 4 5 (comfortable)

How easy/difficult do you think breastfeeding will be like for you?
(difficult) I 2 3 4 5 (easy)

Do you think you will have any difficulties if you breastfeed your baby?
yes no don’t know

 

 

 

(Please do not write below this line)

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